How do you explain something like ocular motor control to a parent without losing them in jargon? This episode sits right in that translation space, the constant move between precise clinical language and words a family can actually use, and follows eye control all the way down to the vestibular system that holds it up. Along the way we get into why a distractible, clumsy little one might really be telling us something about eyes, head and body learning to work as one.
This one grew out of a report Michelle was writing during the week, where she kept typing the word motor and stopping herself, because what does motor even mean to a parent who is new to their child’s development? That tension, holding a precise clinical picture in one hand and accessible language in the other, runs through the whole conversation.
From there we follow ocular motor control as our way in: eyes in head, head on body, and the vestibular and proprioceptive processing sitting underneath it all. We talk through one of Michelle’s little clients whose distractibility and clumsiness traced back to not being able to separate her eyes from her head, and we get into why testing eye control lying down might tell you more than testing it sitting up. There is a fair bit of friendly ribbing about Cory reaching for AI while Tracy reaches for her shelf of neuroscience books, and a real point underneath it about telling good information apart from confident nonsense.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Tracy: In the mentoring space and the clinical space, this idea keeps coming up: how do we help parents and educators understand some of these complex ideas, but make them really accessible and use language that translates? That is what we are doing all the time, translating science into practice. Finding the right language is part of that, and we have been having some fun conversations about it, so we are going to keep that conversation going.
Michelle: Awesome.
Michelle: I was writing a report this week and this idea kept popping into my brain, because in my mind I kept thinking motor, and typing motor, ocular motor, even praxis. And I am writing this report for people who are new to the diagnosis journey with their child. So it was like, stop writing motor. What even is motor in the context of a little child who is playing and moving and new to their family? It was this juxtaposition of being very clinically focused and precise, formulating the assessment results and a description for them about how all these apparently random presentations are showing up for this little one, and already thinking about intervention. The word motor kept coming up for movement, but that is not how I want to introduce eye function, hand eye coordination and early movement patterns to a family. So that was very front of mind for me this week: how do we sit in two spaces, a very precise clinical space in our mind, and a very accessible space for people who are new or early in the journey?
Tracy: I love calling it the two spaces, and even within that, sometimes those spaces get subdivided. The clinical space is a little different in Australia with NDIS funding compared with how things are funded here in the States, but we often have to tie things back to a medical coding language so that our services get reimbursed. That is an advocacy piece. We live in a clinical space that also interfaces with a medical billing space and the language of medicine. Sometimes we have to tie our work to a more formal label or diagnosis, and then we move into the two spaces you are talking about, where clinically we refine our reasoning and figure out the layers, and then all of that has to be translated again for parents, in a way that lets them understand all the lanes and layers without feeling overwhelmed, and without it feeling deficit based. So there is a lot of translating, and that is exactly why we are having these conversations.
Cory: Yeah, totally.
Cory: Excuse my sick voice this episode, but I am here. The other thing both of you brought to mind is that we are always trying to translate with precision, and that is so hard. You say ocular motor, and because I am a clinician I have all this associated imagery that helps me understand it. But if I have to explain that without the term, I have to use all of those other words to give the same picture, without being too complicated, and still help them grasp that the eyes are moved by muscles, and those muscles have to coordinate so the eyes move together and not separately, and the vestibular system is the gravity receptor. Very quickly I am into all this other language that I then have to explain. It is a fine line between the detail and the precision, but not too confusing, while still accurately reflecting what is going on. I think that is what we are going to try and do today, with the routes of sensation and affect. So where do we want to start?
Tracy: What would be fun is if we connected it to ocular motor as a starting point, because that is what you both started to do as you were talking. This is the translational space we have to live in and build out in our minds.
Tracy: If we are thinking about ocular motor, ocular is to do with our eyes, and our eyes move. But our eyes are in our head, and our head is attached to our body. So as occupational therapists, when we look at eye movement we look at it in the concert it lives in: eyes in head, head on body, body as a whole mover, with a set of sensory systems supporting it. In the high route of sensory discrimination, when there are basic sensory integrative challenges in vestibular processing, in the visual system itself, or in proprioception, all of that contributes to the way our eyes work and how we access the world. So right away we go into the sensory circuitry across the domains. The genius of sensory integration is understanding it is not one thing, it is the integration. But then we have to look at the bits and the parts and where the issues might be, so our treatment is effective and not just general. And as OTs we are always pulling back out to the lens of how this impacts everyday life.
Tracy: With parents the starting conversation is usually around what is important in daily life, and then connecting them to the bits and parts of what might be going on. We listen so carefully to their description, and sometimes we land on, so you are telling me your child often cannot find you when you call their name, and they do not seem to know how to look up to see you have entered the room. If that is what they are describing, it cues us in to look at some of these parts. Ocular motor is such a way in to seeing what is happening in the integration of vestibular function in particular, and that is so foundational in our work. Each of these things on the SPIRIT form, like ocular control, has a story behind it, all this depth and richness. It can be mind boggling at first, but it is also a problem solving journey all the time.
Michelle: I love it, because it gets to be really strength based and neurodiversity affirming and positive.
Michelle: The question that came to me with this little child was, why is she so distracted and why is she so clumsy? That took me to look at tracking, saccades, convergence, divergence, the vestibular system. The family watched me do the assessment, and it was like, oh, look at her eyes do that. When I could then say, she cannot separate her eyes from her head, so she is moving her whole head, you could see them join the dots. When a noise is made, her whole body turns towards it to find it, and then, oh, that bag looks exciting, Michelle’s ball is over there. That is possibly the base of the inattention and distractibility. It happened several times while I was with them, so it went from, please pay attention, to, I just saw it show up again, did you see that? She is not trying to not be with us. That saccade was not happening without her head moving as well.
Tracy: So you are connecting how the ocular system, which on the SPIRIT form we think of as a foundational motor capacity in the low route of motor, immediately links to the high route of sensory discrimination, because the vestibular system underlies that midline orientation and the ability to organise smooth, accurate tracking. It is a set of cranial nerves using the vestibular system as the foundation. And then we connect into the high route of affect, because these saccadic eye movements, being able to look toward something and come back, are how working memory begins. That is where distractibility is anchored: I know what I am looking toward, I look at it, and that informs what I was thinking before. But if you have to turn your whole body, it takes you out of the here and now into the next thing and the next thing. So we see distractibility in the ocular motor system, founded in that very first executive function, which is really saccadic eye movements.
Tracy: We connect those dots and then we know what the treatment plan is. If you only see the distractibility, you follow it as a behaviour and you do not understand its foundation. The high route of sensation and the high route of affect are supported by the low route of motor.
Michelle: It is kind of liberating, because then we do not go down the behavioural route.
Cory: A hundred percent. I love the executive functioning box on the model, because you might see something appear in multiple boxes, and that is Tracy giving you clues that this function relates to many places in the brain. It has got sensory modulation and regulation there, because regulation impacts your ability to access all of your executive functions. It has got orient and reorient to goal, eyes, ears and midline, which brings you to the postural box, and prospective motor control. It is about integrating the sensory motor functions to be able to do the executive functions. We could work on lots of cognitive strategies, and they are useful, but I want to pair that with understanding why that capacity, attention for this child, is not available. If she has to reorient, she has to physically come back too, which is way harder than just moving her eyes back, and that is tripping up all of her attention. I love that the model can cue you, and you do not have to know every term on it. For a long time I just used the S, the A and the M in my head, guessing whether something was more motor, affective or sensory based, and then added layers and layers.
Tracy: We started with ocular motor, but the other description of this little one was about not having the smoothest coordination generally. It is not uncommon to see coordination issues coincide. Sensation for a use, that is sensory integration, and the purpose of sensory discrimination always lands in some kind of skilfulness. Looking is fairly automatic, but we can get better at it, and we can get a whole lot better at using our fingers, our feet, our arms. All of that sits back in the sensory discrimination foundation, and it is liberating as a clinician to know that.
Cory: I am thinking about my four and a half month old, because eye control and vision are not really there at first. You look at a new baby and their eyes are kind of everywhere. They cannot hold their eyes easily. Then three months later, when the head is stabilising on the neck, when there is enough support and stability from a surface, the head and neck pull and hold together enough, which relates to the maturation of the proprioceptive signals in the neck telling you the position of your head, and the vestibular system telling you the head is tipping or not. Those two come together enough to get the eyes to find things and see things, and then suddenly it is, oh my goodness, I am reaching. We try to get these things to integrate in multiple positions. I look at my baby in prone on a supporting surface and she can do it, it is integrating for her there. But put her upright in sitting and it is not integrated yet, there is not enough stability to do it in that position. We often get kids much later in life who are up and moving, but things have not come together, so we look at it coming together not in one postural position but in many planes. Can you even get it for your kiddo in upright sitting, Michelle?
Michelle: I have never thought about testing it in different positions. I always do it in upright, more supported or less supported.
Cory: I had the thought while watching my baby, maybe I should test everybody in saccades, because that is where we first get it.
Tracy: It is where we first get it. It is funny, because we think about things but do not know to apply them across. Michelle, you have had opportunities to learn about vestibular ocular function, maybe some training from Mary Kawar, who talks about vestibular activation and getting kids out of upright, working in supine and prone for these very reasons. But sometimes we learn about a clinical observations test in one frame and do not apply other knowledge we already have.
Cory: A hundred percent. I said prone, but I meant supine, lying on their back, instead of using the terminology. And just to make you feel better, Michelle, I never tested kids for eye control lying on their back either, until I had such a tangible experience of seeing it emerge developmentally. Now I think, maybe I should test them on their back and then in upright and see how that differs. That would give me such a big clue about the head, neck, proprioceptive and vestibular communication that helps you get your eyes working.
Michelle: And what capacities do they have it at their best, and maybe it is in a different position. So interesting. That is the point, Tracy. Sometimes I get a little administrative: we did the SOSI-M, we did COMPS, we did the Clin Obs, which originally is from Ayres and has been adapted. Administering those is not in supine or prone, so I just have not married the developmental knowledge with adapting it.
Cory: You are supposed to do them standardised, which makes sense in upright because kids spend their time upright. But if we tested lying down and saw it was better, it would be such a clue for our clinical reasoning about why that is happening.
Tracy: That is where you start. In the SPIRIT training the content is there, but it is the application I love exploring with you both. In the low route of motor we have a beautiful graphic that goes through all the developmental positions. When you are thinking about a capacity, we map it onto a spiralling continuum and the idea of the landing pad. So if you see a child struggling in upright with ocular pursuits, and that derails something, you want to ask, where is their landing pad, what is the foundation below that? Often you go down into those developmental motor patterns, to a lower level, and see, is it still struggly there? If I get them out of gravity, is it still struggly? If I support their vestibular and proprioceptive processing, can they show me whether this is still there? Then I find the lowest level where they are solid and work up from that. A developmental approach to sensory integration is really what I am trying to promote. We have the thinking tools, but we do not always remember to apply them to every aspect of what we are learning about an individual.
Cory: And it is a deep learning for yourself as well, integrating those two separate pieces of information and knowing how to let that inform what you do. If they cannot get it in upright, what comes before? And if you do not know that, where do you get that information? So we look at all those discriminative functions. What is the vestibular system’s job in its highest form, which is discrimination? It has to discern precisely the movements of the head in relation to gravity and to the body, and help the eyes adjust to all that movement. So I can do the Clin Obs and look at you picking up against gravity, then look at you trying to track something, then tip you a little off centre and see if you adjust. We are looking at the discriminative adaptive functions of the vestibular system. And it is not just the vestibular system, which is why it is hard to learn, because it is always integrating with the others, including the motor system, since it has to help the body respond to gravity.
Michelle: Where does motor even come from? I guess it comes from the physio world. How did it become a thing? Is it a Latin word that started years ago?
Tracy: I actually do not know the answer, which is fun. I think about the movement systems and all the parts of our bodies that move, with increasing skilfulness over time. There are automatic parts of our movement and more volitional parts, and we have to know the difference to improve motor skills. The movement of my social interaction, of my affect and energy, but also of my limbs, fingers, eyes and shoulders, all of it has movement. Here is a hilarious trialogue thing: I would begin by looking it up in my trusted sources and advisors. I would go to my NDT books, to Ayres, to Lois Bly, to my neuroscience books, fifty of them within reach. And Cory would go to AI, and I would laugh.
Cory: I would go to AI, but then I would not trust it. That is the whole point I am trying to make. It can be helpful, but it is deceptive.
Tracy: It is deceptive, and that is why I brought it up, not to make fun of you, but to poke at it. You cannot just Google this stuff. You can on some level, but you have to know what your question is and where your curiosity arose, and you have to guide it, or you will be deceived. I am going to trust my knowledge partners, the research and evidence based practice, very quickly compared with an open question on the internet. I love that we are talking about this, because it is so important to be discerning in an era where you can get information quickly and it may be totally inaccurate.
Cory: You could so easily get an activity. A parent types in, my kid seems really clumsy and cannot pay attention, and without you, Michelle, they would not even have known that controlling the eyes was hard. AI might pump out a bunch of activities, but it never understands the background, where it is not integrating and why it might be hard for that child. You could do a bunch of cognitive strategies for attention, but you never then build the adaptive capacity to discriminate head position in relation to the neck, in relation to stability and midline for eye control. It could produce a whole home programme based on who knows what, and do it really well, but it is not where they are at yet, it is not developmentally appropriate.
Michelle: If you provide that context, I am likely to do both. I will go to AI and say, using Lois Bly, Ayres, and feed it some context, and it still does not quite know it. I was searching the history of neurodiversity, and I knew Blume was the first to write about it in text, and it was not pumping it out. On the third question I had to say, find the quote and the source from Blume. So you have to know what you are looking for. Even when you feed it, it is not refined enough, and it might land in the wrong spot.
Cory: It also makes up stuff. You can tell it not to make anything up, but Sam Altman, who helped create ChatGPT, says people trust AI way too much and just take it as fact. It is not fact, you have to check it. I did look up the Latin root of motor, although it is all AI integrated now, so how do we escape that, I do not know. The root is mot, from the Latin verb meaning to move. So it makes sense, motor, to move.
Cory: Who is it that says motor is the final common pathway, Sherrington?
Tracy: Yes, he does. And recently I was rereading a lot from Daniel Stern, one of my favourites, who is really the father of interpersonal neurobiology before Dan Siegel. He said the movement system is where we learn everything, how we understand everything, where we obtain our understanding of what is happening. For him it was about the development of self, of self and other connectedness and relationship, and that you can see everything in the motor systems. In the SPIRIT model we connect that the motor capacities come from foundational motor systems, but they are also linked to the sensory discrimination functions, and they draw from the activation circuitry of the regulatory system. So where you see kids struggling with ocular pursuits, it might not be sensory discrimination, it could be that they are in a protective state, unable to move out of a frozen, vigilant midline to have the ease and fluidity of scanning and tracking. You can see kids in states of freeze or activation through their movement patterns, often through their ocular patterns. The treatment plan for someone with distractible ocular pursuits is very different from the one for a child who is frozen and unable to pursue anything other than the most stable thing in the environment, which might not be a human. They can look similar if you just tick the boxes on the SOSI, but the findings are there for entirely different reasons, and we have to be careful about interpretation. That is where the whole art of therapy comes from, interpreting what we are noticing, then deciding what to do about it. That is clinical reasoning in a nutshell.
Michelle: Gosh.
Cory: I have a body felt sense of a kid who is stuck frozen, in a protective state, not able to saccade, but I am not sure I could describe it. It depends what protective state they are in. Tracy, can you give more of a description?
Michelle: Can I jump in? This resonated and it was harder for me to talk about, because it is absolutely part of this little child’s history, early childhood. There is sympathetic activation happening, and also, due to some perhaps insecure attachment, I do not think they are worried about having errors. They are on the go and fun loving, and not chasing refinement. When they are on the go and not going for precision, and they fall off a ball, their sense of self is not solid enough yet, because of attachment issues, I am making some leaps here. So they keep going and going, not going for refinement or goals. That is the other layer. We are not necessarily going to precision, because of the real low route of affect issues, sense of self, agency, and the motivational pull to get precision. It is easier on the sense of self to be a go-goer, fun and doing, feeling the risk of the fall.
Cory: I just had an aha as you were talking about attachment. When that is a bit disrupted, and we have kiddos who have been removed and have big disruptions, I was thinking about relational safety helping reinforce stability in midline. If you never have safety and stability to come back to midline and sit in, then you will just go, go, go. It has to be reinforced relationally, because that is how it works. Then you dance with these kiddos, where relational interaction can feel full on or disarming to them, because it is so unfamiliar, so you visit it in and out, because they do not trust it yet. But we are not saying every kid who has trouble tracking an object has trauma. Please do not go away thinking that. Just know there is more than one reason you may have trouble with eye control.
Tracy: That is right. Our job is to remain open to exploring all the options. Even when we notice a clear connection, that an ocular pursuit issue is based in motor issues grounded back in the high route of sensory, vestibular and proprioceptive processing, and then links to the high route of affect, that stickiness and start stop signalling, it always connects to sense of self and sense of other, because the start stop mechanism also comes from the relational space. Knowing those thread connections on the SPIRIT helps you say, the evidence based starting place here is the low route of motor, let us look at the pursuits, now let us look at the high route of sensory, figure out what is happening for vestibular and proprioceptive processing, connect that to the high route of affect, and then down to the low route of affect, because there are direct neural networks that do that. Those lead us to ahas, and then we can deconstruct it for the family and talk about how we coach them to support their child’s affective system, to find shared moments and prolong them, and to use our bodies and systems to explore all of that in meaningful ways. We can keep it simple in our language with parents, and also make sure we are connecting the threads.
Cory: I would still like to go through some of the terminology of the high route of affect, the motivational bias and the stick-to-itiveness. We mentioned it a lot today but have not yet got to it, and it is important, because what we were talking about comes into what is interesting to a child and how that shows up in executive functioning. Maybe we cover that next time, depending on the mood. This is a good place to stop and integrate, so thank you both for such a wonderful conversation.
Tracy: Thank you so much, and thanks for the fun little detour about using our resources wisely. Cory, you are creating some really fun content around this, separate from the podcast, in the space where you share your OT mind, so keep doing that. It is so fun to have this trialogue with you guys.
Cory: Thanks, mate. See you guys.
And that’s a wrap on today’s episode of Spirited Conversations. We hope this sparks something for you, whether it’s a new clinical idea, a fresh perspective, or just the reminder that you are definitely not alone in this work. If this conversation resonated, we would love for you to share it with anyone on their own learning journey. You can find information about the podcast on our website, and you can join us in the courses and communities the Developmental FX team have put together at developmentalfx.org. And if you’re enjoying listening, please subscribe or leave a review, it genuinely helps more people find us. Until next time, keep the conversations spirited!