We promised more terminology and then did what we always do, followed a real child instead. Cory brings a three and a half year old who was stuck with dressing, flooded easily, and sat a beat behind socially, and what looks at first like a praxis problem turns out to be an autonomic one. When the nervous system is that loud, there is no room for praxis to build. This is sensory integration and polyvagal theory working together, with a Lycra sheet, a dinosaur puppet and a claw grabber doing the heavy lifting.
We sat down planning to keep unpacking terminology and, five minutes in, decided to do a case instead. Cory talks us through a little boy who came to him at three and a half with no diagnosis, struggling with dressing, quick to flood, and socially a beat behind, the kind of child who goes along with whatever happens because asserting himself is not yet available to him.
What makes the conversation sing is Tracy reframing it in real time. Before we get anywhere near praxis, his autonomic nervous system is so loud that it does not leave space for discrimination to do its job. So Cory’s very ventral, play-based treatment, Lycra wrestling, a dinosaur puppet, a claw grabber, was the thing that finally let the somatosensory work land. Michelle brings a two minute video of another child meeting a barrel for the first time, and you watch praxis unfold in real time, ideation, planning and execution, and we land on trusting the theory even when the path is not yet clear.
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.
Cory: Here we go. Another time, another joy. We are continuing on our terminology journey, although we are going to do a case today. We decided that five minutes ago, so bear with me as I remember the details of the beautiful little individual I worked with. I will chat about my little guy, and then we can talk about terminology relating to praxis. In the last episode we were sitting in the high routes of sensation and affect, and we linked that beautifully to the low route, the circuits that help with the motor system and set up the postural system. We talked about it in relation to the vestibular system, discrimination and eye control. This time we come at it through the lens of praxis, because the high route of sensation and the high route of affect do not just support eye control, they do lots of things.
Cory: So, all those crazy terms aside. My little guy came to me at three and a half, no diagnosis, just really struggling with what I would call activities of daily living. Super frustrated and emotional with dressing. In a family with a bunch of other siblings, a wonderful family, and mum is already saying, what is going on, his younger siblings can already dress better than he can. He did have a little disruption in early development: he had sepsis in a bone in his foot and needed a lot of treatment, but by the time he came to me that had all resolved. There were still some midline challenges around finding his centre of stability, but that was not the core feature, so it was there in his history and I was aware of it, but it was not what was shining brightest to me.
Michelle: Not salient for that.
Cory: So he is struggling with dressing and he is really emotional, not just around dressing but generally. I go and see him in a daycare environment. The third thing that was tricky is that he had glue ear, to the point of almost being deaf, and it was not picked up. All of that had been resolved too, but his speech was still almost incomprehensible. He is a gorgeous, delightful little boy, but in daycare I could see a lot of social hesitancy. Another kid comes along, wants the toy he has, takes it off him, and he is a little frozen, kind of, whoa, what just happened? A bit behind the beat in that dance. He was highly compliant, so he would just go okay, without being able to assert his idea or his need in the interaction. So those are the functional things: a social element, a dressing challenge, and some emotional regulation. Those were the three goals mum needed help with. He had already been seeing an OT for at least six months before me, working on dressing, and it was still very tricky. That OT went on a year long holiday, and they found me.
Cory: I did not get him to dress his whole body. I just got him to do his shoes and socks at the start and end of the session so I could see what was happening. He was trying to use his hands to hold up his body instead of being able to sit upright and reach down to work his socks and shoes. So he did not have enough stability in his postural system to get his feet and legs to work independently of his trunk. That is the postural part. The second part, which is really useful for describing the praxis function, is not knowing the tension of the sock, which direction his foot is pulling. The toe gets caught in the heel, and there is no understanding that there is tension there, that he needs to back it up and shift it and pull it a different way. As soon as he hit an issue he was flooded, because it was so hard for him. Same with the shoes, the tongue getting caught and chomped down the bottom, not knowing to open it up, not knowing which foot was which.
Michelle: Would he give up in frustration, quite external, yelling and shaking off the shoe, or more a giving up, I cannot even do it, do it for me?
Cory: There was a sort of floppy, ugh, the whole body giving out on him. And if you tried to encourage and push, more irritation would come out. So I would not push him that far, I was just trying to get an idea of what it looked like normally. It would have been the same with his shirts and shorts, the whole process, having done it so many times every day and getting frustrated and not getting any better. It was so triggerable, the emotional dysregulation around it would come so quickly.
Michelle: Tell us some of the strengths, because in terms of treatment that was so important.
Cory: He was so delightfully social, and so able to do things with some positive social interaction and support. That was the key strength I could draw on for all of my sessions: some kind of play and social interaction to supplement the discrimination challenges he was having.
Michelle: So you were acting as his co-regulation when it got sticky, but also helping that motivational bias system be driven to do the thing that was tricky, that he was not driven to do himself.
Cory: Yeah, and to be honest, most of the time I was not even working on dressing directly. The only time I worked on dressing was getting the shoes off to start and on to finish. The majority of the session was me finding ways to play that gave him relational somatosensory input. Through interaction with me I was trying to give feedback to him about his own body, looking for deep pressure and a whole lot of tactile stimulation, led by his interest but in a relational, playful way. That worked so well for him, and it was cool to watch it unfold. Do we need to unpack any language before we move into treatment, because I could keep going forever.
Tracy: I am doing this coding of what you are saying, and an interesting question comes to mind. When you first described him, it took a while for us to get to the sensory discrimination box, because we were really talking about what is happening in his regulatory capacity and his postural system. And you said a couple of things about how, socially at school, he goes into almost an appeasement collapse.
Tracy: The way his autonomic nervous system and his postural system worked, he was losing stability. He could not figure out how to activate, and he could not really figure out that tonic phasic relationship, because activation for him was a little threatening. So as you talk about helping his somatosensory system, in co-regulation, find agency of his body, that is so powerful. Before, we were thinking about this guy from a praxis perspective. But one of the things that happens is that when the autonomic nervous system is really loud, it does not make space for the discriminative functions to do their job. He was living in this landscape of the low route of sensation, the low route of affect and the low route of motor being so dominant that it did not give him room to work on the upstairs stuff. This is really the sensory integration story: the low routes and the high routes have to come into integration. You can see a child struggling with praxis, but really what is happening is that there had not been space for praxis for him.
Cory: Probably. When you observe a child, certain things jump out, and one was that he did not really know how to discernibly and skilfully use his hands. He had hands that just did not seem very precise somehow. I remember thinking, you have got hands, but I do not feel like you know how they work. The tone and quality of his hands and the way he used them jumped out as a somatosensory issue from the get go. The second piece I talked to mum about was the social freeze and appease profile. I said, he is so wonderfully delightful, but I really want him to be able to advocate for or express a thing and have agency socially, because that is so important for his wellbeing. I could see it, but I did not label it as autonomic. I was putting it down to a processing issue, not keeping up, and not having the praxis to know what to do. But you are a hundred percent right, the autonomic piece comes in and does not allow the praxis to be built. If you did not have a polyvagal lens, you would not know. You would just see a kind kid who lets the other kids do what they want.
Cory: But I could see a moment of, oh, I did not really want to give that toy away, but now they have taken it and gone, and now I am a bit lost, what now? So definitely it could be his story of getting flooded or autonomically dysregulated, and then not having the opportunity to develop the sensory discrimination functions he needs for skilfulness.
Michelle: And that auditory system, screaming because of the hearing issue he has had, and then the somatosensory discrimination around and in the mouth, so that he can articulate, hey, that is my toy. It is almost the praxis of communication, to be able to communicate.
Cory: All of the above, genuinely. It is funny how my treatment was very ventral, helping him access a state of ventral vagal activation for safety and embodiment, but it was not intentional, that was not what I had planned, although I am always trying to access ventral. I think that was the allowing factor for working on discrimination. If he had six months of work on dressing and had not been able to be effective, then without the ventral vagal access to work on the discrimination and integration, he could not build the capacity for more refined use of his hands and body, regulating his emotions, staying with the interaction, advocating for his needs. All of it.
Tracy: And part of integration is differentiation. His body kind of goes into this pattern, and it is not really a reflex so much as the autonomic nervous system holding him. So he could not figure out the top of space and the bottom of space, the holding pattern and the release pattern, because the tonic system was on guard, holding him away instead of letting him lean in and activate and participate. By default, because you as the therapist are in ventral and you know safety, when we have a more play-based relational approach we have that as a safety net, because it is so essential in treatment. But then the differentiation, I really want your body to feel all of this somatosensory information so you have more ability to use your hands effectively and your body in all the planes, those were important goals on top of that. I do not think we can overlook how essential that ventral, safety piece was for the success you had with him.
Cory: What a beautiful description of how nicely the sensory integrative knowledge and the polyvagal theory work together. I could have sat just in, I need to give this child safety, and that would have been useful, but I also had the precision of what I was aiming for once I had safety, which I got from the model. The feedback from his own body, about the bits and parts and where they were in space and how he planned them, was not helping him be skilful. So his proprioceptive awareness and vestibular processing were not helping him once safety was available. Safety was available, but he still had this underlying integration challenge around knowing where his body was and using it for skilful action, planning that in a social way, being in relation to another. He was so easy to develop a relationship with, because being social was in him, he wanted it.
Cory: I am treating him in any space, on the lounge room floor of his house or in daycare. So I took a Lycra sheet, a cloth tunnel, a dinosaur puppet and a claw grabber, the kind where you squeeze the handle and it closes the end. He did a variety of things, I had other toys, but those were the main tools to help with the somatosensory awareness and discrimination I was working on. We did a lot of wrestling with the Lycra sheet. At first he just wanted me inside it with him, so we would put it over the top of us and sit there. He liked the bear hunt, so he was the bear. Then he would be the dinosaur, trying to eat different parts of my body, and I would say, you cannot eat me, and grab him with the sheet, giving him an opening so all the tension of the Lycra would pull on him and he would try to get out. He would play almost the whole session doing that.
Cory: Then the puppet, and this is where the somatosensory discrimination piece was really obvious. It was a rubber dinosaur head with a big opening, not a hard puppet to put your hand into, you just had to bring all the fingers together and oppose the thumb. For the life of him he could not figure out how to shape his hand to match the object. Same with the claw grabber, he could not discern which direction to pull, he would tug the inside and the lever would twist and get stuck, and he did not know where to put his thumb or how to orient his hand, even when I showed him. Then a couple of weeks later he is putting his hand in the puppet and working the claw grabber, and it is so fun to see the outcome when they make progress.
Michelle: You can see that unfolding. I have got the praxis process in my mind, ideation. Even though you were visually cueing him into how to hold his hand, giving him that opportunity, and he is very visual dominant, so he was looking, he could not create it from his eyes because he did not have the somatosensory access to this is how I do my hand. I often see kids who are looking, looking, comparing hands, and it is wildly inaccurate, because they do not have that felt sense, embodied, this feels right, let me visually check, and the monitoring then looks right. With the object I was thinking about that perception action piece, that affordance piece, where he is starting to see his hand can act on a thing. His intention was, I want to get my hand in that puppet and chomp Cory. Then he had to look at the perceptual qualities of the puppet, notice it was hard, it has an opening, and if I put my hand in this way there is a match and a natural opening. But he could not put together the perceptual qualities of the object with altering his hand shape into a schema to act on it.
Cory: And it was all in the bigger picture, the gestalt of wanting to eat me with the dinosaur. He did not care about getting his hand in the puppet, the goal was, I want to eat you with this thing.
Michelle: Exactly. Stick-to-itiveness, motivational bias, and that contagion energy, I am going to eat you with a puppet, figuring out how to do it.
Cory: This is the cool part. Over the course of working with him, his daycare reported he was socially going much better, joining in, which was fun to hear. His ideas expanded too. It was not just, I am going to eat you, the whole session, which is where it started, the most basic of games, and that was okay, that is where he was at. But then it was, oh, what else can I eat, and now I have eaten something and I need to do a poo. Which is a big thing, because he had also put together that if he does not do a poo his tummy hurts, another discriminative thing to feel and know and sequence. That is not always an automatic connection for some kids.
Cory: It was a really nice way to see the efficacy of our treatment in a single nervous system. He did not have a particular diagnosis laid on top, so I could see the impact quite clearly. In every nervous system there is capacity, but the way it develops and the timing is different for each individual. For him, he had the capacity to unfold quite quickly, and it is fun when you get those individuals, because it reaffirms what you are doing, you can really clearly see the impact. There is never not an impact, but for some kids there are so many external and environmental factors that it is hard to feel like you have clear vision of how what you are doing is effective. We are lucky sometimes to get a situation where it is just so clearly effective. Other times you are kind of, was it, was it not, and then a few months down the line you go, oh yeah, definitely, it just took longer, or I had to pivot. I hope everyone gets cases like that, because it is them teaching us something. Clearly I was learning something specific about sensory discrimination and his overall occupational participation. And now you have brought in the autonomic piece too, Tracy, which is even cooler, as the foundation for what I was doing and why the integration then occurs.
Michelle: I just want to pick up on that idea of trusting our theories, polyvagal theory, interpersonal neurobiology, sensory integration theory. I have the great honour of mentoring, and a shout out to one of my mentees who sent me a two minute video that brings something to life. She was working to learn about praxis, which is complicated, so we will keep diving into it over future episodes. In this clip a little boy is introduced to a piece of equipment he has never seen, a barrel. Initially he was looking at the different colours on it, very into the perceptual qualities. He picked up pretty quickly that it was round and that he could push it, and did a few different things with it. At one point he held onto it and rocked it gently, but there was a real pause, I am going to say twenty seconds, quite obvious, and he was looking. Then he came back to the barrel and pushed it. He weight shifted, graded his force to push it, ran alongside it, weight shifted in the other direction and put his hands out to catch it, a new way to use it. I could have cried, I got very energised, because we just saw it.
Cory: Did you see that?
Michelle: We just saw the process of praxis unfold in that two minute clip. He played with it for about four minutes in total, so I did not see all of it, but you literally watched him come up with different ways to interact with it and shift his body. He was not in a whole-of-body visual tuning in to the OT, but he was in the game, engaged with her, sharing that opportunity. If I could, I would just say, here is praxis, everybody, because I saw it happening, that uptake, motor planning, and it was pretty sophisticated. The gorgeous OT was wrapping her head around it too. And the reason it worked is that she did not get in the road, she followed the child’s lead, waited and watched, and gave him space. She paused long enough not to interrupt his plan, and that let him actively interact in a new way with the object. We are all still wrapping our heads around praxis, refining the detail, getting as precise as we can. But sometimes the not knowing is okay enough, when we stay with the guiding principles of the theories that work for us. We will catch up. The child will show us. Just do not get in the road.
Cory: Especially when you clinically reflect after the fact, because that is where she builds that knowledge. In the moment she would have been thinking, something is happening, I do not know what it is, but I am going with it, I am going to let it unfold. And then later you go, what just happened, how do I make sense of that. That is a beautiful way to do it.
Michelle: You reflect and reflect, and sometimes you bring in a colleague or a different perspective, and with the video it is just so obvious. I am so grateful that will be etched in my brain. The barrel rolling and catching is praxis for me now.
Cory: I love that you danced across the boxes on the SPIRIT there. He started with the perceptual qualities, the colours of the object, then how it was round and could rock, then he moved into ideation, had the plan, executed it, and it became a game.
Michelle: For different children the profiles are a bit different. His sensory discrimination was more robust, so he moved quickly, and he actually did not do it again. He had that one go at rolling, then he was pushing it, and ended up kicking it with his feet. The OT beautifully facilitated him. He leaned over it, and because it was hard it maintained its shape, so it became a roll-over-the-ball thing, getting somatosensory and vestibular input, which was really alerting. So with the support of the therapist, who did a little imitation, he went through five opportunities to use it. On that occasion he did not notice the hole, that it was a crawl-throughable or a throw-throughable, and that it was flat on the bottom, a standupable. It is fascinating how quickly he went through the affordances, and once he did one correctly he actually did not repeat it, as if to say, I did that in a refined way, let me move on to the next thing.
Cory: Is that not mastery drive, so cool? Once they feel something is mastered, they want to master the next thing. It is a constant pull to the next landing pad.
Michelle: His monitoring in executive functioning must have been spot on, because he executed it with precision, it was perfect. It was like, I got that, I do not need to refine the catch or the grading of force, that was embodied, and his drive was curiosity to keep doing it in different ways. Sometimes we just do it again for the coolness sake, even though we got it right, but he was, no, what is next, what is next.
Cory: It sounds like he is really playing out the affordances of a new object, which is developmentally what you see children do. When you present something new that is not obviously this is what it does, they play out the affordances before they play with it in a bigger pretend gestalt. He cannot decide to use it as a cave to hide from a bear before he explores that it is crawl-throughable, a space to get in and out of. Then that could land him in a place where he represents it as a cave.
Michelle: The story is that he has projects. He is in the rolling project now, generalising across, noticing the roundness of an object makes it rollable, so he is on rolling, where the last project was throwable. He is building his classification system, finding all the rollable things, are they soft, hard, bigger. Some kids have to go through the execution of lots of things to classify, where others can make inferences and do not have to roll every single thing they see.
Cory: Is that partly the job of the cerebellum, the generalisation and prediction, the pyramidal cells and predictive piece?
Michelle: You nerd.
Cory: So bottom up might be doing a lot more with the body to feel it, and top down is, I do not have to do it on everything. That is cool.
Michelle: It is worth noting whether they are choosing not to do it because of the motor execution, or because they have got it and it is sitting in executive functions now as an option they can do robustly if they want to.
Cory: Those are the qualities we have to discern and observe in sessions.
Michelle: That was a pearl in the last episode for me, Trace. Cory and I, and lots of us, are trying to wrap our heads around development, and also be sound and precise administrators of the tests. Sometimes you are moving through the administration as quickly and precisely as you can, but you have got to hang on to the fact that administering the test may not take you down the developmental path, finding where the child is at. So you do the administration, then come back the next session and try to land it developmentally where the administration did not let you. That was a really good piece for me, to go back and do the work.
Cory: Oh man, what a joy. Ever learning, we are.
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!