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19. Sensory 'Seekers' - Vestibular Discrimination Part 1

Updated: Mar 24, 2023

"The vestibular system is like the grand integrator and in that it does connect to our sensory systems, it connects to our vagal circuitry. So in that it's connecting to basic regulation functions, our basic physiological functions, but then it also is connecting to our body schema and the envelope of our somatic sensation that holds our sense of our bodies in space connects to the visual system in really direct and specific ways. The auditory system in really direct and specific ways."


TRANSCRIPT

Cory: Yay. Welcome back 2023. We are here. We are very excited to be back, to be having these amazing discussions, to be sharing them with you all. And I think, Michelle, you have our topic for today. What are we, what are we talking about?


Michelle: We are going to talk about, Vestibular integration.

We, in episode 17, heard from Tracy and her experience assisting a beautiful young woman who had some Vestib integration challenges. Her profile was one where she. Uh, avoiding movements. So it had her really trying to limit her experience of the vestibular system really, because she wasn't, making sense for her.

So I, when Tracy was talking about it, I was so into what she was saying. Quite a few things, which we'll dive into, but I then thought of the other end of the spectrum, the other behaviours that we can see when the vestibular system isn't integrated and they're the kids we classically, talk about.

They're on the move. They're on the go. They're seeking movement, you know, can't sit still. So it was the busy kids that I think has a root in lots of things, but the vestibular system. So I kind of wanted to hear about that, that just because we, in the literature after the episode, I went back and had a bit of a dive and it's more common that in The books that we read to talk about vestibular integration when there's a lack of, or avoiding of the movement.

So yeah, I just wanted some clarification around the other side really and what, what that is about.


Cory: I wanted to quickly ask something as well and in relation to this, but I wanted to clarify some, hopefully in relation to this. , I wanted to clarify some language because

Yeah. I know recently we talked about like, well, not we, I didn't, I wasn't there.

The Polyvagal summit - Tracy talked about how we talk about under and over responding. Gosh, that's a tricky thing for my brain today. Anyway, you were saying we really should try not to use those terms. Like at all. And that's just because it doesn't reflect what is really underlying that behaviour, I guess. Is that right, Tracy? I just wanted to talk about that a little bit in relation to the vestibular system and when a child seems to be not registering the information from movement, how do we describe it? What language do we use? How do we talk about this?


Michelle: What's more correct.


Tracy: Yeah, those are big questions I think.


Cory: I'm sorry, haha


Tracy: No, that's all right. So it sort of starts with the beauty and power and importance of the vestibular system and of course, in the Ayres sensory integration work highlighting and putting a lot of clarity on vestibular processing.

is really central to the theory. So we're interested in this, not just because Jean Ayres tells us to be interested in it, but really because if you look at a lot of basic neurological functions, both modulation and discrimination based functions, the vestibular system is a key partner in ensuring. that things actually get integrated.

Mm-hmm. and in some ways, the terminology of sensory integration rings true. The truest because of integration that's vestibular based. And I think that, you know, as we study these things, The vestibular system and the way that it creates a reference point for our postural system, our balance system, the bilaterality and basic functions.

But also, it's really the source of information for all of our spatial functions.


And our spatial functions underlie. Our social functions, they underlie our understanding of language and place and time. They underlie our ability to plan and organize and sequence, and a lot of our higher level cognitive capacities depend on the integrity of that processing.

And then the vestibular. system also, organizes the basic rhythmicities of all of our systems. It sets the suck Swallow breathe synchrony. Mm-hmm. , it organizes our starting and stopping in inhibitory mechanisms and our initiation mechanisms throughout our nervous system. I mean, it does so many things. Mm-hmm.

So when OTs talk about the importance of the vestibular system, it's because there is rarely a child that we would see where the stickiness in their development doesn't, on some level touch into. Vestibular function and the vestibular function as we work on creating true integrity, activation and integration in the vestibular function.

It does have a really critical role in sort of orchestrating developmental progress.


So, you know, it's really an important topic. And some of the terminology and categories are hard to understand for anyone. Even for. Vestibular scientist, which is not what I am but it's hard for people to understand this concept.


Cory: So if you have a child that maybe you've identified that they have challenges integrating the myriad of sensations to actually perform skilled movement or I don't know get dressed in the morning or whatever it is, so that you've identified that have sensory integrative processing challenges.

Then most of the time, I mean, I know that I often am writing challenges with vestibular processing challenges with proprioceptive processing or tactile processing. When I come down to the assessment phase, they're usually key things that I'm writing in most of my reports, and I remember getting to a point being like, am I overseeing this?

Or is this actually like, but I'm like, no, look, the cluster of behaviours reflect this. This is what I'm seeing. But it just seems to be so common. The thing that changes all the time is the individual presentation of the behaviours that reflect the challenges with those underlying systems.

But I just wanted to make sure that I was kind of processing what you were saying, Tracy, in the right way because I feel like what you were saying was that if you can help the myriad of sensations or the sensory systems that we have integrate and organize with the vestibular system in a better way, then that's likely to have improved impact on their function and development.

Like not always, but when you have a vestibular based challenge, which is pretty often in our work. that it's so integral to the other systems that you really wanna make sure that you're able to address it and target it in a way that's, I don't know, correct. Or precise maybe is a better word. Was I, am I getting that right?


Tracy: Yeah, I think so. In some ways you could think about, the vestibular system is like the grand integrator, and in that it does connect to our sensory systems, it connects to our vagal circuitry. So in that it's connecting to basic regulation functions.

our basic physiological functions. But then it also is connecting to our. body schema and the envelope of our, somato sensation that holds our sense of our bodies in space. It connects to the visual system in really direct and specific ways. Mm-hmm. the auditory system in really direct and specific ways, and those systems are relying on the vestibular system

like a compass almost. So if you're out in the world and you're navigating you need a reference point, you need a north star, you need that here I am. And then here's where I'm going. So the touch system uses the vestibular system that way The proprioceptors do. The sound system, the visual system

they all use the vestibular system as that orientation point. And then when they start to address more complex layering of processing, any of those systems, they pull in the partners and the vestibular system helps to keep that all synchronized, if you will? So the synchrony of our systems depends on the Synchrony of the relationship back to vestibular integration.


Cory: Okay. I feel like this is why the work's so hard because we're moving between the, the synchrony of all those systems. and you're trying to figure out which behaviours reflect what underlying potential processing challenges.

Like you have to, you know, do I directly target the vestibular system? But then the functional issue is, I don't know… not being able to reference my social partner in space. And so it's like, right, I can't just target the vestibular system because I need to make sure that it's integrating with the visual system and the auditory system and the postural system so that they can do that function of looking to their social partner or whatever.

So it's like this is the dance that we're trying to do all the time.


Michelle: And also which one's perhaps more robust. Which systems perhaps more robust, that will allow you to start to move into the sensory system that's, Perhaps not. So if the auditory system, like the partners?

Yeah, the partners. So sometimes you can go direct to vestib. Other times it has to be, you know, the auditory system, which then will allow, which is probably a little bit what happened with the lady you worked with previously. Like the music and relationship allowed you to bring in the vest system where other kids, we have the mind that are really, as I mentioned before, that.

Seeking kid. They're in their vestib system. Well, they're activating their vesttib system. They're in it and they're ready for movement. It's not refined and it's not purposeful necessarily, but it's like, oh, okay. You got a lot of vestibular processing activation. That's perhaps not refined. We need maybe some more prop, maybe some more tactile.

Maybe more auditory or refine their ocular motor system to have that to partner with the vestib to make it have a better quality about it.

Cory: So previously, like what Michelle's describing, that child that moves and moves and moves and moves, we might have said that they were under responsive to the vestibular input.

What could we say now that would be better? A better way to describe that?


Tracy: So what I wanna do is I wanna hold us to the distinction between modulation and discrimination. And sometimes it takes a little bit of discerning, it takes a lot of observation. We don't have great tests for some of this, for much of it honestly.

But if you have a child who seems like they're under responsive it could be from a modulation perspective, the leading cause of under responsivity turns out that it's probably not a threshold of response problem. It's more likely that the person is not able to stay in a regulated state to access responding that might be more typical. And the, so the driver of under responding is probably that they're shifted into too much dorsal vagal activation. And so you're getting a shutting off and a shutting down, and people miss that all the time, right? So you can have kids who moving through space is so disorienting to them because of vestibular discrimination problems that as they move through space, they stop processing space because the nervous system says, this is too overwhelming to you and we're gonna shut you down and protect you from having to deal with the complexity of that. So sometimes we think about it, that dorsal response is more of a trauma response, but you know, many and in sort of a odd way, not having enough sensory discrimination of vestibular activation. Creates in your system a lack of enough information to make sense, and so it's gonna keep you from processing normally. So this all gets pretty complicated. And the thing is, is that some of this is a little bit theoretical how I'm describing it to you, because we don't have great ways of testing that.

I think what you would see on different tests is a profile of not just low vestibular activation, which you would see if you could test that person, which may be really hard actuallyBut you may see no duration of nystagmus upon a turning, so a visual reflex that should be produced as you turn and maintain

orientation of the horizontal canal, for instance. That's the most classic way we would do that is yep, have the person in a sitting or standing position, but hold their head in 45 degrees of neck flexion, move them in a really pure rotation, and then when you stop the movement, because of the, of the fluid, maintaining flow.

It should produce a continuation of the eye movements so that's the nystagmus. response that we're looking for. And there are particular ways we can test that. And if you are trained in the SIPT or now the EASI you would learn how to do that but you can also do it from reading the literature because this is a pretty standard thing that is done in ENT and neurology clinics and PT and OT clinics all the time outside of sensory integration. Right. We don't own this. Dr. Ayres didn't invent it. So you would probably see a marker of weakened vestibular response potentially.

You may also see the other core adaptive products that you can test, things like balance would probably be off bilateral rhythmic coordination would probably be off.

Ocular tracking and pursuits and saccadic eye movements would probably be weak. You might even see poor head righting orientation and postural righting responses because those are all mediated by the vestibular apparatus. So when we do clinical observations, even just in play and we notice those things, we would see that profile and it would be a cluster, not one symptom, but many together. And that can lead us to make the conclusion, that this is based in the vestibular processing. So if it's lower, under responsive.

It could be that it's actually weak discrimination, weak vestibular activation and processing. So it isn't really an under response. It's a lack of response and that's a really classic vestibular discrimination problem instead of it being a sensory modulation problem we're cross categorically needing to discipline ourselves to think about this.


Cory: The question I had when you were talking about if potentially they're going slightly more dorsal vagal into a shutdown state and they've got less access to discrimination functions, I wondered if it does that same thing, if they go slightly sympathetically activated into a threat state, cuz I'm assuming that you have impact on processing. Both those directions, is that, would that be correct to presume?


Tracy: right. Yes. For sure.


Cory: Okay. And then that might be why they get such varied performance in their day to day.


Tracy: That's exactly right. That's exactly right. And you know, if the person gets super activated, by movement, and then they might have a little bit of sympathetic activation.

Well, one of the hallmarks of sympathetic activation is an increase in muscle tension and an increase in holding patterns in the sagittal plane and a restriction of movements out of that plane. That will also impact vestibular processing because in the vestibular apparatus, as you move through, space you should have the fluidity and freedom of movement to three dimensionally be able to be aware of the things going on around you. And so if you're moving forward in space, you can scan and track and see, oh, the sidewalk is changing to a step in front of me. I'm gonna change my motor plan and my pacing and my timing to take care of that spatial change. And as I do that, I might notice, oh, there's a rail to the left side of me.

Maybe I'll move in that direction so I can hold onto it if I want. And it gives us freedom of choices and fluidity and coordination and control. But if you're restricted, either because of a modulation isssue or if you're not able to integrate and take in the details of space movement, prediction of gait and proprioception with the movement pattern, that is more discrimination, you're gonna miss all of that

And so we see our kiddos that we're treating. That's what they look like as they move through the world. And then, we may say, oh, every time he gets to the stairs, he grabs on and tap, tap, tap, tap, tap. And smashes his feet. Smashes his feet, and he's proprioceptive seeking... Well, that's probably true because he's pulling in a really viable partner to help with the vestibular function, but the treatment then isn't to give him more prop, it's to address the vestibular problem.

So when we label things through those generalized labels in the modulation, Framework like sensory seeking for instance. And that'll bring us back, Michelle, to your question at the beginning.

Cory: Sorry, .


Tracy: No, that's okay. That's, I love these conversations cuz everything is integrated. But yeah, then you, you end up sort of applying the logic of the treatment of that. Which isn't exactly what the person needs, so Wow. It's hard. That's why we have these conversations. Yeah.​


MUSIC BREAK


Michelle: It's making me think about discerning a behaviour and what might be the root, and you are explaining of some of the clinical signs of the vestibular system and thinking about the polyvagal theory and mobilization. I just put that together that if the vestibular system through some of those clinical tests, Looks robust across a cluster, and it could be explained by a mobilization.

So a more an arousal specific. Issue that's presenting, like all this moving around in the clinic that isn't functional or purposeful. Um, but it's, IM mobilization. And that would explain some kids who flip and flip and flip like they're in that sagittal plane and maybe do. I don't know, racing through space.

And they might do a, some assault, but then it's just racing, racing, racing, running. And they, they don't kind of get fatigued of the run, but it doesn't fill 'em up and they don't get sci, they don't finish that up and go, whew, now I'm ready for you, Michelle . Um, anyway, that was another, that's separate to the modulation discrimination.

It was like, okay, well, mobilization can look like it's on the go too. Thanks Trace.


Cory: But it, it relates to your question Michelle around seeking, which is what we've started with right, was we want the opposite end of this spectrum around the child that has really hard time processing vestibular information and they go into a more of a shutdown, gravitational insecure pattern of behaviour versus the kid that seems to not process vestibular information but goes into the move all the time behaviour. And we were trying to think about the difference between these two. I think that's one thing we have to consider is there's an arousal piece to the movement. Of course, always. But if the arousal is in a certain state..


Michelle: and it could be the arousal that comes first, it's that reticular formation system. For whatever multitude of reasons, but that's driving movement sometimes we do see all the movement, you know, the crashing and the banging and the falling and the chaos that comes with that can lift the arousal, but it's the secondary thing and. The place with which the drive for movement came from.

Oh my goodness. We make it bigger and then we kind of come back in sometimes.


Cory: Well, I was thinking as well then about… how am I gonna talk about this? That's not, like, confusing… If you, you're hypothesizing that it's driving from weakened vestibular processing and they move a lot and that just results in constant movement.

But it doesn't seem to produce an adaptive response. It doesn't seem to allow them to be more adaptive in the task that they're trying to do. Then that makes me wonder about what's the treatment for that versus the child that moves, and it seems to help them learn. Can you guys picture those two kids?

Can we sort of figure out what's the difference there?


Tracy: Yeah. So I think focusing the conversation on that adaptive response and focusing your clinical reasoning on that adaptive response is always a pivot point, right? Around how you get to clarity. So if you have a child who's constantly moving, moving, moving, moving, but the movement itself isn’t

fueling anything that's higher level adaptive. The first question to ask yourself is if I anchor this movement into my best guess of an adaptive function, that they seem like they're missing. What would happen then? And sometimes kids kind of do this themselves because sometimes they're moving, moving, moving, but they're also sort of crashing and seeking lots of proprioceptive input or lots of spatial cues from their environment or something like that.

So if you meet them there and have them get intensity of vestibular play and allow them to have that proprioceptive load really increase at the end of that. But then if you do the math formula, basically of - this adequate vestibular processing plus proprioceptive processing - should equate to beautiful body schema or wonderful spatial reasoning or the foundation of it anyway, or really strong spatial social processing or something like that. And it should give the person a platform of choices. Not like everybody has to have social interaction, but they can have a choice around social interaction. So if you do the math formula, if their brain is getting the right inputs for that math formula, and if at the end of that you don't see anything changing, then you can back up and say, wait, is the input going in, actually the right input going in?

Is it adequate and is it strong enough? And very often what you'll then notice is that the. has one or two patterns of movement, but they aren't actually activating the full vestibular apparatus and they're avoiding parts of it. They don't understand backward space. Or maybe they don't understand what happens when my head is out of a certain position and they may flip and float.

You know, they may flip around, but they aren't actually activating all of the suite of the five partnered, the 10 receptors, and they aren’t pairing that to what is all the possible adaptive functions. So as OTs we're, we're pretty careful to come in and create that precision. And a child can't create that precision on their own, right. Dr. Ayres used to say, if they could treat themselves, they would. Cory, I've heard you say that kids like this. Gosh, they should be like the most coordinated. but it's, they're not


Cory: that was Jean. I got it from her Blue book. She was like, if movement was the thing that allowed neuroplasticity and integration in the brain, then they'd be the most integrated individuals we ever saw.

But the movement itself is not the thing They’ve gotta be able to integrate it and organize it and whatever. So yeah, that wasn't me. That was just me going, Jean, you're amazing.


Tracy: Yeah. So that's really true. But then you also have the kiddo who's seeking, they're moving a lot and they're finding their way in space.

But you see these micro adaptive changes that just refine, refine, refine. And those kids are easier to treat. We treat them faster because the adaptive response is really cooking, and that's why the treatment goes faster. The tricky part for the first kiddo is that we're not getting “for the purpose of what?”

Vestibular activation for what purpose? Movement input for what purpose? It's the adaptive response. That's the cornerstone of the intervention. And if the kid can't activate it and you can't figure out how to get around to activate it, that's where the problem solving has to come.


Michelle: and also that social connectedness because when they're on the go, , I can't keep up even if I try to match them and we do it together in circles and Michelle gets really dizzy, but you know, if you go for it and then try to be with them and then taper, slow it down really playfully, kind of need a bit of a rest.

Get in the road and try to slow them. These kids don't care. Many of them keep going past me and, and don't see it as a real collaborative or together connected activity. Some of them won't even let you in it so that you don't have that social piece. That's the glue. To help to facilitate an adaptive response when they're just doing it for themselves, and you might put a barrel there, or they jump off the loft onto the crash mat and you think, oh, let's load proprioception up even more.

So I'll add a tunnel at the end, and then a mini trampoline that they jump on and then they go up so that you're trying to build that prop input that they might be seeking for themselves. They will often avoid that and cut that out and just go and repeat their things. So not only that, don't they readily accept some pieces that you might be putting into work on the hypothesis “does more prop support this?”, but they don't let you in either to go, “oh, let me co-regulate you, let me add social connection to this piece.”

You know, I find these guys tricky.


Cory: Yeah. I think you just did something really interesting too, Michelle, because many of the partners that we use are sensory based, but of course another partner is the affective system - social engagement, and the point is not to force them to be social. The point is to use that system to help them make sense of the experience.

You know, in a way that feels joyful. And you can tell when it's supportive. You can tell when it's working. You can tell when that's the way in for a child. It's really interesting cause I'm just thinking about this other child that I've worked with in the past, and he was similar to this profile, and I'm thinking about the partners again here.

So when he was in contained space, contained space also had visual references. So visually contained and physically contained. and I guess auditorily contained because he's in the corner, top corner of the room. Right. So spatially the partners around those pieces were reduced, or the demand was not as much for processing [auditory, spatial and visual] information, but also he kind of did this himself.

But when that happened, he no longer flipped. I mean, he was able to do the social when those partners were mitigated in his own way. Like he did that himself and I just followed that lead and then he wanted to do the social. So say that was a situation that you had and you thought you found that they could get really juicy, you could follow their play ideas really clearly. They could be more adaptive in a social way. And it was driven by them when that experience happened. So I'm just wondering, I guess if in treatment that's part of the “Okay. We start with that and then we see where we can expand to and still stay adaptive?”

So how far out into space can we come, or what is that like, I'm just thinking about how you move forward in treatment for that child because he still needs the vestibular piece, but I'm not getting at it when we are still in this contained space.

So… Yeah. I don't know. That's the questions I have.


Tracy: Right. So, so many questions. There's a couple things that are interesting for me right now that I want to comment on. One of them is that a lot of this integration really when it's happening, where things really come together for little developing kids, all of this circuitry just is almost automatic.

It's in the background, it's supportive. It allows for other higher-level skills. When we run into kids where that integration hasn't happened, the vestibular system now has to be an active thought in your mind, just like the social piece and the spatial piece and the language piece, and thinking about the academics or whatever other things you're interested.

And that's also happening in their brain that the automatic stuff is not automatic. And now it is drawing resource from those other things. So sometimes kids will seek, if you will, a containment because it reduces the degrees of intensity that they're having to process. And it frees them up to actually show you a deeper level or higher-level skill that they wanna work on.


We can kind of get stuck treating the vestibular in both directions. We can want to make sure that it's well addressed, but sometimes if we just remove the degrees of freedom and contained it a little bit, the kiddo may show us – “You know what I really wanna work on here is turn taking with you. What I really wanna do is play this pretend game with you. And it's so funny when I hide and then you find me, and I love that hide and seek game, and I'm over here in this corner that is making the world make a lot more sense to me. But now you're bobbing your head around. That Is enough vestibular activation through ocular pursuit that we're getting there.”

And you don't have to do more than that.

For another kid, you may have to do more. So I think part of it is if you map out all of those vestibular functions and think about the really foundational adaptive capacities that they support. And then I think this goes to your question, Michelle, which is something we've talked about before, and I love this about all of us, and that is - that sometimes we have to go a little bit slow to go fast. So when we have a kiddo who's doing these kinds of things that feel to us, far away from that bigger adaptive thing I wanna work on. But if we remember to follow their lead and know that the connection is there between what it is they're working on and that higher capacity that we can stick with them and allow that slower trajectory instead of feeling like we have to create high level adaptation about every little thing that we do. Does that match what you were thinking about ?


Michelle: It, it does. I think what I'm pulling from, from Cory's example of having the container and that, I guess that emphasized other sensory systems that will help the integration of multiple systems. For the kiddo who's in my mind, who is on his fifth week, like I've had different hypothesis about what to do, insert myself in there, you know, I'll be the player the next week. I'll say, okay, let's see. For auditory, if I really amp up the auditory partner and do I insert some music and rhythm, does that help?

The third week, it's like, okay, visuals, let's really mark out the space with room and see if his vestibular system, whether he looks more adaptive when he's got some more [visual] markers to outline space. Does he have less of a need to move? When the sessions can be 40, 45 minutes of 50 minute session and it's run, run, run.

You know, that's where I start to think, oh my gosh, I get a bit like,


Cory: What am I doing?


Michelle: Well, yeah, you get glimmers of more information and there's moments that look more adaptive and I just, that's where you settle into trust the theories and trust the process and know that this is gonna come together perhaps in session.

23, 43, whatever. But, every week if I have a hypothesis and a thing that I'm inching towards, we'll get there. But yeah, so yes, it does Trace


Cory: and they're, the sessions that you work pretty hard to do reflection on and reason around because they're so, “what am I doing?” And I think in that, exactly what Tracy said, you go back to that - understanding the vestibular processing and all of the sensors and their adaptive responses, and then the situation that's in front of you and how you're gonna try to pull in any of those pieces. So whether you, reduce auditory processing of space. Increase the visual markers?

Sometimes we just serendipitously end up landing on something that seems to hit the spot. You get this glimmer into their recipe, right? That moment that I was talking about with that kid, him up on the loft like that. That wasn't a planned thing that I did, but I just had the knowing that that I needed to see where it was gonna go and if it would support him, and then later I was able to break down the math formula.


Michelle: And I think Cory, that comment “is this working for me” was like, am I too scattered here? It was a co-treat session and I was asked to come in to support another therapist. So that's a tension for me - is it working? I'd rather reframe that for myself to go, is it working enough? Right, because I think the child I have in my mind his integration issues were multi-leveled and multi-sensory. So it wasn't that I just had to go harder, you know? Provide more intensity to the vestib system. It was that, oh, I need to find a component of the visual system that allowed you to go with that activity. Auditory I can influence here in this, but it was just, did this help enough so that we creeped towards you being adaptive enough to then creep towards the next thing that allowed you to be a little bit more adaptive. That allowed to be a little bit more adaptive. So it's, did it help enough rather than did it help.


MUSIC BREAK


Tracy: Okay. So in our work, there are lots of moments where have to let it be enough and we have to really trust. then we get to come together and have a just a talk session like this where we get to do that. But we really hope people find those thought partners so you can pause and think it through.

Maybe you make a mind map of say, what is the vestibular function for this kiddo, and what are the partner systems doing how are those resourcing the capacity that I'm interested in. And do some of that thinking because in our assessment tools, you know we don’t have enough of them, but it can also lead you to some questions like “Hmm, have I actually looked at that discriminative function enough?

I’m having trust in vestibular based treatment, but have I vetted for myself that the partner is the right partner, or the strong partern, or that maybe there’s a low duration nystagmus that I can really identify, or may really importantly, there’s a long duration nystagmus. And what’s really important about that is that in the research Dr. Ayres has done and follow up studies that Shelly Muligan in particular has published. There in an indication that with prolonged nystagmus, that some of this treatment may have less efficacy. So it’s also really important to pause and say, do I know enough about what’s happening? To continue to trust that that’s the direction to do And most of the time it’s about discerning the relationship between the integrative partners. So it isn’t just the pure vestibular function.

So if that kid was just crashing and burning and crashing and burning and never letting anybody in and they’re not really aware of themselves of other, we might need to move into the vestibular treatment when they’re ready to participate in a different way.

And so we might have to take a different tactic upfront and then return and revist it. And the vestibular processing can change pretty drastically as the processing overall changes. So if right now they’re not amenable. It doesn’t mean that in six months they wouldn’t be. But maybe in those six months, you’re gonna work a lot more on predictability and start, stop routines and having your prescence be a partner to that child. And when their brain start to say, and they through their interest and engagement, show us they they’re ready to participate on a different level sometimes it shifts then too.

So I don’t think you want to keep playing a record that isn’t working, but at the same time you wanna trust. So I’m kind of giving both messaged. And some of that is to step back do a little more thinking about what is the assessment data that you have to help you understand in you’re on the right path or not. And then remember the power of going slow to go fast.


Cory: I was thinking about what you said earlier in that snippet, which was you gotta come back to the underlying functions and how they create the adaptive responses. Because if I can notice in the way that they move, what components of that are related to the vestibular processing? Then I can start to observe which parts of the vestibular system in the discrimination functions might be the weaker parts. And then I can figure out how to adjust the treatment to address that.

And then again, it just comes back to I really have to know the system. Yes, I can know the pathways and whatever, but I have to know how the input relates to the output [in function]. So if I move the head, how the eyes move, how the proprioceptive system responds, how it changes their processing of themself in space, I have to know all that. But I also have to just be able to identify it in function. So like in play, I need to be able to see when it's not there and when it is there.

Like I'm just thinking about. Maybe just a clear example of sometimes I'll have a kid on a swing and then suddenly their eyes are “whoop” [misaligned]….We got some work to do there! But I don't necessarily go and do the astronaut protocol with that child. But I know that the vestibular ocular reflex is disrupted somehow.

And then that's going to impact on their ability to stay attending to the task, on their ability to use their eyes, on the ease in which they can do things, which many skills relate to those functions, you know? And like you said, if it's not automatic, then they're gonna have to put effort in, then they're gonna get fatigued.

I don't know, I'm not really saying clearly how it would treat that, but I'd be mindful of it. So if I was playing on the swing, and when they were swung in a broader arc or a certain direction and their eyes misaligned, then I would, I'd try to avoid going to the point where the child lost their ocular control.

I try to stay within the range of where they could maintain control and then see if I could grade that out and grade that out, and if they could have an adaptive response around the input. So if the, that's kind of like, I'm not giving an activity here, but that's kind of the principle that I would follow in that example.

I dunno if that brings up examples for you guys or thoughts, but Yeah, my brain went that way.


Michelle:: Oh look, I love it. I think that we need, particularly as we see them in the clin obs in as much as we can do with them, and then we, you know, some of these kids actually resist all of this, or it's not appropriate to do some of these tests with them, so then it's just performance, their function and quality in the context of play and because it's kind of ever changing if we are making little impacts, its that assessment through observation in play is what we are constantly trying to gather and then reassess, take it back to our mind map as Tracy suggested, and then think, oh, okay.

Sometimes….Busy kids, I sometimes can't think fast enough. I might spot it and think, okay, there was an eye thing, you know, something happened there. Note to self, Michelle videoing, particularly with these kids, (makes me dizzy when and when I watch it back) But you sometimes they're so fast and we’re on the [hop], oh wow, how am I gonna make something out of this?

You know, it, it's often the next session. That sometimes we have some inspiration in the moment. Like you might have caught you there to go, oh, I caught that. I'll slow the swing down, sometimes I don't, and it's the next session and it's like, ah. Note to self, look at that again. in Slowmo,


Cory: Or in the reflection itself is when you put the pieces together, and I know we harp on about that, but it actually is really a thing. I was just talking about that child that I was talking about to the both of you that went up on the loft into this contained space and I only now put the pieces together of, oh, like maybe that's why that worked. I followed his lead and we had good treatment, but I guess it's in the reflection process that I can then recreate that with other children in different situations.


Michelle: And otherwise, that activity that he did that was really adaptive is a bit lost on you because when we're in the moment and truly present and we are avoiding getting shot at. Cuz we are the police person and the baddies coming, you know, whatever elaborate thing's going on, we have to be in that.

And so then it's later we get flashes of inspiration sometimes, but other times it's like, what was that about? Why did we even play that game? It looked good, but why?


Cory:I was thinking about as well. early on in my career when it was harder to really pick up those finite little observations that I would just do like four ClinObs At the start of the session, I would do a Tonic lab and I would do standing on one leg with the eyes closed and I would do a Superman and I'd, you know, I'd do a couple of those ClinObs and then I would do my session, and then I'd repeat them again at the end.

And sometimes I'd clearly have a difference between the start and the end of the session just. those clinical observations. And so that was really helpful as well because it was clearly a difference right there in front of me. And the parents also were like, oh, that was better. And that's pretty powerful too.

So sometimes I had to go back to the actual, just do the test because I couldn't actually figure out in the moment to observe exactly what was happening. And like you said, Michelle, it's still hard now because I've gotta be really present if I want to have good effect.


Michelle: You don't wanna be shot Cory! You have to watch the bullets.


Cory: Yeah! Yeah, you have to be in in the moment and you have to be able to match them and meet them and then move them. But yeah, there's a whole moving between thinking clinically and being in the moment. I had this exact experience when I was learning DIR. At the end we have to give, to present your case vignette and what you've learned and I remember talking about feeling like I had an inverse curve of performance. So when I didn't know much about the DIR theory, my treatment was almost better in a way. And the more I learned, kind of the worse I got in my treatment sessions. Cause I was thinking so much and I was just like getting stuck in my head around thinking about all the steps and the developmental ladder and how I was trying to get to the next thing and I, my ability to meet the child got worse.

And then as all that knowledge integrated, I was able to sort of let it go and, and then obviously at the end, you're better off from where you started. But there is that process of learning that makes it tricky. .


Tracy:It is. It is tricky. So when you have questions that you're, you're knowing and you're trusting of the theory.

Is is rubbing you like, Ugh, I don't know if I'm feeling trusting. I don't know if I think I've got it. That's the time to go back to: let me do some observations of this child in a more particular way. Let me put them in a more targeted situation so that I can gather what I need to answer those questions and that process is natural.

We should encourage that process. It's okay to not know and it's, and it's okay to go slow and it's okay to let it be enough of an adaptive response.





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