3. The power of praxis.

In this episode, Cory and Michelle Maunder, alongside Tracy Stackhouse, delve into the complex concept of praxis in pediatric occupational therapy. They discuss a composite case to illustrate praxis and its components of ideation, planning, execution, and monitoring. The conversation also touches upon developmental approaches, clinical reasoning, and the balance between playful exploration and structured intervention in therapy. This episode is a comprehensive exploration aimed at enhancing the understanding of praxis and fostering effective treatment strategies.

Timestamps

00:00 Introduction to Spirited Conversations

00:49 Diving into Praxis

02:05 Case Study: Understanding Praxis

04:57 Exploring the Concept of Praxis

08:54 Challenges in Praxis and Motor Skills

17:04 Assessment and Clinical Observations

32:43 Managing Swings and Obstacle Courses

33:37 Joyful Exploration with the Ball

34:36 Clinical Questions and Theories

36:56 Balancing Playfulness and Precision

40:32 Refining Sensory Systems

44:58 Integrating Theory into Practice

49:23 Encouraging Playful Engagement

53:30 Final Thoughts and Takeaways

Listen in as Tracy helps to make sense of this complicated and incredible concept. Here is the visual used to guide our thinking during this episode and scroll down for the full Transcript:

Transcript

[00:00:00] Cory: Hello. Welcome everybody. Episode three. Um, we are hoping. To be able to dive a little bit into praxis today after our discussion about posture. Um, last episode, we all just went, Oh, can we please talk about praxis? Um, welcome Tracy. We love having you. Good to see you too.

[00:01:08] Hi Cory. Um, I get to see these lovely ladies every week and I love it. So we're going to pull together. Well, I didn't do it, Michelle. You did all the work this time, um, of pulling together a composite case so that we could talk about Praxis in a, I guess, a tangible way. Um, and hopefully that will give everyone who's listening a better sense of this concept, which I even now I'm still trying to wrap my head around the complexity of it because it is really complex.

[00:01:41] And I just wanted to drop a side note in, Michelle and I both. brought our Sensory Integration and the Child, Jean Ayres original blue book today. Um, just in the spirit of wanting to feel connected to Dr. Ayres. So, um, I just thought that was a fun little thing to add. So I'll hand it over to you, Michelle.

[00:02:02] You go for it.

[00:02:03] Michelle: Thanks, Cory. So last week, last episode, when we were talking about posture, the whole time this, um, a couple of kids kept coming to mind because they initially came to us and the biggest challenge was posture. They certainly had issues with praxis as well, but. Posture was where we needed to start.

[00:02:25] So as we progressed through treatment, as we discussed in the first episode, um, we have got, uh, this little kiddo that I'll explain to a point where he's now actually. Um, he's got enough, um, stability and bilateral coordination and, um, interest in playing really physically that he's moving around, um, lots more.

[00:02:53] So, um, his postural challenges haven't resolved, but he's now really in the room and playing with objects with a vibrancy that he didn't have before because posture. didn't really allow him to. So he's much more passive. Um, I can dive into this case a, um, a bit more in a minute though, Tracy, did you want to say anything about Praxis before we start to kind of intro the concept?

[00:03:22] Tracy: Sure. So I think, you know, in the course of this podcast and, and for all of us as clinicians, One of the things that's so beautiful and interesting is how, uh, these issues tend to connect to each other. And one of the journeys that we all have to go on to refine our treatment and to really deepen what we're offering is to disentangle those connected dots and sort out The bits and the parts, basically, and then sort of put them back together.

[00:03:55] So this idea of integration requires us to be able to, to look at that big picture. How is this child, what is his vibrancy? I love the description and I love the energy that you describe him using that, that idea that this kiddo wants to play and he wants to engage and he wants to. accomplish and achieve and, and, and participate and do all of the things of childhood.

[00:04:21] And yet the things that are tricky for him, we can zoom into the bits and the parts. And so, you know, it's very common that we're going to dance across these topics and that kids don't just live in one Concept or one area of difficulty, they often show us difficulties in a, in a way that integrates our thinking.

[00:04:48] And so this guy, you know, early on had some difficulties with posture and now you're seeing more difficulties around praxis. So when we say the word praxis in our sort of air sensory integrative frame of reference, Um, Praxis really is related to the capacity that all of us have to generate novel skillfulness.

[00:05:14] Um, it's, and, and so what is that? Like, you know, anything that we've never done before, whether that be kick a ball or, um, move against gravity or use our hands skillfully as tools or, use our social selves in interaction smoothly. All of those things, the first time we do them, are novel. And that novelty requires so much neural resource to pull from every aspect of our sensory, affect, and motor processing.

[00:05:51] and our cognitive and language processing. And so when we have this concept of praxis, it's really big. So I think, you know, we'll put and throughout this, um, this discussion together today in a spirited way, we're going to kind of refer back to. a visual that gives us a little bit of a roadmap around what is praxis and what are all the bits and parts of praxis.

[00:06:17] And we might not talk about all of the things that are on that visual map, but from an AYRES perspective, Dr. AYRES did two critical things, and then we're going to talk about the case, but I want to, I just want to highlight these two critical things. The first is that there's a sensory discrimination foundation to our ability to have.

[00:06:39] And the second is that praxis kind of works in a process of ideation, planning, and execution. And then we monitor our performance across those different elements. So in the motor learning and dynamic systems theories, we use four parts. Ideation, planning, execution, and monitoring. And Dr. Ayers wrote about the three core parts of that.

[00:07:08] So we'll kind of date us

[00:07:10] Michelle: They align, Tracy. So those theories align somewhat, but they just have a fourth, yeah.

[00:07:16] Tracy: Yeah, they absolutely align. And those are the theories that we're going to draw from. For our evidence base that really creates the structure of how we might approach the intervention. I'm getting really

[00:07:29] Cory: excited because both Michelle and I have signed up for a neurodevelopmental technique like module one, kind of, which is, you know, fun, but also, um, pushing our knowledge around some new stuff.

[00:07:42] Um, but I bought the motor control textbook, um, and have read chapter one. And so when you were talking about. the dynamic systems model. I could now actually visually see it in my mind. Whereas I know when you brought it up in the first episode, I think about how mostly we learn that at university and I was like, Oh man, I did not learn that and was like, couldn't conceive of the idea of what you were talking about.

[00:08:12] And so I was just like, Oh, this is exciting.

[00:08:13] Michelle: Yeah.

[00:08:17] Tracy: That's great. Cool. All right. Well, let's hear about this little, um, wonder that you have in mind and kind of proceed from there. Cause I think when we can picture it, Cory, whether we can picture the concept like a Like the concept of dynamic systems or the concept of ideation, or if we can picture a child, that deepens our clinical reasoning because we, we have to land this in what we know and what we can see and what we can touch and make tangible.

[00:08:47] And we hope this conversation does that for people, that it allows you just to question and wonder about, well, what is that? What is praxis? So, yeah. So let's learn about praxis from the lens of this kiddo. Yes.

[00:09:01] Michelle: Yes. Yes. is, um, that I've put together, is six years, nine months. He, I just get a smile and sit upright and get all giggly even thinking about him.

[00:09:12] He's, um, just delightful. He's full of energy. He has a. big smiley face. He is really clever, um, and he's very social. He has lots of ideas, um, and he's really eager to play. Um, initially, when I first started seeing him, um, he had a lot more rigidity, and so that he was the classic, um, you know, because he had postural challenges, so he would really sit and talk a lot and direct play and we need and had some rigidity.

[00:09:52] So we, he wanted to have a plan and we'd sit and negotiate that at the start. Um, at home, mum and dad, uh, delighting him in the same, for the same reasons, but also, um, these are my words, not his, uh, theirs, say that he's kind of hard work, um, because he lacks organizational skills. He doesn't really get himself together in the morning.

[00:10:18] He's only six years, but he isn't dressing, um, and cleaning his teeth and coming out to get his lunchbox for school, um, as they've got other children. And so they kind of like, you know what, we have to coach him through each step of that early morning routine, which they thought. Um, they might not need to do, um, anymore.

[00:10:42] He gets really rigid after school and so if there's a little change in, um, activity, they've got to go and pick up something, he really, uh, gets emotionally dysregulated and has a big kind of meltdown about that and just wants to go home. Um, My wondering in part that he's tired and really had enough, but it also is this sense of rigidity and predictability that he clings onto, I guess.

[00:11:08] Um, he has siblings and so they, um, he's a source of quite a few fights because he has lots of ideas and lots of rules and he wants things his way and gets pretty frustrated, um, and then kind of cries or wrecks again if it doesn't go his way. I don't really see that in the clinic so much. So I guess that's my observations of a really vibrant boy.

[00:11:37] Um, so when I think about him in the clinic, I'll use your image of the praxis process to guide my thinking of his presentation in the clinic in much more detail. Starting with ideation. As I mentioned, I think he looks much stronger in this area. I haven't done the string. Uh, tests from Theresa May Benson, but he generates lots of ideas with little objects right through to, um, ideas and schemas for play.

[00:12:07] I say he's got great initiation. If anything, he's too fast. He's too on the ready to dive into things. And that's what I think causes errors. Uh, so it's. Having the idea, but pausing before the motor action component. Uh, I'm not sure if the imitation sits in here, uh, but the simple test of gestural praxis, he's okay on that.

[00:12:30] He's lacking some precision, um, in, uh, the, precise location of his body tied with, you know, the tactile probe systems as, as what I'm asking him to do increases in complexity. Uh, the second component is planning. I think he's really restricted in this sequencing component. Um, in planning, right through from his movement actions through to the, you know, a number of tasks that make up a complex, complex activities such as getting dressed in the morning, which we can see in play, but, and at home, but we can also see in clinical observations such as a sequential finger touching, alternating forearm rotation, copying clap, clapping patterns.

[00:13:19] Um, doing skipping. So he's really just not getting, um, the sequence of the movements right, right through to adding the tasks, um,

[00:13:36] The third component, uh, that we're looking at is execution. So, motorically, this is really restricting him a lot as well. When I look at the clinical observations of tasks such as finger to nose, uh, finger, sequential finger touching, um, as all, and also in play, so things like drumming, um, and swinging, his timing and rhythmicity is really out.

[00:14:02] Uh, his movements, uh, show much more ballistic and jerky rather than that smooth control of movements. He's also not grading force well either. He tends to be much too hard. Um, so adding that with the sequencing component, we're just seeing really ballistic, um, movements that lack that precision fluidity.

[00:14:28] So he looks quite refined. Uh, when I think of body scheme and body awareness in space, it's improving, um, but it's still emerging when he moves to bigger spaces. So in the clinic, he, uh, if we're in just a little, um, section of the clinic, he looks quite contained and moves more precisely and is really aware of.

[00:14:51] Um, his body position, uh, in relation to objects and me and within that space. But when we move to the whole gym space, uh, he loses that and he can bump into things and kind of stumble over mats, um, and, uh, other items there. With simple feedback, he's much better than complex feedforward required to do things like kicking a moving ball.

[00:15:18] His bilateral integration is really reduced with left right, um, not being discerned well or, or working cooperatively well. But also his upper limb and lower limb, he's really dominant in the upper limb. So when we're doing things like running, walking up a ramp, for example, you You're seeing him really trying to climb up the ramp with his upper limb without much flexion and activation through those feet and toes.

[00:15:46] So lastly, uh, is monitoring. Um, when he's doing more sedentary tasks and he's much more cognitive, then he presents Um, with this as a real strength, I think he can problem solve quite well, um, with my assistance. But when he's moving, so once he's in action, and I guess the, um, which is in his strength and the, um, demands of the tasks is more complicated for him or taxing for him.

[00:16:18] Uh, this monitoring aspect really regresses and he just then is going with the flow. Well, not even going with the flow, but looking much more, um, reactive to the environment rather than, um, purposefully moving, you know, and completing a task and monitoring his progress in that task. He's got an adaptive strategy though, of changing the rules.

[00:16:40] And so that. is a source of great frustration for everybody because instead of monitoring and going back and improving and adjusting, he just makes the rules different to suit his new, you know, he's not perfect, um, action. So as I mentioned, I haven't conducted a formal assessment, um, of him recently to gain more data.

[00:17:01] These are just my observations through play.

[00:17:04] Cory: Well, I was actually thinking, Michelle, because we, I was thinking about this the other day actually, was sometimes, um, I feel like if I'm in a session, I'm looking at a kid and I'm like, Oh, that looks. Um, something about that is, is, is not coming, coming together like either it, and, and sometimes I'm not a hundred percent sure how to pick out the piece that's not coming together.

[00:17:29] And because I do know that praxis falls into these three categories, right, of, of the ideation part, and then the actual plan that the brain has to put together in the moment and then actually right before it happens and then execute that plan. Um, and then of course in that. dynamic systems theory, evaluate whether it worked, right?

[00:17:52] So, but sometimes when I'm looking at a kid in a session, I'm not a hundred percent sure how to figure out which element isn't coming together. So, and, um, that can be a little bit tricky. So I, I had a genuine question around how, like, how do we best observe or even assess practice? If, if you don't have the SIPT, or if you're not SIPT trained, um, what are some really great ways we can start to even find out a bit about.

[00:18:20] praxis for a child. Does that, I don't know, apart from being like, they look clumsy, you know, cause it's really broad.

[00:18:28] Tracy: It is really broad, but it's interesting. Um, so I want to talk about the assessment, but I kind of want to talk about this word clumsy for a minute because, you know, before there was ever, um, uh, A dyspraxia, a description from an heirs perspective or even in, um, the lens of coordination or a developmental coordination disorder, Dr.

[00:18:54] Gbe, who wrote way back in the 1960s, and, um, he, he. talked about this thing called the clumsy child syndrome. And interestingly, you know, Dr. Ayers was able to really take that notion of seeing when kids were struggling with basic coordination, and they looked like things that should come easily to them, things that should, um, Be smooth and accurate and fluid when you are missing those qualities that there's often an underlying reason that that that's present.

[00:19:33] And so whenever, you know, we hear about a child who has It's a struggle with coordination or clumsiness. It makes us wonder, like, why, what is that? What is that? Because really, on very many levels as human beings and as kind of animals on this planet, we're meant to be movers. We're meant to be smooth operators and really efficient at that

[00:20:00] Michelle: for our survival, Trace.

[00:20:01] Like we, if we were falling over when the lion was coming for us,

[00:20:05] Cory: no more, Michelle. Goodbye,

[00:20:07] Michelle: Michelle.

[00:20:08] Tracy: Or distracted when the line was

[00:20:10] Cory: coming.

[00:20:11] Tracy: That's exactly right. And then, not only that, are we meant to be movers so that we're efficient and fluid in our environment, but so that we can creatively engage with the things that we encounter.

[00:20:24] If we come across. that's climbable, we want to climb it. If we come across something that is pick up able, we want to pick it up. If we come across something that's put able or place able, we want to make that and finesse that. And we're, we're kind of driven to, um, create. and to use, um, what we can do with the thing that's out there to be operated on.

[00:20:53] And so there's this interaction that happens between our body and what we're capable of doing or the affordance we bring to that action. And then we interact with the bits out there in the world, the environment out there. Um, because children that have sensory integrative processing issues struggle with anti gravity control, with with those basic actions, like what is it to be a kicker if it's hard for you to pick up one foot and move it in space separate from the other foot, or what happens if you understand that throwing means From here to there.

[00:21:34] So you kind of get space, but but if that space is confusing to you, you might not organize it well, you might not get that. Um, you know, the ball is supposed to go up, but up means all the way to the stars instead of just a little bit of up. So we start to see this lack of smoothness, This lack of grading, this lack of control that is often in the execution part of, of that formula.

[00:22:06] But sometimes it's related back and as you were talking about this little one, Michelle, you talked a lot about how he struggles with sequencing, like in the morning with his dressing routine, for instance. Um, So sequencing is part of planning and a lot of times when we see kids who have these difficulties, we're going to see it break down in sequencing.

[00:22:33] So really, Can I jump in? Trace? Yeah, please.

[00:22:36] Michelle: So there's a relationship between sequencing, um, Uh, I think Theresa May Benson has this in a text of hers, the sequencing of even neurons to muscles to tasks to, you know, across all of the day. So I can relate, or we can relate, listeners can relate. Um, difficulty organize or sequencing, um, tasks like getting dressed in the morning may have relationship to him sequencing, um, throwing of the ball, uh, watching it and then kicking it, for example, in the kicking thing.

[00:23:15] So that it might extend beyond just muscles, tasks, activities, um, across his

[00:23:24] Cory: day, right. So I think I got a little bit lost there. So were you saying Theresa May Benson is linking a neural process of how the message gets sent to, from the brain to the muscle to then activate, like the sequence of one neuron to the next, to the muscle, to the muscle activating, do you mean that process?

[00:23:46] To then make the muscle move is a, is a neural process of sequencing. And then that relates to the ability to actually sequence actions in the right order, as in actions of my body. So if I go to walk, I can't put both feet forward at the same time. Like, I have to sequence one foot and then the other. I know walking is much more automatic function, but even if I go to pick up a cup, like, I have to activate certain things before I activate others, otherwise I'm not going to, I'm going to miss the cup or I'm going to fall over before I even get to reach the cup or.

[00:24:20] And then when you can do that. Yeah. So then if I can sequence my body in those, those little actions, then I can start to sequence bigger, complex, more complex plans. Or like even across time. Is that what you mean? Like as in now I can sequence my, I need to get dressed before I go out to the kitchen. Okay.

[00:24:37] Cool. Yeah.

[00:24:38] Tracy: That is so spot on.

[00:24:44] So, you know, let's go back and talk a little bit about the assessment bit. Um, there are standardized assessments that we can look at to, um, ascertain the qualities of praxis in that process in ideation, planning, execution. But there are also, there's always an invitation to do clinical observations of that and to listen to stories from parents.

[00:25:11] to inquire about daily life function related to each of those elements. And really at the end of the day, clinical reasoning is critically important because any assessment that you do, the numbers are not going to tell you. Exactly what's going on in terms of the underlying integrative process that always takes your skillful observation and your ability to Interpret the information back and to use the theory to help you make that Interpretation and then to create the treatment plan.

[00:25:49] So when we're looking at At Praxis, just from a, you know, assessment perspective, we, we do want to discern ideational skills. Teresa Mae Benson, who we mentioned earlier, she has, you know, a couple of tools that we can use to look at ideation. The things with string, task, is the one that I probably use the most, but, um, there are other tools.

[00:26:13] tests like that in neuropsychology literature as well. Um, generativity tasks and a number of other things. The, the base of that though is really understanding affordances and we could just do like, you know, I don't know if we will do a whole episode on, on affordances, but it's a really amazing topic for us to dive into.

[00:26:35] Um, and so we want to understand the affordances that, you know, of the child's. system and how they interact with objects out in the world. And so that's going to come really from observation. We want to understand how they generate ideas, how they select schemas, how they match that to the context around them.

[00:26:57] So ideation itself is pretty complicated. And then we move into that, that planning bit, the sequencing bit. And when we were just talking about sequencing, you know, there is a truth to, um, the neural process of sequencing and the daily process of sequencing and that there's a relationship between them, but it isn't really a causal relationship.

[00:27:21] So when a child is It's struggling with sequencing like finger thumb touching, for instance, um, touch your index finger, touch your middle finger, that, that's an underlying sequential process that's cerebellar in nature, um, that is really based in somatosensory awareness, our body awareness, that body schema, that Clear body map that gives you precision, and that's the sensory discrimination underpinning.

[00:27:53] So if we watch something like finger, you know, thumb, finger touching tasks, we're getting both the quality and rhythmicity and timing. Those are motor execution parts, but we can also observe that sensory discrimination underpinning of awareness. So those are things that you're always going to be, um, both observing for a formal assessment and evaluation, but ongoing in every session, you really have to make those observations to fine tune what is it that the child's struggling with and why is that so hard for them.

[00:28:34] So you're going to be looking at those motor planning. You know, sequential schema selection, how they transition from, through the sequence, through the flow, and then into the, the grading and timing and execution. And then what happens when they make a mistake? Um, lots of times when our kids are not very coordinated.

[00:28:55] They, they make a lot of kind of little errors in their actions and sometimes they're not even aware of it. They, you know, kick the ball too hard or too far or too soft and they don't really even know that that's an error or how to correct it. So, your observation And your formal assessment are always partners in trying to sort out what's going on, and then trying to tie it back to that sensory processing underpinning, which in most, most cases for a child with dyspraxia, it's related back to that sensory discrimination.

[00:29:35] So having said all of that, Michelle, what does that bring up for you in terms of both what you know about this little one from your assessment, and then also, your clinical questions about, about treatment and what you do next. Yeah. Look,

[00:29:50] Michelle: it brings up heaps. And I guess, um, at the moment, while he has made some great gains, um, he still does present with, um, sensory processing difficulties, specifically proprioceptive, um, vestibular, uh, and the tactile.

[00:30:09] Uh, interestingly, when I did clinical observations, um, he's, um, eye function, um, visual function. It was his convergence and divergence that was most affected. He did have some skipping over the midline, um, three out of 10 times, for example. So we certainly saw some, you know, issues crossing midline, um, uh, which, uh, but it was, I think, the convergence, divergence that is impacting his spatial, uh, awareness, his ability to kind of look.

[00:30:42] close and then, you know, zoom back out to see the bigger world. So that spatially is where he's at. So, um, definitely there's still some process, uh, sensory processing challenges. Um, um, what I'm also seeing is this pattern, um, of, um, lots of ideas with a lot of, not a, not a lot of monitoring. And I, um, He's an energetic boy.

[00:31:09] Um, so I, look, I've got some questions about his attention and I guess inhibition as well. So that when he has an idea, um, uh, he, Instead of really working hard to make it succeed, he flips on to the next one. So while generating all those ideas is a real strength for him, particularly when he wasn't moving around so much, um, uh, it is actually restricting him now because you don't see him keep sticking at something and, and, you know, trying to improve that, um, um, as readily as he does other things on

[00:31:48] Cory: his own.

[00:31:49] Does that come back to that posture? So I'm just wondering about, you know, cause you were saying when he's sitting seems to be more generative in terms of ideas, but once he's up and moving, he's, um, like then a lot more impulsive looking. Yeah. I mean, I, I, we definitely talked about posture, but does that sort of Do you feel like that comes back to some of that postural stability?

[00:32:10] Michelle: I think it's in part all of it. It's the postural stability. It's the spatial component to it. I think, um, so this one little example is that, um, We have done lots of work, um, with, uh, the STIB import, um, to improve posture. Uh, so he's used to swings and he can now pump a swing on his own. And we've done lots of, you know, a smaller glider, a larger platform swing, a very big, um, what do you call that thing?

[00:32:42] Oh, it's glider, I guess. It's a big So he can now, um, manage all of those swings and I can make challenges up where he has to stand on it and go sideways, for example. So I think when he's with the, um, he's got a little bit of constraint so that we're working with swings or we're working with an obstacle course, he's got some containment and he looks better.

[00:33:08] Um, the, there was a. Uh, time where we were doing some, um, a ball was in the room and he just happened to, um, a roll it to him and he jumped it and then he, well, he tried to jump it and then he decided to kick it. And then, you know, within moments he had it in the air and then it was. trying to kick it. And then at one stage you look like he was trying to kick it with two feet and then it went near the wall and it bounced up the ramp.

[00:33:34] So then he ran up the ramp trying to kick it up the ramp. And so it was just this, I just was watching because lots of things, which I guess is the crux of the questions I want to ask you, Tracy, is that he was so joyful. He was internally motivated. Um, it looked like it was the first time he was exploring an object with his feet or the ball with his feet.

[00:33:59] And he was running through all of the opportunities. Um, and he just was like a kid in a candy store, really like, Oh my God, I could do this. Oh, there's a ramp. And I could do that. And I could do this. None of them from my perspective. Expected. Was successful. He didn't land. And so it was like, Hey, what are you doing there?

[00:34:18] Cory: And

[00:34:19] Michelle: he really did two things didn't engage with me, which he's so social and usually he wants me to be his play partner. So he's really truly in his own little world and he wasn't doing it to master. So in some aspects it was just joyful, explorative play. And I guess my questions, um The clinical questions are Tracy is, yes, I need to keep working on his sensory processing, those specific components of it.

[00:34:48] Um, I guess looking at a dynamic, uh, motor theory is looking at the need for repetition, um, and then some variation. And then I guess the other theory that we work with with children is looking at play and, and, you know, as, Um, internal motivation and the just right challenge and, you know, me, and I guess that's my wondering because at the moment it's not adaptive, but it is he at that really early stages of having found some posture and, and enough, um, uh, spatial awareness enough body scheme.

[00:35:25] Um, and that he now picks up a ball and is he in this joyful. a really emergent stage of, ah, I could do all of these things. And in my mind, there's no mastery, but is that yet to come? And that this is just

[00:35:40] Cory: joyful exploration. Or do we have to be really mindful as, as the therapist to figure out how we're going to create that refinement mastery.

[00:35:48] If it continues to look like super clumsy or, you know, then it's like, okay, how, how do I get that to be? Um, looking more efficient, more adaptive. So that without

[00:36:01] Michelle: getting too cognizant to be like, Hey, if you want to play ball, let's play soccer. You do this. And first let's start with, I roll you the ball and you stop it with your foot.

[00:36:11] Like that boring. Yeah. Yeah. He won't. He didn't want to. He actually ignored me when I did suggest that.

[00:36:19] Cory: And I think I go to Cognitive a lot of the time anyway, when I'm trying to do practice in them. You know, I'm like, get in the middle of the swing and I'm tapping the middle of the swing. They don't know where the middle of the swing is and I'm like, put your head here and put your feet there.

[00:36:32] And I'm like, Oh man, there's, I probably should be doing something else, you know, but sometimes you catch yourself and going, Oh gosh, they just, they don't have the underlying concept of the middle.

[00:36:43] Michelle: Like

[00:36:44] Cory: You know, just

[00:36:45] Michelle: peel it back. So I've got heaps of, you know, more, um, specific clean obs, um, trace, but anyway, what do you think?

[00:36:54] Yeah. I'll throw to you.

[00:36:55] Tracy: Yeah. I, well, you know, so I love the way that you're, um, describing his. attempts at playfulness and how asynchronous development is, right? Especially with our kids that have struggled with their development. So if this little boy was not six years old, let's say that, um, he's 16 months old and his play would have looked joyful and robust and so interesting to us.

[00:37:24] Like, look what he's doing. He's kicking the ball. He's slinging the ball. He's putting it up. He's putting it down. And that early affordance based play is so clever. But by the time you're six, we think about how all of that should be being strung together into logical sequences that turn into something more, but the journey to get there is that you joyfully explore.

[00:37:50] Michelle: So he's at where he's at. He's at that level of development that he's got stability and he's got some mobility and now I'm joyfully exploring.

[00:37:59] Tracy: Totally. And then, you know, through, um, imitation is such an underpinning for praxis, but kids don't want to imitate if they're exploring their own ideas and their own affordances and their own interactions with object.

[00:38:15] And so when we try to put too many constraints on that, we can. we can take away the joyfulness. And yet, what you want is to scaffold some level of sequence that makes interesting sense to him. So, you know, in a session that is unbounded, let me kick it here and kick it there and kick it everywhere. When he starts to show curiosity, like, how do I make that happen again?

[00:38:44] Or how do I get more precise? Or how do I make that be about a you and a me game instead of a just a me game? Then you start to build towards something. But if you impose it, you tip the balance of playfulness away from him and toward you. And then that sort of doesn't allow him to continue to be an agent in that experience.

[00:39:08] So it's really a balance. And

[00:39:10] Michelle: intuitively, I really haven't ever seen him play like that before, individually, without me. Like everything has been pretty, um, planned and with me and, you know, let's do this together and then I'll, you know, interrupt that and help him. Be flexible. You know, so this, um, has just caught me and stay with me because it was like he was playing differently for the first time.

[00:39:39] Tracy: Yeah. I love that. So, you know, the thing that's interesting is that each of the elements of praxis in and of themselves have a developmental story to them. And that's why it's so complicated to treat because you have to really observe on all those levels. Mm hmm. And you do want to allow him to explore and play, and you also know that with just a tiny bit more precision or just a tiny bit more goal directedness, that maybe that would sync up a little bit more quickly for him.

[00:40:14] And so you're going to be infusing that Um, you know, that guidance for him, but not imposing it. So it's kind of that, it's really a fine line, and I think it's really fun for us to try to talk about it, and also hard to define. I

[00:40:32] Michelle: want to dive in, I know that he needs more precision in, um, vestibular system, proprioceptive system, tactile, and probably visual as well.

[00:40:44] So, I. Absolutely no, I need to keep going there. Um, uh, um, so we'll, and I do need to look at the monitoring and problem solving and, you know, that component. But if, um, and then if I work on them, During play, I guess, and then, um, bring it together in a game that he's interested in, which at the moment is the ball, and then try to still allow him to joyfully play with the ball.

[00:41:15] So I'm not going to make soccer the game, but you know, just, it's the key, was the key

[00:41:20] Cory: point. curiosity opening, the window of curiosity for him of, Ooh, how could I actually get this to go up there? Rather than just kicking the ball. Is that the key point that when that, that is that when you start to. embed the, the, the more goal directedness or the more like, was that the key point?

[00:41:45] Was that, because I'm trying to distinguish between in my head when I'm observing a child, I'm trying to distinguish between is this playful exploration and I can just let this unfold because it hasn't happened before. And wow, you like, this looks really funky for a six year old, but. This would look great for an 18 month old and this is where, yeah, this is where you're at.

[00:42:07] But now I need that cue for me as a therapist to go, when can I now go, Oh, you're opening this up now for me to be able to help refine this. And it's, it sounded like it was the window of like more planfulness around. Okay. Now I actually, cause it sounds like he didn't have a plan at all. It was just like kick the ball, blah, blah, blah, you know, whatever.

[00:42:30] So as soon as he wanted to actually don't even

[00:42:31] Michelle: know that he had a plan going in. that each time the ball moved in a different way, he had a new idea and that's his asset, but I think that's what's tricky for him because the plan kept changing. And, um, because he's not fully in his body yet from a proprioceptive perspective and probably tactilely, and he's not.

[00:42:54] In the room fully from a visual spatial perspective. I think it was a, it wasn't reactive, but he was behind the eight ball. It wasn't a two feet forward.

[00:43:07] Tracy: That's exactly right. So he's kind of behind the eight ball because he doesn't quite have capacity to offer back to the play a little higher level skill.

[00:43:18] And so it happens at this lower level because that's kind of where he's cooking. But what's interesting is um He's he's so keen to play and kids like this will be so eager to play that what you're looking for is when he wants to repeat something with a little bit more like I want to do that again, or I want to refine that a little bit that that's really your window in and you can You can start to, um, then model and demonstrate and build through imitation for him.

[00:43:53] Oh, when you kick it up there and then it falls down here, watch what happens next. And then you can kind of woo him into creating a little sequence. And then the sequence, when it When he wants to repeat it instead of just randomly be pell mell and do whatever, then you're going to start to be able to build something, but you can't really force that.

[00:44:15] I mean, you can train it if you decide to take that treatment approach. It doesn't generalize well. Um, and so I wouldn't. necessarily encourage that, but there's a pull we have like, come on, just put it in the bucket or put it up here or make the target or do the soccer or whatever, but allowing for play and then looking for refining around the discrimination elements that support it really and and letting him be that agent of his own change is really powerful and it's also requires us to trust our theories so very much.

[00:44:53] Love

[00:44:57] Cory: that Tracy. And I, I genuinely do find the theories behind these concepts just incredibly helpful because they can help you make hypotheses. Uh, hypotheses about what might be going on and go about testing that and trying to figure out how to treat it. But sometimes you'll have the theory and you'll sort of be aware of the concepts, but you're still struggling to translate that into what do I do in this moment in, in my treatment session?

[00:45:28] Like, how do I then pull that into a, operable thing that I can use to help shift the function. So, I mean, I don't know what you guys think about how you go about even just starting to think about treating practice, practice. Yeah. Like do you guys have any thoughts about which way you start doing that?

[00:45:47] Tracy: So from an AYRES perspective and really neurologically from a dynamic systems perspective, you know, you can start in.

[00:45:56] In the direction of the base of the sensory motor functions, or you can start in the direction of the end point, which is more the playfulness and his zesty sense of exuberant stuff that he brings to the world. Um, and really you're going to be working in both directions. And so in your treatment planning.

[00:46:16] Uh, we do want to bring about that discriminative precision. We know that that's going to synchronize things for him and sync it up and that that's a missing element. So anywhere we get a chance to start to infuse some of that, but again, without taking away from his playfulness. So it's, it's really a fine balance in, in terms of that.

[00:46:38] And then, Michelle, you really, you know, uh, observed in him that it is across these basic sensory systems that he is missing some of the foundational bits. And so you're going to have to continue to work on infusing opportunities to refine vestibular processing, refine, The bilaterality, even though it's gotten better, it's still not where it needs to be.

[00:47:04] And, you know, in the recent Sensory Integration Theory and Praxis textbook, they talk a lot about how the somatosensory system and the bilateral systems are sort of continuous in terms of their support of the praxis function. And this little guy is really demonstrating that to us. So we really want to think about bilaterality and the vestibular base.

[00:47:29] We want to think about the body base, the body awareness and body schema, refining his control around that. His, uh, his basic awareness of space and timing. So those are things that, you know, theoretically are rich. I think in the treatment session, what I like to do is just really be present with the child and let them play and see what they're doing and then try to bring in those.

[00:47:52] bits to it, but not in a forced way, in a partnered, playful way. Um, and so I think that's what you both do so exquisitely anyway. And it's always the journey that we're on is to build our playfulness and in the present moment. And, and really what's so tricky about these complicated, beautiful kids we treat is the clinical reasoning is so heady, but the treatment requires us to be present.

[00:48:20] And so you're always having to kind of maybe do that thinking, um, not so much in the moment. Um, and just be present with him and see what you can add. And then think later, um, how could I have made that a little bit more proprioceptive? How could I add in a more discriminative element in terms of space?

[00:48:41] So maybe we take, you know, visual cues like pool noodles and put them at spots so that he's starting to target or aim, but not requiring that, but just giving. Boundaries and configuration and detail for him to pick up on. It's like amping it up a bit.

[00:49:01] Cory: Instead of like making it a requirement, but being like, Ooh, there's something over there.

[00:49:05] Let's see if we could hit that or, and, and drag and pull him into that drive to want to then try that too. And as long as I genuinely delight

[00:49:14] Michelle: in that, he's so ready to play that it's like, Oh yeah, great idea. Michelle.

[00:49:20] Cory: Mighty nice. When you're talking about. That clinical reasoning part being quite heady, like get in your head.

[00:49:26] I, I, it made me flash back to when I was first learning the DIR model and, and my final case vignette presenting this graph of like my skill and. Not knowing much and feeling like I was much in much more able to get a flow and then learning more and feeling like my flow dropped way down because I was thinking so much about all the concepts and then finally letting it settle in and feeling like I could pick back up into her being able to.

[00:49:57] get this flow again. So it felt like learning a new concept sometimes interrupted my ability to be present and have a flow because I was thinking so much. Then sometimes once I then let that integrate into my own knowledge, then I can then go back to being able to say present and pull things in, in the moment.

[00:50:16] So it just made me think of that, that process.

[00:50:21] Tracy: What's so true is that that's development for us, like that happens for us. And the same thing is happening for the kids in this session, right? So if you, if you push too hard in any one direction, you're going to get them to feel a little. like they're taxed and that this, I'm losing my play and I'm losing my, my Jewish here.

[00:50:42] Um, and so the, and that, that happens, okay, that's all right. And then we come back and re refine and all of that. So anyway, what an interesting way for us to jump into talking about praxis. I think that air theory is so rich and the primary source to draw from for this. Um, and really, even though there are, um, you know, some top down treatment approaches that we didn't talk about at all in this particular episode, that people sometimes approach, um, Praxis from, really, there is It's such a good evidence base for using an AYRES approach, and her model beautifully fits um, the developmental needs of this, this little person you've talked to us about today, Michelle.

[00:51:29] So, I really, um, think that study of, of the, the core theory of AYRES sensory integration, it's just fuel for us as pediatric OTs, and I, I, yeah, I know it is for you guys too. And look,

[00:51:43] Michelle: it absolutely is, and it fits, um, intuitively from where he's at in this emerging play skills as well. And the idea of following the child's lead and him being really active, um, and you know, not, not passively sitting down and talking down the plan that he's actively engaged in it.

[00:52:04] And that I just need to playfully set that, I, you know, think really hard out of session, but construct, you know, some more, um, Boundaries, I guess. Not boundaries. Amplify. Amplify. Some pieces of it so that you can be more

[00:52:20] Cory: planful. And

[00:52:21] Michelle: then kind of let it roll on at the time really playfully. And you do a good job of that anyway.

[00:52:26] Yeah,

[00:52:27] Cory: it's just helpful to refine it. And I think, Tracy, I mean I've heard you talk about the top down approaches to practice a lot. And they're fantastic when they're ready to be, when you need them. They're wonderful, you know. I guess what you were saying before, it's like, it's It makes sense to me that you would use a combination of things because the brain is so complex.

[00:52:50] You would never just use one. You would never just use top down in terms of the, because the brain is not just a, just a cortex. So I guess, you know, you would pull all the pieces together and try to get the brain to integrate.

[00:53:03] Michelle: And for my little kiddo. That's where he's been living already in his, you know, he's thought he's, he's had to think play where now it's like his body's doing it and he is joy, really, truly joyful in the action, the motor execution of it, even though it's clunky.

[00:53:20] So it just intuitively feels like it will help him and I need to get to it, but it's not where I want to start with him quite at the moment. Um, Awesome. Awesome. So did we want to, um, encourage listeners to have a think about, uh, Praxis? Yeah. Yeah. I just

[00:53:38] Cory: think, yeah, that if you start to think about the concepts, cause I didn't personally, Tracy, know anything about Dr.

[00:53:46] Ayers model of Praxis until I met you. I only knew about co op or Um, some of the top down queuing models for helping kids learn, learn a skill. So even if people are just introduced to the possibility that there is multiple ways of looking at this and it's complex and that you don't, you can have, I guess.

[00:54:13] ways of treating it that aren't just cognitive based, and you can use multiple ways of getting at this, then that's, I would encourage them to do that.

[00:54:23] Tracy: Yeah, absolutely. And when this little guy says, you know, to you through his affect, through his words, through his action, I want to do that again. And he identifies the goal and he, You know, is more in is more purposeful about that.

[00:54:39] Then you can do goal plan, do review with it. You can say, you want to kick it up there? Really? Let's try it. What happens? And you can start to infuse that. And Dr. Ayers did that in her treatment all the time. But if he doesn't have the playfulness and the somatosensory awareness and the um, discriminative ability to even be able to begin, then that doesn't really help him to solidify this skill in the long term.

[00:55:08] So integration is always about both, and our journey is always about both, but it's that fine tuning of. Of the when, and you know, the way we get there is through these kinds of conversations with ourselves, with our colleagues, because it isn't just straightforward and there isn't a formula or a recipe.

[00:55:28] Um, the evidence base is rich and strong and clear, but it isn't formulaic. And that I think is one of the things that makes it. Amazing and also really challenging for us as the professionals, um, but we can clearly identify it, assess it, create a clear treatment plan and march kids forward over and over and over again because these theories really work.

[00:55:55] So what a cool thing. Um, and we'll, we'll provide some really wonderful resources in the show notes, some readings and some direction to go. Um, and hope that. Praxis Fire kind of gets caught by some of the listeners because it's a really powerful topic and a life changing topic for for kids all over the world.

[00:56:18] All

[00:56:24] Michelle: right, so we'll share our key takeaways now. I guess mine was Uh, is feeling really comfortable that I can continue to, um, work from watching, um, from as, uh, um, constructive watch following the child's lead and really allowing, um, this little kiddo continue to play and explore and just being on the ready, having all of this, um, the process, the theory, uh, in the ready.

[00:56:54] So when I receive So, as you can see, the invitation, um, then I'm ready to kind of add, uh, elements to this to support his monitoring, to support, you know, his posture, his spatial awareness, all those elements that, uh, are weaker for him, um, in just the right way that allows him to look for and feel more masterful with the activity that he's choosing.

[00:57:17] Yeah. Yeah. Beautiful

[00:57:17] Cory: takeaway. That's, I, I like that one. I think I personally, I guess the big thing that I thought about for me in this discussion was the fact that I hadn't been exposed to this theory or this way of potentially viewing this construct of praxis and treating it, um, in a different way from The strategies that I had been using until I met Tracy.

[00:57:41] And so I would encourage people to think about who they can go to, to have these conversations about Praxis and where they can try and start integrating some of this information into what they're already doing and start to just start to understand what the possibilities are in this way of treating.

[00:58:01] So go and find people that if you can go and find people you can have these conversations about Praxis with. What about you, Trace? Awesome.

[00:58:07] Tracy: Awesome. Awesome. Yeah, I think for me, a takeaway, and maybe it's in different words than what we said actually earlier in the episode, but, um, you know, children who struggle with coordination, clumsy, you know, kids who have a clumsy profile, they don't outgrow it, uh, and they, Really can have an easier, more playful, more engaged level of participation in every part of their life with the right support.

[00:58:37] And they really, we know exactly what to do. Our treatment is gorgeous and fun and really effective. And the process of OT is just so powerful for these kids. And I think having more kids who struggle with clumsiness, being able to access. They're, um, you know, this kind of support and this kind of intervention is so critical and just, wow, it can, it can change things for, for any of those kids that are struggling.

[00:59:07] So I, I just, I hope it helps more kids find the care that they need.

[00:59:11] Cory: Yay, well, thank you everybody for listening to our third episode. Um, and hopefully we'll see you all next time.

[00:59:20] Michelle: Great. See you, everyone. See you, Trace.

Other Resources Mentioned:

• Dr S.S. Gubbay. 1975. The Clumsy Child: A Study of Developmental Apraxic and Agnosic Ataxia. In Major Problems in Neurology, Vol 5. W.B. Saunders Co

• Teresa May-Benson

• Bundy, A.C & Lane, S. 2020. Sensory Integration Theory and Practice 3rd Edition. F.A. Davis Company.

  • Chapter 5 Praxis and Dyspraxia and;

  • Chapter 8 Assessment of Sensory Integration Functions Using the Sensory Integration and Praxis Tests.

• Check out this website for courses, webinars and research on Praxis www.spiralfoundation.org

• Ayres, J. A. 1985. Developmental Dyspraxia and Adult-Onset Apraxia. Lecture Prepared for Sensory Integration International. Publisher: Sensory Integration International