7. Treatment and Sensory Modulation

This episode we work to put the concepts from the last two episodes together with a clinical case.

We mention the DIR (Developmental, Individual-difference, Relationship-based) model and Sensory Integration a few times during this episode. You can find out more about each of those below:

DIR

• https://www.icdl.com/dir

• https://profectum.org

Sensory Integration

• https://www.cl-asi.org

TRANSCRIPT:

[00:00:44] Michelle: Welcome to episode seven. We are here mentoring with the wonderful Tracy Stackhouse. Again, this is my favorite time, I must say so. Uh. We are bringing to you a case that, uh, will hopefully pull together the information that we've discussed. In the last two episodes, we did a deep dive into modulation and state, and we broke down sensory modulation in particular, and we were mentioning how it's really state dependent.

So, because there's so much information in that and, uh, our job really is to take information that we are learning and bring it to our sessions so that we are making a difference in the lives of the children in front of us in the moment. We thought it would be a great opportunity to take a case that, uh.

Cory has prepared for us and to see how she's exploring state modulation, um, in action through a series of, uh, three or four sessions, uh, and how we really integrate the theory into our practice. So welcome, Cory.

[00:02:00] Cory: Yay. Hi, Tracy. Hi Tracy. I'm keen to get. Started today. I think it's gonna be a good episode. I know that we did talk about way, way, way back in the first episode that we were gonna do.

Cases and it felt like we needed to get some information outta the way first. So I'm really excited 'cause I actually have permission to talk about our little friend today. So this is a young boy that I have been working with and he is seven years old. He has a diagnosis of autism spectrum disorder. And they classify that in levels he's been diagnosed with level two.

There are a couple of reasons that I wanted to bring this case today, but I'll give you a little bit of a background on my little friend. So in the initial phases of treatment and assessment, um, a few things came up that sort of prompted me to think about. Sensory modulation just off the bat before I'd actually even laid eyes on working with him.

So a couple of things were. Uh, in his questionnaires, things like he hates, hates having his hair cut, or, um, his face washed or wiped. But then in the same vein, he wants to have as limited clothing as possible and be barefoot. On really quite intense surfaces. So like sharp bark chips, like to the point where sometimes his feet will get cut and he's like, not always, like that's not a thing that he.

Worries about, like, he kind of wants to seek that out. Um, he also, it's, uh, is really interesting. He has auditory sensitivities to certain things, to the point that he will almost refuse to leave home because he's worried about certain sounds. Um, particularly dogs barking tended to be a really, really hard one for him.

On the opposite end of that, he will seek out really intense sound. In the form of music, like, and heavy metal rock music absolutely loves it. I think some of the other behaviors that made me wonder about overall ability to regulate and modulate input were, hi, the intensity of his bouncing and the way that he would hit his own body to try to, um, like organize himself.

Well, that's what I would hypothesize that he's trying to organize his, his own nervous system, but. Like his dad would say that he would do that like really frequently throughout the day. So some of the goals for him just upon when we started were to be able to, um, sustain his attention for one task for a longer period.

He tended to have a really hard time staying with anything, without needing a break, without needing to go and move his body. And he was just, you know, some of those const, those words that parents say often, like constantly on the move. And then. The other one was like to be able to go to the shopping center and to be able to, you know, stay regulated enough through that experience, because that was really tough for him.

So they were some of the really clear like functional goals, um, that dad brought to the table straight away. And then, so I guess in terms of, for me and why I thought this case would be helpful today is because there are things that I think. Clearly demonstrate the modulation challenges that we've been talking about in the last couple of episodes.

But there's also, I guess there's the chance or the possibility here for me to sort of explain the process of clinical reasoning for, for, for him, because it wasn't super, super quick and easy. I kind of, I kind of had to, I had to be really purposeful. About it. Um, so that I could figure out his recipe.

'cause I was especially initially, was really struggling to figure out what exactly was going on and to make sense of that and to know how to then intervene. I'm

[00:06:05] Michelle: so grateful you've bought a real case, um, because we can get buried into all these textbooks. So, but this is. Why we bury into the textbook.

Yeah. So thanks Cory, for bringing that.

[00:06:18] Tracy: Yeah. And I think you, the whole, um, beauty of what we're, um, sharing together here is just so much the real deal that every time a clinician steps into the space with a child, um, we're really trying to address things from the a, a base of. Theoretical and therapeutic.

Um. Clarity and sometimes these kids can, the clarity can be a little elusive. And so I think the first thing in clinical reasoning is the whole reason that I think most of my career I've, um, super dedicated myself to the process of clinical reasoning is that every one of us have these questions. Mm-hmm.

And we can be in the moment and we can be wondering. Do I have clarity about what it is that I should be doing here? Now I say that and don't, and hope that that doesn't, um. Kind of scare the parents or other disciplines who refer kids to us, knowing that they are trusting that we have really sound practices.

And we do. But the thing about the work that we do in integrated pediatric therapy is that it is not. A recipe that is replicable from one child to the other, to the other, in that it's not a formula and it isn't just a checklist that we go through.

[00:07:55] Cory: Hmm.

[00:07:56] Tracy: All of our work is based on individual differences and on learning about that child's nervous system and re, but learning about their nervous system as the whole of who they are, the wholeness of them.

[00:08:11] Cory: Hmm.

[00:08:11] Tracy: And so in that, as we identify where the struggles are sometimes. The rules that kinda live in the textbooks don't always apply. Mm. And that's why we have to have clinical reasoning models. Because we have to be willing to be vulnerable enough to say, I'm confused. I don't exactly know what that's about.

What that, what is going on for this child? Why does it look so different from. This situation to that moment and all of that variability, um, is, is even more present when the child is struggling with modulation and state related issues.

[00:08:57] Cory: Hmm.

[00:08:57] Tracy: So that's why we really need clinical reasoning is that we need to be able to say it isn't straightforward, it isn't always the most, um, formulaic and clear cut and yet.

When we pause and know what questions to ask, when we pause and know that we have a process that we can trust, and we work through that process carefully, then we do come to clarity, and that clarity then guides the really purposeful holding of the moment. And what I know is true for every clinician I've ever met is that when you get.

To the point of purposefully holding the moment, that's when change happens. Hmm. And that was true for this kiddo, right? Yeah, Cory. So I think that it's in the, the clarity that you are able to foster adaptive responses and without clarity you can struggle. Any of us can struggle to really get to that level of adaptation that facilitates progress.

Um,

[00:10:10] Cory: and I think, I guess you, you sometimes it's okay to get bits of clarity as you work through the clinical reasoning and then recalibrate that every time you get more information. So I think that's kind of how, how it felt like for me in this case was that. Each time I saw him, I kind of had more information that I kind of had to unpack and figure out potentially, like, what's my hypothesis?

You know, sometimes you can be like, I really, I'm really am not sure. I'm trying some things that I think might be helpful, but um, seem to be missing the mark. Or are partly getting me there, but not sticking. Um, and so I'm not then moving into the state or getting him into the place that I want to be able to get him into so that I can do the work on the goals.

Um. So I don't know, what do you, what co comes up

[00:11:14] Michelle: for you, Michelle, what do you think about, I'm thinking about what Tracy mentioned in terms of, um, having parents and educators and others listening and, and hearing that we don't know it all, all the time. Um, and I'm actually okay with that because, um, for two rea for multiple reasons, I think some of the families that we work with, um, have children.

That are very complex and, um, when we are really honest and saying, wow, his profile, um, is complex. He has a few comorbidities. It's going to take us a while. Will you partner with me? To what do you know? How do you understand him? I wonder why you think he hits, you know, thumps himself quite hard a number of time in the day.

I think that be allows us to become a team and rather than me directing the show and I don't feel a number of years in now, I don't feel like I need to be the boss of the show. In, in the clinic. And so I love fostering that, um, relationship with families so that we are partners in wondering, I wonder what will happen.

I wonder what if he does this? I wonder this week let's focus on, I. Rotation or let's focus on sound. I wonder how that looks. Will that impact his capacity to participate in the family during meal times when you go shopping? Um, so I love bringing them in to be a detective with me and that they share in that process of trying to work it out.

Because what I do in the clinic or what we do in the clinic, as we know, the kids can present vastly different in other circumstances in other. Places, but in other states of arousal. Um, so I wanna know about that and let them, you know, give them some information so that they can help, um, you know, bring information to share in the solving of the problem for their child.

So I love

[00:13:21] Cory: that. Give you more clarity 'cause they give you the information that you don't see in the session. Yeah. And, and it's the functional information that really makes a difference to what you, you are gonna try to. Figure out in the session, right? Yeah.

[00:13:34] Michelle: And in the long term, we dip in and out of these children's and families lives and they're in it for forever.

And so part of that is empowering that this is what I'm, this is what I'm wondering about. There's this thing called modulation. There's this thing called state, you know, let me tell you some information about that and what do you think about that and, and, um. They just share volumes. Often when I explain a concept, they will bring lots of more information than our questionnaires or what I might have wondered about in a session before.

So, um, so I love that work. And if I, you know, now I'm vulnerable enough to say in particularly with these really complex kiddos,

[00:14:15] Cory: yeah,

[00:14:15] Michelle: this is gonna take us a little while. Will you help, you know, join with me as we try to solve the problems for this kiddo. So, um, I, I think it can be really positive.

[00:14:26] Tracy: Absolutely. And I think it's super, I love how you are sharing that really positive team empowerment that we really wanna go for. Because sometimes when the parent comes in and the, the goal is let's be able to go to the shops, which is a quality of life goal that many of our families have.

[00:14:49] Cory: Hmm.

[00:14:50] Tracy: But when we start to design the treatment plan, it can feel kind of far away.

Yeah. And very often clinicians. Ask me to help them figure out how do they connect the dots between the parents' goals and what you see clinically. And sometimes those can feel a bit far away. So in clinical reasoning and then in in letting families know that really our treatment process is this process of connecting the dots.

And the more we partner on that and wonder together and learn together, instead of it being, I have some expertise that I'm gonna download to you, it's so much more effective. And I think it really is empowering the family to. Learn and deepen their understanding. And from that deepened, you know, base of understanding their ability to thrive as a family is, is enhanced.

Which at the end of the day, regardless of the goal, that's kind of what we're always going for. So I really love. Love what you're sharing, Michelle. And I think that that's the attitude that we wanna convey. Yeah. It also, as the clinician, as you land in that space with the child, it just feels so much better to say, we're gonna sort things together going forward, but I'm not just doing to you.

And I think that, that, that attitude is really about. What is a relational model of intervention? What is an airs si model of intervention and how do we bring that? And, and so that, that just, um, feels. Exactly right. And I love how you explained that. Yeah. Mm-hmm.

[00:16:38] Cory: Yeah, I think that resonated strongly with me, Tracy, that I'm not just doing to you.

I never, I never feel like that in a session. And I, and, and if it does, if it started to tip that way, it doesn't feel like I'm allowing for adaptation. And so it doesn't. It doesn't feel effective or there's a quality to it that doesn't feel quite right when it starts to tip in that direction. Um, and I think it might just be the joy and the sparkle that you see when you have that just right challenge or that just right mix of things for that child and then they become super adaptive.

Um, so. Yeah. So I mean, Cory,

[00:17:22] Michelle: I think it doesn't feel quite right sometimes for the kids either. Like we are like, oh, I'm talking too much, or you know, I didn't get the task quite right. So we don't feel in the flow of it. Yeah. And really in it, but I think nor do the kids and you see that pulling away in a bit of, ah, I don't wanna do this anymore, or whatever.

Yeah. So I think together it doesn't feel quite right. The kids of all capacities know. When it doesn't feel quite right.

[00:17:51] Cory: Yeah.

[00:17:51] Michelle: So, Cory, I wonder, um, what you would've been bringing lots of, um, theory theoretical models and approaches, um, to this beautiful 7-year-old boy. So, I guess, um, one of them, the, one of the first thing that we reflect on is the profile.

So he's. Uh, profile is autism spectrum disorder. Yeah. So you would've had this big chunk of information. What other chunk of information did you take? Did you have in your mind, um, uh, in coming into

[00:18:27] Cory: treatment or, or just

[00:18:28] Michelle: reflecting on him on, in paper?

[00:18:30] Cory: So before maybe you got in Oh, before, before I came in.

Well, definitely I had the. Information that you would get when you collect the questionnaires and all of that, that stuff that we ask about in terms of function, so in each area of their li daily life, like social participation and, um, grooming and dressing and feeding and sleep and toileting and, um. I, I guess, school, all of that information that I would, I had prior to, because sometimes autism helps me in a way, in, in one way, in that it does give me information about what might be presenting, but then I, I literally have to go in and find out exactly how that's coming about for that child and that family because, um.

They're all have that every single child that I work with, and no matter what diagnosis, but particularly with autism, have taught me different things because they present in very different ways of how their autism is, is unique to them. Um, so the, the second big thing that helped me was. I was chatting with, um, his mom and dad prior to seeing him, because that just gave me a much, much clearer picture of him from the get go, and I could, I had a working hypothesis right from then.

Mm-hmm. Before he even got into the clinic. I was like, okay. My hypothesis is that he is really heightened in his arousal and he is working really hard throughout the whole day to try and organize himself, um, to function. And that's where I kind of started not, it's not super specific, but that's where I started as before I even got there.

But as a state

[00:20:14] Michelle: challenge that he has autism, he has a state challenge and I guess modulation. Yeah. And particularly sensory

[00:20:21] Cory: inputs. Are difficult to organize for him and there's something that's he's trying to manage. Yep. Um, to be, to be doing what is asked of him throughout the whole day.

[00:20:32] Michelle: Yep. I guess we also bring an as si approach, so that's one of our approaches.

And I know you've trained in DIR floor time. Yeah. Yeah. Um, was there any other piles of knowledge that you were

[00:20:46] Cory: bringing? It's so hard to define when it's so implicit to you, isn't it? Um, yeah. I think just like you said, my big, big, um, theories of working theories that I draw from are SI and DIR because of, um, of the way I'm trained.

Um, the other thing that I also think about, of course, is. The motor system and how that, that plays into the mix.

[00:21:15] Tracy: So Cory, when you start to treat kids and you formulate that initial theory of, of how they are, that helps to guide what you might do in the clinic. And then I often think about how in our sessions we have to allow ourselves to. Have that theory so that we can almost put into practice the direction of organization, the direction of regulating that nervous system.

Um, and one of the things that we do in the spirit tool that I think we've shared in the last few episodes around regulation and modulation and state, is that the more simple linear models of. Under responding and over responding often don't help us in our clinical reasoning, and we have to dive a bit deeper and we have to have a theory that matches the complexity.

So this case really helps us to start to share with that, that, and part of what's tricky about that is that it isn't straightforward like a linear continuum. It really is more complex. So you have to formulate your. Hypothesis of what's happening for this child as they try to process and organize and adapt.

And then you, in your session start to, um. Go forward with a particular notion of what you think might organize and regulate them. But because our work is so relational, it's hard to observe yourself doing that work. So one of the things that's super helpful is to videotape yourself and to be able to watch it later so that you can more deeply consider what's going on.

So I think it would be helpful for us to hear about both of those things. Cory, first about that. Videotaping yourself and what that experience is like, and then what you learned about this precious guy from observing that and how it deepened your theory of him.

[00:23:29] Cory: Hmm. Well, um, one reason that I did end up videoing was because I.

Felt like I needed additional strategies to reason out what was going on. And because when you have, um, a kiddo that's really complex in front of you, it requires such, um, attention and presence to be in that session and in that moment because you're, you are, you are, you're working at, at every level to track and.

Especially with the really, really complex kiddos. Um, you are, I guess you're trying to, um. Be as specific and focused as possible without losing the connection to the child. And those kids almost demand every element of attention and connection that you have in the session. And so sometimes. It feels a little bit, you'll come in with a bit of an idea, and then when that potential, I don't know, um, plan doesn't quite work the way you expected, you then sometimes can feel like you're a bit behind the eight ball trying to regather and trying to figure out, okay, how do I get ahead of this again?

How do I, how do I reorganize? Because that experience was actually disorganizing, but in the moment. It's sometimes hard to do both of those things, and so I, um, like to film because. I think it captures things that you just don't get to always see in the session. Um, you know, and the amount of times that I've turned around to grab a toy and something has happened on the film that I didn't see in the session, um, that watching back later I was able to pick up is, uh, like actually more than I would expect.

Um, or something that I didn't even see when I was literally looking at the child that later watching, I could notice. And go, aha, that was my moment and I missed it. Um, and that's okay. Um, but I think people can, it, it honestly is super confronting the first time you start to film yourself. And it took me, um, the first couple of times.

Of filming and watching it back. I, I think it took me, I had to watch it back a number of times before I could get over the sound of my own voice. Um, but it's also in that confronting experience that I've done my most significant learning, um, and had the most, uh, uh, I guess being able to refine what I was doing, um, and have the option to talk about it with.

Somebody who, uh, I know I respect and can help me in that process. 'cause it can feel really, um, embarrassing almost to put yourself, 'cause you, you bring yourself to the clin, to the treatment and so that can feel, um, yeah, you have to be able to be vulnerable to do that. To, to say, okay, I'm gonna film what I'm doing because I think I'm there.

I think I'm partway there, but I think I could. Get that last little bit refined. So the filming part piece, I don't know. Michelle, you film as well, so

[00:26:50] Michelle: Yeah. How do you film? I love to film. Um, I don't show, when I first started doing it, I didn't show people and nor did I need to. Um, I realized that I was, um, I.

When you're in the flow of a relationship, and I was totally immersed in the moment with the child that there was some entrainment, I guess. And I, the first video that I look back on myself, I, um, was talking to this, um, 9-year-old girl who presented. Um, at a much lower level in a really baby sing-songy, high porosity voice that was fitting for a toddler, which in some, that's kind of where she was at, socially and emotionally, but it was just not right.

But I had inadvertently slid down to, um, her level of capacity and it just was not the right thing to do. And so I was really, um. It was wonderful to have, have that awareness. Um, so I regularly, randomly feel myself sometimes to, definitely to work things out, but also just to be like, am I on, am I right here?

You know, what, what's my voice doing? And, you know, what am I doing? Am I moving too fast? Am I being entrain into, you know, the impact of that Charles? Um. System. Am am I falling in? I guess I don't know the technical words for that, but, um, yeah, I kind of wanna hold rather than fall into,

[00:28:19] Tracy: um, I think right.

It's, it's one of the things, you know, for clinical reasoning, I think it's the power of clinical reasoning is that I. Therapeutic use of self isn't always intuitive. Mm-hmm. And how you inform your intuition, how you shift a basic response that you might have to a child, but it may not be the most adaptive response and the only way to to get that is to.

See it and be able to talk about it and to be able to problem solve it. So on some level, clinical reasoning is sort of naming, not that there's a big problem, but that there's um, there are elements and approaches that need fine tuning and they don't always match Exactly. The intuition.

[00:29:07] Cory: Yeah.

[00:29:07] Tracy: So you are both exquisitely intuitive and you're so attuned to children, and yet it's the.

The therapeutic use of self is informed by our practices and by our theory.

[00:29:21] Cory: Yeah.

[00:29:22] Tracy: And so you do have to spend time in clinical reasoning to get that fine tuning. Um, and that's the dedication that we're hoping that this conversation inspires. Because we know the power of it. Mm-hmm. And you all are demonstrating the power of it.

So thanks for being willing to share that. It's so beautiful. I feel really privileged to hear and to have seen your journeys in that and to see how much growth you've reached. Achieved because of being willing to film yourself and watch it and try something a little bit different.

[00:29:58] Cory: Hmm. And I think, like you said, Tracy, you have these intuitions, but you actually almost need to refine them for every single child.

So early on, um, some things that I was doing that I was just kind of doing automatically worked for some kids, but. Didn't work for others. And so I needed, I needed to be able to have this exquisite ability to readjust my therapeutic use of self so that each of the children that I came across were able to have a matched.

Partner in the work. Um, and so that, that was a real, that I reckon, that took me like a, it's, I'm still working on it, right? Child, you continue to refine it. But, um, for this little guy, the reason that I wanted to film him, um, was to try and get clarity around his recipe because, um, I was trying some things, some of the principles that I knew that I had had success with.

So I wanted to try. Um, linear vestibular input on a swing, or I wanted to try resistive movement in cra I wanted to try intensity because he was going for intensity in, in, you know, in all many things that he was doing to try and organize himself. I wanted rhythm because the. The qualities of what he was doing, the ways that he was trying to give his self himself input were rhythmical and he likes music.

So, um, that innate drive that kids have to organize their own nervous system. Um, but every time that I came at it in sessions, I, it seemed to be, um, not quite what was. What he needed. So I'd try movement on the swing and he would just start to, um, I would lose, first of all, I would lose connection. Um, and he would almost just start to get wound up into a script of his own and then throw himself off the.

Swing and then laugh and scream manically, and I was like, okay, that's not helping you. Like I've something about, this is not quite where, where we need to go. And so I had multiple different sessions where I tried different things where, you know, we tried jumping off the loft into the pillows, all things that he was seeking out.

So I was not telling him like, I would put up the swing and I'd, I'd just, should we try it, you know? And he'd get on and we'd try it and didn't, didn't quite work. Or the loft. He would go up and he would jump off and then he would start crying and. You know, it was like, okay, we're going from like, woe to go, there's no, there's no modulation.

There's no organization here. And so I was like, that, that, that's it. I just need to film this because I, I need to figure out what to do. I need to figure out how to. Tweak this. Um, and luckily the first time I filmed, he jumped on one of the exercise balls and I had the, uh, intuition and the gut instinct to, um, anchor his legs, anchor him through his knees to the ground, and he threw himself backwards.

We, I. Both, we both had a kazoo. Um, and so I then started to rock him with rhythm. I was giving rhythm with the kazoo and then, and he was upside down and rocking so that his head kept sort of just bumping lightly into the soft mat under him. And he then did that for a period. I don't know, it couldn't have even been that long.

But then he sat up and he had spontaneous language directed looking at me, directed to me for the first time I think I've ever, ever had in a session. And I just was like, oh, what just happened? Like that was really different. Like he was really connected, really organized. Um. And then, you know, he didn't stay in and he lost him for a bit, but he came back again and I was able to catch it quick enough because his postural system wasn't good enough to stay on the ball and replicate that himself.

Second time, able to catch it quick enough to then do it again, that it sort of then allowed me to have this back and forth with him in an interaction in a much more organized interaction. So. I don't know. There's that, that's the reason I wanted to film because I wanted to figure out what was going on and I was just lucky enough to capture the moment where I was like, okay, I think I know how to organize you, but my question is, Tracy, like what was going on there?

Like what, what mechanism was I hitting into there? Like how was that so helpful? 'cause there's so many bits that are part of that, but I just wanted to hear what you, how we unpack that.

[00:35:01] Tracy: Yeah, so I think we should try to unpack a couple of the key bits. One is the rhythm, the rhythmicity. Now he, throughout many of the sessions and in his daily life is showing you that rhythm is a thing that he's going for.

So sometimes when, um, kids have a certain, particular quality

[00:35:24] Cory: mm-hmm.

[00:35:25] Tracy: It's important to find a way to use that. But one of. One of the things about him is that rhythm for him is giving him a sense of, here I am, and he does that over and over again, but here I am isn't quite enough because of the fact that he has a.

A mixed state where he needs incredible intensity.

[00:35:55] Cory: Mm.

[00:35:55] Tracy: And yet he also needs inhibition because intensity just undoes him. Mm. Um, and rhythm isn't enough to hold it. It's not enough to bring it into enough inhibition.

[00:36:10] Cory: Mm.

[00:36:10] Tracy: So the quality of rhythm through auditory. Vestibular vibration, tactile proprioception, rhythmic input, has a grounding, organizing quality to it.

And as you offered that to him, and I had a chance to watch the video, so it's hard to convey this maybe, um, in an, in our forum here, but I think every clinician has had that experience where. When you really on purpose find rhythm that resonates to the child's nervous system. You start to want to repeat it and they want you to repeat it.

[00:36:53] Cory: Mm.

[00:36:53] Tracy: So it becomes a shared experience. It's not just the cold delivery of rhythm through sensation. You were doing it relationally.

[00:37:05] Cory: Yeah.

[00:37:05] Tracy: And you were doing it through multiple channels. You were using audition breath. And vestibular and somatosensory together.

[00:37:18] Cory: Yeah. Yeah.

[00:37:18] Tracy: So you're coupling sensation. And not just using one channel, and you're doing it with a very clear sh shared purpose that starts to entrain between the two of you.

The magic of that shared, um, experience, I. Moves a child from dysregulation into the possibility of connection. So instead of him trying to regulate himself, you become a co-regulatory partner. And co-regulation is so much more powerful and opens the possibility. Of engagement and reciprocity, which he's deeply seeking, but he doesn't know how to get there.

So that's a big chunk. The second thing that I think is super important to talk about is inversion. So when you have a child who needs intensity, but they need to downregulate and inhibit. Head inversion in particular, you goes through the barrow receptive reflex that really affects the, um, physiological regulation.

So if you were to feel his heart rate before inversion, his heart rate would be very fast. His, his respiration was fast. And what happens when you have head inversion is that the. Um, the receptors in the, uh, arteries and in the va venous system actually get pressure, and that pressure says down, regulate the heart, the heart is going too fast, bring the heart rate down, so you're, it's like a physiological switch, and that switch sends a different signal to his nervous system that instead of being on and going and fast.

I need to slow down. And that slower space with intensity, it's the coupling of inhibition and intensity. That's his just right formula. And when you hit that, he has an adaptive response that you've never seen before and it looks like magic in the video. Watching his dad's face in that moment was so priceless because.

He suddenly was also leaning in. The dad was like, what's happened here? And he felt a different level of trust around what is happening in the sensory realm that supports adaptive outcome. It, it's really beautiful work, but it takes that knowledge of the sensory elements. Infused into the adaptive response of what's possible when you get regulated.

So a lot going on there.

[00:40:21] Michelle: I love that. Um, Tracy, because I think we can see it when it happens, um, and that we can understand the mechanisms. That are occurring. I get greedy. Um, when Kim Hel, um, was come and co treating with us, she made mention that we were greedy because when, um, that I did see the video too. And so Cory had this intense, um.

Really adaptive moment, um, with the child following that. He fell off the ball, was still watching Cory, but he rolled off and, um, moved away from, um, that he then ran around the room and uh, um, within a couple of minutes came back to Cory and they re, re repeated it and he stayed for a lot longer. Um, I wonder, can you help me understand, um.

The, the, the rolling off the ball or, or the gaps that when we see, um, the child respond really positively and that they come back for more, I'm so greedy. I don't want them to disconnect. My wonder, my guess is that that disconnect might have, um, particularly with, uh. Kids with a profile of autism, um, that there may be some, a flooding, you know, whether that's from an AP effect, um, response or a body-based sensor series motor response.

But, um, I'm just wondering what may, um, cause that moving away from something that looks so adaptive and that I'm greedy for more of and that they they come back.

[00:42:01] Tracy: Yeah, absolutely. So the window of adaptation. Doesn't just crystallize and solidify in a moment and then be present forever. And in fact, that's true for all of us.

Um, one of the things that I think I've really learned from children and adults, uh, who have autism, that they have a different pace and time just like you and I do. That says. I'm here fully present right now, and then I need to regroup a little bit and especially when a new skill is coming together, the regroup and consolidation and move away from, in order to move back toward is such actually the critical part of adaptation.

We always. Move in and out of Synchrony, we always move in and out of engagement. And so even listening to this podcast, our listeners are gonna listen in and listen out and fade in and fade out. And that's the rhythm of life. It's the rhythm of humanity.

[00:43:12] Cory: Hmm.

[00:43:12] Tracy: People, autistic people teach us the rhythm of humanity and it's such a gift.

So allowing a child to be with. And then move away from and allowing them to come back. What you see is that window of engagement, window of tolerance grows in its plasticity, and that's what we're going for. We're not going for a set point. We're not going for a. You know, um, this is it. We've achieved it, and now we're done.

We're going for the fluidity and flexibility that is human interaction.

[00:43:50] Cory: Hmm.

[00:43:50] Tracy: So for allowing a child to be with you and have an intense experience for a child. Like this guy to have that shared experience with Cory, that was pretty full on. It was a big deal and it was rich and full and deep, and. That's hard to take in.

So let him do it and then move away. And then what's so cool is he comes right back and then wants to repeat. Mm-hmm. And the repeat often produces even more. Mm-hmm. So we know repetition is critically important. Repeating those adaptation moments and then growing them is critically important. But it's not static.

It's not like we're gonna just stay in an intense interaction. Um, we can't even do that with each other, right? We, we play, we can play the eye contact game, and we're gonna have to look away. We can't be greedy. We can't say, keep going, keep going, keep going. Because our nervous system has to look away. It has to blink.

It has to soften. It has to regroup, and then we return. Hmm. So serve, return, come back, revisit. That rhythm is coming also from the rhythm of the proprioception and the movement, and that's. That's communication, that's relatedness and that's what's gonna grow. So I imagine Cory, once you started to find that formula for this guy, the next sessions must have been really juicy because he's gonna find that and wanna share that and, and that's gonna be amazing.

It was

[00:45:35] Cory: so fun. Like to go from that point forward because, you know, the sessions before that were, were, um, I, I felt like I was trying to work really hard to figure it out, to try to get to the bottom of what was going on. Um, and then we had this moment where I was like, okay, I think I've got something that really works.

And, and I didn't get really regimented about forcing him to redo it in the same way. I just found different ways that we kind of. Found the similar thing. So it wasn't always the exact same way that we did it, but it was always with rhythm and, and intensity and usually inversion. Um, and then he needed it less and he was able to stay.

It, it kind of allowed for the reciprocity to. Be sustained for longer periods. And it was just so exciting because, you know, he loves, he loves annoying Orange, the YouTube clips where the orange talks and he is like an annoying little orange that just talks. And so he would be the orange and um, I would actually let me, he'd let me be the hamburger and I'd be like, oy, orange.

What are you doing? Like come over here and he would tune into that. He would come over and he would imitate as orange what I was doing as hamburger. And it was just, I'd never, like before that, we'd never had, it was still around a sort of a script, but it wasn't scripted. Um. It was familiar, but it was, um, adaptive and it was interactive and it was just super exciting to actually be part of that process with him.

And, um, and his dad is, was super involved in sessions too. And so it was just, we were all just like, um, loving it and his dad would be like, oh, he's doing so many different things. And, um, it was just really exciting to be on that journey with them. So it was cool.

[00:47:29] Tracy: And that pivotal skill of imitation. Um, you know, from, from regulation into engagement.

Reciprocity, those first three levels in the DIR model. Mm-hmm. Now that's the social emotional developmental frame that you are trained in and that you were using. Um, and I think it would be really, really fun for us to, to jump into that in a future episode, to talk about this social emotional development and also how pivotal imitation is as a skill that.

Allows for growth and change once kids authentically, not through, you know, rote training, but once they understand imitation and what it buys them, watch out. Because all kinds of things happen from that base of. Engaged imitation with moments of reciprocity. All of that starts to make, um, the world really different for, for kids like this.

So how amazing that you were able to use sensation and use sensory integration to find that for him. Hmm. Um, with him. Yeah. Together with him. Um, really powerful.

[00:48:45] Michelle: Oh, I can't wait to discuss, uh, the next podcast, uh, content with you, Tracy. Okay, so wrapping up this one. Let's talk about our takeaways. I think for me, I love being reminded, um.

That I can, um, just sit back and hold space that, that when the child moves away from, um, then that just as you said, Tracy is part of, uh, communication and that I can just wait and be available for them to approach me and. Help parents, um, and everybody around, um, be available and open and ready for the return, um, and not really contract and, you know, worry about, ah, the moment's over and how am I gonna catch that again and, you know, get all antsy about it, that I'm just gonna.

Be be and, and help communicate then the being available is what's really important. And even though the moment is finished and we're all super excited and wanna high five and happy dance that you, you're just not gonna do that right there.

[00:49:53] Cory: Mine is probably, um, to, to be willing to ask parents to video and, um.

Take, take that leap and, and give yourself the space and the time to really think deeply about the children that you're working with. And, um, you'll quickly, I promise, you'll quickly get over the sound of your own voice and you'll be able to watch a video without feeling super, like, oh, this is just so embarrassing.

So it'll, it'll be really helpful if you take that leap for yourself. Um, it'll push you in the right direction.

[00:50:26] Tracy: Mm-hmm. Awesome. And for me, I think this episode really highlights the. Complexity yet again of sensory modulation. So we spent a few episodes talking about it, and now this case illustrates that those mixed states of intensity and heightened responding combined with the need for.

Uh, inhibition, but also the cues of what does the child need? All of that requires discerning clinical reasoning. And we can't really do this work without clinical reasoning. We can approach, um, uh, you know, over and under responding in formulaic ways, but for kids like this, it takes much more than that.

And I think it's a privilege to. Hear your clinical reasoning and see how, how effective it is when you go there. And while it feels complex, it's doable. We all can replicate this with fidelity and we know that from the Spirit tool, the step Aside tool from Error sensory integration from the DIR floor time, these are all replicable.

Tools that allow us to articulate and identify exactly what we're doing. So we need these deep tools and we all need to be brave enough to, to do this work. So thanks for your generosity and sharing your, your beautiful work. Thanks for talking it through with me guys.

[00:52:02] Cory: Thanks ladies. See you all next time.