This is a topic near and dear to my heart. Early on in my career, I met a great number of children who were anxious and uncomfortable with movement. Philosophically I decided it was important to prioritize the child’s comfort over the attainment of a therapy goal. In therapy I experienced that when a child felt safe they would choose to take movement risks in ways that were meaningful to them and this would allow us the opportunity to make functional gains. In the years since then I have spoken to adults who experienced therapy as a child and this has reinforced my philosophy. 

I have written about the impact of emotional regulation on postural control before. Anxiety impacts our vision, predisposing us to use our peripheral vision rather than our central detail vision and negatively affecting both the contribution of this individual sensory system as well as our sensory strategies. It impacts our muscles by increasing muscle tone as part of the fright/flight response, negatively affecting the musculoskeletal components of postural control. And it impacts our ability to learn, as our attention prioritizes scanning the environment for threats. But beyond all of that, being anxious just feels yucky. 

I’ve seen our understanding of emotional regulation develop by leaps and bounds over the past decade. Discussions regarding the neurobiology of sensory processing disorders and self-regulation as well as the impact of emotional state on balance have contributed greatly to my practice.  We have also recently begun to appreciate the impact of developmental trauma on posture and movement.  Given that so many of our clients have experienced trauma in one form or another, I consider this to be a major issue in our clinical practice today. While the DSM-V doesn’t recognize developmental trauma as a diagnosis, trauma is defined as “a single occurrence or an accumulation of experiences that creates a stress response that takes a person out of his/her window of tolerance”¹.

I had thought our profession was making progress but a recent textbook on PT for children with CP illustrates just how far we still have to go. I had assumed the chapter on therapy related behaviour would be full of the research on emotional regulation, the neurobiology of trauma, the impact on postural control/movement and learning. Instead there was nothing but a simplistic discussion regarding distraction and use of behavioural techniques. As a profession we should demand that critical research be reflected in our educational resources. 

My bottom line is this: emotional regulation matters. It matters more than walking, it matters more than sitting, it matters more than any PT goal we will ever write. Many of our clients come to us already having experienced trauma and many go on to experience mental health challenges.  We can embody the knowledge that every child is their best self when they are calm and emotionally regulated. This is also the space where they learn best, and it doesn’t matter if that learning is coordination of movement or calculus. Ultimately, this may be the most important information we have to teach our clients and families. 

6 principles of trauma informed practice ¹:

1. There is always a reason for the behaviour.
2. Promoting a culture of comfort and safety. 
3. Recognizing situations that are potentially re-traumatizing.
4. Reinforcing clinical training for all staff in identification and implication of trauma.
5. Having a common language.
6. Recognizing the role of relationship as a healing force. 

When you see a child, these are some of the signs can alert you to the fact that they are in an a state of increased emotional arousal:

*  Dilated pupils

*  Reddening at the tops of the ears or flushed cheeks

*  Breath holding

*  Difficulty self-calming

*  Rigid thinking

When you interact with a child who is in a state of emotional dysregulation, you can use your relationship to support their regulation:

* Get below their eye level.

* Speak calmly, quietly and rhythmically. 

* Model taking deep breaths.

*Acknowledge that they are having difficulty – “I can see this is hard for you”.

*Offer assistance for emotional regulation and don’t proceed until they are calm – “I can help you to get ready”.

1.Barthel K. Trauma Informed Practice. NDTA Network. September/October 2019.