The next component in my contemporary model of postural control (see below) is emotional regulation. Interesting that in the postural control model I began with, emotional regulation was not even considered. Historically this has been the case and yet our emotional state affects everything from our muscle tone to our alignment to our body schema and therefore our postural control so it is incredibly important. Understanding emotional regulation is crucial to the assessment and treatment of motor skills.

Many, many of our clients experience difficulties with emotional regulation. The reasons are varied; motor challenges, sensory processing challenges, mental health difficulties, developmental trauma. But motor skills can contribute to emotional well being, even becoming an area of competency and mastery for some. Postural control is a crucial foundation for these motor skills.

When we move into emotional dysregulation (often termed stress) the sympathetic nervous system is activated, moving into fright/flight which elevates muscle tone in the extensor musculature. Fright/flight also impacts the breath, driving a shallower upper chest respiratory pattern with an increased respiratory rate. Stress also triggers the release of cortisol which impairs memory formation and makes learning in this state much more difficult (Porges 2011). It has been documented that trauma impacts central alignment (Ogden 2020) and we know that alignment impacts muscle recruitment (Burtner 1999). All of these can negatively impact postural control.

How do we reconcile that some learning literature discusses that a level of stress helps us to learn? I think this question is one of semantics. Dr Ayres talked about the “just right challenge”- that activity that pushes the child’s boundary slightly and also motivates them to reach for a goal without triggering a sympathetic nervous system/stress response (and consequently creating dysregulation). So if we differentiate between challenge and stress we have our answer. We want to create the just right challenge for our clients but not stress them and contribute to their emotional regulation challenges.

Recognizing dysregulation is not always easy. Neither are conversations with parents who are often anxious themselves and may be focused on compliance. Conversations reframing the behaviour we are seeing in terms of neurobiology, sensory processing, emotion, challenge and learning have worked for me in the clinic – explaining that the child “cannot do what I am asking, rather than will not do it” (Barthel 2022). And working with gifted OTs with advanced skills in sensory processing and mental health have helped advance my understanding and recognition of emotional regulation/dysregulation.

Learning to treat children with emotional regulation difficulties requires patience and curiosity. Sometimes it is the activity itself that is dysregulating, sometimes it’s the level of challenge, sometimes it’s the environment or the structure of the session, sometimes it’s the perceived demand or even my relationship with the child. Occasionally it is all of these. With patience and curiosity we watch the child carefully, reading their facial expression and physical cues, guaging the level of challenge as well as their response to my verbal and nonverbal-verbal cues adjusting as we go. If dysregulation occurs, the child’s ability to feel safe in our therapeutic relationship is key; co-regulation is the most effective tool a therapist has to support clients. Often this requires us to suspend our attachment to the postural control/motor goal in the moment and focus on the child’s emotional needs.

In our clinic we put the mental health of the child at the very centre of our practice. Sacrificing emotional regulation for the sake of learning motor skills – “pushing through the behaviour” as some frame it – is a false choice. Research suggests that skill learning doesn’t go well when a child is stressed. And sadly, the research also suggests that children who have early challenges with emotional regulation are more likely to develop anxiety later in life (McMahon 2019). So it turns out that one of the most important things we can do as therapists is to help everyone involved understand that every child is their very best self when they are calm, connected to those around them and emotionally regulated.

Porges S. The polyvagal theory. New York, W. M. Norton & Company, 2011.

Ogden P. Sensorimotor psychotherapy. New York, W. M. Norton & Company, 2015.

Burtner P. Woollcott MH, Qualls C. Stance balance control with orthoses in a group of children with spastic cerebral palsy. Dev Med Child Neural. 1999; 41: 758-57.

Barthel K. Global Mentorship Alliance. January 2022.

McMahon K, Anand D, Morris-Jones M et al. A Path From Childhood Sensory Processing Disorder to Anxiety Disorders: The Mediating Role of Emotion Dysregulation and Adult Sensory Processing Disorder Symptoms. Front Integr Neurosci. 2019; doi: 10.3389/fnint.2019.00022.