Chapter 13, Step Three, Executive System, 4-17-17

Review of Chapter 12:

1. Importance of sensations providing all the raw data to the brain, with interoception, proprioception, and vestibular modalities added to the core five sensations.

2. Review of the stability and flexibility in the Executive System: Stability through an accurate information processing hierarchy and flexibility through an ability to modulate the duration, intensity, and rhythms of sensory modalities according to one’s developmental abilities and the context.

3. Review of the sensory information processing hierarchy and it as a functional capacity; review of sensory modulation and it as a functional capacity.

4. Presenting and introducing sensory functional capacities to parents.5. Treatment implications working bottom-up:

a. Identifying individual sensory preferencesb. Individual sensory thresholds c. Links with safety, challenge, and threatd. Linking sensations with Levels of Engagement (LOE)

6. Suggestions for Bottom-up Sensory Modalities for Calming and Modulation (Building Stress Tolerance)

7. Suggestions for Top-down Sensory Strategies for Calming and Modulation (Building Stress Tolerance)

8. Intervention Principle: the use of Duration, Intensity and Rhythm (DIR)9. Matching vs. Countering10. Journaling for Discovery of Patterns 11. Sensory Toolkits, Macro and Micro 12. Sensory Toolkits, Self and Co-regulation

For Supplemental Material, Please Read Chapters 10 and 11 in the NRF Textbook on the Executive System

The importance of movement. As a precursor to the functional capacities of the executive system, it’s important to understand that often executive function is equated with intelligence, or IQ. It is not! It is often also misunderstood that the reason for our brains is to think. Again, it is not! The embodied cognitionist’s point of view is that the real reason for brains is to move. Dr. Daniel Wolpert refers to himself as a motor chauvinist and he explains his position in this engaging Ted Talk: https://www.ted.com/talks/daniel_wolpert_the_real_reason_for_brains “The brain evolved for the purpose of increased control over action, not for the purpose of cognition, per se” (Budding, Knowing and Doing: The Inter-relation of Cognitive and Motor Function, PDF, slide #8, 4/23/2014). Movement, then, is the bottom-up part of “doing” which is now understood as the underbelly to “thinking.” What is now known is that there are many links between bottom-up movements and top-down thinking.

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Jeremy Schmahmann’s work on the cerebellum highlights this part of the brain as an “integral node in the distributed circuits subserving sensorimotor, cognitive [executive system], autonomic [regulation], and affective [relevance] processing” (Jeremy Schmahmann, Harvard University, lecture at the University of New Mexico, 2011, https://www.youtube.com/watch?v=QuqDnwkuCHI , brackets added; Notice that the cerebellum has links then with all of the brain regions and networks the NRF emphasizes]. Executive function, then, grounded in sensorimotor coordination, includes the influences from the ANS – states of arousal, the limbic system – motivation, and cognition – thinking and planning. All parties hold a piece to the puzzle. It’s important to note that decision making is not solely relegated to the pre-frontal cortex. With these distributed networks, “decision making is found within the same sensorimotor circuits that are responsible for planning and executing the associated actions” (Budding, Knowing and Doing: The Inter-relation of Cognitive and Motor Function, PDF, slide #30, 4/23/2014). Thus, to the brain, from this sensorimotor learning perspective, movement is not treated any differently from thought. We will begin in the toolkit section with the quality of sensorimotor development.

Flexibility with Stability. As mentioned, each brain network has functional capacities that honor stability and others that honor flexibility. What’s unique about the executive system is that all circuits are feeding information to this region of the brain! The executive system is often portrayed as an air traffic controller or a juggler, having multiple sources of information to manage. There are three functional capacities in the executive system. What’s unique about these functional capacities is that they each hold some tension between the more top-down aspects and the more bottom-up aspects of behavior. Thus, the first functional capacity is juggling spontaneous events with automatic routines. Here we see that one would need to be flexible in order to handle novelty and one would have to have stability in order to function with rote automaticity. This, of course, is the dance within the dual tiered brain networks of top-down and bottom-up processes described in Chapter 9. The added piece to this first functional capacity is that as these spontaneous and automatic processes mature, conscious and effortful control emerges, with now more capacity to juggle these spontaneous and automatic events.

The second functional capacity of the executive system is the capacity to integrate bottom-up influences of emotions with the top-down control of thoughts. Here, again we have a juggling of the dual tiered brain, working towards integration. Affect can offer more spontaneity (flexibility) and thoughts offer more control (stability); both are necessary for good decision making.

The third capacity of the executive system is the capacity to assess, integrate, and prioritize one’s own internal (self) needs in relation to external (context/other) needs. Again flexibility with stability is required in order to juggle these two, often competing items. Staying true to oneself is important and provides stability; being flexible to shift to the context and other’s needs, as they arise, is equally important. The art is in being able to juggle one’s own priorities with boundaries (a sturdy hand that can be assertive) while noticing other’s needs (a warm heart that can be responsive) and to make good decisions in the moment (a clear head that can make decisions) that balances these priorities over time.

Just as there was a cascade effect within the three functional capacities of the relevance system, so there is now a cascade effect between the three functional capacities of the executive system.

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As one is able to juggle (or not) spontaneous and automatic events, with the maturation of conscious and effortful control, there is a better chance that one can manage to juggle (or not) the powerful forces of emotions – sometimes referred to as elements of “hot” executive functions and thoughts – sometimes referred to as elements of “cool” executive functions. And, as one can juggle one’s own feelings and thoughts, one can get better at knowing oneself internally, from a private world point of view. This is where the green zone “head” skills allow one to weigh one’s emotional reactions and one’s contemplative thoughts in a reflective way about life’s experiences. As one knows oneself with more depth, one can often better juggle caring for oneself and for others.

We now summarize the three functional capacities of the Executive System and offer some prompts on the right side of this table for you to see how you might already have access to that information or where you can find it and follow it.

Three Functional Capacities of the Executive System1. Capacity to express

spontaneous, automatic, and consciously controlled behaviors in a flexible and purposeful manner

Once you know the colors from mapping out adaptive vs. toxic stress, you have an idea of what the patterns are for “spontaneous” behaviors vs. “automatic” behaviors, and if they are adaptive or not. At first glance this may seem foreign to you because you are not consciously thinking of the colors in these terms. However, if you have a positively red zoned child/youth/adult, you already “know” that there are a lot of spontaneous behaviors occurring. Similarly, if there are a lot of quick upswings into high intensity red zone aggression, you have a similar phenomenon, where the patterned rhythm, is to regularly or intermittently, quickly explode.With pervasive anxiety/combo zone children/youth/adults, there may be much more perseverative behaviors that are rote, repetitive, and ritualistic.With pervasive blue zone activity, there is a greater chance of

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automatic and rote routines at play. Depression and dissociation often block spontaneous joyful responses.Now, it is possible to have a depressed child/youth/adult who is also anxious, who also quickly goes into red zone rages, who also is inattentive. This complexity would include a mixture of high spontaneity along with high automaticity, with little conscious control to manage any of these ranges.Adaptive versions of this functional capacity would be a child/youth/parent who can show a range of spontaneous joy and stress responses, yet also has solid routines in place that are functional and efficient. There is conscious and effortful control to inhibit wild reactions under stress, and to juggle one’s schedule, staying steady while also having some flexibility.You also will have information from the Learning/Educational Story Interview process here to add to the complexity of the executive system. If teachers are complaining about a child who cannot “sit still” and is always moving, s/he might be seen as having too much spontaneity. If there are concerns about blue zone behaviors, this child may not show enough spontaneous behaviors or initiative doing school work.You also will know from the Levels of Engagement Assessment, if age appropriate, in addition to the colors of regulation, where things are in terms of early levels of spontaneity through expressions of joy (levels 3); age appropriate levels of maintaining circles of communication and reading emotional gestures and cues would show a balance of both spontaneous and automatic routines (levels 4 and 5).

2. Capacity to integrate the bottom-up influences of emotions with the top-down control of thoughts

Once you know the colors, you have a take on one’s emotional range. Top-down capacities with language bursts kick in around 2 years old and the capacity to inhibit occurs between 3.5 to 4 years old (see Chapter 11). So, this capacity is age appropriate for 3.5 years old on up!Again, the interview process and the ongoing nature of learning about the Learning/Educational Story will add layers of knowledge as trust is built re: strengths and challenges within learning environment settings.You also will know from the Levels of Engagement history, you know, if age appropriate, if you have healthy levels six and seven. These LOE bring together ones emotions with cause and effect thinking, furthering the integration of bottom-up emotions with top-down reflections.

3. Capacity to assess, integrate, and prioritize one’s own internal (self) needs in relation to external (context/other) needs

The trickle-down effect from integrating spontaneous and automatic functions, along with one’s own feelings and thoughts, prepares one for being able to juggle one’s own needs with other’s and external demands from the context.The integration of the colors with the relational styles of Heart, Hand, and Head give you a lot of information re: the balance of

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oneself in relationship to others. What is the rank order of the stress response? High combo zone anxiety is often paired with an over-accommodating heart, caring more about what other’s think than knowing what one’s own needs are. This stress response can lack being sturdy and assertive of one’s own needs. High red zone activity is often paired with being an overly demanding hand towards others. This relational strategy can lack being thoughtful about other’s needs, while overly concerned about one’s own needs. High blue zone activity is often pared with being lost in one’s internal world, having a self-absorbed stance along with being a detached head in relationship to others. This stress response can actually lack both taking care of oneself well along with being dismissive of other’s needs as well.A healthy balance of HHH gives one the capacity to juggle all three aspects - one’s internal world, being assertive towards one’s own needs, and being responsive towards other’s needs.The LOE’s give you an experience of how well a person juggles reading other’s cues along with expressing one’s own emotional cues within a dyadic dance (level 5).

Introducing these capacities to parents (Micro level).

As you have just seen in the table above, all of the other “steps” have given you a lot of information that may automatically give you the orientation you need to fill out the Early Assessment Form re: to the strengths and vulnerabilities of these executive functional capacities. As you get to know the family over the first month or two, there may be additional time to ask some of these questions in an organic way. Asking about how well one is juggling all the things they have to do is often an easy link to make when discussing stress responses, which make the juggling all the harder! I often refer to the multiple juggling acts involved with caring for a newborn – keeping a balance between attending to the baby’s needs and perhaps other children’s needs, let alone one’s own needs. This conversation, while clearly about the third capacity is inherently also about the first capacity - how well one juggles both spontaneous events (such as sudden needs or moments of joyful play) up against automatic routines (feeding/bathing/sleep routines with the baby). These can both be conversations as well as observations. One’s own experience of the parent/child as a practitioner, as you have conversations with the parent, will most often organically inform you as to the balance or imbalance of a parent/child’s feelings and thoughts up against the context. Does the parent have any reflective capacities? Can they share their emotional reactions as well as engage in problem solving with you (levels 6 and 7 of LOE)? An observant practitioner may be able to answer these questions without them being asked directly.

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Further Assessment of Functional Capacity Triggers.

Capacity #1, balancing spontaneous events with automatic routines. While most folks might think of this first capacity as also starting at an older age, because of its reference to conscious control over spontaneous and automatic processes, the balance of spontaneous with automatic routines begins right away. How well does the infant you are assessing balance engaging in spontaneous events of joy with participating in his or her routines of feeding, bathing, sleeping, and playing? With your knowledge of the history of my twin A, you can begin to notice that something was off right away. Feeding routines were interrupted with his trauma from choking while he was fed, due to his poor vagal tone resulting in poor coordination of his suck, swallow, and breathe capacities. Sleep routines were difficult to manage due to his being inconsolable. Bathing routines were a nightmare due to his tactile sensitivities to wetness. As you recall, diaper changes were triggers for prolonged stress responses until the age of 2. While we managed to have some, there was very little time left for anything spontaneous emerging from the green zone; the imbalance here is obvious. By 3.5 to 4 years of age, for typically developing toddlers, we begin to expect more capacity for top-down inhibition, and that there can be some capacity to inhibit stress responses further with more room to juggle and to “make better choices.” On that note, it can be disheartening to see two year olds expected not only to “use your words” but to also “make better choices” followed by punishments when they are incapable of many of these adult demands.

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Now, sometimes the lack of balance can be contributed to by the parent’s struggles with balancing these events as well.

If the parent struggles to balance these two events, the parent may need scaffolding and co-regulation from a partner. Sometimes parents are complimentary in this way, and other times they are become polarized. Always be looking for ways to help partners appreciate their differences and to work togther to complement each other, whenever possible.

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There are ongoiong discoveries and controversies within the group of psychologists, neuropsychologists and neuroscientiests that identify with being a part of the “embodied cognition” perspective. Within this group, one of the proposed models is that the development of “conscious and effortful control” that can juggle both spontanous and automatic events well, actually emerges from sensorimotor control. “In fact, sensorimotor control is primary and paramount, while conscious cognitive control becomes subordinate. The final “decision,”or the selected action/behavior, is an outgrowth of cortical-basal ganglia interactions” (Koziol, Budding, Chidekel, 2011, page 5 from on line). Here we see a reveral of the usual way we are trained to think about motor development. Rather than the thought leading to action, it is action that leads to thought. Treatment for cognitive, executive function challenges, then, from this perspecitve will always include some type of integrated sensorimotor activity embedded into the daily rhythms.

In having mature “effortful control”, there is much more than the juggling act itself of managing automatic routines with spontaneous events. In addtion, the “sensory and movement challenges of difficulties in starting, stopping, continuing, combining and switching motor action, speech, thought, memory and emotion” have to be considered (Anne Donnallon, 2010). When children/youth/adults rely too heavily on automatic routines, any abrupt shift in the expected schedule can easily turn into a challenge, often defined as “oppositional” behavior. Shifting and swtiching from one modailty to another can often be very diffiuclt during these transitions. Often, these emotional and executive challenges are accompanied with sensorimotor coordination difficulties.

Capacity #2, balancing feelings and thoughts. Damascio made it clear in Decartes’ Error (xxxx) that good decision making requires the connections between feelings and thoughts to occur.

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An imbalance within this dialectic can lead to emotional rigidity from obsessional thoughts as an example at one end, or complete spontaneity based upon whatever one feels like doing in the moment at the other end, such as with mania. Again, the question as to what/who balances you out comes into play with co-regulatory relationships. Too often, the differences are seen as barriers to communication rather than necessary compliments. Other times, the severity of the imbalance requires investigating medical support.

Capacity #3, balancing self and other/context. The NRF views the balance of giving and receiving, and making good decisions about those items from a well-developed reflective and private self (healthy, executive, head skill), as important for healthy relationships. While some cultures value dependence and a hierarchy, our culture leans towards valuing autonomy at the expense of breeding isolation and

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loneliness. Theories of mind constructs are integrated into the challenges inherent with this functional capacity.

The extremes of this imbalance can lead towards what mental health jargon would reference as “pathological accommodation” where one can be emotional subservient to another out of extreme anxiety, lacking a healthy internal self at one end and “narcissism” where one can lack empathy for others at the other end. With such extremes, it is recommended the parent receive individual mental health treatment.

Other considerations with those that lack empathy for others are those on the Autistic Spectrum or those with non-verbal learning disorders (NLD; not in the DSM, but some neuropsychologists still use it as a reference point). Simon Baron-Cohen wrote a very interesting book called The Science of Evil, (2011). He discusses how that several personality disorders along those on the autistic spectrum can lack empathy, but the origins of the lack of empathy differ substantially. He includes how those on the spectrum are at risk for them to become involved in the criminal justice system, without police officers and others in the legal system often realizing the differences. I’ve had adult clients who have come to me, having been in psychoanalysis for years, being treated for a narcissistic personality disorder, when, in reality, they were high functioning spectrum adults never diagnosed. When ones sensorimotor feedback loop, both from inside one’s body as well as from the external world, is giving one inaccurate or missing data, having a mature theory of mind can be very challenging indeed. This is very different from an intact sensorimotor feedback loop whose lack of empathy comes from neglect, abuse, or both.

Again, at times, a complimentary relationship can help shift one more towards balance.

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On a Macro level, the Executive System parallels many of the questions integrated into the Educational/Learning story. As one understands that the Executive system is all about the balance of polarities, one can see where some large scale “diagnoses” lean towards highlighting too much flexibility that borders on chaos – ADHD, and others lean towards too stability that lends itself towards rigidity – Autism, Obsessive Compulsive Disorder, and Depression. Already, one can be thinking, from a macro level systems point of view, about Macro level toolkits in terms of resources. How much one might need to team up with other practitioners, whether it’s someone from the school district, an Educational Therapist, a Speech and Language Pathologist, a Physical Therapist, or a medical practitioner for medical support?

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Go to Early Phase Assessment Form, pages 22 to 24, or the Early Phase Assessment Executive Form, pages 1 to 3. Now you can fill in the functional capacities on the designated case that you have been following.

Treatment implications in the Executive System: Working Both Bottom-up and Top-down with Triggers and Toolkits

Knowing Yourself: Just as it was emphasized for you to know your own range of colors, your own range of feelings, and your own range of sensory preferences, it’s now time to layer on these items your awareness of balance and imbalance between bottom-up and top-down processes. How well are you able to juggle the dialectics of spontaneous and automatic routines? Do you have the capacity for effortful control to manage and juggle these events? Are you pleased your choices? How well are you able to balance your feelings and thoughts? How well do you balance taking care of your own needs as well as others? The dialectic of both/and applies here. We are balancing the teeter-totter of life and relationships!

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Executive System Toolkits:

Motor development. As mentioned, treatment for executive challenges begins with the motor system. “Motor development and executive function are inexorably and inextricably linked because deviantions/abnormalities in motor development represent an early failure in “action control” which is essentially an early form of “EF.” ….The motor system allows cognition to evolve in order to develop simulative, “off-line,” cognitive control capacities. We believe that deficits within the motor system, as might be manifest by abnormalities or inconsistencies in motor development, generate (or at the very least, predict) developmental disorders (Koziel, Budding, Chidekel, 2011, page 12).

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As mentioned before, arousal itself is a distributed property – taking into account ANS reactivity, sensory reactivity, emotional reactivity, and finally, in this section, motor reactivity. All of these degrees of reactivities from different brain circuits co-create what color(s) of arousal one is in! Motor is involved in all of our fucntional behaviors from all of the brain systems! In the NRF textbook we give the example of the emergence of speech involving the integration of the green zone, looking at faces and hearing sounds (sensory), imitation of emotional and facial features that stimulate circles of communication (relevance), and the coordination of breathing with diaphragmatic support (regulation) with oral-motor sequences to vocalize, babble, and eventually articulate phonetic streams (executive) (NRF Textbook, page 372). In fact, please go now to pages 372 to 379 to read the section in Chapter 10 on motor development, paying attention to Table 10.2, which is a detailed developmental progression of motor development from newborns to two years old.

Other resources for motor development for parents can be found at: www.pathways.org They offer visual information on motor milestones as well. What is most impressive are their video clips (birth through six years) that showcase both typical and atypical motor development. These are very important for learning – to see them is to begin to learn them!

Of course, with any motor delay one will need to get help from a Physical Therapist or an Occupational Therapist. Physical therapists hold expertise in working with gross motor delays – challenges with tummy time, rolling, creeping, crawling, walking, running, etc. Occupational Therapists have expertise in fine motor skills (e.g., feeding, cutting, tying shoes, handwriting) as well as overal motor planning and praxis. Under the umbrella of Sensory Processing Disorder (SPD), there are two motor classifications that OT’s treat. Sensory-Based Motor Disorder (SBMD) is the broader category, with two subconditions. Subtype 1 are Postural Disorders and Subtype 2 is Dyspraxia. Postural disorders are characterized as having low tone, “poor balance between flexion and extension of body parts, poor stability, poor righting and equilibrium reactions, poor weight shifting and trunk rotation, and poor ocular-motor control also may be noted…Dyspraxia is an impaired ability to conceive of a plan, sequence, or execute novel actions…Often…associated with ideational problems (e.g., formulating goals or ideas for actions)” (Miller, Anzalone, Lane, Cermak, & Osten, 2007, page 138).

The description of dyspraxia follows tradtional theory development regarding motor planning following a seriel information procesing framework – progessing from perception (sensing), to ideation, to planning (thinking) to sequencing action (acting). Sensorimotor embodied cognition challenges this linear approah to motor development for both typical and atypical motor skills alike. The same critique would apply to any similar apporach to sensory integration or sensory processing disorders that is baised by a perception-cognition-behavioral model. [Notice a similar criticque to the linearity of the sensory information processing hierarchy in the Sensory System, Chapter 12]. In contrast to these linear and more top-down models of development, some within embodied cogntion endorse a sensorimotor interaction paradigm by stressing the significant overlap and interaction between cortical and subcortical regions that serve both top-down (conscioulsy controlled) and bottom-up (procedural learning/memory) circuits as they occur in “real-time” (Koziel, Budding, Chidekel, June/2011, page 772). The actual performance of the activity is essential in creating an internal “model” of that acitivity’s requirements. Through repeated procedural practice, a sensorimotor model is created in the cerebellum

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that holds all of the essential features in order to perform the activity. As this internal model is being created, it then predicts and anticipates the consequences of motor (behavioral) activities. The capacitiy to anticipate/predict is critical because the “direct sensory cortical feedback process operate too slowly for us to generate effective responses in “real-time” “ (Koziel, Budding, Chidekel, June/2011, page 776). Over time, with enough practice, the cerebellum learns to perform procedures faster with more accuracy. This explains how we gain more skill and control with automaticity through practice. (That’s how you learn the NRF!) The cerebro-cerebellar circuitry projects the most efficient way of executing behavior to the motor cortex, allowing the cortex to store the actual procedural memories. At this point, the person no longer needs to be consciously in control or aware of the intention to initaite a movement. At some point, the anticipatory model switches over to an automatic action model that functions without thought or awarenss (becomes unconscious). “…many of the same regions that appear to be involved in movement planning are also active during movement execution…neural correlates of both planning and execution processes can be found even in the activity of individual cells” (Cisek & Kalask, 2010, page 273). At this point, just the context (with a sensory preference or a sensory trigger) can stimulate the behavior (hence, procedural memories and procedural enactments).

Thought with effortful control, emerges from the motor control system. Rather than thought leading into action, its action that leads into thought. The maturation of higher order thinking skills are an extension of the motor control sytsem that is situated in the basic anticipatory internal models. The cerebro-cerebellar functions play a role in facilitating and allowing frontal systems to plan, to think ahead, to execute, and to abstract. (EC, page 4, left column). When declarative memory and langauge kicks in during the toddler years (2 to 3 years old) we now have additional support to the subcortical networks already at work. We can add langauge to our procedural learning experiences. Now, we have both bottom-up and top-down networks supporting our learning patterns.

What are the practical treatment implications from this perspective?

1. Repetition, repetition, repetition. This not going to happen by attending a clinic once or twice a week or having an early interventionist or consultant come to the home once a week or once a month. The most repeition is going to occur in the context of one’s natural environemnt with one’s caregivers. Caregivers must be taught whatever is most salient for developmental improvement so they can replicate the practice multiple times a day. This goes for any developmental improvement you want to see (speech, motor, sensory, emotional).

2. These motor (behavioral) loops are created in an intergrated cerebellar network with links to the ANS, sensations, emotions and cortical circuits. Thus, regardless what the “motor” (behavioral) intervention is, whenver possible:

a. Always “work”and practice from the green zoneb. Always “work” and practice within a relational and sensory environment with the

child/youth/adult preferences c. Always “work” and practice with positive comfort and joy from within the parenting

relationship. Use LOE as your guide for how you are conducting your specialization. d. As practitioners and parents, “work” to anticipate and predict triggers for stress patterns

to be a step ahead of them instead of surprised by them

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3. As practitioners and parents, learn to anticipate and predict what the needs are. Just like the cerebellum is creating an intermal model of anticipation and prediction, we are doing the same with mapping out the known triggers and gathering toolkits to catch things at the front-end and to have adequeate stress recovery tools at the back-end. As we can anticipate, we can change the action and the motor experience, creating new patterns, working to reduce and then eliminate the toxic stress pattern.

In terms of what sensory modalities to pair up with enhancing motor development, it is important to individualize this. The NRF is very cautious about generalized recommendations such as any one particual sensorimotor experience such as dancing, drumming, rocking, etc. While Dr. Perry’s six R’s are very informative, the NRF, along with DIR, focus’ on Individual Differences! In line with this, there are many existing motor programs that exist for parents to choose from that are organized and sometimes, corporate. One way to evalute a program is to ask these questions:

1. Is there an awareness of stress responses built into the progam so that if the child is either not in the green zone or becoming more dysregulated the practitioner will notice?

2. Is this a program that encourages the parent to do the activities with his or her child? 3. Is this a program that encourages a playful or joyful state when doing these activities with his or

her child? 4. Are there any of this child’s sensory preferences integrated into this [motor] program? 5. Is this a program that is rote or does it have anyway to flexiblyl individualize it for this child’s

needs?

Integrating sensations with movement. It goes without saying that integrating a variety of sensory modalities in conjunciton with movement would be a NRF principle. This can be done through an OT’s discression and clinical wisdom or through following a child’s sensory prefernces.

In Chapter 12 I mentioned Porges’work re: the imporance of the middle ear for picking up safety and threat. Here, I want to mention the research being done on motor rehabilitation in conjunction with music. Until recently, visula and proprioceptive modalities have had the most research done on them in relationship to motor control. Music has been viewed as a sensory preference but not as contributing to motor control. …”many studies have now shown that auditory rythmic cues can entrain motor responses” (page, x on the web). Thaut, M. H., McIntosh, G. C., & Hoemberg, V. Front. Psych. 18 Feb, 2015 http://journal.frontiersin.org/article/10.3389/fpsyg.2014.01185/full

Suggestions for Working with Capacity #1:

As mentioned, the balance of spontaneous events with automoatic routines is essential for smooth executive funcitoning. Spontaneous expressions include bursts of joy and play that begin in infancy throughout our lifecycle. The NRF is inherently dyadic in its focus as well as play-based. Getting to green (safety), comfort, and joy are always the first three goals of getting the dyadic relationsihp on line. If the child does have language and symbolic play skills, then, using these to express a full range emotional

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themes is critical. Here, top-control can be partially gained through play. When there is too much spontaniety, and all other items have been ruled out, one might wonder if there is ADD or ADHD at play.

Too much spontaneity: For this child/youth/adult, the challenge lies in continuing and combining motor action, speech, thought, memory and emotion (as per Anne Dollellan). For young children, teens, youth and adults who suffer from this, building in “external” executive functions are really useful. Just as most of us use our phones for off loading our executive functions as adults, these can be used for much younger children, as well. More and more, teachers are also using electronic devices to help. Uploading assignments and actual documents students work from in google drive are enormouly helpful. Papers are no longer there to be carted back and forth from school. They do not get lost this way! Taking picutres and uploading htem into a google file are also ways that inforamtion can be passed back and forth froom a pre-school to home and vice versa. I’ve had young children with ADD or ADHD diagnosis go from getting C’s and D’s because their work could never be kept track of in the to and fro of home/school to becoming A students due to their homework no longer being lost in a desk or some folder at home. Having a visual schedule with a velcro strip of pictures can be useful. Young children can have pictures of themselves doing their own routine. The more “say” they have in what order and sequene things get done, often, the better. Here, participating in setting up the morning or evening routine can give a child agency and internal motivation for participating in a sequence.

Educational therapists (ETs)are also very valuable regarding the support of students with poor executive function. With a good neuropsychological evaluation in hand that guides them to where the breakdown in skill lies, educational therapists are able to work on remediation of reading, writing, and math skills. Some ETs are able to smoothly move in between all three of these skills, others specialize in only one of these three skills. ETs are also able to help scaffold those with sequencing problems. ETs, again, when trained in the NRF, can track the child’s arousal state to know how to scaffold and titrate the cognitive work load to prevent toxic stress patterns. ETs are also excellent at helping youth organize themselves with long term projects that have to be done over time. Educational supports and work load accommodations most often have to be negotiated within an Individualized Educational Plan (IEP). These are done best, ideally, with a neuropsychologist’s understanding of individual differences and one who can be a “language translator” to the classroom setting. For those whose budget cannot afford an ET, some ET’s offer tutoring servcies under their guidance. The ET team leads the project, perhaps having a once a month check-in, with weeklky tutoring services, which can be less expensive than using the ET’s services weekly. Some after school programs offer tutoring support that help keep a young child on task, getting the “homework” done before going home. Many times, off loading the homework stress onto a neutral person can be very useful, reducing the parent/child stress within the relationship.

Too much automaticity: Oppositve of spontaneous events are automatic routines, which are necessary for effective and efficient functioning. If we had to think about everything we did, we would not be effective with our time management. For those with too many automatic routines, the goal becomes to improve flexibilty and spontaniety. Here, the goal is less about structure and more about being able to stop, shift, and switch motor action, speech, thought, memory and emotion (as per Anne Dollallon). Emotional rigidity often comes into play here (see the Relevance System/Chapter 11) so all of the relevance suggestions on co-creating joyful states, building an emotional muscle, as well as the Sensory

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Systems/Chapter 12 on individual sensory preferences and triggers are used with children who hold this inflexibility. Any abrupt changes in schedule or routine often creates a guranteed stress response with a person who has an imbalance of too much automaticity. Within a schedule that is adhered to, minor alterations in daily life often have to be dealt with. Whether its using sensory-motor strategies without words (sensory), or using words to mirror the disappointment (relevance), or a combinatin of both, the capacitiy for flexibility is built. Stanley Greenspan referred to providion of mild perturbations as “playful obstructions.” For young children, playing Colombo or playing confused can help expand a child’s creativity in problem solving and in stress tolerance. Providing organic problems to solve, help expand the emotional and problem sovling range towards becoming more adaptive. Some of examples include, a missing blanket from its usual location, placing two socks on one foot, having a cup overturned when it’s time for a drink, mixing puzzle pieces from two or three puzzles, and placing a hat/scarf on one’s elbow. The goal is for playful problem-sovling to occur, with an emphasis on the being playful rather than too frustrating. http://www.floridahealth.gov/alternatesites/cmskids/providers/early_steps/training/documents/floor_time.pdf

The goal of this first capacity, is to have a balance and integration of both spontaneous and automatic activities, with the development of top-down, conscious control that can juggle whether one should break away and shift to something pressing or stay on task to finish an internal need (e.g., eating) or external demand (e.g., work deadline).

It cannot be emphasized enough, that from this neuroscience perspective, that bottom-up sensorimotor activities, using the joyful engagement of the parent/child or with older adults the adult/therapist relationship is always going to be favored over sedentary top-down, talking only activities. While the child is developing conscious control, we combine both the bottom-up sensory-emotional experience with top-down talking. Practicing new strategies through role plays is useful because it is creating new action plans. Engaging in collaborative problem-solving, which requires more active engagement between both parties (see below) can be an advantage over rote compliance. So, for example one young child I worked with, during our play sessions had a very hard time managing his red zone escalations

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when he lost a game. The first phase of our work was not to talk about it. It was to teach him to use a sensorimotor strategy to contain his desire to scream or yell. He chose curling up into what we referred to as a “turtle” (a curled up fetal position on the floor). With practice when he was not red zoned, he grew to being able to quickly grab a weighted blanket, throw it over on himself and curl up in a ball. Mom and I knew to be calm and quiet. No talking allowed! This transferred from my office to a procedure he could use as school. Rather than yelling out in the classroom, he could pull his legs up onto the chair, wrap his arms around his knees and squeeze tightly. These were sensorimotor strategies that helped him begin to contain his anger. Later, we grew into talking about his disappointment, where he located that in his body, what that felt like, and what triggered the shame/disappointment. So, we moved from bottom-up into top-down strategies in his gaining more control over his emotional outbursts. Next, we see a variety of coping strategies for developing conscious control over high intensity emotional states.

Go to Adaptive Coping Strategies. As mentioned, the bottom-up side of developing conscious control occurs through much practice that begins to create internal models of anticipation and prediction. In the Regulation System, I introduced the concept of connecting to one’s visceral cues as a way to begin to be aware of one’s stress responses. In the Relevance system, we reviewed the concept of Exit Strategies when one’s stress responses were too intense. In the Sensory System, we introduced the concept that sensory preferences can be used both for calming and for modulating stress responses, helping to build stress tolerance at mid-range levels of intensity. In the Executive System we pull all of these together into a big picture that one can use for planning, practicing, and executing. When working at an executive level, it is ideal for one to be able to begin by recognizing a stress response. So, if that is the first step, begin with suggestions from the regulation system to develop more arousal awareness. As part of building awareness, being able to acknowledge the intensity levels of one’s stress response become useful next. This overlaps with recognizing the impact ones outward stress response expressions have on others. Sorting out one’s intent (to express one’s angry feelings) up against impact (scared a friend) is important to know (appraisal from relevance system and juggling self and other from executive system). Can one understand that high intensity negatively valenced red zone behavior can be frightening to others? If not, the practitioner may need to hover there to further explore that disconnect.

Next, we can begin to pull both the exit and the modulatory strategies into one big picture. In the Range of Adaptive Coping Strategies Worksheet, one can work with the parent or older child/youth together to individualize one’s plan. There are several different types of exit strategies. These are specifically for high intensity scales or SUDS levels. There are two different types of modulatory skills – with sensory objects (fidgets) or without them. These are for mid-range intensity scales or SUDS levels. These imply that one might not have to get up and move now if the strategies are nearby and accessible. The key to any of these coping strategies being successful is practice. The physical and mental exit strategies are meant to be practiced when one is in the green zone through role plays or actual moving through the exercise of using the materials chosen. The modulatory sensory objects or movements are also meant to be practiced while one is in the green zone. Having easy access to the sensory objects is obviously important for success. Practicing the self-regulatory ones is all the more important to learn the motor plans for each of the chosen options. One cannot expect to use any of these with mid to high intensity

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levels without automaticity. Just saying one will use a preferred method is not good enough without practice! This is a good example of a hybrid model. As one practices and gaining automaticity, one is also reflecting and talking to someone about what one thinks will work/will not work, etc. The trial and error level of experimentation also gives time to process what worked, what didn’t work, etc. Page 2 of this Worksheet has built in reflection upon the old strategies (e.g., screaming, hitting, biting, harming) up against the trail of the new ones. This back and forth process of bottom-up practice with top-down talking and thinking is optimal for the use of a both/and model.

Matching Treatments: The NRF is a type of meta-psychology that allows us to always be thinking about the match between child/parents and treatment modality. We use HHH to reflect upon where things are weighted, as well as the four brain systems. In an exercise of matching, I took all of the treatment modalities mentioned in Bessel Van Der Kolk’s latest book, The Body Keeps the Score, and offer a suggestion as to where each treatment suggested in treating trauma, be weighted. Again, knowing where the neurodevelopmental location of a treatment modality is useful when treatment planning and matching bottom-up, top-down, and hybrid models to the child/family’s neurodevelopmental capacities and needs.

Bottom-up and Top-Down Treatments

Using Bessel’s Suggested Treatment Modalities

Bessel Van Der Kolk’sThe Body Keeps the Score

Treatment for Trauma Neurodevelopmental LocationNeurofeedback Bottom-up RegulationYoga Developing Top Down control over Breathing,

Bottom-UpEMDR Hybrid, but requires the top-down narrativeSensorimotor psychotherapy Bottom-up, Reg/SenInternal family systems RelevancePsychodrama Sensory & Relevance (enactments)Theatre Sensory & Relevance

Suggestions for Working with Capacity #2:

This functional capacity is akin to integrating relevance and executive processes. As mentioned prior, neuroscientist Damasio (xxxx) and others have made it clear that one without the other is not healthy executive function, and integration of thoughts and feelings make better decisions rather than one without the other.

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Determining Which Direction the Integration Requires. For some, integration will require increasing connections to bottom-up connections to one’s body (viscera) to one’s emotional self (relevance). Suggestions for connecting to visceral and emotional cues are found in the regulation and the relevance system chapters. Other times, the growth is towards enhancing one’s capacity to think and to reflect. Making verbal cause and effect links (LOE six and seven) are one place to begin with a 3 to 4 year old. This can be done through symbolic play or pretend play. Answering the what, when, where, why, and how questions during play or conversation will enhance this process. Levels of Engagement that continue onward developmentally, promote further integration of thoughts and feelings. Ultimately, this functional capacity is about blending bottom-up with top-down links, creating balance between the two. The full embodiment of this is where one has a full range of positive and negatively valenced feelings that one can identify through one’s visceral cues with language where one can reflect upon them.

Additional developmental levels include the following “stages”, which increasingly develop clearer distinctions between self and other with increasing reflective capacities: multi-causal and triangular thinking (ages 4 to 7), grey-area thinking – emotionally differentiated thinking (ages 6 to 10), growing sense of self and an internal standard (puberty and adolescence), an expanded sense of self (early and middle adolescence), reflecting on a personal future (late adolescence and early adulthood), stabilizing a separate sense of self (early adulthood), intimacy and commitment (young adults), option for creating a family (early adulthood), changing perspectives on time, space, the cycle of life, and the larger world (middle age), and wisdom of the ages (aging) from Greenspan & Shanker, The First Idea, 2004.

The practice of integrating feelings and thoughts. The integration of feelings with thoughts is aided by the way in which parents/practitioners integrate Heart, Hand, and Head interpersonal styles into their conversations when there is a stress response. As mentioned before, the order of these three modes offer a developmental progression. Most times, a full conversation cannot take place until later, when the green zone has returned for both parties. Sometimes, the accurate mirroring with the 3 Yeses (in Relevance, Chapter 11) will calm down an angry young child. Even with very young children, if they have receptive skills, mirroring can bring relief. First, one has to be calm and curious in order for the conversation to be sustained. An attitude of all feelings are acceptable even if all actions are not, is a

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basic starting point of mutual respect one needs to convey if circles of communication are going to ensue. One has to mirror the bodily and feeling states that the young child “shows” us through his or her facial features – eyes, face, voice, and gestures (our states of arousal organized through our colors).

Heart (listening) skills can be broken down into three basic components:

a. Mirroring: repeating back exactly what the child/teen/youth/parent said or what one’s non-verbal bodily cues appear to be communicating. This can get confused with parents or partners who translate what someone has said, giving their own version of that message back rather than being very precise in using the person’s own words or non-verbal cues.

b. Validating: stating how this feeling makes sense! Acknowledging that the context makes sense as to why that feeling is present.

c. Empathizing: wondering out loud how that might feel to have that feeling. Imagining what that emotional state is like. Asking the sender if these suggestions are accurate is very important.

A very important piece to this “conversation” being successful is that there is only one person talking (sender) and only one person listening (receiving) at a time. Many unsuccessful attempts occur due to no one listening. This requires that the parent or practitioners place the oxygen mask on him or herself, first, so that listening capacities are on line. If parents are not capable of having this skill, practitioners are encouraged to develop them so they can model and offer this experience to the parent (for more on listening go to the Relevance System, Chapter 11 or search for Imago therapy, such as http://imagoworks.com/the-imago-dialogue/steps/).

The next phase is to switch the sending and listening role. This can only occur when the original sender feels understood and are “done” being seen for his or her feelings.

Hand (sending) skills, which enhance one’s sturdiness, having a self, and defining oneself as separate from another, also have basic components that can be taught to children (and parents) as they have more arousal regulation and can narrate their feelings:

a. (For older youth/teens/adults) Sharing intent: whenever possible, reassuring the listener that one’s intent is for more connection and to be understood in order to improve the relationship can set the stage for the listener to feel safer.

b. A No shame or blame towards self or others stance is crucial: Since shame and blame can occur both verbally and non-verbally, there are two guidelines used for this below. Each partner can be aware of the “no shame or blame” rule and can comment when that’s occurring, asking for it to be interrupted. Since shame is an attack on one’s personhood, it is not considered constructive feedback and needs to be interrupted. If the person sending cannot stop themselves from attacking that’s a good signal that a state change has occurred and one is in a red zone. At this time, then, the listener can set listening boundaries. The conversation goes on pause and, if needed, an exit strategy may be used, until the sender has stress recovery back into the green zone.

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a. Using “I” statements: are important to diminish the shame and blame attacks that can be under the guise of “sharing” when they are more harpoons towards one’s partner with “you” statements rather than useful communication. Even younger children can learn how to speak for themselves and to distinguish this from blaming someone else.

b. Monitor tone of voice and body language: again, the person with upset feelings can not only offer an endless stream of attacks on the other through words, but can offer them non-verbally as well

c. Offer appreciations when the listener gets it right! Giving positive feedback along the way can go a long way for the listener’s patience and endurance when they have to stretch to take on his or her child’s or partner’s point of view. (For more information on Sending skills google Imago therapy sites, such as http://imagoworks.com/the-imago-dialogue/sender-instructions/)

The talking/listening roles can go on back and forth for a while or over time, depending on the nature and degree of the conflict. While with children, parents need to be able to offer Heart skills rather spontaneously, when both are back to green, for parent couples and with older children/teens/youth, the sender is recommended to ask for a conversation appointment! In the Imago guidelines, issues that require a reflective conversation deserve to have a designated time for the discussion. The sender asks, with the listener offering an acceptable time within a 24 hour time frame. Parents certainly can ask for such an event as well, and with this modeling, children can follow suit. After each partner is satisfied in being heard, if triggers have not been integrated into the conversation, then a sending/receiving process of reflecting on triggers is necessary. The goal is always mutuality and expanding one’s capacity to hold more than one person’s perspective. This overlaps with the next functional capacity, being able to juggle self and other. Then, the Head skills of problem-solving are the last phase of this process (see below in capacity three).

The Head problem-solving skills require holding on to both subjective points of view, building a real reflective capacity for self and other, while getting into a creative flow of brainstorming that lends itself towards a win/win for both persons. The brain storming process encourages saying whatever comes to mind, even if it’s going to get vetoed. Because each partner can veto solutions that are too uncomfortable or do not “work” for them, there is freedom to speak up and to put things down on the list of solutions as part of contributing to the creative energy. After the brain storm portion is complete, each person rotates, taking turns crossing things off the list. Usually there are two or three ideas left on the table. Those are then prioritized as to what to try first, second, and third. Following this, once a solution is tried, it is evaluated. Thus, building top-down, reflective capacity is built into the emotional range as well as the problem-solving range. (for more go to NRF Textbook, Executive System, page X)

Guidelines from VISIONS, INC. that help build-in the practice of mutual respect are as follows. These are interpersonal guidelines that the NRF uses for any course and small group discussion.

1. Try on: learning new skills is important. Changing patterns cannot occur without new skills that turn into new procedures with enough repetition. Trying on can require being brave and facing

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our fears when we are new at something. We get support and co-regulation so that we can move forward with our learning.

2. Be aware and separate intention from impact: as mentioned previously, often one’s intent is not to harm, even when there is a negative impact. It is not possible to never have a negative impact! The attitude of an open learning system is one wherein we are always learning from our mistakes. “Fail early, fail often” reminds us that learning requires this process of making errors. Honoring both processes allows there to be a two-person exchange. Just as there is the designated sender/receiver, having a chance for both to walk through this process is essential. Without this bi-directional exchange, the person who feels injured or violated, may feel listened to, yet then, if the sender does not listen to the other person’s perspective, an acknowledgement that the other person’s intent had other meanings is lost. Both parties can learn about each other in this way.

3. It’s ok to disagree: “holding the tension” between multiple points of view is one of my favorite sayings. While the sharing of perspectives can lead to more arenas of agreement, the end goal is not to wipe out disagreement. We are all different and accepting differences lead to more capacity for pluralism in our professional and personal communities.

4. Practice both/and thinking: if we believe in multiple truths that can co-exist, then we are committing to practicing both/and thinking. We can see each other’s differences. If these differences stimulate a stress response, we cycle back into a reflective process (outlined above) when all parties have stress recovery. Our western culture usually offers an either/or perspective. It takes more effortful control to hold more than one perspective in mind.

5. Practice self-focus: when triggered, one can use conscious control to either being reactive (without thought) or to choose to focus on one’s internal state and triggers. When ready, one may need to send a “sender” signal to a person or group members for a sending/listening process to occur. The sender’s skills apply here, such as making “I” statements, revealing an “ouch” and asking for some behavior to change.

6. Notice process and content: some individuals and communities value content, other’s process. The balance of both is another invitation for a both/and experience. It’s a juggling act for sure. Finding the balance requires trial and error with each community. I’ve had some community leaders encourage me to use adult learning principles when I’ve come to train, suggesting I offer multiple ways to process content (e.g., shout outs, working on an exercise with a buddy, small group & large group sharing, moving around the room, sensory-motor breaks, doodling exercises, etc.). There is always a variety of reactions. For many, they have enjoyed the ability to process through various mediums. For others, the feedback has been, less process please, more content. Striking a balance is key and an ongoing learning process in each setting.

Dialectical Behavioral Therapy (DBT): For older youth, teens, and adults, Dialectical Behavioral Therapy (DBT) offers many core cognitive principles based upon several modules that guide one through a variety of ways to gain more emotional control. These three core modules are labeled Distress Intolerance, Assertiveness, and Interpersonal Effectiveness that involve skill building. http://psychologytools.com/dbt.html

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A range of activities are organized and taught to those involved in the training modules. For example, the Distress Intolerance section supports using mindfulness methods to create an emotional distance that allows one to “watch and accept” the comings and goings of them rather than to engage with one’s emotions. Using the metaphor of watching the wave come and go might be an example of how someone gains some emotional detachment. Using grounding methods described in the Regulation System, Chapter 10, are also always ways to refocus one’s attention, becoming engaged and present with the moment. This is one way to build up stress tolerance!

The Assertiveness module offers excellent skill building for modulating arousal, staying in the green zone, while delivering negative information or consequences that involve being sturdy with one’s needs. If one needs help to become a sturdy hand, here are skills that support that expansion. This PDF offers examples of the heart “giving too much” and later resenting it. Our Hand skills support our assertiveness capacities to develop. http://www.cci.health.wa.gov.au/docs/Assertmodule%206.pdf

The Interpersonal Effectiveness module includes becoming more aware of our impact on others when in the red zone. Distinguishing between healthy anger and problems with anger is useful. NRF jargon would define that as the difference between adaptive and toxic stress red zone patterns. Finding ways to down-regulate within DBT include use of exit strategies, humor, distractions, and relaxation techniques. http://www.cci.health.wa.gov.au/docs/Info-anger%20coping%20strategies.pdf Yoga is a way to engage with relaxation through our bodies and is a bottom-up strategy that meant to connect our bodies with our inner selves and to calm our minds. It does require some initial top-down control, however, to participate, which is often in a group setting, while following the instructor’s lead. Finding yoga groups that can titrate the learning to one’s arousal levels is ideal.

The issue of receiving top-down only treatment is in question regardless of the age of the client. Just as we always begin with sensory-motor work and bottom-up strategies with young children, we would do the same for any adult parents. In a small comparison study wherein eight weeks of DBT only was compared with eight weeks of yoga only, the measurement of heart rate variability was only impacted through the yoga, not with the DBT. With persons who have traumatized bodies, tolerating their bodily sensations and developing the capacity to notice their interoceptive cues can be an entire therapeutic task unto itself. Bottom-up strategies are always to be integrated into treatment and top-down strategies without bottom-up integration is considered to not be trauma or neurodevelopmentally informed care.

Time Travel: Another useful dialectic is the balance of mindfulness, calling us to stay in the present, with our use of conscious control to “time travel” – a form of reflection that holds the past, present, and future parts of ourselves. As important as it is to be present, it is equally important to learn from having a landscape that traverses past events, recognizes the recurrence or difference in the current event, and makes conscious control decisions either by planning ahead, or adjusting in the moment, continuing forward or to making a change. This form of reflection requires “knowing” oneself enough to recognize patterns of behavior. The Colors are where we often start with learning about our own patterns. The Colors often lead us into our past stories, helping us see if we are repeating something in the present. With reflection, we can evaluate if the re-occurrence has a positive or negative valence to it. If

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negatively valenced, we can think about choices. If we cannot find choices, we can ask for help. Often changes in patterns will require a use of a Heart, Hand, or Head skill that lies dormant or has not been developed. These skills can emerge through the use of symbolic play (for young children), through role play (for older children), through family psychodrama (for teens/adults) and through theatre work (for teens/adults). By enacting old and new patterns within our sensory-motor (embodied) selves, we gain access to skills that would not be possible otherwise. The emphasis on action in skill building is the NRF’s alignment with embodied cognition.

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Suggestions for Working with Capacity #3:

The cascade effect applies not only to the challenges when things progressively lack development from the first, to the second, to the third capacities, but also to the maturation of each of these as well. Hopefully, one can notice that developing conscious control, with top-down inhibition, is a huge step forward in development. Conscious control undergirds one’s capacity to integrate thoughts and feelings and to juggle self and others. The development of a private world, through one’s “Head” skills also comes along with conscious control capacities. Our internal reflections allow us to be able to make decisions about how to integrate our thoughts and feelings and how much to weigh our needs up against others’ needs. Children with developmental trauma and/or developmental delays will likely be behind in the 3.5 to 4 year markers when these inhibitory controls are normative to push forward. Always remember there can be a gap between one’s chronological age and one’s developmental age.

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As the relational skills were laid out with Heart (listening with empathy for others), Hand (sending one’s assertive message to others), and Head (problem-solving collaboration), a thread line through all of these is making room for two people, rather than this being for only one person. This is another reason why parent/child and parenting/couple treatment holds so much more power than individual treatment, for any age. We change mostly through the push and pull and tugs of relationships that influence our responses. Interpersonal neurobiology requires there being a relational component to treatment. A parallel shift has occurred within traditionally one-person psychologies, such as psychoanalysis, wherein the power of change is seen as occurring between the two persons engaged in an analytic process, rather than the change occurring through the interpretations of the analyst to the client, about the client, in an interpersonal vacuum. While individual child therapy may be necessary under certain contexts (e.g., a hostile divorce context) the norm for an interpersonalist would be working within the relationship.

The NRF textbook contains a rare Executive Function Table that shows the research behind emerging executive skills within each functional capacity. These emerge and are developed over time, as one can see. (Table 10.3, Pages 382 to 389).

One can see the developmental progression of what is referred to as “theory of mind” on page 389. While we see a big leap at 3.5 years of age, please note the 18-months-old onset of perspective taking. When the research experimenter offered goldfish or broccoli to 15-month-olds, they naturally chose goldfish. When the research experimenter showed a preference for broccoli and gesturally asked for it, the 15-month-olds stared at her, and then offered her the only “reasonable” choice of goldfish, using their own preferences as a guide. In contrast, the 18-month-olds stared yet actually gave her the broccoli she showed she wanted. Thus, perspective taking begins early! The research study for this can be found at Alison Gopnik’s Ted Talk at https://www.ted.com/talks/alison_gopnik_what_do_babies_think

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Collaborative problem-solving. The Heart, Hand, and Head skills provided in Chapter 11 and in this Chapter 13 (pages 20 to 22) lead up to the Head’s collaborative problem-solving skills. Table 9.9 on pages 344 to 345 in the NRF Textbook provide additional examples of how Heart, Hand, and Head skills can be used. In the Relevance System/Chapter 11 setting the stage for organizing 1s (non-negotiables), 2s (negotiables) and 3s, (one’s choice) often need to be integrated into the discussion. Some non-negotiables can have some negotiable aspects to them, such as when one brushes his or her teeth (before PJ’s or after) or what time of day one does his or her chores. Anytime one can have conversations and negotiate the item, it provides an additional experience of mutual respect and having to hold two perspectives in mind.

Summary

The executive system is now where one begins to hold all of the Triggers and Toolkits! Anticipating stress triggers from any brain system begins to be thought of in advance. Whatever can be caught at the “front-end” is done when it’s reasonable according to the context. In particular, with this brain system, knowing if the child/youth/adult leans more towards too much flexibility/spontaneity or too much stability/rigidity, helps one know where the triggers will be and whether to assist by providing more structure, more flexibility, or what the right balance of both is for this child/parent. Using our Heart, Hand and Head skills continue to be an integral guide in integrating our feelings with our thoughts, and building reflective and collaborative problem-solving experiences at the “back-end”.

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Teaming up with educational practitioners is critical to have in your relational community! On a macro level, this includes knowing where your high quality early care centers are, Early Head Starts, Head Starts, and school teams exist. As mentioned, specialists in helping sort out learning breakdowns include neuropsychologists and Educational Therapists. If advocacy or legal support to parents is needed, having solid referrals for help is critical. While medical support is often last on a practitioner and parent’s list, having solid pediatric and psychiatric medical support is critical when medical management is needed.

As always, co-regulating and scaffolding a young child is where we begin with learning executive skills. As that takes hold through repetition and turns into procedural memory, the child/teen/adult can often then provide oneself his or her personal sequence or can use external tools to stay on task. When there are lifelong challenges in this domain, we support parents to find community supports for their young adults who may need external support over the course of a lifetime.

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Here we end with this brain system’s reflective questions on cultural awareness, parallel processes, and power differentials.

Executive Brain System

Cultural Reflection

1. Does the family’s culture value movement and exploration (i.e., explore things orally, walking vs. being carried, being allowed to explore and move away from the parent)?

2. Does this family value dependence or independence or both? How does this family support these for their children?

3. How does this family’s cultural group view play (i.e., value or devalue)? Parent role in play? Play as a learning experience? How does this family play together?

4. In this family, who do they believe is their child’s best teacher?5. From a cultural view, how does this family believe children learn the best?6. What are the culturally laden expectations around attention? Impulse control? Being on time?

Thinking about others? 7. From a cultural perspective, what do the parents think his or her child needs, in terms of skills,

to make it in life?8. From a cultural perspective do these parents have “reflective” time to think about things and to

collaborate with you? 9. From a cultural perspective, how does this family view “intervention”? What is this family’s

cultural view of seeking intervention? Medical care? Psychological care? Mental health care?

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Parallel Process Reflection

10. Are you similar or different from this family in terms of sharing how learning as “play-based” is viewed?

11. Are you similar or different from this family in terms of values regarding attention, time, impulse control, and thinking about others?

12. If there differences in your professional values around any of these items, what are they? Does this cause discomfort? Alarm?

13. Do you find yourself comfortable or uncomfortable around the ability to hold his or her baby in mind in this home (e.g., parents distracted, cannot keep appointments, frequent cancellations)?

14. Do you have any professional concerns that the executive ability of the parent (i.e., to hold his or her baby in mind, to keep track of necessary schedules, appointments, and play-based learning) is dangerous to this child/spouse?

15. Whom do you go to for reflective practice to process your concerns?

Power Differential Reflection

16. Are there experiences for this caregiver/family in which they have felt excluded, discriminated against or treated poorly in terms of his or her own ability to learn and be educated?

17. From a cultural perspective, what makes this caregiver feel empowered/competent to work and to learn?

18. If there is a cultural difference between your value system and the parent’s value system in regards to learning, staying on task with schedules and appointments this child or parent needs? How comfortable are you with the differences?

19. If you are “triggered” by differences in how executive items are viewed, what stress responses (red/blue/combo) do you have?

20. If you are triggered by the differences, how does this affect your capacity to use your heart, hand, and head skills?

21. If the family is “triggered” by the differences, what stress responses (red/blue/combo) do they have? How do you respond to their stress responses? With your heart/hand/ and/or head?

22. If there is a professional concern that is alarming or reportable (e.g., refusing or inability to keep appointments for self-care or child’s needs, inability to plan ahead and follow through with necessary items), how will this be experienced by the family in terms of dominance and your use of power? Is there any way you can prepare them or modulate that for the parents?

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