Modulation
It’s important that, as therapists, we understand that respiratory function is related to regulatory functions in many areas from levels of arousal to digestive functions to neuromuscular and postural/motor development. A nervous system that is often or constantly in distress from fear, anxiety, sensory defensiveness, pain, or compromises in body functions will undoubtedly demonstrate compromised respiratory function.
When the brain perceives anxiety, fear or pain the automatic response is Flight/Fright/Freeze/Fight. This results in energy and blood flow being diverted to the extremities. If a child who is extremely sensitive to sound is sitting in a classroom and the fire drill sound unexpectedly happens, we might see any or all of the Fs reflected in the response. For instance; covering ears, rocking rapidly, hand flapping, screeching, running, lashing out at other children or adults. Anyone at any age may respond with vomiting, diarrhea, headache, dizziness, fainting, and short shallow breathing before an exam at school, or a big game or performance, giving a speech, preparing for a big date or getting married.
Developmental Dysfunction
It is also important to look at the many facets of development influenced by and/or dependent or interdependent on adequate respiratory function. There are demands on rate, depth and grading of respiration to support a long list of outcomes. For example: breath holding for stability will negatively influence the fluidity and skill in the desired outcome, for example handwriting, climbing the ladder to the top of the slide on the playground, interacting and communicating with others.
That means that if we are focused on one outcome area, for instance speech, eating, fine motor skills, etc., we may be missing the support necessary to make any gains in that area.
Respiration begins with practice in the last trimester of fetal development. The regulatory
functions of rhythmicity and variation of same are also practiced in response to their own
movements and in response to mother’s activities or lack thereof. Anyone who has been
pregnant will tell you that babies become annoyingly active when mom is trying to sleep during that last trimester. At birth baby already has ways of self-regulating all be it very limited and for short lived periods. Their repertoire includes cry, suck and gnaw.
Intervention
Because of the primary and foundational nature of respiratory function to all aspects of
development, we should address the suck/swallow/breathe (SSB) synchrony that normally
develops into a synergy as a place to start in both assessment and treatment. Most adults
intuitively know when an infant, toddler, preschooler or older child is out of their own resources to solve a regulatory issue and may also know when sucking is necessary or rocking or bouncing or patting or changing positions or environments. In many cases these same strategies will provide the necessary support for re-regulation. It is often misconstrued that this kind of support is giving in or somehow impeding the child/grownup from learning how to care for themselves. I would contend that it is up to others to help a child re-regulate and learn strategies so that their arsenal of options will increase their own ability to manage difficult situations. We know this goes on for a lifetime. How often do we suggest to someone to “just breathe”, “take a deep breath”, or “stop and come back to it later”, giving time for respiratory and cardiac rates to drop into a zone that allows the system to re-regulate itself if it can.
Examples
Children with a diagnosis of autism, cerebral palsy, or sensory defensiveness typically present with difficulties in regulating or a demonstrating a variety of ways to manage depth, rate and grading. The child with a diagnosis on the autism spectrum typically presents with short, shallow respiratory patterns with limited abilities to vary depth and rate thus keeping them in ranges that do not support many options to re-regulate. The same is seen in both cerebral palsy and sensory defensiveness. All three diagnoses may also demonstrate difficulties with suck/munch/bite and chew. Respiratory variation and oral motor function variation behaviors offer the longest list of most accessible and most powerful tools for self-regulation we have from womb to tomb. In the case of cerebral palsy, the child is, in many instances, also extremely limited in using motor and postural functions which is the next most powerful set of tools we have. Postural/motor differences are also seen in the child with a diagnosis of autism and/or sensory defensiveness and will demonstrate this in dysfunctional respiratory and head/neck/mouth, face and trunk patterns.
In each instance there are many other outcomes requiring different therapeutic approaches but addressing and monitoring respiration should always be a priority in each case. In some, it may be beginning with primitive SSB functions. In some, basic regulatory functions. In others, it may be looking at early postural development (jaw, tongue, neck). Any or all of these may need addressing regardless of the diagnosis.
Patricia Oetter, MS, OT, FAOTA