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OTSH 71: The Eighth Sense - Interoception with Dr. Kelly Mahler, OTD, OTR/L

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Welcome to the show notes for the Episode 71 of the OT School House Podcast.

In today's episode, we have Dr. Kelly Mahler on to introduce us to Interoception. Very few people have ever heard of interception and even less know what it means. This may even be the first time you hearing the word interoception. Well, whether it is or is not, you're going to want to listen to this episode. Dr. Mahler is a true genius when it comes to interoception and she has so much to share with us today. Press play to learn how you can assess your client and understand whether or not they have difficulties with interoception.

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Episode Transcript

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OTSH 71_ The Eighth Sense - Interoceptio
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Jayson Davies 00:00

Alright, let's see if I can do this. interoception, interoception interoception. That actually wasn't too bad, better than when I practiced it. Anyways, today we are talking about interoception and we have Dr. Kelly Mahler on to talk about it. Very few people have ever heard of interoception and of course, even less know what it means. I can only imagine what they might think when they first hear the word. And maybe this is your first time hearing the word interoception. Well, whether it is or isn't, maybe you've heard it several times, you're gonna want to stick around for this episode. Dr. Mahler is a true genius when it comes to interoception. And she has so much to share with us today, like little tidbits on how you might even be able to look at your kid and understand whether or not they have an interoception difficulty. Alright, so stick around, put your phone in your pocket, it's time to enjoy the OT school house podcast. We'll be right back after the intro.

Amazing Narrator 00:53

Hello and welcome to the OT schoolhouse podcast, your source for school based occupational therapy tips, interviews and professional development. Now to get the conversation started. Here is your host, Jayson Davies. Class is officially in session.

Jayson Davies 01:10

Hello, hello and welcome back to this episode of the OT school house podcast where we are doing a deep dive into interoception with Dr. Kelly Mahler. We're going to get into this pretty quickly I'm going to go ahead and introduce Dr. Kelly Mahler and then we will go ahead and get started. So I am excited for this. I hope you are as well. Dr. Mahler has served kids and adults as an occupational therapist for 18 years. She is the winner of multiple awards, including the 2020 American Occupational Therapy Association, AOTA emerging and innovative practice award and a mom's choice gold medal. She is an adjunct faculty member in the Department of OT at Elizabethtown College in Pennsylvania, and is actively involved in several research projects pertaining to topics such as interoception, self regulation, trauma and autism. Kelly is an international speaker and the author of eight different resources for interoception and kids with autism. So we are very fortunate to have her without any further ado, here is Dr. Kelly Mahler.

Jayson Davies 02:12

Hey, Kelly, welcome to the OT school health podcast. How are you doing today?

Dr. Kelly Mahler 02:16

I'm doing good, Jayson. Thanks. How are you?

Jayson Davies 02:19

I'm doing fantastic. I am loving it here in Southern California. We have some springtime weather and it is just amazing. Remind me again. Where are you located?

Dr. Kelly Mahler 02:28

I am in Hershey, Pennsylvania. And so I'm very jealous that you're having spring already have snow on our ground. Although I think it's like 40 degrees today. So hey.

Jayson Davies 02:40

Nice. So I mean, you're in Hershey, Pennsylvania, obviously that is known for being like the birthplace of Hershey, right?

Dr. Kelly Mahler 02:47

Yeah, that's right, like so on good days. You can smell chocolate in the air. And our streetlights are in the shapes of Hershey Kisses. Like, it's like the sweetest little place on earth to live.

Jayson Davies 03:01

That's awesome. And have you been like a lifelong Hershey Pennsylvania resident? Or how's that work?

Dr. Kelly Mahler 03:07

So I grew up in the next town over. It's called Elizabeth town, Pennsylvania. So my whole family still lives there. And so we're very close to help with lots of babysitting and you know, being a big part of my family's life. But we're also a little bit closer to like the Hershey Park amusement park and lots of good restaurants and stuff like that.

Jayson Davies 03:28

Well, I had no idea there was an amusement park.

Dr. Kelly Mahler 03:31

Oh, yes. My daughter's think that every small town has or has an amusement park, which is obviously not true. Very handy to have it in our back yard.

Jayson Davies 03:42

That's awesome. Yeah, I missed when we used to have like community fairs in my old town. And now like, it doesn't happen anymore. You know, that little Carnival just never. They don't do it anymore, miss those. But all right. Well, I am so glad to have you here. As you know, I actually recently attended a training that you did, actually, last week, it was a two day six hour training or so. And it was great. So much practical information for school based OTs. But unfortunately, I know not everyone has the opportunity to hear you speak to that manner. And so I'm just excited to have you here today. So how did you become? What's your background in the OT world? And how'd you get where you are now?

Dr. Kelly Mahler 04:18

Yeah, so I always knew that I wanted to work in pedes. Um, and when I got out of school, I graduated OT school in 2002. So I'm in my 19th year in the biz. And I didn't get a pedes job right away. It took me a few months, but I finally landed my first job and it just happened to be in school based OT. So I've been that's been the biggest part of my job ever since as being a school based OT. And I really love it. I've worked in so many different niches like I've been in like I've been the like primary OT for a whole school district. I've also worked in Pennsylvania, we have intermediate units, and so those are like staffing for a variety of different special education classrooms out there. So I've been in IU classrooms. And then I've also which came in super handy six years ago, I started contracting with a cyber school. And so I was hired originally to provide OT school based OT services to the cyber school students that were not benefiting from telehealth the telehealth model. So I got to go into their homes and provide OT in their educational setting, which was their health, which was such a different experience for me as a school based OT because I didn't have such interaction with families. So you know, we have a little bit, but like, I was immersed in a family culture, and it was so exciting. And then as I got to know these students, sometimes we did a hybrid model where we were doing work in the home. And but then I was also doing supplementing with a telehealth model. So I got my feet wet with telehealth before all of this COVID. So I just have always been really passionate about working with school aged children. I've done preschool school age, and I do have some young adult clients now as well. Oh, wow.

Jayson Davies 06:07

Yeah, you know, that's interesting. I mean, so many things that you said, I have questions I could go on just on that alone. But the last thing you said is having some young adult clients, and I've been getting a lot of questions. One is about interoception. And another one is, what do I do with, you know, those in between students, the transition periods, students, the high schoolers and the young adults? What do I do with them. And so I think that's a growing area for OT. Obviously, that's not exactly what we're here to talk about today. But I think it's going to be a huge emerging area for Occupational Therapy.

Dr. Kelly Mahler 06:39

I agree with you. And I think sometimes as a pediatric OT, it can be really intimidating to start working with adults, because you feel like maybe you don't have the skill set. But when we're talking about especially like the clients, I'm serving their neurodivergent clients, and honestly, it's this, they need the same things that I do with my school based clients, it's just done in a slightly more mature way. And working with those adult clients helps me to better understand my younger clients that don't have the insights yet, like so it has been like such a blessing to my career.

Jayson Davies 07:15

That's awesome. Great. I love that idea that you were actually able to see the kids that maybe telehealth wasn't working for. Because as I'm kind of looking toward telehealth, obviously, we've all been doing telehealth the last year, and you know that there's some kids that just don't benefit from telehealth as they would from in person. And so that's cool that you were able to find a program where they understood that and then worked with you to actually go into the house to to provide that service, that must have been really a really great opportunity.

Dr. Kelly Mahler 07:42

Great opportunity. Yeah. eye opening for me what families really go through on a day to day basis.

Jayson Davies 07:49

Nice. Alright, so we are here today to talk about interoception. And I think the first question I should ask is, what is it because I know not everyone has been well just, I guess heard this term even. So what is interoception?

Dr. Kelly Mahler 08:05

So interoception is our eighth sense. So it's just like all of our other senses where we have like, for example, our sense of vision, each sense, we know has a set of receptors and you know, this is OTs, right so your sense of vision, your receptors are your eyeballs pulling in information about all they see it outside of your body. So interoception works exactly the same way as all the other senses has a set of receptors pulling in sensory information. This time the information is being pulled from the inside of your body. So intro receptors are working. You have these receptors, first of all located extensively throughout your body. So you have them in all of your major organs. So you have interceptors in your heart and your lungs and your stomach and your bladder, your colon, your skin, your muscles, you have like very extensively almost everywhere. And these interceptors are pulling in information about how all of these different body parts are feeling like what is the condition of these body parts. So I usually give the example of your stomach like so you have interceptors the lining of your stomach pulling in information about how your stomach is feeling so is your stomach like does it feel gassy? Does it feel nauseous? Does it feel cool? Does it feel empty? You have like that tingly butterfly feeling in your stomach. And so just like all of the other senses, these interceptors pulling in all of this information travels up pathways in our spinal cord in an area of your of our brain called the insula. So what we know is the insula uses these incoming interoception messages as clues to your emotions. So if you go back to the receptors in the lining of your stomach, maybe your stomach like feels crassly or empty then your insula can use that as a clue that you feel hungry. Or if your receptors your interceptors in the lining of your stomach. Get That like, picks up that you have that little little butterfly or tingling feeling that maybe your insula uses that as a clue that you are anxious or nervous. So interoception is the sense that gives us information about how our bodies are feeling. And it provides this very tight body emotion connection.

Jayson Davies 10:21

Gotcha. And I'm going to ask you about that body emotion connection just a little bit. But I want to ask is the insula, it's been like 12 years since I took an anatomy physio class, is that this same part of the brain where all the all the senses kind of go through or is that more specific to this interoception?

Dr. Kelly Mahler 10:40

It tends to be more specific to interoception, and it is nicknamed the interoception center of the brain. However, like I think we have so much to learn. But I know that smell activates the insula, which kind of makes sense. I think all of our senses change the way our body feels. So like when you're listening to a certain song, it changes though it can change the way your body feels. So all of our senses are interconnected. And interoception is not something that's separate. I also was just reading some research that the certain vestibular input activates your insula. But in traditional like neuroscience literature, the insula is really known as the primarily is processing interoceptive information.

Jayson Davies 11:26

Wow. Okay, so know that insula, perfect. You mentioned research a little bit, where are we at in terms of research for interoception?

Dr. Kelly Mahler 11:36

Great question. We are in the infancy stage, like newborn J. Two, if you compare it to all of the other senses, and interestingly, there's a guy named Sir Charles Sherrington. And he defined interoception, back in the early 1900s, he wrote this paper, and he defined two senses. He wrote about something called proprioception, and something called interoception. Read he won a Nobel Peace Prize for his work. Yeah, everyone's like, oh, sir. Charles Sherrington, your idea on proprioception is so brilliant, right, and proprioception took off. And everyone's like, your work on interoception is so strange, we're just gonna ignore it. Over 100 years later, it was largely ignored until a brilliant neuroscientist named not named Dr. Boyd Craig. Key started studying interoception in his lab, and he was really able to give a lot of definition to the system and put a lot of research behind it. And then all of a sudden, people realize, like, holy cow, like this is a really important sense. And it does exist. And so since 2002, research has begun to emerge, and it is just exploding right now. Like the interoception. field is on fire, in neuroscience. In OT, it's getting there. I mean, there are new studies coming out almost daily.

Jayson Davies 13:10

Gotcha. And actually, the reason I asked you that, partially because you mentioned it, but also I wanted to know, are there any norms established at all for interoception?

Dr. Kelly Mahler 13:18

Yeah, not yet. So we know very little on the development of the interoceptive sense, we know that it's present from birth. Like if you think about like, most infants, from day one, they are equipped to notice discomfort in their body, right. And they, they're noticing that discomfort because of their interoceptive sense. So they noticed discomfort, their urge to cry, and then that is when the caregiver hopefully steps in and tends to their needs. And so from day one, we know that interoception was present. We don't know like what that developmental trajectory should look like in typical norms yet, do we need that information? It would be very helpful. But yeah, like I said, we have a lot, a lot to learn about interoception, especially from a practical application standpoint, and that's like where I want us. I mean, I'm biased, but I want us to step in and start figuring all this out, because we are the experts of performance and function and development.

Jayson Davies 14:24

I have a question, but then you said something. So I have a different question. And that is, you want OT to be in the forefront of interoception. Well, who right now is in the forefront of interoception and what are they doing that we might not be doing?

Dr. Kelly Mahler 14:38

Well, right now, the people on the forefront of interoception are neuroscientists, some medical practitioners and they're really trying to understand interoception from like a brain-based level or you know, neurology level. And like I said, very little work is being done on the practical application. By like, so how does interoception truly impact a whole wide variety of functional areas. And so that is where I see us as OTs to come in, take this really rich body of neuroscience, and help it to become more practical in a way that nurtures our students abilities to flourish and thrive.

Jayson Davies 15:28

Yeah, definitely. That's great. Obviously, as OTs, we really have that plaque, that practical application in the real world, so that'd be great. The other thing that I was I was thinking, as you were talking last time, was that you're talking earlier about his stomach, and you know, whether or not you're hungry, whether or not you're sick, you need to use the restroom, whatever that might be. But in terms of when a baby is hungry, sick, whatever, they cry, they don't give us a different type of cry, necessarily, maybe your mom and you can, you can determine the different cry, right, but they just cry doesn't matter what their stomach feels, they just cry. So that kind of leads me to my next question, which is, you mentioned two very different terms. And those terms were implicit and explicit interoception. I think that kind of talks about that a little bit.

Dr. Kelly Mahler 16:19

Yeah. So the interoception system has two main arms or categories or whatever you want to call them two main pieces. And so the first is what you said, implicit interoception. And that side of this sense is happening beneath our level of consciousness. It is all of the things that are happening in our body, that are helping to regulate our body to helping to strive for homeostasis, like that's it here, there's a word from blasphemer pass. So interoception is our sense of homeostasis. And so our interoceptive system, it notices when there's a certain change in the tissues in our body, and it activates a series of responses in order to help that homeostasis process happen. So these are things that we're not ever really thinking about, like, we don't wake up in the morning, and we're like, wow, like my livers releasing a lot of enzymes today, like it's happening, right. But then we also have the other side of interoception that you mentioned, and that's the explicit side, and that is the side of interoception, that reaches our level of consciousness. So like, we noticed when our body feels cold, and that's what urges us to regulate, like, maybe we put a blanket on or a jacket, or we go inside, or maybe we notice like a growling stomach. And that's what urges us to want to regulate to eat to help restore that comfort with our body. So there's two different arms of interoception always at work, always striving for that state of regulation.

Jayson Davies 17:58

Gotcha. And so again, I already asked you about norms, you know, we know that even babies have that sensation of something's going on, but they aren't able to kind of put a, I don't know, maybe a brainwave to what that actually means. And then you have that ability to actually put something to it, you use the term, I believe it was called interoceptive. Awareness is that kind of when you link the implicit and explicit together

Dr. Kelly Mahler 18:21

interoceptive awareness is typically referring to the explicit size so that the process that reaches our level of consciousness and interoceptive awareness involves our ability to notice a body signal. So we noticed the growling stomach, but then we also have to be able to connect that feeling or that body signal to the emotion like we know that when our stomach growls, it means I'm hungry, or when my heart races, it means I'm anxious. So being able to notice the body signal and then give it meaning is what interoceptive awareness can be defined as.

Jayson Davies 18:58

Gotcha, perfect. So you have spent a lot of time in the schools. And I'm sure you've experienced great opportunities in school. I'm, I'm also assuming that you probably have experienced some pushback in the schools. When it comes to interoception. And the schools, how do those really tie together?

Dr. Kelly Mahler 19:17

Well, there's a lot there's many, many different ways. So I think I should talk about probably the number one way and interoception has such an influence on so called challenging behavior. Yeah, so I prefer to call it regulation, but it's, um, I know that it's still and that's the pushback that I get still to this day, and 19 years and and challenging certain behavioral approaches. But if you are not understanding the way your body feels, when you're not understanding your emotions, you are not equipped to regulate those feelings and emotions independently. And what does that look like? It looks like major dysregulation all referred to by others I don't understand referred to as challenging behavior.

Jayson Davies 20:06

Gotcha. So behavior is one way, does it also impact actual functional output of handwriting using scissors, other occupations on the playground and stuff like that?

Dr. Kelly Mahler 20:16

Yeah, so intersection has been linked to a wide variety of aspects of our life. So it has been linked to body awareness and motor imitation, and all different kinds of self care, like sleep and dressing. And I mean, so many different I could just spend like probably the next hour listening, of course, that intersection has been found to influence in some way. It even influences social participation and our ability to understand how other people are thinking and feeling. I mean, it's so vast the influence that we're just now starting to understand how big of a deal interoception is, for a lot of our students.

Jayson Davies 20:59

Gotcha. And when you started to introduce the idea of interoception into your school, I mean, I can just imagine you sitting on an in an IEP and just bringing up this, how many syllables and just interoception, like six syllables, and people just looking at you like, what the heck are you talking about? How did that go when you started to introduce it into your school?

Dr. Kelly Mahler 21:21

Well, my schools already knew me as having very wild idea. I was challenging the norm. But I know and like, if you ever created this word into inception, it's not very sexy, like, I wish it were. And I was like, ooh, tell me more. But it's not right. Once you start to, like, really explain to people what interoception means, and you relate it to their own life and their own experience, like, so if you're like asking them tell me how you know, when you it's time for you to eat, or how do you know when you know, you need to go to the bathroom, or whatever it is, it's always comes back to, it's based on the way my body heals. And our bodies are designed to feel uncomfortable like that discomfort is important, because that serves as our urge to act and our urge to regulate. And so if that urge is missing for our clients, or it's confusing for our clients, or students, then it that that's where the dysregulation the breakdown comes from.

Jayson Davies 22:23

Gotcha. So I'm just still trying to think of like how you got into with this school. And so when you're in the school, you're in the IEP. Now you've mentioned interoception, you say you want to work on this. Now, kind of where do you go from there with a student? Once that student? Yeah, you say I have some some concerns with this? Where do you go from there?

Dr. Kelly Mahler 22:45

Well, I also try to tell and explain to the school how incorporating interoception would be a benefit of them to them. So whether it How is it going to benefit the classroom teacher? Well, if we're really actually addressing the deeper reasons behind why the student is having a hard time regulating or whatever it is in the class, then we can help them to see the benefits of what it is we're recommending. So I always try to bring it to and directly speak to whoever the stakeholders are in the room, like the administrator, how is it going to benefit the administrator like, you know, all the different players in the room and try to speak to, you know, their buy in. And then once they start to see that I still have to work hard at getting certain schools on board. And sometimes I just need to, you know, the proof is in the intervention and seeing the amazing gains that the students can make, then helps the school get on board. And I'm sure like, I mean, I'm probably no different. Like, I always pick that one teacher that loves OT so much. And I'm like, Hey, I'm gonna pick a student in your room, and we're gonna do this together. And then they start, like, create the buzz for you, right?

Jayson Davies 23:53

Finally. That's one of the things I teach in my course. Yeah, exactly what you just said, One, know, your stakeholders who you're talking to know what their goals are, because they're the people that have the decision making power. You know, as OTs, we don't have a lot of decision making power, we need help from above. And then the other thing Yep, start with one teacher. Just start with one. If you can get one on board, you'll be amazed by what can come with that. So

Dr. Kelly Mahler 24:18

yes, absolutely. And honestly, there's so many caregivers and people starting to learn about interoception like the schools have to get on board because especially if they're living in a if you're in a district that has a high degree of legal issues happening and due process and all that kind of stuff like you have to you have to know about this, because those savvy parents and caregivers are becoming educated and are starting to ask and push with us in schools.

Jayson Davies 24:48

Yeah. So I'm going to ask you what I think it might be a little bit of a tough question and I think people out there would like to hear your answer. What about because I know OT the field can sometimes be split on a few ideas. What about the OT that says, you know, what? Does interoception really belong in schools? And you've already given some great examples as to why but what do you say to someone who's maybe a little skeptical about it, whether it's an OT, maybe a teacher, but obviously the audience here is OTs.

Dr. Kelly Mahler 25:18

Why? Well, I would encourage you to think about how interoception is either impacting or supporting your student's ability to participate in the school. And we do know, like we mentioned that interoception in the research has found to influence so many aspects of participation. And so if your student is having a breakdown in participation, it is our job as the OT in the school, to think about all of the different whys and all of the different factors that are limiting that participation. And interoception is not always the main piece, it's just a small piece that we're missing. And when we incorporate it in enhances all of the amazing things that we already have in place.

Jayson Davies 26:01

Absolutely. I knew you'd have a good answer for that. Great. All right, on to the next question. And that is, what concerns are red flags, perhaps should OTs look for during their file review and the evaluation that may lead you to think hey, I need to look more into this student's interoception?

Dr. Kelly Mahler 26:19

Yeah, I mean, number one, that whole aspect of regulation piece, so like, if they're really struggling to manage their anxiety or frustration, or boredom, I definitely would, that sets off a curiosity in my brain, like, I need to look at their underlying interoception. If you're putting regulation supports in place, like you're using a specific curriculum, and they're memorizing the curriculum, or they're memorizing your coping strategies, and they cannot use them in the moment, that is a huge red flag to me. Like, they have to know, notice how they're feeling in the moment in order to realize, Oh, it's time for me to use the coping strategy that might have taught me or Oh, that's like, where I'm at in this, like, whatever, on my my five point scale, like, so if they're memorizing the things you're teaching, and but they're not using them in the moment, I would be suspect of that. But then there's a whole other variety of participation factors you can look at such as like, are they having accidents in the school like toileting accidents? Or are they like, are they the student that is either sprinting down the hallway last minute, because they're like, Oh, my gosh, I have to pee, you know, it's an emergency, or are they the student that is seeking out the bathroom all the time? Because they're confused about the way their body feels? Also, like looking at their feeding habits, their drinking? their sleep? So many different factors? For sure.

Jayson Davies 27:40

Yeah, and I think you're right on as well. What side of sensory integration? Or how does sensory integration sensory processing play in with interoception?

Dr. Kelly Mahler 27:51

That's an area we don't know a lot about yet. We know that interoception is the eighth sense. So it is not something that's working all on its own. And it you know, works alongside of all of our other senses to help us navigate the school or the day our daily routines. But exactly what that looks like.

Jayson Davies 28:11

No, sure. Yeah. Yeah. because like you said earlier, you know, we have our five regular senses that everyone knows, and those do come from external stimuli. But similar to interoception, proprioception and vestibular, obviously, as OTs we know, come from more that internal stimuli are muscle stretching, and the whatever canal inside of our ears, that's not an external stimuli. And interoception is obviously in a similar so I would kind of think that those three specifically would be tied a little bit more closely together.

Dr. Kelly Mahler 28:42

Yeah, I would agree with you, for sure. I can't wait to see what we learn and then next.

Jayson Davies 28:48

And you're going to be right at the forefront of it. So all right, I want to continue on a little bit. You just talked about, you know, some red flags, self-regulation, being some concerns, behavior, being some concerns, being able to even just like putting types of issues as concerns. Where can therapist go from there? Alright, the teacher came to them, they have these concerns, or you're seeing these concerns, in your observations? Are there evaluations available?

Dr. Kelly Mahler 29:13

Good question. And as you know, for my course, like this is a big dilemma. And the intersection feels like no one can agree on the best way to assess interoception. I do have an assessment tool called the Comprehensive Assessment of interoceptive awareness. And I'm going to be the first to admit that it is nowhere near perfect. It was just I created it for myself as a school-based OT because I needed a formal structured way to assess this new thing we were talking about and to justify why I wanted to include it in the supports that I was providing. It's not standardized, but it is really this assessment tool is so enlightening. When you administer it, you get such amazing qualitative feedback from either this Didn't themselves or sometimes we give it to like a school staff person, like someone that knows the present well to try to get as much information about their, their interoceptive experience, and it can be quite enlightening and give us insight that we might not have considered before.

Jayson Davies 30:17

Gotcha. And is that part of your manual online?

Dr. Kelly Mahler 30:20

Um, yeah, and do the assessment is available through a different publishing company, it's autism, Asperger's publishing company, and it's available through their website and through the current publisher.

Jayson Davies 30:33

Alright, and I always put together show notes. And so I will be sure for everyone listening out there that I will find the link to it. And I'll put on the show notes if you want to find where you can get that. Alright, so we do the evaluation, we have this type of tool, aside from that actual evaluation, kind of what do you do just when you're working with a kid and you just have that little concern? Maybe you call it a screening? Or they're just some questions that you like to ask the kid or like the parents? Are there specific questions that you tend to lean toward?

Dr. Kelly Mahler 31:02

Um, well, some of the questions from the interviewer that's a part of the assessment tool, I could give you some of your listeners now. And it's like, they're kind of fun questions to play around with. But like, I would just start asking the student, I mean, these are for the students that I'm supporting that have like the cognitive and communication abilities to answer some interview questions, I would just start by asking, like, tell me about like, like, what does your body feel like when you're hungry? or What does your body feel like when you're sleepy? And then I would start moving into like, some aspect of emotions, like, tell me about what your body feels like when you're excited? And then what does your body feel like when you're anxious? Or whatever emotion words would be a match for their age? and just see, like, are they like in touch? Like, Are they aware of any internal signals? Are they able to connect to those internal signals to the meaning? What is their inner experience? Like, I promise you that you will hear sometimes some very surprising insights, and things that will probably shift your ability to understand the student a little bit better, and then provide more targeted support for that learner?

Jayson Davies 32:08

Yeah, and you mentioned, sorry, go ahead.

Dr. Kelly Mahler 32:11

If they like, if I'm asking you those questions station, you're like, I have no idea. Like, I don't know how my body feels like, then you're like, oh, okay, like, it's too far forward thinking of me to be giving you coping skills, and regulation strategies to seek out on your own or a help card or a brake car, like you don't notice those need that feeling that need in your body, like, I need to rewind a little bit and help you to understand your body better, before you're ready to and equipped to use those strategies that I might have been doing a little bit too far ahead.

Jayson Davies 32:46

Yeah, that's perfect. I was just gonna ask you to kind of elaborate on that just a little bit. Because I agree, you know, sometimes we jump two steps ahead, and we have to back up. And so for that kid, I know, this isn't the training to go six hours, I do not have you for that long. Nor do I wish for any podcast the last six hours long, I'm not Joe Rogan. But I would love to just kind of maybe hear one thing that you might do with a kid who is having that difficulty putting, I'm hungry with an upset stomach, or that feeling of an upset stomach.

Dr. Kelly Mahler 33:21

So we always start like we're trying to build what we call body emotion, action connections. And it that is in line with the way that neuroscience currently says that self regulation develops. So the body peace comes from being aware of our body signals. So being aware of tight hands or hot skin or racing heart or growling stomach, and then we begin over time to learn what those what those sensations or body signals mean, like. So when my fists are tight, that's a clue for me that I feel frustrated or when my stomach growls, that's a clue for me that I feel hungry. So we start at the body level first. And we just want to help our students start noticing body signals within different parts of their body. And we do so we have tried to chunk this down and make it as easy as possible because it can be very overwhelming for many learners and students to start to notice and understand body signals. So we start with one body part at a time. And so like, sometimes we start with hands and we notice all the different ways your hands can feel. And we do it during like a lot of like fun and playful activities, helping them to notice the way their hands are feeling, understanding those body signals, and then we move on to a different body part. So over time, we're slowly building to their ability to check in and notice their entire body and understand their entire body. And you know, from the course like we are always emphasizing like there are no right or wrong interoception experiences, which is what I kind of like about this work because we're not coming in telling someone that they need to fix something like they're not doing any thing wrong. And I feel like sometimes we give that accidental message and some of the supports that we use in the schools. And so what we're trying to do with this work is to just help our students to discover self discover their own inner experience, or validating their own experience every step of the way. Because what your body feels like when you're hungry is different than what my body feels like when I'm hungry. Like what your what your hands feeling when you're squeezing a stressful is definitely what my hands are feeling when I'm using a stress ball. So we're honoring and validating each person's unique experience. And we're just trying to help our students to understand their own experience.

Jayson Davies 35:40

Absolutely. That's awesome. So I have a question. And it comes straight from all the listeners and followers of the OT schoolhouse podcast. They always want to know, how do you incorporate it into a goal? How do you make an IEP goal? You know, as a school based therapist, IEP goals are like, that is the thing, you have to have an IEP goal, because then you can't have services without an IEP goal. So how do you incorporate interoception into an IEP goal?

Dr. Kelly Mahler 36:06

So whenever a district is willing, I am always advocating for not having an interoception specific goal, I want to look at interoception as one of the supports that we're using to help to foster growth towards a participation based goal, a function based goal, like I don't personally, like really care if a student improves their interoceptive awareness. Like I want to know what was the like, the functional gain from that, right? Like if you just develop your ability to notice your heart rate, and nothing else, like what's the meaning of that, like you like if that helps you to become more aware of when you when you grow anxious, and you're starting to then seek out a coping skill on your own, and then you're able to stay in class longer, or participate in math class, or whatever it is, then that is amazing. So I try to never ever write interoception based goals, and help schools to see that this is just a support that we're providing your students in order for them to meet their function and participation based goals. Now, that being said, I have had some pushback from a few districts and I have agreed reluctantly to write it an interoception based goal that I like, I'll do whatever I need to help my students get the support they need. But that's not ideal.

Jayson Davies 37:31

Yeah, I understand. We all want to try and make collaborative type of goals and participation, you know, in the classroom types of goals, and to make a goal where you know, maybe Little Johnny will be able to identify that he needs to use the restroom or something like that would be a very interesting goal on an IEP, then in that case, you're trying to collaborate with the teachers and have the teachers create this goal. Where do you then? Because I'm kind of in the field, you know, if you don't document it, it never happened. Are you writing then a treatment plan? And in that treatment plan, you're kind of writing how you're going to work on interoception? Does it go into the notes of the IEP? Does it go somewhere on the IEP? Or how do you do that?

Dr. Kelly Mahler 38:12

Well, it really depends on your situation. Sometimes I put them in the SDI, like if I know like I want a student to have access to a body check chart, like that's just a strategy that we have, then I will put like something like that in SDI. But like I won't put them usually in a specific goal. Okay, you

Jayson Davies 38:32

said SDI just elaborate on that because terms go crazy when you move from district to district, county to county state to state?

Dr. Kelly Mahler 38:39

Yeah. Okay. So in Pennsylvania SDI stands for specially designed instruction. And it's like a list of things that we have in the IEP that once they get in that list, and the school is legally mandated to provide it. They're like if I put access to body check chart in the SDI is and that's something that feasibly should be happening. And we do have to, like, even specify the duration. So I could say, like, one time a day, or a five times a week, or whatever it is. And then hopefully, and I don't try to be like as highly specific law, but I'll say access to a variety of interoception supports, and then I'll put in parentheses, for example, the bar chart, or you know, whatever it is that we're recommending, and then we'll put the duration and that's like, a wish list kind of duration. That's supposed to be happening. But, and I do try to write those it definitely with support and collaboration of the classroom teacher.

Jayson Davies 39:37

Yeah, and for anyone listening, every single IEP has that section. It just is called something different. It might be called your accommodations section or your instructional strategy section. But yeah, you can add accommodations or whatever it might be into that area. And that's a great example of what you might put in there. Alright, so we're going to wrap this up pretty shortly but this entire talk you have been mentioning your work and where interoception might be headed in five to 10 years. So with that, I have to ask, what are you working on? Or what are who are you working on with what? Oh, my,

Dr. Kelly Mahler 40:13

okay, well, I have a lot of intervention based research going right now we want to make sure that I have the the interoception curriculum, which is our like framework for building interoception. And I use that all the time in the schools. But we want to make sure that what we're telling people and recommending to people is evidence based, and that we can come to the table, especially as OTs, we are notoriously bad. I putting evidence behind our interventions. And I do not want to continue that streak. So we are working so hard we are in year five, we have amazing outcomes through all of the work. So that's a big passion project right there of me doing all of that research with colleagues. And yeah, that's what I think the one of the biggest things, we're always working on new intersection resources to help people practicing in a variety of places. And we have new online courses that we're always trying to kind of push the bounds on new topics. Yeah. So we're just having a lot of fun with everything.

Jayson Davies 41:16

Awesome. And so with that, then where Can everyone go to find out more about you? I know you have some free resources available. So where can people find those?

Dr. Kelly Mahler 41:24

Yeah, so we have so many free resources on my website, it's at tele dash So my last name is spelled Mahler. So it's, which I'm sure you'll put in the show notes.

Jayson Davies 41:38

Absolutely. Yep. Of course, wouldn't miss it. Great

Dr. Kelly Mahler 41:42

There's tons of free videos, printables. blog posts, you name it. It's there free resources.

Jayson Davies 41:49

Yeah. And for anyone listening, if you ever have the chance to go see Kelly, whether it be live on zoom, be sure to take that opportunity. We spent, I don't know how many people were on that about 300 or so. Yeah, yeah. And so it was fantastic. We were on zoom. But if you eventually can see her live, I'm sure that'll be coming up here hopefully soon. Be sure to take advantage of it. Because you can use interoception not just you don't have to be the interoception occupational therapist. And I think some people get a little bit like, Oh, my gosh, I have to use whatever I just learned. And I'm actually gonna let you speak to this in a second is how important is it not to just use interoception? in your practice?

Dr. Kelly Mahler 42:36

Yeah, it is only a small piece of what it is we do as OTs. It's a it's a really big missing piece right now. But it but it is a small piece of what it is we do.

Jayson Davies 42:46

Yes. And so Kelly has so much on interoception, but she also has so much of good occupational therapy knowledge just in general. So be sure to go check her out. And with that, I want to ask you, do you have any other information that you want to share or anything like that, that I don't know, just anything for that therapists that might be looking into interoception

Dr. Kelly Mahler 43:06

Yeah, I don't know, just I would just start with the free stuff and learn a little bit more about interoception. Think about how it could be impacting the students that you serve. And it has completely shifted my ability to support my students, especially the dysregulated ones in a more meaningful way. And it really falls in line with what we believe in as OT is because it's a process of validating another person's experience. It's not us coming in and telling someone what their experience should be like and how to act, quote, unquote, more typical, like it's really honoring who they are as a person. And that's what I think I love most about science.

Jayson Davies 43:42

Great. Well, thank you so much for joining us today and I look forward to keeping in touch to see where you go with interoception. That'll be great.

Dr. Kelly Mahler 43:49

Thanks, Jayson for having me.

Jayson Davies 43:51

Definitely take care. Alright, and that wraps up this episode of the OT school house podcast. I really do hope you enjoyed that conversation with Dr. Mahler. She is just so knowledgeable when it comes to interoception and so many other areas. Be sure to check out the show notes for this episode, as well as her website To learn more about her and check out the resources she has, some are free, some are paid, but they are all wonderful. With that take care and have a great rest of your day. See you next time. Bye.

Amazing Narrator 44:26

Thank you for listening to the OT schoolhouse podcast. For more ways to help you and your students succeed right now. Head on over to until next time, class is dismissed.

Be sure to subscribe to the OT School House email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs.

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