Dr. Marielly Mitchell
As an occupational therapist, I work really closely with families and helping children thrive by connecting their brain and their body more, getting them more integrated from a sensory perspective and more coordinated from a physical perspective. Sensory integration is what really drew me into working with the nervous system.

And then, when I started to learn how breathing and sleep impact the brain development, it really caught my eye and was fascinating to me, and I saw it day in and day out in the clinic. So I started to merge the world of traditional occupational therapy and the other therapy called orofacial myofunctional therapy, which is about the mouth and the tongue, and most importantly, the airway.

So when a child has an optimal airway, they breathe well, they get enough oxygen, nitric oxide, etc., and their brain can fully function. And when they’re not breathing well, like mouth breathing, that can have a detrimental effect on their brain. I really honor that facet of development and principle so that everything else can fall into place that we traditionally work on in occupational therapy—whether it’s regulation, handwriting, catching and throwing, feeding yourself, etc.—because we work on a lot of different things, but you want to make sure the brain can process all that.

Elaine Taylor-Klaus
As a mom—my eldest kid is 30—I had lots of years of occupational therapy in my realm for different kids and reasons. Before we hone in on the orofacial myofunctional (which I think I got right? Mm-hmm. Yeah.), I want to help parents understand the correlation between occupational therapy and complex kids. What I remember learning was there’s a vestibular system and proprioceptive system, and my friend who’s an OT used to get really upset when I’d say, I don’t know, it’s voodoo, but it really works. A lot of our kids with complex needs benefit from a wide range of occupational therapy support as you described. Can you give us the broad base of why it’s so important to kids who are struggling with ADHD, autism, anxiety, etc.?

Dr. Marielly Mitchell
Absolutely. So if I can show you a visual really quickly, I think this, yeah. So this is called the hierarchy of learning. Okay. And so I've adjusted this, but what this is is a triangle that kind of shows you how the nervous system and the brain and the body connect. And so, um, I've just added here things that I think are really important, but I. What occupational therapy works on is really this middle of this triangle and the sensory processing at the bottom, which is really critical for you to have sensory integration that leads to regulation and coordination. And so a lot of our children with like A-D-H-D-A-S-D, et cetera, or like coordination challenges, if you're not processing that input, it's hard for you to have an output. Whether that output is a thought that you have to, what you wanna say to someone or to what Putting. Pencil a paper of what your thought is for what your assignment is in first grade and so.

Elaine Taylor-Klaus
So can I slow that down for a second? 'cause I wanna make sure everybody understands what you just said. So I get that there's a nervous system relationship to the hierarchy of our brain's ability to learn. Right? And then what you, you talked about regulation and correlation, so. Sensory process. We talk about kids with complex issues as having self-regulation issues all the time. And what you're saying is it's not just the behavior of did you act out or misbehave or follow through with what I ask, but it's a lot of internal self-regulation that you're talking about.

Dr. Marielly Mitchell
Absolutely. If I can show you a visual really quickly—this is called the hierarchy of learning. OK. I’ve adjusted this, but it’s a triangle that shows how the nervous system and the brain and body connect. I’ve added things I think are really important. What occupational therapy works on is really the middle of this triangle and the sensory processing at the bottom, which is critical for you to have sensory integration that leads to regulation and coordination. A lot of our children with ADHD, ASD, etc., or with coordination challenges—if you’re not processing that input, it’s hard to have an output. Whether that output is a thought you want to say to someone or putting pencil to paper with what your thought is for your first-grade assignment.

Elaine Taylor-Klaus
Can I slow that down for a second? I want to make sure everybody understands what you just said. I get that there’s a nervous system relationship to the hierarchy of our brain’s ability to learn. And then you talked about regulation and coordination. We talk about kids with complex issues as having self-regulation issues all the time. What you’re saying is it’s not just the behavior of “Did you act out or misbehave or follow through with what I ask,” but it’s a lot of internal self-regulation you’re talking about.

Dr. Marielly Mitchell
So our children with regulation challenges typically have a sensory integration issue. If your sensory profile is craving something all day long and you don't get that, you're gonna be dysregulated. Can you give an example of what somebody might be craving all day long? If I don't feel my body in space really well, I might be seeking—like what you said earlier—proprioceptive input (pressure) or vestibular input. I might be rocking or spinning or flicking things to visually stimulate myself, and I am essentially, as a child, grasping at straws environmentally to find something that gets me more integrated and more regulated.

And so that's where we look beyond the behavior, cuz every behavior is a form of communication. Typically it's a sensory need that's not being met for that particular person's sensory profile. As an OT, what I look at is: What is this little person's sensory profile, and is it getting the nourishment it needs neurologically every day? Does it get the movement? Does it get the pressure, or is it too sensitive and everything bothers it—for auto typically, or tags in your shirt. Everyone can be hypersensitive or hypo, which means they need it more. OK. And so that's what I do: I read what the nervous system is telling me and then create experiences to get them more integrated. Once something's more integrated, then they can have more—

Elaine Taylor-Klaus
Reactions that are appropriate. So what does it mean to be integrated? Help me understand that language, because that's very—OTs know what you mean when you say that, and we parents are like, yeah.

Dr. Marielly Mitchell
When someone's integrated, it means that they are, at baseline, at a really good, optimal level of arousal. It means they can sit and attend. If you're familiar with the Zones of Regulation, you're in the green zone—you’re available, ready to learn. You're here for it. You're not too overstimulated, you're not anxious, you're not overly excited, and you're also not lethargic and kind of slumping around. So you're in that Goldilocks zone. When you're integrated, you have a Goldilocks zone for arousal, and then you can act upon that arousal level and do what you need to do—whether that's play on a playground, listen to your teacher, pick up a pencil, put it in your backpack. You're not distracted by the need—that basic need—of your nervous system and wanting something else, whether it's rocking or moving or whatever it might be, or being distracted by something that bothers you.

Elaine Taylor-Klaus
So we see a lot of the autism world—the tendency to put on headsets to reduce stimulation, turn down lights. Is that helping for regulation, or is that just accommodating the problem in the first place?

Dr. Marielly Mitchell
It's both. The accommodation is helping regulation, and that's the balance you look for when you're working with a child. The accommodation that you're providing—Is it appropriate for the environment? Can they still do everything they need to do? And a lot of those accommodations work really well for a lot of kids.

Elaine Taylor-Klaus
Beautiful.

Dr. Marielly Mitchell
OK.

Elaine Taylor-Klaus
So thank you, cuz I think that sets the stage—OT is really fundamental and can be complicated for those of us who really—

Dr. Marielly Mitchell
Absolutely. I think OT’s like a double-edged sword. It’s a blessing and a curse of what we do. It’s hard to explain it, even though it’s really simple and it’s very functional. I can relate to that. And it’s hard to explain; it’s very abstract, and there’s a lot that goes into it. So yeah, OTs always have that—the ability to explain what we do is not a five-second elevator pitch.

Elaine Taylor-Klaus
No. It’s complicated. The simplicity is that when you help a kid become more regulated, it’s really extraordinary how it shifts their availability. I’m a big proponent of OT, and there are times—cuz I talk to a lot of parents I’ve never met before—when I’m listening and what I’m hearing is, “Have you gone for an OT evaluation?” I can hear when there is seeking. The term I often use is when a kid is seeking—seeking input of some variety.

Dr. Marielly Mitchell
Yeah. And those are the kids who are hyporesponsive. Those are your seekers. They need and crave and want that. They’re under the Goldilocks zone, and until they get that input, they’re gonna keep seeking it unless you give it to them in a more appropriate way for the setting. So you’ve got seekers, and then you’ve got avoiders, then you’ve got kids who are a mixed bag in between—different profiles within different settings. So, beautiful.

Elaine Taylor-Klaus
So you’ve got the seekers who are under-regulated or hypo, and then the avoiders who are hyper-regulated and need to be downregulated. And then some people have both, depending on what’s going on—depending on the system, right?

Dr. Marielly Mitchell
So you can be auditorily really sensitive but seek a lot of vestibular input. Those are the kids who are covering their ears and really startled by the fire truck, but need to be swinging and moving all the time. Or they’re really sensitive to tactile input—their clothing, or getting their hands dirty—but they seek a lot of proprioceptive input, so they’re constantly leaning on people or their gradation of force is off. Every profile has a different presentation that’s uniquely theirs.

Elaine Taylor-Klaus
Beautiful. That was beautiful. So let’s take a quick break, and then let’s come back and talk about brain and sleep. OK?
My guest is Dr. Mari Mitchell, and we’ve been talking about occupational therapy, sensory regulation, and why it’s so relevant to kids with complex issues. What we really want to move into is a conversation about sleep, breathing, and your insights from the OT lens. Talk to us a little bit about what’s important about that for our community.

Dr. Marielly Mitchell
Yeah. So, like we were talking about earlier, every child has their own unique sensory profile. Our children with different diagnoses often have sensory profiles that are more at risk for challenges with processing sensory input. That’s a neurological process. Sleep, oxygen, nitric oxide, and the amount and quality of restorative sleep are biological and physiological, but poor sleep can exacerbate how things present neurologically because the brain struggles when you don’t sleep well—especially in a developing mind.

If you’ve got kids who wake up at night, snore, grind their teeth, have nightmares, or wet the bed, these are all symptoms that the brain is having a hard time while that person is trying to get good restorative sleep. We essentially heal when we’re sleeping, and when we’re not sleeping well—especially with diagnoses like A-D-H-D and A-S-D—that can be one of the things that goes along with the diagnosis. It can really exacerbate what you’re seeing neurologically and turn up the intensity of the symptoms quite a bit.

So, as a clinic, we really specialize in bringing those two worlds together and making sure that kids are always breathing through their nose while we regulate them from the traditional OT perspective, and making sure that their airway is as open as possible and growing in the right direction so their jaws grow forward and outward, and not really narrow and tiny. That’s what we do.

Elaine Taylor-Klaus
As a mom of young adults, a part of me is trying really hard not to panic—and myself, because I couldn’t breathe till I was 12 since I was an allergy kid back before that was as well managed. One kid’s a mouth breather, another kid’s… I’m hearing you describe this and I’m thinking you’ve just described all of my kids’ entire childhood. I know I want to talk about kids, but can I have a moment of “it’s not too late,” or it’s not a crisis if they’ve hit older years?

Dr. Marielly Mitchell
Yeah, absolutely. You can always work on this. I have a dentist here in LA whose latest patient was 96. The person developed sleep apnea and wanted to address it, so you can work on this. Especially for females, because our bodies are more flexible due to hormones and childbirth, we have a lot more dynamic movement through the rest of our body. Everything’s connected, right? What you want in the lips, you get in the hips.

The younger the better for addressing it, but you can absolutely work on it. Every patient is different. If people are noticing they’re having a challenge with their sleep and it’s impacting their day-to-day life, it’s something to definitely prioritize, because sleep really is—especially as we’re starting to understand with technology—so critical to our overall health and wellness.

Dr. Marielly Mitchell
But I think you can definitely address this as you get older. When I learned about this 10 years ago, I had all my own challenges, so this is very near and dear to my heart. I had reconstructive surgery of my nose. I’ve had an expander in my mouth. I was 30, 32. I still need to expand again, but it’s something that I prioritize, and it changed my life. So, yeah, you can do it when you’re older.

Elaine Taylor-Klaus
Yeah. When sleep apnea was discovered as an adult, it definitely changed my life. So, let’s go back to kids. What do you want parents of younger kids to understand? Because I hear that if you’re older and you’re more fully cooked and developed, there are some consults that you might consider if you’re breathing through your mouth, if you’re noticing sleep interruptions, that kind of thing. Let’s talk about kids.

Dr. Marielly Mitchell
Yeah, I would say something that should be understood is that you should always be breathing through your nose unless you’re talking or eating. Really, you’re not supposed to be breathing through your mouth. When you breathe through your mouth, a few things happen. First, your brain perceives that as gasping, so it makes you more dysregulated. It puts you in fight or flight, which, for our A-D-H-D-A-S-D population—sensory kids—that’s not something they can really afford to have more of. That kind of neurological tone is not something that works in their favor.
In addition to that, you’re ingesting germs; you’re ingesting a lot of things in the air—dust, allergens, etc.—which, when you breathe through your nose, you have filters for, which is great. And you have a microbiome that neutralizes those kinds of viral loads and bacteria so it doesn’t go into your body, as opposed to straight in through the mouth. I call it the oral portal—stuff goes in your body you don’t want.

If a parent notices that their child is breathing through their mouth, I would try to educate your child and attempt to keep their nose really clean. Some kids you can just really keep their nose clean. If your child is having a hard time blowing their nose or doesn’t like you touching their nose, desensitizing that nose over time is a good idea so you can eventually keep it clean—like toothbrushing. You want to get in the habit of that and keeping their nose really clean so it can work.
If a child still has those challenges, I would recommend going to their pediatrician and getting the airway evaluated, and looking for an airway-centric dentist is a really good option. There’s a lot you can do, especially before age 6—about 80% of the jaw develops by then—where you can get really gentle expanders to help the direction of the jaw growing so everything has the room that it needs to and it can be supported to close well. And also, if you need to do therapy, then you can work on the strength and endurance of the mouth too. Every case is different. Not every case needs therapy. Not every case needs expansion. It just depends on the child.

Dr. Marielly Mitchell
Yeah, absolutely. You can always work on this. I have a dentist here in L.A. whose latest patient was 96. The person developed sleep apnea and wanted to address it, so you can work on this. Especially for females, because our bodies are more flexible due to hormones and childbirth, we have a lot more dynamic movement through the rest of our body. Everything’s connected, right? What you want in the lips, you get in the hips.

The younger the better for addressing it, but you can absolutely work on it. Every patient is different. If people are noticing they’re having a challenge with their sleep and it’s impacting their day-to-day life, it’s something to definitely prioritize, because sleep really is—especially as we’re starting to understand with technology—so critical to our overall health and wellness.

Elaine Taylor-Klaus
What are the kind of symptoms, if you will, that parents might be looking for to see that something that’s happening during the day may be impacting the trouble kids are having at night?

Dr. Marielly Mitchell
Yeah, so during the day you’ll see excessive drooling. You’ll see chapped lips is another one. They’ll have that red ring around their mouth a lot of the time cuz their lips are really dry, so then they lick their lips and the skin barrier gets compromised. You can also have halitosis, which is bad breath, because the pH balance of the mouth changes due to the air coming in and drying the mouth. Sometimes these kids will also have a tendency to have reflux more because they are swallowing air all day, so their little bellies get full. So it’s this vicious cycle that they get into.

They can also be more dysregulated during the day. Or they’ll have “allergic shiners,” which is what we call them, where they have really puffy or dark circles under their eyes cuz fluid’s not moving in their cranial region. The mouth is just open; the mouth is not really being used a lot. They’re probably weak there, so they’re not chewing things. Things aren’t “pumping and dumping” in this region. So they tend to have more fluid buildup in their face or puffiness here, or you can see poor circulation. And those are also some clinical signs during the day.

These kids tend to be a little bit more dysregulated. I have my kids who are “tired and wired” and present more as hyper—is that the word that they would use?—and then my kids who are falling asleep at circle time and they’re really tired. If you’ve got a 6-year-old who falls asleep every day after school, that’s something that, you know… Most parents know—if you’re thinking about something, your gut’s already on it. I’ve never had a parent really bring something to my attention and be off. Your intuition’s right as a parent. If you’re thinking something, parents are typically pretty accurate: “I don’t know about this.” Looking for people who are airway-centric is important in your community. Airway-centric dentists are a great starting point for families, I would say.

Elaine Taylor-Klaus
All right, so before we go there, I wanna go back to this—to drooling, chapped lips. A lot of kids, especially sensory-related kids, will chew on their clothes. Is that an indication, or is that something else that’s going on?

Dr. Marielly Mitchell
That actually can be one. Yeah, because what’s happening is that child’s trying to breathe better, so they open [the mouth], but they’re also getting sensory input to their jaw. So it could be both, or it could be one of them. But what happens is, when they chew on these chewies, they’re perpetuating an open-mouth posture, which can be more dysregulating and make them want to chew more. The same with nail-biting or hair-sucking, or needing to have something in their mouth all the time. A lot of the time, when you eventually meet those sensory needs and then teach them to breathe through their nose and close their mouth, that satiates a lot and it actually stops. The tongue is supposed to be suctioned to the roof of your mouth like this, to give you deep pressure—it’s like the weighted blanket in your mouth.

Elaine Taylor-Klaus
So when children don’t have that, they’re grasping at straws? The tongue is kind of floating in the mouth instead of pressing—is that what you’re saying?

Dr. Marielly Mitchell
Yeah. It’s not giving the sensory input to the roof of the mouth like it should. And there are other habits—thumb-sucking, pacifiers, bottles, etc.—that do that as well. When they don’t have things like that, they’ll use what they can environmentally: their shirt, their hair, their fingers. But their tongue should be providing that input to the roof of their mouth.

Elaine Taylor-Klaus
Everybody else listening right now is pushing your tongue to the roof of your mouth and trying to assess how often you do that. I’m just saying it’s… yeah.

Dr. Marielly Mitchell
Yeah. And that’s where your tongue should be. My tongue should— So that’s where everyone’s tongue should be. Your tongue is your natural expander and retainer. That’s what it is.

Elaine Taylor-Klaus
So you’re not pushing your teeth. You’re actually supposed to be doing that?

Dr. Marielly Mitchell
The tip of your tongue goes where you say the letter “n,” and then the rest of your tongue should suction to the roof of your mouth. Your lips should close gently without clenching, and that’s like a weighted blanket in your mouth. It gives a lot of sensory input to the roof of your mouth and also acts as your natural expander and retainer to sustain the space that you should have there.

Elaine Taylor-Klaus
Wow. I mean, just hearing that and trying to do it and realizing I don’t do that all the time. Is it that we typically do it and don’t notice, or do we have to train ourselves to do it?

Dr. Marielly Mitchell
That’s a good question. It depends on your epigenetics and your oral history in infancy. In places with longer maternity leave and more consistent breastfeeding followed by real foods, jaws tend to develop wide, with room for all the teeth. With that background, everything should work as it should, and the tongue has enough room on the roof of the mouth.

When bottles and pacifiers are introduced, the physics can push the tongue down and sometimes create narrowness in the palate (which is the floor of the nose). Then the tongue has nowhere to go but down, which can contribute to an open-mouth posture. Some people are also genetically predisposed to a more petite jaw, which leaves less room for the tongue.

Elaine Taylor-Klaus
Yeah. So let me tell people how they can find out more about you, and then as we begin to wrap this conversation, I want to ask you to think about what you want to leave parents with—because we’ve got parents listening with kids as young as 3 or 4, but also 24 or older, into their 30s.

Just reminding everybody: our guest is Dr. Marielly Mitchell. You can reach her at theraplayla.com and on Instagram as “Dr. Mary, all spelled out.” There are resources and free gifts there, and it will all be in the show notes so you can find her easily.

Elaine Taylor-Klaus
Mary, this is fascinating, and thank you. What do you want to leave parents with who are listening? Is there something we haven’t talked about that you want to make sure we hit? Or is there something you want to reinforce?

Dr. Marielly Mitchell
I would say for parents, I empower you to trust your intuition and your gut. If you think something’s going on, find people who will investigate a little bit further. If something you’re doing isn’t working, definitely look into sleep and airway health. Obviously, nutrition and elimination are also really important, but sleep for neurological conditions—I really believe in honoring biology and physiology before we go to neurology and psychology. I really think that a lot of kids with some of our neurological diagnoses have their sleep impacting the severity of their symptoms, and it’s something that can really be optimized. I think a lot of people don’t know that yet, and it’s definitely more on the cutting edge.
But optimizing the airway is an amazing way to help the nervous system function as best as possible. You can do that during the day as well as at night. You can do the therapy we do to help people learn where to put their tongue and keep it there morning and night, because when the tongue drops into the airway when they’re sleeping, that can make sleep less restorative. They move around, grind their teeth, snore—all that kind of stuff. It’s kind of like a baby cousin of sleep apnea.

Elaine Taylor-Klaus
Beautiful. Wow. So much here—so much to learn. Thank you. I really appreciate it, and I’m really glad you’ve had these insights and awareness and that you’re bringing it forward to the world, because it’s really important, and it’s not something I’ve heard a lot of people talking about over the years. Thank you. I really appreciate it.

Dr. Marielly Mitchell
Yeah.

Elaine Taylor-Klaus
Before we tune out, do you have a favorite quote or motto that you want to share with the community, just for the fun of it?

Dr. Marielly Mitchell
Truly: “Biology and physiology before neurology and psychology.” I really think there are a lot of things you can optimize for our populations that can really help with their overall neurological function. It’s something I’ve seen time and time again, and I encourage families to look into those things.

Elaine Taylor-Klaus
Beautiful.

Dr. Marielly Mitchell
Yeah.

Elaine Taylor-Klaus
Thank you again. Thanks for being here and thanks for what you’re doing. To those of you tuning in and listening, take a minute and think about what insight you’re taking away from this conversation. There’s a lot of information, so maybe what you’re taking away today is information you want to apply—some awareness you have. What are you aware of now that you weren’t aware of 30 minutes ago? What do you want to do with that information? How do you want to apply it? Is there a provider you want to talk to? Is there a conversation you want to have with your kids? Is there some curiosity you want to bring to your family dinner table to talk about what you’ve learned? What’s coming up for you, and what do you want to do with it?

As always, folks, thank you for what you’re doing for yourself and for your kids. You make an extraordinary difference, and I love Dr. Mary’s message: trust your instincts. You know better than anyone, and sometimes it’s really hard for us to remember how important it is to trust ourselves. I’ll leave you with that, and I’ll see you in the next conversation. Take care, everyone.