Facilitating Physiological Flexibility Following Early Autonomic Disruption: A Clinical Framework

 DRAFT COPY

Holly Bridges BA Psyche

LicenseToThink

https://www.arthollybridges.com/

 

 

Abstract

Early disruption to autonomic organisation has been proposed to influence physiological development across the lifespan. Building on Polyvagal Theory and Kram's Perinatal Autonomic Cascade, this paper explores the clinical implications of incomplete autonomic organisation and considers how continued developmental organisation may be facilitated in adulthood.

Building upon the proposition that early autonomic disruption may contribute to a restricted physiological repertoire, this paper presents a developmental clinical framework describing how functional availability may be progressively expanded following therapeutic intervention. Functional availability is defined as the moment-to-moment accessibility of physiological and psychological processes under prevailing autonomic conditions. Rather than directly targeting higher-order cognitive or behavioural functions, the framework proposes that therapeutic intervention first facilitates increasing access to autonomic states associated with safety, creating the conditions from which physiological flexibility and broader physiological and psychological organisation may progressively emerge.

The framework is operationalised through the Anxiety Reframe Technique (A.R.T.), a movement-based therapeutic approach developed through more than a decade of clinical practice. The paper presents an observational clinical case involving a 45-year-old autistic woman who participated in one preparatory session, a five-session intensive delivered across five consecutive days, two follow-up sessions, and a four-year follow-up. Clinical observations are organised according to four progressive themes describing changes in physiological flexibility, functional availability, subjective awareness and participation.

Across the intervention, clinically meaningful changes were observed in behavioural initiation, interoceptive awareness, emotional accessibility, sensory processing, social engagement, agency and participation. 

While conclusions are necessarily limited by the observational nature of a single case, the paper presents a clinically derived framework integrating Polyvagal Theory, Kram's developmental model and the concept of functional availability. The framework provides a basis for future clinical research investigating continued autonomic organisation, physiological flexibility and participation following early autonomic disruption.

Introduction

The autonomic nervous system undergoes extensive organisation during the perinatal period. This developmental process supports the coordinated organisation of multiple physiological systems, including cardiovascular, respiratory, vestibular, proprioceptive, sensory and affective function. Early autonomic organisation provides the physiological foundation upon which later emotional regulation, social engagement, learning and participation develop. Disruption to this process has been associated with enduring consequences for physiological regulation and neurodevelopment (Porges & Furman, 2011; Kram, 2025).

Polyvagal Theory has contributed substantially to understanding how autonomic state influences behaviour, emotional regulation and social engagement throughout the lifespan (Porges, 2011). By distinguishing physiological states associated with safety from those associated with defence, including both mobilisation and immobilisation, it provides a functional framework for understanding how autonomic state shapes behaviour, experience and participation. More recently, Gabriel Kram's Perinatal Autonomic Cascade has extended this developmental perspective by proposing that birth involves a coordinated sequence of autonomic initialisation across multiple physiological systems. Kram further proposes that disruption to this sequence may result in incomplete autonomic organisation, while suggesting that aspects of this developmental process may remain capable of later reorganisation (Kram, 2025).

These perspectives are consistent with a broader body of developmental neuroscience demonstrating that nervous system organisation remains experience-dependent throughout life. Although the perinatal period represents a time of heightened developmental plasticity, physiological organisation continues to be shaped by movement, sensory experience, environmental interaction and learning across the lifespan.

While considerable attention has been directed towards understanding the consequences of early autonomic disruption, comparatively little has been written about how clinicians might facilitate continuing physiological organisation in adults whose early autonomic development may have been compromised. Many therapeutic approaches aim to reduce symptoms, improve regulation or increase adaptive functioning. Less understood is how clinical intervention might expand the underlying physiological repertoire available to the individual.

From a developmental perspective, restricted autonomic organisation may be understood as limiting the range of physiological states available for experience and action. As physiological organisation expands, previously unavailable physiological states and processes may become accessible. In turn, psychological capacities—including agency, interoceptive awareness, behavioural flexibility and participation - may become increasingly available, not because they have been directly taught, but because the physiological conditions that support them have emerged.

This paper presents an observational clinical case illustrating one possible developmental pathway following early autonomic disruption. Drawing on an eight-session intensive intervention with a 45-year-old autistic woman, we describe a sequence of observed changes organised around four clinical domains: physiological flexibility, functional availability, subjective awareness and participation. Rather than proposing a new theory of autonomic development, this case offers a clinically derived framework for observing how expanding physiological organisation may be accompanied by progressive changes in psychological functioning and everyday participation.

Clinical Framework

The clinical framework proposed in this paper describes four interrelated domains through which developmental change may be observed following therapeutic intervention: physiological flexibility, functional availability, subjective awareness and participation. Rather than representing discrete stages of treatment, these domains are understood as interacting processes that emerge and reinforce one another as physiological organisation expands.

Within this framework, physiological flexibility refers to the capacity to access, tolerate and transition between physiological states in response to changing internal and external demands. Increasing physiological flexibility is proposed to provide the physiological conditions from which broader psychological functioning may emerge.

Functional availability is introduced as a clinical construct describing the moment-to-moment accessibility of physiological and psychological capacities under prevailing autonomic conditions. Rather than proposing that intervention creates new abilities, the framework suggests that capacities previously constrained by restricted physiological organisation may become increasingly accessible as the individual's physiological repertoire expands. This may include changes in interoception, emotional accessibility, behavioural initiation, executive functioning, agency and social engagement. The emphasis is therefore not solely on symptom reduction, but on increasing the range of functions available for participation in everyday life.

Within this framework, subjective awareness is viewed as an emergent process rather than the starting point of change. As previously inaccessible physiological states become available, individuals may begin to recognise bodily sensations, identify patterns of physiological regulation and develop a more differentiated awareness of themselves. This awareness is considered to arise from changes in physiological organisation rather than preceding them.

Participation represents the broader expression of these developmental changes within everyday life. As physiological flexibility expands and functional availability increases, changes may become evident in relationships, communication, work, learning, self-care and community participation. Participation is therefore understood not simply as behavioural performance, but as the lived expression of increasing physiological and psychological availability.

The present case explores these four domains through repeated clinical observation across an intensive intervention. The framework is offered as a clinically derived model to support the description and investigation of developmental change following early autonomic disruption.

Clinical Method

The intervention was delivered as an eight-session intensive consisting of five consecutive daily sessions followed by three follow-up sessions over the subsequent weeks. Session were conducted online.

The clinical approach was guided by the proposition that following early autonomic disruption, further physiological organisation may remain possible throughout life. Rather than targeting behavioural symptoms directly, intervention focused on facilitating expanding physiological flexibility through carefully titrated sensorimotor experience.

Treatment began by establishing a shared physiological understanding of the participant's experience. Clinical discussion emphasised the relationship between autonomic state, bodily experience and everyday functioning, providing a framework through which physiological changes could be recognised and explored.

The primary intervention consisted of slow, rhythmical lower-limb movement using an inflatable exercise ball positioned beneath the feet while seated. The movement was deliberately low effort and was individually titrated according to the participant's physiological responses. Following brief periods of movement, the participant was invited to pause and simply observe any changes occurring within the body.

The duration of these observation periods was not standardised. Rather, intervals were determined clinically according to the participant's capacity to tolerate emerging physiological experience without becoming overwhelmed. Initial observation periods ranged from only a few seconds, gradually increasing as physiological tolerance expanded. Throughout the intervention, movement and observation were alternated according to the participant's ongoing physiological responses.

Clinical observations focused on four domains identified during analysis of the case: physiological flexibility, functional availability, subjective awareness and participation. These domains were not used to direct treatment but emerged inductively during repeated review of the session transcripts. They subsequently provided the framework through which developmental changes across the intensive were examined.

No explicit behavioural training, cognitive restructuring or social skills instruction was provided during the intervention. Changes in behaviour, awareness and participation were observed as they emerged spontaneously throughout treatment and were documented through session transcripts and participant report.

Case Presentation

Sarah (pseudonym) was a 45-year-old autistic woman who sought intervention following a recent recognition of her autism. She described lifelong difficulties with physiological regulation characterised by chronic anxiety, autistic burnout, hyperacusis, sensory hypersensitivity, profound exhaustion and longstanding feelings of loneliness despite maintaining relationships. She reported increasing difficulty tolerating everyday sensory and social demands and expressed concern about the impact of these difficulties on her health and quality of life.

Prior to commencing intervention, Sarah had undertaken extensive independent study of autism, Polyvagal Theory and related approaches to nervous system regulation in an effort to better understand her experiences. Despite this, she reported that these conceptual understandings had not translated into meaningful changes in her day-to-day physiological functioning.

At the time of referral, Sarah had recently commenced neurofeedback but was not receiving any other psychological intervention. In her initial correspondence she wrote:

"I am so happy to finally encounter someone who I resonate with when it comes to how I may be assisted in gaining some sense of safety and trust in my own system."

Sessions were recorded at the participant's request to support memory recall and continued practice between sessions. These recordings were subsequently transcribed for observational analysis.

Clinical Observations

Review of the session transcripts identified four recurring domains of change across the intensive intervention. Although presented separately for clarity, these domains frequently overlapped and appeared to influence one another throughout treatment. Physiological flexibility was evident from the earliest sessions, followed by expanding functional availability, increasing subjective awareness and broader participation in everyday life.

Physiological Flexibility

The earliest changes observed throughout the intensive were physiological rather than behavioural. During the initial sessions, Sarah described subtle changes in bodily organisation following brief periods of movement and observation. Early responses included reports of "spacing out... but in a nice way" and a growing awareness of previously unnoticed bodily sensations, including throat constriction and subtle emotional release. These changes occurred before any meaningful behavioural change had been observed.

As treatment progressed, these physiological changes increasingly generalised beyond the treatment setting. Sarah described faster recovery following social interaction, explaining that her physiological activation "usually doesn't come down until I'm alone... yesterday... it came down." She also reported increased tolerance for prolonged social engagement, observing that she would "usually... collapse," but on this occasion, "I didn't."

By the later sessions, Sarah increasingly described remaining physiologically organised during situations that had previously resulted in prolonged dysregulation. Rather than recovering only after stressful events, she reported remaining present during them, suggesting that physiological flexibility had become increasingly available during everyday life.

Across the intensive, physiological flexibility appeared to expand from brief physiological experiences occurring during treatment to a more stable physiological organisation that generalised beyond the clinical setting.

Functional Availability

As physiological flexibility expanded, previously unavailable physiological and psychological capacities appeared to become increasingly available during everyday life. Rather than describing the acquisition of new skills, Sarah repeatedly described functions becoming accessible with less effort and greater spontaneity.

Early in the intensive, this was reflected in small but clinically significant changes. Sarah described considering behaviours that had previously felt unavailable, explaining, "At least I'm thinking about it," when discussing her ability to stop distracting herself and simply remain present. She also began initiating more authentic interpersonal conversations, describing a desire for "a more open conversation" and spontaneously discussing her autism with a friend.

By the middle of the intensive, these changes had broadened considerably. Sarah increasingly described trusting her own physiological experience when making decisions, recognising interpersonal patterns, establishing boundaries and allowing herself to respond differently. She explained, "I'm looking forward to finding the right words to let him know that I'm absolutely not interested... I can feel that that doesn't work for me." These observations suggested increasing behavioural choice emerging from changing physiological organisation rather than deliberate behavioural training.

Later sessions demonstrated increasing spontaneity across multiple areas of functioning. Sarah described previously effortful processes occurring automatically, observing, "Usually I would have to think about the question... but then the words just came." She also described leading a workplace meeting with increasing confidence, engaging more naturally with colleagues and experiencing interpersonal communication with substantially less cognitive effort.

Taken together, these observations suggested an expansion in functional availability, whereby capacities that had previously required considerable conscious effort became increasingly accessible through everyday physiological organisation.

Subjective Awareness

Subjective awareness emerged progressively throughout the intensive and appeared to follow changes in physiological organisation rather than precede them. Rather than beginning with intellectual insight, Sarah increasingly recognised changes occurring within her body before developing new understandings of herself.

Early observations included statements such as "I got it now" and increasing awareness of specific bodily sensations that had previously gone unnoticed. As treatment progressed, Sarah began recognising longstanding physiological and behavioural patterns with increasing clarity, commenting, "I just became aware of that pattern." She also described understanding the relationship between her thoughts and physiological state, observing that "my thoughts are just trying to make explanations for what's going on in my body."

Later in the intensive, awareness became increasingly differentiated. Sarah described recognising established protective patterns while simultaneously experiencing them as no longer fitting her current physiological organisation, commenting, "I'm running the same pattern, but now it feels really, really weird." Rather than becoming overwhelmed by these observations, she increasingly described curiosity, discernment and growing trust in her own physiological experience.

These observations suggest that increasing subjective awareness accompanied expanding physiological flexibility and functional availability, supporting the proposition that awareness may emerge through changing physiological organisation rather than serving as its prerequisite.

Participation

Changes observed during treatment increasingly extended beyond physiological experience into everyday participation. As the intensive progressed, Sarah described approaching relationships, work and daily life with increasing authenticity, agency and confidence.

During the early sessions, participation was reflected in subtle interpersonal changes. Sarah described feeling "more relaxed" during conversations and increasingly able to engage authentically with others. As physiological flexibility expanded, she began navigating previously challenging interpersonal situations differently, reporting successful conversations that had historically resulted in distress or withdrawal.

By the later sessions, participation had broadened into occupational functioning and everyday decision-making. Sarah described leading workplace meetings with increasing confidence and recognised that communication, leadership and social engagement required substantially less effort than previously. She also described organising her life around her own physiological needs rather than continually overriding them, observing that she was becoming "much more accepting of myself."

By the conclusion of the intensive, participation appeared increasingly integrated into everyday life. Rather than simply reporting reduced symptoms, Sarah described a different relationship with herself, characterised by greater trust in her own physiological experience, increasing behavioural freedom and expanding participation across multiple areas of daily life.

Discussion

This observational clinical case describes developmental changes observed in a 45-year-old autistic woman during and following an eight-session intensive intervention. Across treatment, expanding physiological flexibility was accompanied by increasing functional availability, subjective awareness and participation. Rather than occurring as isolated improvements, these changes appeared to form a coherent developmental pattern that became increasingly integrated throughout the intervention.

The earliest changes observed were physiological rather than behavioural. Initial sessions were characterised by subtle changes in bodily organisation, including increased physiological settling, altered sensory experience and greater tolerance for periods of quiet observation. As treatment progressed, these physiological changes were accompanied by increasing behavioural spontaneity, emotional accessibility, interpersonal engagement and participation in everyday life. Notably, these changes were not explicitly taught during intervention but emerged progressively over the course of treatment.

One interpretation of these observations is that intervention facilitated an expansion in the participant's internal physiological repertoire. Throughout the intensive, changes in physiological organisation consistently preceded broader psychological changes. Rather than describing the acquisition of new skills, the participant repeatedly described previously effortful functions becoming increasingly spontaneous and available. This observation raises the possibility that therapeutic intervention may facilitate access to physiological and psychological capacities that were previously unavailable rather than simply improving regulation of existing autonomic states.

This interpretation is broadly consistent with developmental perspectives suggesting that autonomic organisation provides the physiological foundation for later psychological functioning. Polyvagal Theory has demonstrated the relationship between autonomic state, emotional regulation and social engagement across the lifespan, while Kram's Perinatal Autonomic Cascade proposes that autonomic organisation develops through the sequential integration of multiple physiological systems during the perinatal period and may remain capable of continuing organisation beyond birth. Although the present case cannot determine whether such developmental processes were occurring, the observations are consistent with the possibility that therapeutic intervention may support continuing physiological organisation throughout adulthood.

The present case also led to the development of the concept of functional availability. Functional availability is proposed as a clinical construct describing the range of physiological and psychological capacities that are accessible to an individual at a given point in time. These capacities include emotional accessibility, behavioural flexibility, executive functioning, agency, interpersonal engagement and participation. Within this case, these functions appeared to expand progressively without explicit behavioural training, cognitive restructuring or social skills instruction, suggesting that increasing physiological flexibility may have been accompanied by increasing access to previously constrained capacities.

Taken together, these observations suggest a developmental perspective that complements existing symptom-focused approaches to intervention. Rather than asking only how to reduce anxiety, improve emotional regulation or modify behaviour, clinicians may also consider how intervention might facilitate continuing physiological organisation. From this perspective, expanding physiological flexibility may increase the range of physiological experiences available to the individual, allowing increasingly complex psychological functions to emerge over time.

Clinical Implications

The observations described in this case suggest that functional availability may provide clinicians with a useful framework for recognising developmental change during intervention. Rather than focusing exclusively on symptom reduction or behavioural outcomes, clinicians may also observe the progressive emergence of functions that were previously unavailable to the individual. These may include increasing agency, emotional accessibility, behavioural flexibility, executive functioning and participation in everyday life.

While preliminary, this perspective encourages clinicians to consider therapeutic intervention not only as a means of reducing distress but also as facilitating continuing physiological organisation and expanding developmental possibility.

Limitations

This paper presents a single observational clinical case and therefore cannot establish causality or determine the generalisability of the proposed framework. The observations were derived from repeated review of recorded clinical sessions and reflect the experience of one participant within a specific therapeutic context.

The construct of functional availability is introduced here as a clinical observation arising from this case rather than as a validated theoretical construct. Further case reports, case series and prospective research will be required to determine its reliability, clinical utility and relationship to existing concepts of physiological regulation, neuroplasticity and functional outcomes.

Conclusion

This observational clinical case suggests that facilitating physiological flexibility may be accompanied by expanding functional availability, increasing subjective awareness and broader participation following early autonomic disruption. While the mechanisms underlying these observations remain unknown, the case provides a clinically grounded framework through which these developmental changes may be recognised and described.

Rather than concluding the discussion, this case raises a broader question for future research. If aspects of autonomic organisation remain capable of continuing development beyond early childhood, an important challenge for clinicians and researchers will be to understand how therapeutic intervention might best facilitate that process.

 

References

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Kram, G. (2025). The Perinatal Autonomic Cascade: A Sequential Model of Neonatal Autonomic Initialization. ResearchGate preprint.

Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. New York, NY: W. W. Norton.

Porges, S. W., & Furman, S. A. (2011). The early development of the autonomic nervous system provides a neural platform for social behavior: A polyvagal perspective. Infant and Child Development, 20(1), 106–118. https://doi.org/10.1002/icd.688 

 

Ethics Statement

The participant provided informed consent for participation and for the use of de-identified clinical information within this case report. Sessions were originally recorded at the participant's request to support memory recall and continued practice between sessions. The recordings were subsequently transcribed and analysed retrospectively for the purposes of this observational case report. Identifying information has been removed or altered to protect participant confidentiality.

Use of Artificial Intelligence

Artificial intelligence (ChatGPT, OpenAI) was used to assist with language editing, manuscript organisation and refinement of expression. All clinical observations, conceptual content, interpretation and final editorial decisions were made by the author, who reviewed and approved the final manuscript.