Katie Vance
A large part of my day is spent helping children discover confidence and success in activities they may not naturally choose outside the classroom. As a primary school teacher, you quickly learn that meaningful engagement comes from more than instruction alone. Children who feel safe, valued, and involved in their learning are far more willing to take risks, try new things, and persevere. When children are given opportunities for choice, connection, and encouragement, they are much more likely to engage genuinely rather than simply going through the motions.
I think about that a lot when I think about airway clearance.
For children with cystic fibrosis, bronchiectasis, or primary ciliary dyskinesia, twice-daily physio isn't optional. It's what keeps them out of hospital. It's what keeps them well. And for most families, they know that, but knowing it doesn't make a three-year-old blow steadily into a tube at seven in the morning. Knowing it doesn't help when a child is melting down before the session has even started.
Now add neurodivergence into that picture.
Between 15 and 20 percent of children and young people in the UK are neurodivergent. For those children, physio isn't just physically uncomfortable or tedious. It's a demand placed on a nervous system that may already be running on empty. And when a child avoids, refuses, or shuts down, that's not defiance. That's a nervous system in survival mode.
Fight. Flight. Freeze. Shutdown.
No reward chart works for a child in survival mode.
I've seen this as a parent as well as a teacher. The instinct when something isn't working is to find a better incentive. A different chart. A bigger treat. A firmer boundary. But for many neurodivergent children, the incentive was never the barrier. The demand itself is the barrier, regardless of how it's framed or what's on offer at the end of it.
This is particularly true for autistic children, where Pathological Demand Avoidance means that the nervous system responds to demands - any demands - as a threat. The child isn't choosing not to comply, their nervous system is making that choice for them.
What I've found, both in the classroom and at home, is that most approaches to this problem are aimed at the wrong target. Getting a child to comply is not the same as building a child's capacity to participate. And for neurodivergent children, compliance-first approaches don't just fail, they often make things harder, because the pressure of the demand adds to the nervous system load that was already the problem.
Shifting the focus to capacity changes everything about how you approach the session before it starts.
Capacity is built from safety. Not reward. Not consequence. Safety.
Safety in knowing what's coming. A consistent, predictable routine before and during the session removes the uncertainty that so many neurodivergent children find genuinely dysregulating. Knowing what comes next isn't a small thing. For a child whose nervous system is wired to scan for threat, it can be the difference between a session that happens and one that doesn't.
Safety in the relationship. Many neurodivergent children need an adult to regulate alongside them before anything is asked of them. Not holding space from a distance but genuinely joining them. Getting to their level, following their lead for a few minutes, and moving toward the session only once you've found a calmer place together. We think of this as connection before direction. It works.
Safety in uncertainty being removed. Visual timers change things. "Nearly done" requires a child to trust an adult's sense of time, which is abstract and hard to hold onto. An end point they can see shrinking in front of them removes that entirely. It sounds simple. It isn't small.
Safety in having a choice. "Where shall we do physio today?" is not a big concession. But for a child who spends much of their day having things done to them for reasons they may not fully understand, genuine autonomy with real choice, not managed choice between two adult-selected options, reduces the experience of demand and builds their capacity to engage.
Safety in sensory support they've chosen themselves. A comfort item. A playlist they've built. A position that feels safer. What regulates one nervous system can dysregulate another, so follow the child’s lead. Whatever helps them feel more settled before the session starts is worth ten minutes of preparation.
Safety in being named for the right things. "You kept going even when it felt hard." Not "good blowing." Not "well done for finishing." The process, not the output. This builds interoceptive awareness and self-advocacy, skills that reach far beyond respiratory care. For children who are so often on the receiving end of correction, being named for their persistence builds something more durable than compliance.
It builds self-belief.
When families come to you and say that nothing is working, that is rarely a failure of participation. It is the child’s nervous system communicating its state. And once you know how to read it, it becomes some of the most useful clinical information you have.
Helping families identify the right framework, one that centres capacity and safety rather than instruction and reward, is as much a part of the care as the physio itself.
The state of the nervous system is always the starting point. Everything else follows from there.
About the Author
Katie Vance is the founder and developer of Bubble FLO® and an Additional Support Needs (ASN) teacher. Combining expertise in education, neurodiversity, and respiratory care with lived experience as a parent, she is passionate about helping children build confidence, engagement, and independence in both learning and healthcare.
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