OccupationalTherapy.com Phone: 866-782-9924

What is the concept of the upstairs versus downstairs brain when treating children with autism?

Cara Koscinski, OTD, OTR/L

February 5, 2021



What is the concept of the upstairs versus the downstairs brain when treating children with autism?


Upstairs vs. Downstairs Brain

  • Tantrum: (Upstairs Brain)
    • Conscious choice
    • Strategic and manipulative
    • Can reason, make choices
    • Emotions under conscious control
    • STOP when demands are met
  • Sensory: (Downstairs Brain)
    • Flood of hormones
    • Over-ride conscious choice
    • Loss of body control
    • Can NOT be reasoned with
    • Not capable of choices

In the brainstem, our responses are reflexive. When something happens in our bodies, the reflex says, "Get to safety, fight, flight, or freeze.” That is the downstairs brain. A flood of hormones, adrenaline, and cortisol comes in and overrides any conscious choice. When a child is in the downstairs brain, they cannot be reasoned with because it is a hormonal response. Until those hormones are reabsorbed, it is difficult to reason with anyone in the downstairs brain. Let's say your worst fear is snakes. If you were in a small room with boa constrictors, I think you might have a hard time concentrating or having any rational thoughts. Your downstairs brain would be responding in that situation. It is chemically-driven, and there is the minimal capability for higher-level thinking.

The cortex is where connections are made from the lower brain to the upper brain. The hippocampus is located in the cortex, and it is where memories are created and stored. Therefore, we can focus and process effectively when the information is in the cerebral cortex. This is where and when we can make those conscious choices.

When a child comes to you for therapy, understand the child is stuck in the downstairs brain, and your goal is for him to think effectively and make good choices. However, they will not be able to do that if they are in the downstairs brain. You are already setting them up for failure.

Drawing of a sailboat on water heading to rocks

I adapted this image from Dr. Daniel Siegel's and Tina Payne Bryson's book, "The Whole-Brain Child." Let's just say there is no wind; therefore, we have to use our rows. We are sitting in the sailboat, and the wind starts up. We may think, "Oh, thank goodness there's the wind." However, the wind starts to blow us toward the rocks. 

Think about how our children with autism would react by being in that boat. They are paddling and catching a nice breeze. When that breeze picks up, or something happens that is unpredictable in their lives, they are going towards rigidity (rocks). At that point, they want to control everything as they are heading towards that wall. To maintain control, they use routines or actions that help them to maintain organization. Sometimes, they head towards the open ocean (or uncharted water), which is very unpredictable. In that case, they need to row back towards a safe, calm pathway of comfort. They are constantly rowing between chaos and the solid, rigid wall. They become exhausted in rowing so hard that they eventually become tired. I think that is where a lot of our children are right now. 

cara koscinski

Cara Koscinski, OTD, OTR/L

Cara Koscinski, OTD, OTR/L, author of the award-winning Pocket Occupational
Therapist Book Series, is a pediatric occupational therapist. She specializes in trauma-informed care, behavior, interoception, and autism. As an educational speaker, Cara incorporates her expertise as a mother of two children with autism. She has published six books and has over 98,000 followers on her blog and social media channels. Cara is also a children’s YOGA instructor.

In addition to her books, Dr. Koscinski regularly blogs and creates fun products for those who work with children
who have special needs. She serves on the Advisory Board of Autism Asperger’s Digest
Magazine. Cara is an instructor for the University of Saint Augustine's Occupational Therapy Program.

Related Courses

Foundations for School Readiness: Executive Functioning in the Classroom (Day 3)
Presented by Cara Koscinski, MOT, OTR/L


Cara Koscinski, MOT, OTR/L
Course: #3843Level: Introductory1 Hour
  'She has real-life experience to share'   Read Reviews
We use executive function skills to manage tasks we complete every day. They help us to decide what to pay attention to as well as help us to manage emotions and regulate behavior. This course helps therapists to understand executive function and learn activities to help children to succeed in the classroom.

Behavioral And Daily Challenges In Children With Autism
Presented by Cara Koscinski, OTD, OTR/L


Cara Koscinski, OTD, OTR/L
Course: #4891Level: Introductory1 Hour
  'I generally work with older adults'   Read Reviews
This course will describe the behavioral challenges of occupational performance for children with autism. The ways in which children show difficulty with behavior will be explored. Emphasis will be placed on the fact that behavior is a form of communication. The use of strategies and supports that OTs can employ to ease the transition, improve task initiation and completion, and better improve overall engagement in occupation will be presented. Numerous strategies will be discussed to facilitate participation in ADLs of children with autism.

Learning Disorders: A Toolbox of Strategies
Presented by Cara Koscinski, MOT, OTR/L


Cara Koscinski, MOT, OTR/L
Course: #3193Level: Introductory1.5 Hour
  'Instructor got fairly chaotic toward the end of the presentation, with verbal instruction not aligning with screen information'   Read Reviews
Millions of children experience learning disorders. As occupational therapists we are poised to teach techniques that improve functional outcomes that continue throughout the lifespan. As such, providing intervention at early stages in learning can positively impact students. By forming an individualized treatment plan tailored to the student’s specific needs, better outcomes occur. Course attendees will list learning disorders as well as treatment strategies for each. This course will provide detail about learning disorders and techniques which can be applied immediately for improved function in both the home and classroom setting. Accommodations, modifications, use of visual and kinesthetic techniques, sensory processing strategies, communication considerations, and social skill improvement add to your tool box as you work with students who have learning disorders.

Executive Function in Children with Autism Spectrum Disorder
Presented by Cara Koscinski, OTD, OTR/L


Cara Koscinski, OTD, OTR/L
Course: #4491Level: Introductory1 Hour
  'Skill of the presenter to demonstrate the concepts with examples of each topic; metacognition, executive function, theory of the mind and interoception'   Read Reviews
Smooth executive function includes the ability to regulate emotions and think creatively about situations by forming multiple solutions. This course describes the effects of EF on participation in play, social skills, and discusses interventions based on the Occupational Therapy Practice Framework, 3rd Edition.

Building Healthy Brains: Sensory Strategies for Optimal Brain Function & Postural Concerns
Presented by Cara Koscinski, MOT, OTR/L


Cara Koscinski, MOT, OTR/L
Course: #3237Level: Intermediate1.5 Hour
  'Engaging presenter, video examples, ways to put it into practice'   Read Reviews
Optimal function of our body occurs when our sensory and motor systems are strong and able to adapt to the demands of the environment. Today’s children often struggle with fidgeting, decreased attention, and immature motor patterns which manifest themselves through frustration and behavior issues. This course will take a look at these issues and identify treatment strategies.