Wednesday, June 30, 2010

The Lost Child: Strategies for the Classroom

In my  last post, I talked about the child who is lost in school.  He has failed to internalize the expectations of the classroom, lacks sufficient internal structure to be able to work independently,  and requires constant adult direction and supervision to be able to do what is expected of him.

The rule of thumb here:  as soon as we recognize that a child has not developed the internal structure required to succeed in his environment, we should provide it for him until he does develop it.  This means writing things down for him, making things as predictable as possible  so that he can internalize routine through repetition, and giving gentle verbal reminders when necessary.  A very young child who cannot read can be given pictures to remind him of what his day will be like and what needs to be done.

A great strategy for any preschool or kindergarten classroom is for the teachers to have a whole repertoire of transitional songs to teach the children and sing them daily.  As soon as the children start singing, expectations click into place and they know what's going to happen and what to do.  I work with a severely autistic child who is so responsive to the song I use to greet him that he starts to transition instantly and is ready to come with me as soon as he hears me sing the first few words.  His siblings, who are often present when I'm working with him, have noticed how effective this is and have started singing to him as well.  He is almost completely non verbal, but he can sing all of our songs word for word!

A child who needs direction to stay on task and follow the classroom routine can be paired with a  buddy who enjoys helping him and can keep the him on track.   Depending on the child's needs, this can include watching out for him on the playground or in gym class, helping the child transition between activities by teaming up together to clean up or to fetch his lunch and coat, lining up together for lunch or recess, and sitting next to him during class so that if the child has any questions about  how to proceed, he has someone who can direct him.  For an older child, his buddy can help him by making sure that he writes down his assignments and has his homework.  If your child is slow copying from the board, his buddy can make sure he's got everything down, or allow him to copy assignments from his notebook.

For an older child who can read, a small card taped in a discreet place, like the inside cover of a notebook, can be helpful for him to refer to for information about the day's schedule, the location of his classes, etc.   The teacher should avoid sharing information in long strings of verbal instruction, and either write things down on the board or keep verbal directions short so they can be digested before the next round of instruction begins.    The child should work with his speech therapist, OT, or learning specialist on developing strategies to help him stay on task, such as writing notes to himself, developing mneumonic devices, and remembering to refer to his written schedule.

A quick email from the teacher or a note home about what is expected {permission slips, homework, etc.} can help as well.  Or the child can have a standing appointment at the end of the day with the teacher to quickly review the evening's assignments before leaving the classroom.

Children who don't have the ability to be mentally flexible due to their sensory issues will have a hard time coping with changes in the classroom routine.   The adults need to take this into consideration and help them get ready by letting them know what's coming up and what to expect.  For instance, a scheduled field trip which other children would view as a welcome break from routine can fill a  child with sensory issues with anxiety.  He doesn't know what to expect, and doesn't know whether this will be something fun to look forward to or something that will cause him to have to face a series of aversive situations, like crowded museums, loud noises, and flashing lights.  Telling the child as much as possible about what to expect will help him rehearse his responses.

One thing I observe about the kids I treat is that this lack of internal structure extends to their ability to organize work on the paper.  I really don't like those marbleized cover composition books, especially for very young children.  It's too hard to keep written work neat in them.  I much prefer Handwriting Without Tears double lined paper and journals.  The double lines are so effective for helping the children keep their letters sized and placed correctly, which trains their hands to do this automatically over time.   If your child is bringing home work sheets that are very busy visually and refusing to work on them, or the work he produces is disorganized, chances are that all that visual clutter is too confusing.  Would it be possible to talk to the teacher about providing worksheets with cleaner, simpler graphics?

{Speaking of which, you would be amazed at how much neater a child's writing can become when working in that double lined paper.  What can you do about getting a sample into your child's classroom so that the teacher can see it?}

The more movement that is built into the lesson plan, the better.  The best learning takes place when it involves more than one sense, since it uses different parts of the brain and forms more connections.  Repetition through muscle memory helps drive learning into the deepest parts of of the brain, where they become automatic in nature.  When doing homework with your child that involves memorization, such as spelling or multiplication tables, make a game out of it that involves hand clapping or accompanying movements.  When the child is required to problem solve or to think something through before writing it down, it's best to allow the child to move while he does it.

Monday, June 28, 2010

Groundhog Day

The movie Groundhog Day stars Bill Murray as a hapless weatherman stuck repeating the exact same day over and over, never learning anything from his mistakes and becoming more and more frustrated and miserable.  For some sensory defensive children, a typical school day is one in which he is doomed to repeat the same mistakes over and over, because he hasn't figured out what is expected of him and the adults don't understand why they need to keep telling him.

One of the observations I frequently hear from the teachers of children who are sensory defensive and have attentional difficulties is that they continually enter the classroom and behave as if it's their very first day of school.  They walk in the door every day and have very little idea of what is expected of them.  They are a bit lost and helpless until someone steps in and tells them what to do.  They haven't learned the unspoken rules of the classroom.

At some point early on in the school  year, the other children in the classroom will have internalized the teacher's expectations about what needs to happen when they first walk in {take off coat, place on hook, put backpack in cubby after taking out relevant classroom articles like homework or permission slips and handing them in, sit at desk, begin to work on assignment posted on board or continue with work from the previous day, etc.}.

The children I treat often remain clueless about what they should be doing and take up more than their fair share of the teacher's attention, constantly asking for directions or explanations.  Because they just don't know what they're supposed to be doing much of the time, they have to rely on the grownups to help guide them.   Many times their requests seem trivial and the teacher feels that they are making up excuses to talk to her or be next to her.

And perhaps it's true: when we are stressed, it is very calming and reassuring to have someone nearby who is not.   Think back to a time when you were undergoing some trauma  {perhaps when your child was being born?} and how wonderfully reassuring it was to have a calm, focused presence nearby.  Somehow this gave you what you needed to go on.

Other children can be equally lost but not show it.  They sit quietly, not bothering anyone, but not learning anything, either.  I see them surreptitiously looking at their other classmates for clues.

Children with sensory and attentional issues who constantly require assistance to accomplish what is expected of them don't have sufficient internal structure in place to be able to work independently without adult direction.   From a sensory standpoint, one explanation for this is that their defensiveness, which dominates their responses, prevents them from being able to internally organize, align themselves with their environments, and to think that far outside of their own internal processes.  They are in survival mode, and can't really do much abstract thinking about what they should be doing and how to go about doing it.  They may also have difficulty generalizing, so that it doesn't occur to them that the rules and expectations from one context would apply to another.

Defensive children have nervous systems that don't adapt to novelty.  For example,  a tactile defensive child's skin will be telling him over and over over that the elastic waistband of his underwear {which fits perfectly} is too tight and is hurting him, whereas another person's skin would register the feel of the garment at the moment it's put on, then filter it out so that it doesn't register anymore.  A nervous system that does not adapt well to novelty is going to continue to perceive school as an unaccustomed, unknown event and respond accordingly.

  Being unable to adapt to novelty will also compromise the child's ability to cope in a noisy classroom.  For example, when you first walk in to a crowded restaurant  at 8pm on Saturday night, with everyone chattering and loud music blasting on the sound system, you may think to yourself, wow, this is really noisy, then  it quickly stops registering in such an intrusive way and you are able to focus on your dinner companions, read the menu, and enjoy your food and conversation.  Your ears still hear it but unless someone drops a tray of dishes,  it doesn't continually travel to the forefront of your conscious awareness and distract you.

 A child who is overly sensitive to noise, on the other hand, won't be able to filter it out.  It won't change into background noise.  The loud, high pitched sound will continually remain at the forefront of his awareness,  and he will be disorganized and miserable as a result. These are the children you see who are running around the room, unable to focus, or trying to hide in the corner.

A child who has visual spatial issues is also going to be at risk for feeling lost.  He can't always depend on his eyes or his sense of direction to tell him where he needs to go.  If his visual memory is poor, he's going to get lost on his way to class simply because he can't remember how to get there.  Maybe he can never quite remember how to open up the lock on his locker.   Perhaps contending with the crowded, noisy hallways is too much for him, and he is so wrapped up in his defensive responses that he forgets where he's going and what he's supposed to be doing.

What are some other reasons why the child can't adapt to and succeed in his school environment?

Perhaps his ability to take in and process language is impaired.  This is common with children who are auditory defensive  -- they tune out voices, especially women's voices,  since the high pitch bothers them.   Or perhaps their learning styles don't mesh well with the school culture.  Some children are better visual learners, but their teacher prefers to lecture and don't back up the information with overhead projections.

A child who needs a disproportionate share of grownup direction in order to survive in the classroom is a child in trouble who needs some help.  In my next post I'll discuss some strategies for helping the lost child keep on track.

Wednesday, June 23, 2010

Activities to Improve Visual Perception

For more information on vision, read my other post on the topic, It's a Vision Thing.

Most, if not all, of the children who come for occupational therapy have an undiagnosed visual problem.  This is because the low muscle tone in the neck and trunk of children with sensory processing issues does not give the eyes a stable base of support from which to operate.  As a result, the fine motor coordination in the eye muscles is compromised, which in turn affects the brain's ability to process and interpret visual information correctly.  This makes tasks like reading and writing, copying from the blackboard, navigating the playground, and participating in team sports an extra challenge.  Because the child has to work extra hard to coordinate the muscular activity of his eyes, his mental and physical energy for the actual task he is using them for is less.   His endurance and performance are going to suffer as a result.

Since the strength and coordination in the eyes is so dependent on the strength and stability of the spine and neck, the child should be given ample opportunity to play outside, and provided with gross motor activities regularly.  This can be a team sport or martial arts class, swimming, tennis, volleyball, bike riding, dance, or anything that the child enjoys and will participate in willingly and happily.  Take the child outside and play catch, shoot some hoops, shag some flies, have him practice running and kicking a soccer ball.  Do sit ups and push ups together, and have the child wheelbarrow walk.

Read to your child every day, and have him sit with you and look at the book while you read.

If your child is continually resistant to close work, has a poor attention span for reading or tabletop activities, rubs his eyes, loses his place while he's reading, doesn't copy well from the board, misses part of the page when using a workbook, or complains of headaches or double vision, he is undoubtedly struggling with weak eye muscles.  If your child is working with an OT in a sensory gym, give it a year.  If his vision doesn't improve after a year of  working on suspended equipment, it's time to see a neurobehavioral optometrist, who can prescribe vision therapy if it is warranted.

Meanwhile, here are some things to do at  home.

To improve convergence and the ability to do close work:

1.  Give the child a drinking straw in one hand and a strand of uncooked spaghetti in the other.  Tell the child to look straight ahead as he brings his hands up in front of his face and slowly slides the spaghetti into the straw.  Repeat ten times.  Do this once or twice a day.

2.  Provide the child with whistles and bubble toys that have moving parts when blown.  They encourage the child to pull the eyes in together to watch.  {If you can even find breath powered bubble toys anymore.  Except for old fashioned bubble wands, these seem to have disappeared off the face of the earth and have been replaced by battery operated versions.}

3.  Give the child a lollypop to suck on while doing close work.  The vacuum created while sucking will pull the eyes in together.  Give the child all of his drinks through a straw, and provide opportunities for resistive sucking, such as smoothies, juice boxes or drinkable yogurt.

4.  Provide craft projects that challenge and motivate the child.  Find lots of fun ideas here and here.

5. Play marbles, jacks, and other eye hand skill games.

To improve pursuit fixation, or the ability of the eyes to track and maintain attention on stable and moving objects:

1. Have the child race a car on a lazy eight {sideways} speedway track on a chalk board or on the floor.

2. Play balloon tennis, either with rackets or hands.

3. Have the child jump on a bosu or mini trampoline while catching small beanbags and tossing them at targets around the room.

4.  Play "I spy" or other visual games, like finding as many out of state license plates as you can, etc, while traveling in the car.

5. Blow some bubbles.  Have the child chase  and pop them.  I  give them a little claw toy or a pair of zoosticks to pop them with so that they are also working on fine motor skills.

6.  Dim the lights and have the child chase the beam from a laser or a flashlight.   This might be a fun activity on a summer evening at twilight with other children from the neighborhood.  Or give the child his own flashlight and play tag with the beams.

To improve visual memory:

1.  Play concentration, where the child has to turn over cards and find matches.  You can either do this with regular playing cards or buy a set.  This teaches the child to develop good strategies for visual memory.  If you type "memory games" into your search engine, you'll find quite a few sites that have games suitable for children.

2.  Play "What's different?".  Put three things on the table, have the child close his eyes, and then change one.  Have the child tell you which one is different.  Use more objects as he gets more skilled.

3.  Place a covered tray with a dozen or so objects on a table, let the child look at it for 30 seconds, cover the tray, and have the child write down or tell you everything that he remembers.  This is a fun group activity.

To improve saccadic vision {the ability of the eyes to jump and fix, the skill required for reading}

1. Lacing, beading, coloring, and cutting activities.

2.  Mazes, dot to dot, and tracing activities.

3.  Have the child draw and paint while standing at an easel.

4. Weaving and sewing activities.

To improve visual discrimination:

1. Play the "what's different in the picture?  game.

2.  Put together jigsaw puzzles,  play Search a Word, and "Where's Waldo?"

3.  Have the child sort things for you, like socks and silverware.

4. Nesting and stacking toys promote pattern recognition, which is critical for learning shapes of letters.

5.  Play Connect Four, tic tac toe, and make a square.

For figure ground:

1.  Hide objects in an indoor sandbox:  fill a large container full of beans, rice, packing pellets, etc.  Hide little toys for the child to find.  Or move this out to the garden and hide things in the grass or among the plants.

2.  When reading a picture book together, play "I Spy" with the drawings.  Describe something to the child and have him try to find it in the picture based on  your description.  Then have him find something and describe it to you for you to find.

Have the child sit on a therapy ball while reading, watching television, or doing homework.  The slight postural adjustments he makes while he's sitting will help stabilize and strengthen his back and his eyes.  Or have the child lie on the floor on his belly propped up on his elbows while working for brief periods. This will strengthen the neck, which will help stabilize his eyes.

Monday, June 21, 2010

Making Sense of Attentional Issues

                                                                                                                                                                                                                                                                                                             Very often, a parent will say to me, "My child couldn't possibly have any attentional issues. He has an amazing ability to focus!  He can spend hours and hours playing a video game {or putting together Legos, or watching television} without ever so much as looking up.  He he gets so lost in what he's doing sometimes that we have to call his name several times to get him to respond.  There's nothing wrong with his attention span!"

What his teachers will tell me:  "The child often can't attend to what is required of him at any given moment in class and we spend a great deal of our energy and resources trying to get him to settle down and focus.   Or when he does manage to sit and concentrate {on something of his own choosing,  like a book or a puzzle,}  he becomes so absorbed in what he's doing that he's no longer actively participating in the group.  He has very little in available to him between those two extremes,  and can't attend successfully to class activities or assignments when there are other things going on around him.  He has to shut it all out completely, or he will become distracted and disorganized.  He often needs a grownup nearby to help steady him, and demands a lot of extra attention, by either approaching the teacher to tell him what to do or by his actions, which require redirection."  

Attention is the ability to concentrate on some feature or features of the environment, to the relative exclusion of others.

 It's the word "relative" that is the gold standard here.  Everyone is capable of getting completely lost in what he's doing.  One of the very great pleasures of life, in fact, is becoming so absorbed by an activity that the world falls away.  We are in a reverie, at one with our hands, our imaginations, and our materials.  We are in another world entirely.  When we are forced to come away from this state before we are ready, we are often a bit discombobulated and have difficulty transitioning back to our actual environment.

This is a delightful state,  and how great art and works of genius are made.  But hyperfocus, to the exclusion of everyone and everything, is not appropriate for most of the demands of modern life.  It doesn't work at school.  The kind of attention we need to succeed there is more flexible than this complete, all encompassing absorption, and is more in tune with the rest of the environment.  It doesn't completely exclude our surroundings.  It doesn't take us so far away from everyone and everything that we need to be called and called to come back.  It allows us to exclude what is irrelevant while remaining in synch with everything around us.

When we are in the classroom, even if we are concentrating hard on our assignments, we should be able to maintain an easy awareness of everything that is going on around us.  Although we may be choosing not to respond to it, we know that there is noise and movement swirling around us, and there are other people in the vicinity talking and doing things.  Although we are focused on the task at hand, we should be able to be called out of ourselves quite easily,  respond,  and then go back to what we are doing without becoming derailed by the interruption.   We should be able to do this even when the class is noisy, there are other things going on at the same time, or when the other children sitting next to us at the table may be engaged in some other pursuit.  We should be able divide our attention easily.  School, like life, requires us to be able to attend to several things at the same time.  While working on an automatic task, for example cutting or coloring,  we should be able to cut or color easily and accurately while chatting with our neighbors and keeping an eye out for the teacher.

The ability to attend is a complex skill and is predicated on many things.  We need be able to control our need and desire for movement so that we can sit still.  We need to be able to filter out distractions.  We need to have the instinctive ability to focus on what is relevant and ignore what is irrelevant to us in that moment.  We need to have excellent command of our close vision.  We need to have the internal structure and maturity in place that would allow us to focus on something other than what would necessarily  motivate us.  We need to be able to tolerate frustration, so that when something doesn't come automatically or easily, we are willing to struggle without instantly giving up.  We need to have sufficient control over our impulses, so if the thought "I'm thirsty" floats into our minds, we stay focused and do not immediately jump up and run in search of a drink.  If people around us are talking, we should not get so distracted by the conversation that we can't attend to what we're doing.  If people get up and start walking around, we should not be so pulled out of what we are doing to watch them that we forget the task at hand.

If your very young child is having difficulty attending at school, it may be that their expectations of the children's abilities are not realistic.  I have visited so many classrooms over the years where the teacher is spending a large portion of her time and energy just trying to get the children to sit still.  I always want to take these teachers aside and point out that the reason these children can't keep still is because they need to be moving!  Movement is what activates the brain and drives development forward.  We should be providing ample opportunities for young children to move, not denying them, especially to children who live in cities and who don't have ready access to nature.

Or perhaps your child's maturity and temperament are not right for that particular classroom.  If your child is someone who has a high energy level and needs to move a lot, it's not fair or realistic to put him in a classroom that requires him to sit for long periods, skimps on the recess and structured movement opportunities, and then to expect him to thrive there.  Most three year old boys are just not ready to go to school anyway, so if yours is struggling there and is fine everywhere else, it's entirely possible that he just needs to wait another year or two before he's ready.

There are some things we can do to help very small children learn the skills to pay attention.  I would strongly recommend reducing or eliminating television viewing, including  educational videos.  The most resourceful, independent, creative people I know didn't watch television when they were children.

The same for computers.  Children need to spend their time manipulating three dimensional objects and moving their bodies against gravity before the age of six.  Your three year old does not need to be sitting in front of a keyboard looking at a two dimensional screen.  He has no opportunity to develop depth perception, balance, or fine and gross motor coordination there.   He'll have the rest of his life, after he has acquired those essential developmental skills, to sit in front of a computer or a television.

{And please try not to spend a lot of time on your cell phone or Blackberry when you're with your children.  Interact with them instead.}

I also recommend making sure the bulk of the child's toys are things that lend themselves to creative play and are open ended.   Limit toys that have lots of bells and whistles but don't actually require much interaction from the child.

Help a child learn to tolerate frustration and solve his own problems by not jumping in every time he struggles.   Play board or card games as a family to teach social interaction skills and learn to lose gracefully.  Other family activities that teach good social interaction and expand attentional skills are charades, stink pink,  Fictionary, Pictionary, and those old fashioned games you play in the car like looking for license plates.

Make sure your child gets outside to play every single day.  The stronger and healthier his body, the more it will support his brain and his hands.

Cook with your child. Have dinner together as a family every night.  Take turns talking about your day.

Read to your child before he goes to bed.

More ideas here.

Wednesday, June 16, 2010

Handwriting Even a Mother Can't Love

Poor handwriting can have a lifelong negative impact on a child's ability to succeed at school and in his career. In most cases, it is easily avoided with proper instruction.

It's really not an exaggeration to say that our handwriting is a direct reflection of who we are. Illegible, poorly organized written work reflects poorly organized thoughts from a poorly organized brain, and prejudices those who have to read it against the writer. It is a mark of respect and consideration for others to make sure that writing is legible. 

Children who don't have good handwriting and struggle to complete assignments on time don't do as well in school as they could. Unfortunately, there's an epidemic of bad handwriting in this country. There are several reasons for this, but mainly it's because very few people understand how to teach it anymore.

Your child's school has a sacred responsibility to teach its students to be able to write fast enough to keep up with their thoughts while writing neatly and legibly . If they haven't learned how, they will not able to express themselves in writing to the best of their ability, which is the entire point of an academic education. Producing handwritten work is something grammar school children are expected to do all day, every day, and yet fewer and fewer of them are able to do it well.

If your child's handwriting is an issue, but he is performing up to speed in all other aspects of school, chances are very good that he hasn't been properly taught how to write, and that with some instruction and daily practice, he could write very neatly. Don't believe people who tell you that he'll be fine once he hits the upper grades and can use a keyboard. Everyone needs and deserves to have legible handwriting, and almost anyone can learn cursive, which is actually much eas
ier than print for some people, if taught properly.

I recently started working with a little boy whose mother sought me out for some help with his handwriting.  I started, as I usually do, by taking a look at some of his writing samples, and by asking him to write his letters and numbers for me, one by one, so that I could see his habits of letter formation.   There is one correct way to write each letter and number which produces the best combination of legibility and speed.  In print, this means starting every letter from the top and having the hand continuously traveling from top to bottom, left to right. 

Almost every letter that this child wrote for me needed to be relearned.  Most of them were started from the bottom, and many of his letters were formed with extra strokes, which slowed him down considerably.  His lower case R was indistinguishable from a V, his lowercase  N and H were the same, and his Q was a squiggle that Prince might have adopted for his own use.  He mixed up his B's and D's and reversed his J, Z, and several numbers.  All of his letters with round curves, like O, were formed clockwise, which also slowed him down and prevented him from being able to control his strokes.  He indiscriminately mixed up  his capitals and lower case letters.  His letter sizes varied wildly; some were huge and some were tiny.

His writing sample, which was written on a blank piece of construction paper, meandered all over the place.  He didn't have the skills yet to keep his writing neat, and no one had thought to provide him with some structure to help him organize himself.

His grip was quite eccentric as well; he used all five fingers and an extended thumb, which made it very difficult for him to move the pencil in order to form the tops and tails of his letters.

  It was obvious to me that no one had ever shown him what to do; he had had to figure it all out for himself.  He had done the best he could, but it wasn't serving him well at all, and it all had to be relearned correctly in order for him to write legibly. {Ever tried to convince a seven year old boy that he needed to change a well ingrained habit?}  When I pointed this out to his mother, who was sending him to a very expensive private school, she shrugged her shoulders and said that he had learned quite a lot about African dance and organic gardening, but didn't seem to be getting much of a grounding in actual academics.

Call me crazy, but schools that don't teach grammar or spelling,  don't provide formal instruction in handwriting, and don't drill children in the foundational rules of arithmetic are setting up their students to have minimal skills to build on when it's time to move on to the more complicated academic challenges.  How can you learn to factor when you can't multiply?  How can you write a coherent sentence when you don't know the rules of punctuation?  How can you learn to hold a pencil correctly and acquire correct habits of letter formation without a grownup to model it for you and then practice it with you until you get it right?  You wouldn't expect someone to be able to play Bach on the violin without ever having been taught all the underlying skills, like reading music, bowing, fingering, and playing scales, would you?   Handwriting is the same.  Rules need to be learned, and skills need to be rehearsed until they are acquired.  It should not be left to chance.  It's too important to your child's academic success.

If your child is starting kindergarten, ask what the school provides in terms of handwriting instruction.   Did the teachers formally learn how to teach handwriting? Who taught them?  What is the school's handwriting curriculum, and whose method does it use?  {Some methods are really poor pedagogy, with Zaner Bloser and D'Nealian among the two worst, although they are very popular.}  Is there time set aside for handwriting instruction every day?  How does the teacher go about it?

Many schools in New York City use the Handwriting Without Tears method, which is in my opinion by far the best I have ever come across.  But it's not enough to just pass out the books and expect the children to learn good habits of letter formation out of them while they work independently, which is unfortunately what happens most of the time.  The teacher must model the correct way to form the letters a step at a time, have the children follow at their desks, and then they should all practice together so that the teacher can keep an eye on them and make corrections when necessary.  This should be done every single day until the teacher observes that every child has mastered handwriting as an automatic skill.

I have been told by more than one kindergarten teacher that "There is no room in the curriculum to teach handwriting."  These teachers are expecting written work every day from their students, yet they don't teach them how to do it!  And can someone please tell me what on earth is more important at that age than learning how to write?

If you're not satisfied with what the school is doing, what can you do about it?  How can you make sure that your child's school is teaching this critical life skill correctly?

If what your child is producing is not acceptable and/or too slow, you may have to either find a handwriting specialist in your area, or tackle it yourself with the Handwriting Without Tears materials.  Either way, if your child can't write legibly, it's up to you to make sure that he can.

P.S:  Did you know that the essay portion of the SAT's is handwritten?

Monday, June 14, 2010

Twelve Ideas for Improving Attention in Class

1.  Make sure that the child with attentional issues is sitting near an adult with his back facing a wall, or better yet, niched in a corner.  A sensory defensive child lives in a chronic fight or flight state, and sitting with his back exposed will make him even more vigilant.  The more vigilant he is, the less he is able to attend.

2.  During circle time, the child’s place should be next to an adult, against a wall or sitting in a chair.  Many times the child just doesn’t have the postural stability to sit in the traditional “criss cross applesauce” position and is struggling just to stay upright.  This means that he doesn’t have a whole lot of energy left for anything else.  If he can sit with his back supported, he’ll have more energy for attending.  The teacher should not insist on the child maintaining a cross legged posture on the floor if it is an obvious struggle.

3.  Auditory defensive children just can’t handle the typical noisy atmosphere of a nursery school or kindergarten classroom without losing their ability to stay organized.  Earplugs can help.  So can having something to chew on, which will help the child dampen sound.  For a very young child, I have a stash of small diameter clear plastic fishtank tubing, which you can buy in a hardware store or pet shop specializing in fish.  For older children, I buy tubing large enough so that it will slip over the end of a pencil. {I don't like chewable jewelry, which I feel is stigmatizing.  The clear tubing is super cheap, and discreet.}

4.  If the child is really struggling in a noisy atmosphere, he needs to have a break.  Send him out of the room on an errand, like carrying a box of books to another floor in the building, or have him carry something heavy in a backpack.  Make sure he stops for a drink of water on the way back.

5.  A small fidget toy, employed discreetly, can help a child maintain appropriate arousal levels in the classroom.  Discuss this with the child’s teacher in advance, and have a small stash available for the child to keep in his pocket or desk.  Or give them to the teacher to dole out when appropriate.  Have the teacher take the child aside, tell him that she observes that his attention is flagging, and that she is giving him a strategy to help him stay present.  Have the child outline some other good strategies that can be employed discreetly in class:  chewing on something, getting up for a quick drink of water, stretching in place, etc.

6.  If there is enough space in the classroom, a large cardboard box big enough for a child to sit in provides a wonderful refuge for any child who needs a break from the noise and business of the school day.  These are readily available at stores that sell large appliances like stoves and refrigerators.  Put a few cushions in there, and store the box on its side so that it’s easy to climb in and out.  Leave the flaps on so that the child can have complete privacy if he so desires.  The rule is that the child must have time in there undisturbed, so no following him in there and forcing him to engage with you or to participate in class from his hiding place.  If there is no room for the box, a couple of bookshelves placed a foot or so apart will provide a little niche in between.

7.  A child who is struggling to read will benefit from a slant board or document holder so that reading and writing materials can be presented upright.  This reduces visual distortion.

8.  A child who constantly fidgets and can’t sit still needs an inflatable cushion like a Disc-o-Sit or Move-N-Sit.  The classroom should have a few available for all of the children to try at the beginning of the school year.  Eventually the children who don’t need them will lose interest in them, and those who need them will continue to use them.

9.  A classroom where the teacher is constantly fighting with the children to sit still is a classroom in which the children aren’t being allowed to move enough. Movement is what activates the brain, increases alertness, and allows for focus and attention.  Is it possible to suggest that more structured movement be incorporated into the classroom routine, such as calisthenics, Brain Gym exercises, or songs with accompanying dance or movement routines?

10.  I’m fighting an uphill battle here, but when I see a classroom get fed a snack of blue gummy bears washed down with Hawaiian Punch, I’m not surprised that the teacher has a hard time keeping order for the rest of the afternoon.  Children should not eat bad food. You can't expect a car to run smoothly on second rate fuel!  What can you do about making sure that classroom snacks are low in refined carbohydrates and additives, and high in complex carbs and lean protein?

11.  A recent study published in the New York Times suggested that children had a much better time of it staying focused in the afternoons when the school switched their recess time to before their lunch break.  Can you see about trying to make this happen in your school?

12.  I have been to unfortunately many classrooms in New York City that have no outside windows, which means no natural light, ever, and poor ventilation.  How would you cope, day after day, in such an environment?   If I were to interview for a job in an office with no outside windows, I would turn it down immediately.  Children should not be expected to spend huge chunks of time on a daily basis in artificial light, with no outside air.   It's not healthy.

Wednesday, June 9, 2010

Why Can't My Child Behave at School?

In my last post, I talked about the child whose sensory issues may not become completely apparent until he is forced to cope out in the world, away from his parents, and is failing to meet expectations at school.

Sensory defensive children often behave in ways that we don't understand. Things that we may not even notice {the sounds made by a refrigerator's motor or the hum of an air conditioner, the feel of an elastic waistband} or notice but perceive as neutral {another person sitting almost on top of us on the subway, eye contact with a stranger or new acquaintance} or think of as pleasurable { perfume, a kiss on the cheek, loud music} are interpreted by their nervous systems as noxious or viewed as threatening, and so their behavior is going to reflect that.  Your child may love you but wipe off your kisses. Or a child may like you but but may respond badly to your scent {which is why therapists and teachers should never wear perfume to work}.

Is it possible that your child is acting out as a result of being sensory defensive?  Here are some clues that may help you interpret some of his behaviors.

Visual defensiveness causes the child to be sensitive to light, and to dislike making eye contact.  He will be easily distracted by anything moving in the environment, because his nervous system is warning him that it may be a predator and he has to keep track of it in case it attacks.

Tactile defensiveness causes the child to dislike being touched, and to respond inappropriately when people come into his personal space by lashing out.  This can be a physical response, like biting, kicking, spitting, pushing, or hair pulling, or verbal, or both.  A tactile defensive child complains about his clothing being scratchy or too confining, hates having his hair combed or washed, objects to lotions and liquid soaps, is often a highly picky eater, gagging and choking on seemingly inoffensive smells and textures, and can have a rigid personality, unable to compromise and insisting on doing things only on his own terms.  He needs to have his world be predictable and ordered and doesn't deal well with surprises.  He has a hard time making eye contact, wipes off kisses, and has a hard time showing and receiving affection, especially to people outside of his close inner circle. Transitions are difficult for a tactile defensive child, and socializing can be quite a challenge.  

The auditory defensive child is often "tuned out," and doesn't appear to understand what is being said to him much of the time.  He often will not hear you when you speak to him.  He covers his ears and grits his teeth.   He hums or makes noises at inappropriate times.  He chews on everything he can find, becomes completely disorganized in noisy environments, and will lash out in surprising ways.  For example, I used to treat a little boy who would cause scenes at the dinner table every evening because he couldn't stand the sound of his family chewing.

Sensory defensiveness is often coupled with low muscle tone and delays in coordination, which means that the child is struggling with his balance and can't trust his motor planning abilities.  This makes the playground and gym class extra threatening.

Young children just don't have the verbal sophistication to tell anyone what's wrong.  They just know that they are being forced to spend time in environments that are a continual assault and that they are being required by the grown ups to do things that they can't do or are afraid to do.  Even a child who can kick a ball perfectly well when it is rolled to him by daddy in the park may be unable to do it on a real soccer field surrounded by running, screaming children.

If you have a child whose behavior is perfectly reasonable most of the time but has outbursts or temper tantrums at school or out in public, it's more than likely that either he is trying to figure out a way to get himself removed from an aversive situation or knows that he is going to be required to do something that he can't do or is afraid to try.  Who among us has not attempted to divert others' attention from our deficiencies, or has not left a party or a club because we couldn't handle the smoke and noise anymore and just wanted to go home?

Sometimes a defensive child simply can't contain his reactions.  I have been on many school observations over the years, and have seen this over and over.  A child who is perfectly capable of being calm, focused and goal oriented in a quiet atmosphere becomes horrifically disorganized in the noisy, chaotic atmosphere of the typical kindergarten classroom or gym class.   

I have seen countless boys who are charming and personable one on one, and a real delight to work with in the therapy clinic, but are simply unable, because of their sensitivity to noise, to participate in any meaningful way in their classrooms.  They become so completely disorganized due to their defensiveness that they can only run around in circles, kick things over, clown around and be silly, or kick, bite, and scratch their classmates.  They are trying to let the grownups know that they are not coping well in that environment and need to leave.  I once treated a little boy who would walk into his kindergarten class first thing every morning after a long, stressful ride on the school bus and tip his desk over.  This was a serious cry for help!

If your child doesn't have a mean bone in his body but is behaving poorly at school, being out of control and disruptive, it's time to take a look at what is driving his behavior.  When is it occurring, and what is he really trying to tell you? 

The best thing we can do for a child whose responses are so consistently aversive is to remove him from a situation that is causing him such distress.  Instead of forcing the child to tolerate a situation day after day that is obviously intolerable to him, if it's at all possible, find an environment that is better suited.  I once observed a child at school who was fine in the quiet atmosphere in the clinic but was disorganized and miserable in the chaos of his large classroom.  I told his parents he needed a quieter, less chaotic atmosphere.  Fortunately, they found him one and he did a lot better.

If your child is consistently acting out in gym class or in the noise of the cafeteria or on the playground, he's trying to tell you it's too noisy and chaotic for him.  What are some other options?  Would it be possible to work with the school to find an alternative for him {and the other children who are in his situation} for those times?

If this is not possible, you can try offering the child some earplugs.  Gum, or something to chew on, can help.  One of the reasons why a child may be so overly sensitive to noise is that the filtering and dampening mechanisms in the inner ear are not functioning correctly.   This is especially the case if the child has had recurrent ear infections.  Chewing can help the child by engaging the tensor timpani muscles, which dampen sound.  Intense spinning, if the child enjoys it, can also help.

  If your child is participating in occupational therapy, talk to his therapist about ways to reduce his auditory defensiveness.  She may be able to implement a therapeutic listening program specifically designed to reduce sound sensitivity.  

If your child is not in therapy, and is exhibiting some of these behaviors, I would strongly recommend an evaluation and treatment by a sensory integration therapist.  Sensory integration OT will teach the child to normalize the way he is processing sensory information, which will help him cope more successfully with the demands of school.

Monday, June 7, 2010

Is Your Child Sensory Defensive When He's Not at Home?

As a fairly new pediatric therapist practicing in a busy clinic in Brooklyn, I worked with a little girl for almost an entire school year before I found out, to my utter astonishment, that she had a diagnosis of PDD, a form of autism.  It wasn't on her IEP, and her mother, who had other seven children at home and was always in a tearing hurry to drop her off and pick her up, never said a word to me about it.

She had huge welts on the backs of her legs {which I never saw} from compulsively rubbing them on the furniture and scratching at them with her nails at school, a symptom of severe tactile defensiveness.  She was echolalic in class, meaning she repeated what others said to her instead of initiating her own conversation.  She exhibited many ritualized behaviors, could not make eye contact, and would speak only with her sisters at school, using a made up language.   She was such a highly picky eater that she would only eat a small handful of bland foods.

This was the child whom the school knew.  When she was with me in the clinic, however, she was open to try any game or activity I proposed, chatted with me about anything and everything, transitioned easily between activities, worked very hard on her handwriting and made exceptionally good progress, and was socially appropriate with the other therapists and children present.  We had a wonderful relationship, and her mother told me many times {always on the fly} how much this little girl looked forward to OT every week.

I would never in a million years have guessed that she was autistic.

A few weeks ago, in my post Look Homeward, Angel, I talked about children who are very nicely behaved out in public but behave like the spawn of Satan the minute they are behind closed doors at home.  

But what about if your child is the opposite?  What if you have a child whose behavior seems perfectly ordinary, maybe just a little overly sensitive to this or that, but his school or his soccer coach are reporting that he is struggling, and it comes as a complete surprise?

Most of the children who come to see me in the clinic have a clinical condition called sensory defensiveness.  This means that because of the way they are wired, many of the sensory experiences which we would consider neutral or would not even register at all are interpreted by their nervous systems as a threat.  

These children may be functioning adequately at home, because there is nothing in their home environments to trigger their defensive responses.  They may also appear to have perfectly appropriate responses in challenging environments when with their parents or a trusted adult.  For instance, I treat an absolutely adorable, highly intelligent little boy who is a pleasure to work with one on one in the clinic, but has such a hard time coping at school due to his extreme defensiveness that he requires an adult with him almost all of the time.  His behaviors are so problematic on the playground and during gym class that he is often in danger of harming his classmates or himself.  His parents were absolutely shocked when they read the school observation section of his evaluation, which outlined a steady series of outbursts, attacks on his classmates, and increasingly disorganized behaviors during the 90 minutes he was followed on a typical school day, because his behavior when he is not at school is so different.  He is the sweetest older brother to his baby sister imaginable.  He and his parents travel together around the busy streets of Manhattan without incident.   He is calm, focused, and organized, even on the subway, with all of its heat, noise, crowding, and movement.  

The difference is that when he is with his parents, he understands that they will protect him and make the world safe for him, and that nothing more than a little conversation will be required.  At school, he has to contend with all of the noise,  chaos, and unpredictability of small children without his parents' protection, while following an elaborate set of rules, having to sit cross legged on the floor for extended periods, socializing appropriately,  and applying himself to learning the day's lesson.  It's far more than he can currently handle.   

It's also entirely possible that your child has trained you and your spouse to respond to his sensory challenges in such a way that you have adapted to his needs and quirks without even realizing it.  Do you give several warnings about upcoming transitions, for example between play time and bath time, as a matter of course?  Do you find yourself withholding information about schedule changes lest your child become too anxious and bombard you with endless questions and complaints?

 Do you only buy your child seamless socks and the very softest clothing you can find, or put up with him insisting on wearing the same two or three pieces of clothing day after day?  Do you allow the child to subsist on white food because it's just easier than having a struggle at every meal?  Do you allow your child to wear a hat indoors and out because he likes to hide behind the brim?  Do you usually give him one brief set of instructions at a time, even if there is a lot to do, because you know if you give your child a complex multi step command, none of it will happen?  Do you avoid concerts, museums, classes, and other age appropriate cultural activities because your child doesn't like them?

If you are living with these things, you tend to become desensitized to them, and may not stop to analyze them until someone calls them to your attention and tells you that your child is having difficulty coping with his environment when he is away from you.

  All of us have our own peculiar sensory quirks.  For example, I have a friend who cuts the tags out of every piece of her clothing before she puts it on.   Another friend has to have a fan going in the bedroom, no matter the weather, because she can't fall asleep without some kind of white noise.  I myself won't leave the house without earplugs because I can't deal with screeching brakes on the subway,  and movies are always too loud for me.  Strong perfumes can have the curious effect of triggering a rage response in my body.  I once got into a screaming match with a colleague who habitually soaked herself in Eternity, a scent I find particularly noxious.

My sensory issues are entirely manageable.  I can have a full, fine life if I just remember my earplugs and walk quickly when I'm on the ground floor of Bloomingdale's. So can my friends, if they have a fan or a pair of scissors when they need one.   But what if your child's sensory issues are interfering with his ability to function at school, to play and explore his environment, and to socialize?

Children with sensory defensiveness issues have a difficult time managing their responses when they become overwhelmed.  Some children respond by leaving their bodies and shutting down when they are unable to cope.  These children may fall through the cracks because they are not bothering anyone.  Others respond by having outbursts or becoming out of control.  If your child seems perfectly reasonable most of the time but predictably acts out in certain situations, like gym class or or on the playground, chances are he's trying to tell you that he can't manage his responses because the environment is too much for him to handle.

Wednesday, June 2, 2010

More Fixes For Attentional Issues

More thoughts about why your child is having attentional difficulties, and some possible solutions.

1.  If your child does not have a set bedtime, it's time to enforce one.  Small children need an average of ten or eleven hours of sleep every night.  If your child has trouble transitioning into sleep, limit computer time and video gaming during the school week.   Turn off any computer activities, which stimulate the brain, a minimum of two to three hours before bedtime.  Try a warm bath in Epsom salts.

2.  Is your child overscheduled?  I evaluated a four year old a few years ago whose parents couldn't  figure out how to squeeze his OT in around all of his after school activities.  He was enrolled in soccer, cooking class, acting class,  woodworking, and ice skating.  I tried and tried to tell his parents, who were both highly ambitious and driven,  routinely worked fourteen hour days, traveled to Europe and Asia on business at least once a month, and socialized with their work colleagues every weekend, that just one of those activities would be enough for a child his age.  Many of his issues were stemming directly from having to be "on" all of that time for strangers, and from being passed from day nanny to night nanny to weekend nanny and back again,  rarely spending any down time with his parents.  They didn't listen, and although his sensory issues cleared up, according to his teacher's report of how he functioned in the classroom, his behavioral issues did not.

3.  For a child who gives up easily, find something he enjoys and can succeed at, and build from there.  What makes your child stand out and feel special? Nothing motivates like success, and nothing impairs the ability to succeed like poor tolerance for frustration.

4.  If your child has attentional issues,  activities that encourage him to hyperfocus to the exclusion of everything else, like video games, should be kept to a minimum.  The best kind of attention for succeeding at school, and for most of modern life, is one that is flexible.  It takes in  and  processes  sensory information while filtering it as needed.  This make it possible to attend to what is most relevant, while registering, without necessarily responding to, ambient sounds, smells, and movement in the environment.  In other words, a child's ability to focus should include an easy awareness of  everything around him, without being distracted by it.  He ideally should have no problems with temporary interruptions and be able to easily switch gears back and forth between activities.

5.  Children who have a hard time attending to fine motor tasks or to close work like drawing, reading, or writing often have undetected visual problems and might benefit from a course of vision therapy.

6.  Does your child have a hard time sitting down to homework? Make sure he gets some time outside, has eaten a nutritious snack with some protein, and has had a good drink of water before demanding that he sit back down.  He's been doing it all day, and he needs to move to activate his brain.  Build movement breaks into his homework time as needed, and incorporate movement into anything that requires problem solving, rote learning, and memorization.  A piece of hard candy to suck on helps the child concentrate and pulls the eyes in together.

7.  Walkers for babies are not a good idea.  They interfere with normal development by keeping the child upright when he should be crawling.  Crawling, among many other things, integrates communication between the two sides of the brain and body, sets up the trunk and pelvis for walking, strengthens the shoulders and hands for fine motor coordination, and develops visual skills like figure ground and depth perception.  Crawling is a critical part of development, and if it is interfered with, or if the crawling phase is too short, the child's physical and neurological maturation can experience delays.  This will in turn affect his ability to sit and attend.  Encouraging low tone children to do activities on hands and knees, like putting together puzzles on the floor and crawling through tunnels, will help recover some of those missing skills, even when the crawling stage is long past.

8. If your child is older than the age of, say about three, it's time to ditch the stroller. I see five and six year olds stuffed into strollers in New York, and it makes me nuts. Children can't develop balance, strength, depth perception, or endurance {things they need to help them sit still for long periods} if they're being strolled everywhere they go.