Wednesday, March 30, 2011

Tactile Defensiveness

Consider these scenarios, taken from my files:

1.  A beautiful little girl who routinely turns down play dates and party invitations, and prefers to spend her weekends sitting alone in her bedroom with her clothing off, playing video games.

2.  A man in his thirties who can't bring himself to be intimate with his wife.

3.  A little girl who routinely wipes off kisses, won't sit on her parents' laps, won't hug her grandparents, and hates and fears the family dog.

4.  A little boy who can never walk to school without becoming, in his mother's words, a "whining, miserable mess," complaining about the tag in his shirt, the seams in his socks, and bursting into tears at the feeling of his jeans rubbing his legs.

5.  A little boy who is at the center of every altercation at school and soccer practice, whether he is initially involved or not.

6.  A little boy whose shoes have to be endlessly tied and retied every morning because no one can tie them tightly enough to satisfy him.

7.  A little girl who absolutely refuses to wear undergarments or tights and insists on going commando and barelegged in every weather.

8.  A little boy who will not try any craft activity if it involves paint, paste, or glue.

9.  A little boy who is so emotionally rigid and controlling that he has everyone walking on eggshells.

10.  A little boy who is so distressed by anyone coming into his personal space or touching him without his permission that he becomes unglued and disorganized for the rest of the day and can't stop talking about how angry it makes him.

11.  A little boy who lashes out at the child sitting next to him without warning.

12.  A little boy who reflexively hits another child when she accidentally bumps into him in line.

13.  A little girl who sits quietly in class, keeps mostly to herself, constantly pulls the sleeves of her sweater over her hands, and insists on having the same exact thing for lunch every single day.  Each afternoon when school is over, she rushes to her mother and bursts into hysterical tears.

14.  A teenaged boy who gags at the sight of all fruit and vegetables, toothpaste, and liquid soap, and who subsists on white bread, chicken broth with noodles, and milk.

15.  An eight year old girl who, ever since she was a baby, finds having her hair washed, brushed, braided, or cut an absolute agony, and still cries when her mother cuts her nails.  Her mother reports an elaborate bath ritual that centers around making sure that no water gets anywhere near her child's face, lest there be a tantrum.

16.  A little boy who always walks on his tiptoes and holds his hands in tight fists.

17.  A baby who arches backwards and screams when someone comes to pick her up out of her crib, and is only made more distressed by stroking or hugs.

18.  A toddler who drives her mother mad by undoing her pajamas and taking off  her diaper at every opportunity.

19.  A four year old boy who absolutely refuses to go barefoot, tears off any hat or headgear no matter the weather, and who simply cannot behave in a calm or organized fashion, especially at school.

20.  A little boy who screams "NO!" and hits at anyone who comes into his personal space, including himself.

21.  A loving wife and mother who can't bear to hug, cuddle, or come in contact with her husband while they are lying in bed.

What do all of these people have in common?  They live with a clinical condition called tactile defensiveness.  Their skin is overly sensitive, and is wired directly to a part of the brain that interprets many kinds of touch as dangerous and/or painful.  Their skin doesn't filter out things that a normally functioning nervous system would not register, like the tag on a shirt or the elastic on an undergarment, and sensations that should be perceived as pleasant or neutral feel painful, threatening, and noxious.   Many fabrics, especially synthetics, drive them to distraction, hugs and kisses feel like an assault, light touch feels like spiders crawling on their arms, and anyone coming into their personal space could be a predator.

A child with tactile defensive skin has a challenging time coping in the classroom.  He can't bear to touch paint, paste, or glue, he doesn't like to sit in too close proximity to other children in case he gets bumped or touched, his clothes bother him, the smells are overwhelming, and he is required to interact with things and people all day long that feel dangerous, threatening, and noxious.  He has a hard time staying present in his body and an even harder time trying to shut off the danger signals so that he can turn his mind to what is being taught.

Next week I'll talk about the implications of tactile defensiveness and what occupational therapists can do to alleviate it.

Wednesday, March 23, 2011

Put Your Lips Together and Blow

I recently started working with a little boy who has quite a routine established.   As soon as he enters my office, he starts zooming around from room to room, checking out every inch of space in the clinic.  His parents always become highly  embarrassed by this behavior and rebuke him sharply, but nothing can stop him.  If he is physically restrained, as soon as he is free, he is off again.

This child is functioning at a very primitive level.   What is driving his behavior is extreme sensory defensiveness.  Most of what comes into his personal space is interpreted by his nervous system as a threat.  He is looking for predators!  This is a child who will require a lot of sensory work to calm down the reptilian part of his brain, and convince it to stop alerting him that everything that crosses his path is threatening and dangerous.

Why is a child's nervous system wired like that?

One aspect of a child's functioning that is absolutely critical, but that often gets overlooked when a child is being evaluated, is the child's ability to breathe.  The reason that this is so important  is that breathing has a profound influence on not only our physical health, but our emotional and intellectual health as well.  Just as our breathing is affected by our inner state, our inner state can be affected by our breathing.

Many of the children I treat, including this boy, are rapid, shallow breathers.  When we are frightened, anxious or stressed, chemicals flood our systems and we begin to breathe rapidly, using only the very top portions of our lungs. This puts us quickly into a heightened awareness and a fight or flight state, as opposed to the slow, deep, relaxed, full breathing of someone who is sound asleep.

Even when we are not under attack, if our bodies are preventing us from breathing fully, we can be living in a chronic low level fight or flight response.  This predisposes us to scanning the environs for predators, alerting to everything and filtering out nothing, and prevents us from being able to focus on much outside of ourselves.  It doesn't put us in a good place for learning,  socializing, or exploring, and makes it challenging to regulate our alertness/arousal levels.

Poor breathing is a symptom of a variety of underlying causes.   For instance, the child could be chronically congested, due to allergies or sinus problems.  He could be living with asthma. In the children I treat, often it is because their trunk tone is low, their posture is poor, and so the diaphragm, and the muscles that serve to expand the ribs, are weak.  They often have breathing issues that are related to birth trauma.  If the baby does not take in its first full, deep breath directly after birth, such as in a C-section birth, it can negatively affect the baby's ability to breathe.

If you have an anxious, rapid, shallow breather on your hands, the thing to do is NOT to say, "Take a deep breath!"  The child already has enough trouble breathing in without someone interfering further!  The best way to help a child who breathes like this is to give him lots of toys that encourage him to purse his lips and exhale forcefully.  I use siren whistles, razzers, blow darts, kazoos, bubbles, party horns, and anything else I can find. You can also make great impromptu blow toys out of drinking straws and light objects such as cotton or ping-pong balls, wadded up paper, beans, and  tiddly winks.  You can stick a bunch of birthday candles into modeling clay or salt, light them, and have the child blow them out.

The reason this works better is because a deep, sustained, forceful exhale will automatically cause the next inhale to be fuller and deeper.

Try this:  Breathe in as big as you can.  What was that like?

Now:  Breathe out until your lungs are really empty, then notice the next breath as it rushes in.

What was that like?

The inhale after the forced exhale was much more relaxed, open, and expansive.  Our bodies know how to inhale beautifully.  Sometimes it's just a matter of clearing the path so that it can happen.

Try playing with bubbles, whistles, and blow toys for a few minutes every day with an anxious, restless child and see if it doesn't help him to be much, much calmer and happier in his body.

Wednesday, March 16, 2011

When a Child Can't Sit Still

One of the most common reasons why a child is initially referred for occupational therapy is that he can't sit still in class.  When a child simply can't stay put, it's vitally important for the grown ups to play detective and figure out why.  Children who can't sit still are children who are driven to move. Before we try to force them to be still, we need to find out what is behind their restlessness so that we can begin to help them, either by fixing the problem that is driving the behavior or by providing them with safe, appropriate opportunities to supply them with the movement experiences they need.

You can get more help here.

Many of the children I treat can't sit still simply because they need to move their bodies.  In big cities like Manhattan, children don't have the opportunity to run around freely, and their overscheduled parents don't make the time to take them to the park.  It often takes much convincing on my part that regular unstructured time spent out of doors, either at a park, beach, or playground, is an essential priority for children, and that constantly strapping children into strollers, car seats, high chairs, play pens, and anything else that prevents them from moving and exploring freely is impeding their neurological and cognitive development.

I often go to schools for observations and leave with the feeling that the adults who are responsible for planning the children's days don't always schedule activities with a realistic view of what is possible and what is not.

  I recently observed a second grade classroom in which the children were required to sit quietly for 90 minutes and write without a break.  After about 30 minutes had gone by, the teacher was expending a lot of energy trying to get her class to stay seated and focused.  Ninety minutes for a group of seven year olds is a long, long time to sit still.  Another time I observed a classroom of six year olds being given a highly structured, rather uninteresting craft activity to do.  After about fifteen minutes, the teacher was working mighty hard to maintain decorum.   The majority of the children had long since finished their task, and were more than ready to move on, but they were required to sit there for ten more minutes.  The children got more and more restive and bored, and the teacher became sterner and sterner as she tried to force the children to sit.  It would have been much less toxic to give them a second task or to give everyone a one minute structured movement break.

 Something else I frequently observe is that circle time tends to go on and on and on.  After about five or ten minutes of sitting on the floor with nothing to do, the children are clearly restless and bored.  The teacher is unable to do any teaching  at that point.  All of her energy is directed towards trying to trying to convince them to sit still, when they are obviously dying to get up and move their bodies.

When children don't have good, solid strength in their trunks due to low muscle tone, sitting in a chair is a struggle.  If a child is constantly rocking in his chair, wrapping his legs around the furniture, leaning his upper body against his desk,  or falling out of his chair during class, he does not have the strength to support himself, and is trying to manufacture it by using the furniture.

 Children who have a clinical condition known as auditory defensiveness, which is oversensitivity to noise, have a hard time in school because they can't tolerate the noise levels.  Their ears don't filter and dampen noise effectively, and the sound waves from the other children's high pitched voices build up in their eardrums and can be quite painful.  A young child who moves around and around the periphery of a noisy classroom, can't settle down or demonstrate any goal oriented behaviors during unstructured play or work time, is having difficulty coping with the sound levels.

If the child's eyes are sensitive to light, he is probably quite uncomfortable, especially if he is in an interior classroom with fluorescent lighting.  I see this quite often in New York:  children in brightly lit classrooms painted a glaring, flat white, with no natural lighting or ventilation.  After a few minutes, I'm feeling sweaty and dull headed, and dying to get out of there myself.

Tactile defensiveness, a condition where the skin is overly sensitive,  can make it very difficult for a child to sit still when his socks are bothering him, his underwear is bothering him, the tag in his shirt is bothering him, and other children are sitting too close to him.

 A child who is restless and reluctant to do table top tasks like writing, puzzles, coloring, or cutting may have weak eye muscles.  He may have quite a bit of difficulty controlling them to do things like copy from the board or pulling in them in close enough to read or write.  This is painful and uncomfortable and makes it extra challenging to attend to close work.  If a child squirms in his chair, rubs his eyes, and is resistant to close work, he may have trouble seeing what he's doing.

Children who have a hard time sitting  are often poor, shallow breathers.  Chronic shallow breathing causes anxiety by flooding the system with adrenaline and forcing the child to exist in a chronic low level fight or flight mode.  Don't believe me?  Try panting shallowly for a minute, and notice the beating of your heart and the restlessness in the rest of your body.  The resulting agitation compels the body to get up and move, partly to survey the environment for predators, and partly to discharge the large amounts of nervous energy that the floods of adrenaline cause in the body.

A child who constantly seeks movement, spinning his body while standing in line, twirling around every light post he passes, jumping on every bench and curb, very likely has an under responsive vestibular system.  The vestibular nerve is responsible for our levels of alertness and uprightness based in part on information it receives as the child's body moves.  When it isn't working right, the child is driven to move more frequently and intensely to make up for the lack of nerve's ability to respond.  His arousal levels are too low, and he's doing whatever he can instinctively do in order to bring them to the level where he can focus and attend.

If a child has a very hard time falling asleep, and doesn't sleep well, his ability to sit and focus is greatly diminished.  If he is a seriously picky eater and subsists on junk food, he won't have the fuel necessary to help him keep centered and focused.  He may be suffering from gut problems, like undetected food allergies or yeast.

Monday, March 14, 2011

Eyes and Hands Are Attached to the Body

I recently received a call from a mother who was referred to me by a learning specialist because her son was having problems with his handwriting.  She started to mention the orthotics a physical therapist had prescribed for him due to his abnormal gait, but quickly stopped herself, saying, "You're an OT, so you are only interested in his hands."  I replied that his hands were attached to his body, and that I was very interested indeed.

Although it's true that handwriting is often not given priority in schools these days, problems with the child's ability to write legibly are rarely just a pedagogical issue. When a child cannot express his thoughts on paper in a manner that is consistent with his abilities, it is a symptom of underlying physical impairments.  If these are not addressed, the child's ability to improve will be limited.

I am often called on to evaluate children who have already had a round of occupational therapy. Invariably, what I hear is some variation of this:  The child was initially found to have delays in his fine motor skills, and perhaps he had some minor trouble functioning in his preschool classroom. 

 Occupational therapy focusing on the child's fine motor control was provided at school with the OT pushing into the classroom, or at home.

  The child made some improvements, therapy reached a plateau, and treatment was discontinued.

A few years have gone by, and the child is now in the first or second or third grade.   Instead of having trouble zipping his coat and coloring in between the lines, he now has serious problems keeping up with the academic demands of the classroom.  He can't copy from the board, he can't finish his in-class assignments on time, he can't keep his writing legible or organized, and although he is bright, articulate and full of ideas, his written work does not reflect this in any way. He is not tuned out, exactly, but he doesn't always know what the teacher has said.    He falls off of his chair several times a day, and although he isn't really a behavior problem, he does tend to take up more than his fair share of the teacher's time and attention.  There's something not quite right, but no one can put a finger on it.

By the time the parents get to me, they are understandably more than a little cynical about occupational therapy and are resistant to the idea of coming back when the child's improvement was limited the first time they tried it.
The reason that the child is still struggling is because the underlying issues that were preventing him from being able to perform tasks in an age appropriate manner were not sufficiently understood and addressed.  The neurological organization and physical stability required to support a high level task like writing has not been fully established in the child's body. 

In order to make lasting changes in the child's ability to succeed, it is critical to address his physical impairments, no matter how subtle they may be to the untrained eye.  The body is the foundation for the function of the brain.  The foundation must be strong, organized, and stable in order for the brain to interpret 
the environment 
and act on it appropriately,  and for the eyes and hands to work together as the brain commands them in a smooth, coordinated fashion.

Just as the stability of a building is dependent on the integrity of its structure, the body's ability to support the eyes and hands for reading and writing, the ears for listening, and the mind for learning, depends on its ability to extend and stabilize strongly, effortlessly, and reliably against gravity.  This stability is in turn dependent on the child's neurological development and the resulting maturity of his nervous system.

Most of the children I treat have retained reflexes.  Their nervous systems have failed to mature in time with their chronological ages, so that instead of being in complete control of how they use their bodies, they are dominated by primitive movement patterns that involuntarily lower their muscle tone when their heads and bodies are in certain positions.  This means that the child can never fully rely on his body to do what he tells it to do. 

Reflexes are built into our bodies in order to allow us to begin to eat and move after we are born.  For instance, if you put your finger into the palm of a tiny baby, it triggers a reflex that will cause the child's hand to grip.  If the baby turns its head to one side, its nervous system automatically signals the arm on that side to straighten, while causing the arm on the other side to bend. 

 These reflexes remain in place while the baby is busy learning to use them to sit up, reach for things, and crawl.  They disappear when the baby is strong and coordinated and no longer needs them to help him move.  But sometimes they remain present in the child's system, and are still triggered whenever the child turns his head or uses his body. 

primitive reflexes disrupt the child's balance and equilibrium, making it difficult to stay upright, and interfere with the functioning of his eyes, hands, and ears.  The child is constantly in a struggle just to sit, stay present, make sense out of what he sees and hears, and coordinate his hands and eyes.  No wonder he can't get his thoughts down on paper!  The part of his brain that should be involved in creating and organizing his ideas is taken up instead with basic survival.  As one mother observed, "My child is not learning in class.  He is just coping."

For a child who presents like this, when the bulk of treatment focus is shifted away from sitting at a table doing fine motor work and more towards integrating the reflex patterns, the ability to perform higher level tasks will spontaneously improve.  The child will have a much easier time controlling his pencil, and his ideas will flow easily from his fingers, when he is not using most of his energy and brainpower to control his body instead.