Notes from the trenches from a practicing pediatric occupational therapist -- because everyone is entitled to my opinion. With gratitude and appreciation to these visionaries: A. Jean Ayres, Barbara Knickerbocker, Sheila Frick, Patty Oetter, Colleen Hacker, Julia and Patricia Wilbarger, Jan Z. Olsen, Mary Sue Williams and Sherry Shellenberger, Bonnie Bainbridge Cohen, Sally Goddard Blythe, Andrew Taylor Still, Lawrence Jones, and F. Matthias Alexander. RIP Steve Jobs.
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
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.