Wednesday, May 25, 2011

You Talking to Me?

One of my favorite cartoons of all time, drawn by the incisive and hilarious Gary Larson, is called  What We Say to Dogs.
A man is pictured talking to his dog, saying, "Okay, Ginger, I've had it!  You stay out of the garbage!  Understand, Ginger?  You stay out of the garbage, or else.  I mean it, Ginger!"  Below, the artist depicts what the dog actually hears:  "GINGER blah blah blah GINGER blah blah blah GINGER."

Many of the children I treat are extreme sources of frustration for their parents and teachers {and, I confess, on occasion, their occupational therapist} because they don't appear to be listening,  or they don't respond when spoken to, or they don't follow directions.

Recently, I had a conversation about a little boy whom I had been asked to evaluate for handwriting problems.  His teacher told me that although he is not a behavior problem, she often feels that he is being disrespectful to her because when she speaks to him, he looks at her blankly or ignores her completely.

I had gone to observe him in school the day before and had walked into a classroom full of children working in groups of twos and threes.  There was quite a bit of chatter, and my friend was standing in the middle of the classroom when I arrived.  I watched as he wandered about aimlessly for several minutes until the teacher got up, walked over, and spoke directly to him.  She told him to choose a book and sit down.  He ambled over to the bookshelf and stood in front of it for quite a while.  She pulled out a couple of books and told him to choose one and sit.  He opened the book, but sat with it open in front of him while gazing around the room.

The teacher then asked the class to finish their discussions and to clean up the room.  My friend stood and began wandering around the room again, until the teacher got up, walked over to him, leaned down until their noses were almost touching, and gave him a specific task to do.

Later she told me that she had learned not to expect him to pay attention to what she was saying unless she was standing very close to him and made sure he was looking her right in the eye, and sometimes even then he would look at her with no comprehension or expression.

I stayed to watch my friend in his next class, which began as a highly structured lecture.  The teacher stood at the head of the class and spoke, then invited  discussion by asking a question and having the children raise their hands and answer one at a time.  My friend was entirely present and focused, and participated in the discussion.  After about twenty minutes, she brought out a project related to that day's lesson.  The children began to work on their individual assignments, which consisted of coloring and decorating posters.  The room, which had been very quiet, was now filled with the sound of chatter.  My friend picked up a marker, then began talking to the little girl sitting next to him and stopped working.  The teacher came over and sat next to him without saying a word.  He refocused on his project, and got back to work.

This teacher has observed that when the class is a tightly structured lecture, he is fine, but when the children are expected to work independently, he can only do so if she sits next to him, and that he can never work and talk at the same time.  She says that although he is one of the smartest students in the class, he is consistently at the bottom.

So what's going on here?  Why is this exceptionally bright little boy not able to function at school without constant adult redirection, and what is preventing him from being able to keep up with the academic demands of the classroom?
If we analyze his behavior patterns, what do we notice?

 He does fine when there is no background noise.  During the lecture, he was present and focused and participated in the discussion.  Whenever the children were split into groups and there was lots of noise and chatter, he couldn't function.

The reason he has always looked so blankly at the teacher when she speaks to him is that when she addresses him from across the classroom, she is generally trying to redirect him in a noisy atmosphere.  He is not able to pick out and attend to her voice from all of the other voices in the room.  His ears don't filter and distinguish foreground noise and pertinent auditory information {her voice directed towards him} from background noise {the sound of all the other children's voices in the room}.

Children with ears that don't filter and dampen sound efficiently tend to block out voices, since they can be painful to the eardrums.  So this boy may be in a state of chronic semi shutdown or  hyperfocus {in order to divorce himself enough from bothersome sensory input} in a noisy atmosphere.  This makes him  far less available for learning.  It also makes comprehending and following a string of instructions {take out your books, turn to chapter three, read the first four paragraphs, and answer the questions written on the board} very challenging.

He can't work and talk at the same time because in order to chat, he has to work extra hard to focus on his classmate's voice.  This takes up so much of his available brainpower that there is not enough cognitive energy left for the task.

When I talk about this with parents, I often hear, "My pediatrician has never said that there was anything wrong with my child's hearing."  It's not his ability to hear sound that's the problem.  It's the way the mechanism in his inner ear works to prepare sound for the brain and to protect the sensitive eardrum.  If this mechanism is not functioning correctly, the child's ability to make sense out of what he hears is diminished, and his ability to function in a noisy atmosphere is compromised.

A few quick fixes for this type of problem include being aware that the child does not function well in noisy environments, and having an alternative quiet space for him to write or study during the school day; gum or something to chew on, since chewing dampens sound, earplugs, or noise cancelling headphones.

I also strongly recommend that the child not be expected to do most of his learning through auditory teaching styles, but be given opportunities to process work visually and kinesthetically.

It's best to keep things short when speaking to the child.  Don't over explain, don't expect him to remember a long string of instructions, and don't expect him to be able to understand what others are telling him in a busy, noisy environment.

Wednesday, May 18, 2011

By Hand

"Man, through the use of his hands, as they are energized by his mind and will, can influence the state of his own health."   {Mary Reilly, 1962}

A few weeks ago I wrote a post called Giving Them What They Need, So They'll Give Us What We Want.  I talked about making sure that children had plenty of sleep, fresh air, exercise, and healthy food in order to support their behavior and ability to succeed in school.

We also have needs that are less tangible, but no less important, as one of my young friends reminded me this past week.  She is a little girl who strikes me, in addition to her sensory processing issues, as being lost and depressed.  Her parents are divorced, her father lives far away, and her mother travels all over the world for her work.  She is often in the care of nannies.  Her attitude is habitually one of indifference, which I think she adopts as a form of emotional protection, and I have found it especially challenging to form a warm connection with her.  She may or may not answer when she is spoken to, and if she leaves the gym to get a drink of water, she may or may not decide to return, but instead wanders into the office area and goes through the items on my colleagues' desks until I go find her and bring her back.

When I first evaluated her, I was quite concerned about her handwriting, so our work together has always included time spent correcting her habits of letter formation and her tendency to reverse letters and numbers.  Her participation in OT has generally been perfunctory and she has rarely made eye contact or initiated any conversation with me.

A couple of weeks ago, coming down with a bit of spring fever myself, I decided to give us both a break from writing and pulled out a potholder loom.  I was mainly thinking about how improving her eye hand coordination and the motor planning in her fingers would support my writing goals. I was halfway expecting her to tell me she wasn't interested and that it looked too hard. To my surprise, she dug right in and worked with absorption and intensity, although weaving the loops correctly was quite challenging for her and she made many mistakes that she had to go back and fix.

The next week, as I pulled out the loom, she sighed happily, "I can't wait to take this home!" and wove with furious concentration for 15 minutes without a break.  When it was time to go, she ran to her nanny for a hug, something I had never seen her do before.

This child needed to connect to a part of herself where no one had abandoned or neglected her, and nothing irritated her skin or hurt her ears.

 Through the act of weaving, she discovered that she could tackle an unfamiliar task and stay with it until she had mastered it.  She could create something unique by making choices while staying within a specific, structured set of rules.  She could recognize and correct her own mistakes, gaining a sense of accomplishment and independence.  She could make a positive impact on her environment with a tangible result, transforming a shaggy, chaotic pile of loops into an orderly piece of fabric.

She could look forward to showing her finished project to her admiring nanny, brother, and mother with pride, dropping her pretended indifference.

Using her will and imagination to direct the work of her hands, she opened the door to a whole colorful, creative world inside of herself, and could begin to heal.

Crafts and hobbies allow us to connect to the deeper parts of ourselves.  Becoming absorbed in the act of creation helps refresh and renew our minds and spirits and recharge from the stress of every day life.  Planning, organizing, making choices, solving problems, using our hands in skilled pursuit of a goal, and looking forward to the reactions of our loved  ones as they admire the finished results of our hard work can be an enormous source of pleasure, satisfaction and pride. The special needs children I work with tend to have a severe shortage of pride and satisfaction in their lives.

Children with sensory processing issues who struggle in school, and who are consistently unable to meet the grown ups' expectations, are particularly vulnerable to succumbing to the belief that they will fail.  Success at a craft, with a tangible result, can be a huge boost to morale and very  motivating.

Just as it's important to work on correcting a child's impairments, it's critical to help him identify, and practice utilizing, his strengths.  A child who feels useful, competent, and confident in his abilities is a child who has the internal resources to face a challenge thinking "I can!" instead of "I can't."

What talents and abilities does your child possess that would allow him to shine?

Wednesday, May 11, 2011

A Moving Testimonial

I know I'm a broken record, but I can't urge you strongly enough, now that the weather is good, to keep your children outside.  It's critical for their mental and physical well being. 

I have a friend and colleague who knows a great deal about alternative medicine, both from a professional interest and a personal one.  She has a son with ADHD.  A few weeks ago, I emailed her a question about using aromatherapy techniques for improving a child's ability to focus in the classroom.  I had to laugh when I read her response:  "Essential oils are good, but intense exercise is even better.  My son joined a lacrosse team and has been doing great, especially on the days when they have practice.  I make sure he gets outside to play every single day now, and it's made a huge difference in his ability to do his schoolwork."

There is a profound correlation between the lack of movement and exercise children get these days and the issues so many of them face in the classroom.  I'm not only talking about the fact that they don't walk to school anymore, that recess is now considered a frill, and that instead of going outside to play in the summer with their friends, many children now sit alone in front of the television or the computer.

I'm also referring to the fact that instead of actively clinging to mom on her hip, and then roaming and exploring freely once they start to crawl and walk, children are increasingly strapped into carriers and strollers as infants, toddlers, and beyond, and are passively wheeled and carried around everywhere.  In New York City, it's common to see six and seven year old children squashed into strollers with their knees grazing their chins.

Every time we strap a child into something, force him to be passive, and prevent him from moving his body, we are interfering with his neurological development.

Why is movement so critical to the ability to perform in school?

Most of the children I treat have depressed vestibular functioning.   The vestibular nerve is responsible for not only informing us about where we are in space, it talks to the extensor muscles in the body {the ones that keep us upright against gravity} and to the part of the brain that is responsible for our levels of alertness, arousal, and attention.

 In a normally working nervous system,  a small amount of movement will cause the nerve to fire and set off a reaction in the body to tell it to sit up and pay attention.  For instance, I'm sitting here at my computer, and I notice that I am slouching, and that my attention and energy are beginning to flag.

I pause for a moment, stretch, lean over, reach for my cup of tea and take a sip.   That will cause the  vestibular nerve to fire.  My back muscles straighten, and my brain wakes up.

 This small action is enough to allow me to refocus and continue.  I'm back to sitting up nice and tall and being alert enough to continue to think and type.

But what if that small amount of input doesn't have any impact on my vestibular nerve?  If the nerve's threshhold for response is very high, stretching and reaching for my cup isn't going to cause it to fire.  I gave it some information, but I'm still drooping and unfocused. The underresponsive nerve  needs much more intensity than just that small, discreet amount of movement before it will do its job.

 If I have no other options available to me at the moment, I can't do anything to get that nerve to fire and to wake up my body and brain.  So my ability to sit up and think and focus is going to become increasingly compromised, and I'm going slump and space out.

This is one of the reasons why children with poor postural control and attentional issues can't stay present in school.  We insist that they sit still, and don't allow them to move, or to fidget, or to chew gum, or to employ any strategies at all that would help them get that nerve to fire so that they can keep their backs straight and their brains awake.

I'm oversimplifying a bit here, because there are all kinds of other factors involved in a child's inability to keep focused in an academic atmosphere, but one of the easiest and most profoundly effective ways you can help him is to keep him moving.

Take him to the playground for 20 minutes before he starts school and have him play on the swings and slide.  Organize a group of children from his class to come early {believe me, yours is not the only one with the problem} and play tag, Red Rover, or a quick game of statues, dodgeball, or touch football.  Run them around until they are out of breath, then give them a big drink of water.  Repeat until the bell rings.

Activities that encourage the child to move his body with his head in all different positions are the best.  Games that require a lot of heavy input, like wrestling, dragging large, heavy items, or jumping from a height of a few feet, are very calming and organizing to the system.

What else besides movement makes the vestibular nerve cause us to sit up and pay attention?  Novelty, intensity, and the unexpected.

 I can see this in action when I watch my cat, who almost always snoozes in the chair next to me while I am working.  Any unexpected sound, if it's loud or sharp enough, will cause him to sit up and look around. 

 Good public speakers  instinctively vary their tone of voice and the media they use to present information to keep their listeners engaged.  Joseph Hayden, the 18th century composer, was so annoyed at the audience's tendency to fall asleep during his concerts that he wrote "The Surprise Symphony" to jolt them back into awareness.

Teachers need to be made aware and be part of the solution when a child needs more movement built into his day.  The child can be sent on errands when he is flagging, or discreetly instructed to go and do some jumping jacks and get a quick drink of water.  Sharp tasting candy, like Warheads or Tear Jerkers, can provide intensity and novelty.

You can sit down with the child and talk to him about some strategies for staying focused while he's sitting still. Ask him about what works best for him and make a list of discreet options for helping him stay alert and focused in class.

Some ideas:

Stretch, change position, run an errand for the teacher,  drink water, suck a hard candy, discreetly play with a fidget toy, squeeze a therapy ball, doodle, rub the upper tips of the ears between the thumb and forefinger, sit on a Disc-O-Sit cushion.

If the teacher habitually attempts to manage the child's behavior by cutting him off from recess, this practice should be stopped immediately.  He needs to move his body more in order to be able to meet the grownups' expectations, not less!

Nor should the child ever be punished by not being permitted to go outside to play.  Find another consequence.   Time spent outdoors should be sacred.

And in addition to exercise, make sure  your child is getting plenty of sleep, lean protein, fresh fruits and vegetables, and water!

Wednesday, May 4, 2011

Another W We Don't Need

Many of the children I treat are W sitters.  Instead of kneeling, sitting on their heels, or crossing  their legs in front of them, they sit in a W, with their legs bent at the knees on either side and their behinds flat on the floor. Children sit this way when they don't have sufficient balance or trunk strength to sit unsupported, so they manufacture the postural stability they need from the wide base of their folded legs.

W sitting is problematic for both orthopedic and neurological reasons.  It's fine to sit like this once in a while, and many toddlers do assume this posture from time to time, but it's not a good default position.  Our bodies were NOT designed to sit like that, and prolonged W sitting is destructive to the bones, muscles, and ligaments that comprise the knees and hips.  Habitual W sitters frequently grow up to be adults who have chronic knee pain.  They may even need knee and hip replacements, their joints have been so compromised by misuse. Anyone who has lived with hip or knee pain even briefly knows how utterly debilitating it is.

Relying on the W position interferes with the child's neurological maturation and development of his balance and coordination.  Sitting this way for long periods every day does not allow the child to rotate his trunk as he is playing.  Rotation of the spine and trunk allows us to reach across the body with the dominant hand to pick up and use objects on either side of us.  W sitting fixes the trunk so that the child must use each half of his body separately instead of coordinating the two sides together.  Since he can't really move much in this position,  he tends to reach with and use the handy hand on the same side, instead of turning, shifting his weight, and crossing over the midline of his body with his dominant hand.   This does not provide the child with the movement experiences he needs to integrate the two hemispheres of the brain, which must communicate together for higher level activities.  This interferes with the child's balance, equilibrium responses, and gross motor coordination.

Children who don't cross the midline due to W sitting often don't establish a strong hand dominance.  Their fine motor control and eye hand coordination suffers as a result, and so does their ability to write and to use their hands to play with toys and games, make crafts, open packages, and manipulate fasteners.

Since they can't rotate their spines, W sitters are also limited in how far they can turn their heads, and so they don't use their eyes the way they should.  Their visual skills, like depth perception and binocular vision, suffer as a result.

These delays affect their schoolwork, since they have not developed the physical underpinnings required to successfully coordinate their hands and eyes for reading and writing, nor the balance and strength they need to sit for long periods.  Because they have not practiced weight shifting and rotating their trunks, which is critical for maintaining balance, navigating the busy hallways, gym classes, and playgrounds at school can be a huge, anxiety provoking challenge.

A child who is observed to be a habitual W sitter at school should be provided with a chair during play and circle time instead of sitting on the floor, or should be given a place against a wall where his back is supported.   Since W sitting in school age children is often an indication of delays in the child's neurological development, a referral to an occupational therapist may be in order.

Home activities that are good for W sitters include toys and games that require crawling or playing on all fours,  like floor puzzles, racing cars, tiddly winks, and marbles.   If your child is small enough, carry him as often as you can on your hip or on your back and give him minimal support.  This will encourage him to grip you with his arms and legs, which will strengthen him. A therapy ball to sit on at home while doing table top activities like homework or while using the computer or watching television is very strengthening to the small muscles of the spine, which are important for posture.  Activities that promote balance and/or upper body strength, like wheelbarrow walking, are helpful.

Teach the child to sit on his heels, or to sit on the floor with both legs next to him on the same side.  These two positions allows him to turn and rotate his trunk.  Train him to tuck his heels under him when he hears a grown-up say "Fix your feet!".

I also recommend to the parents of W sitters that their children not wear shoes indoors, since it's much easier to sit on heels with bare feet.