Wednesday, September 28, 2011

Look Before You Label

I would venture to guess that virtually every child with a diagnosis of ADHD is living in a body that doesn't support learning.  Before we label and medicate, we should assess and treat the impairments in the child's structural, metabolic and neurological functioning.

  We also need to be sensitive to what we are demanding of a child.  If we are constantly expecting the child to perform at a level that is higher than his neurological age, the child will fail over and over, and behavioral problems are certain to result.  This is also true of a sensory defensive child who simply can't cope well in a noisy, chaotic atmosphere.

Knowing what the child's life is like outside the classroom can also provide many clues as to what is preventing the child from being present, focused, and available for learning.

I have a little girl on my caseload who simply can't sit still.  She is a tiny four year old who is preternaturally articulate, bossy, demanding, and obstinate.  She knows exactly what she wants and what she doesn't want and is not shy at all about demanding it. She is constantly on the go, exploring her surroundings, opening drawers, rummaging through shelves, examining and manipulating every object she can reach.  It's a rare activity that can hold her attention for more than 30 seconds before she is up and off again.

Her SEIT {one on one teacher, assigned to special needs preschoolers in NYC} is very concerned about this little girl's lack of ability to function at school.  The child is extremely bright, but has no attention span for the activities the teachers choose for her, is not interested in learning or joining in, doesn't care about pleasing grownups, and won't align herself with the rules and expectations of the classroom.

The SEIT recommended to the child's parents that she be tested by a neurologist.  I know that she, and the school, believe that the little girl has ADHD.

It's very true that the child has attentional issues.  But what is behind them?  What is preventing her from meeting our expectations?

This child had a somewhat traumatic birth and was delivered by Csection.  She had a hard time feeding and didn't sleep very well.  She sat up on time, but when it came time to crawl, she got up and walked instead.  

Her mother owns a day care center, where she works long, hard hours, and when the little girl is not at her preschool, which is busy and noisy, she is at the day care, sharing her mother with the other children.  She's been in some sort of school since she was about two years old, and at the day care center since she was born.

 What I discovered during our first session was low muscle tone, poor balance, weakness in her trunk and legs, retained primitive reflex activity, impaired vestibular functioning, and tactile and auditory defensiveness.  Because she had not spent any time crawling, she had missed out on some key developmental experiences.  Consequently, her body is disorganized and weak.  Since crawling integrates the two sides of the brain, develops the vision, strengthens the neck and trunk, stabilizes the shoulders, and readies the hand for fine motor tasks, any child who does not crawl, or crawls for only a very short time, or crawls in an unusual way, is at risk for learning problems.

Low tone and trunk weakness make it difficult for this child to sit still. She doesn't have the effortless strength and stability in her spine and trunk that are required to support it.  Her impaired vestibular functioning drives her to move her body in order to stay present.   Auditory defensiveness prevents her from being able to concentrate in all the noise and chaos in the classroom. Her nervous system can't filter it out, and the incessant classroom chatter is bothersome and painful.   She doesn't like to allow people into her personal space, because it makes her anxious and uncomfortable.  Her clothing often bothers her, further distracting her. She is a highly picky eater, subsisting on white food, which causes her blood sugar to spike and drop.  She doesn't have good fine motor skills, which makes using a pencil or scissors a frustrating experience.

Like any four year old, she doesn't yet possess the internal organization or stability to learn to read and write, but her school includes them in their nursery school curriculum.  When the teachers insist that she engage in these tasks, which are at least three years beyond what she is capable of developmentally, she resists.

Children who are struggling with this combination of sensory defensiveness and physical weakness are not thriving in their school environments; they are merely surviving and coping.

  Many of the children I treat who live with sensory processing disorder crave a lot of solitude and quiet time in order to recharge their batteries, because they find daily life so stressful, but this child doesn't get it.  She goes directly from a noisy, chaotic school to a noisy, chaotic day care center, where she watches her mother nurturing many other children.  Then, when her  mother is finally done with work, she is exhausted.  She doesn't have much physical or emotional energy left in reserve to give to her daughter at that point, and she still has to take care of her home, so she parks the girl in front of the television while she prepares dinner and does housework.

In my clinical opinion, between school and day care, this child spends a great deal of her time in environments that are not suitable for her.  Consequently, she is overwhelmed, overloaded, and overstimulated much of the time.  The demands that are placed on her at school are too difficult for her at her developmental stage, which is far behind her chronological age.  She has no way of articulating to the grownups that she simply can't comply with their expectations, so she rebels and shuts down by getting up and walking away.

We need to give this child a stronger, more organized, less sensory defensive body, a better diet, much more time spent playing outside, a quieter, more structured classroom, a school curriculum that is more in line with her developmental abilities, less time in front of a TV, regular quiet time, and more quality time with her mother, before we label her with ADHD.


Peg Healy said...

Very thoughtful. I'd love to know, as a therapist, how/whether you can help her with exercises? She seems like the kind of child who would be much better off living on a farm in the country with a grandmother and tutor.

Loren Shlaes said...

Hi Peg! Nice to see you here.

I agree, most children would be much better off living out of the city. But since that's not an option for this family, we have to work with what is possible.

It does seem unlikely that mere "exercises" would help this little girl, judging from my description, doesn't it? She seems very involved. Sensory integration therapy consists of playing with this little girl, using specific activities that are designed to target the delays in her neurological development. The right "exercises" will make profound changes in her functioning.

For instance, one of the big issues I see with this girl is her Moro response. The Moro is the reflex that is triggered by baby's exit from the birth canal. When the baby hits the cold air, it takes a big breath, its limbs fly out in all directions, its head pulls back on its spine, and it cries out. It then pulls its body back into tight flexion. The Moro is completed, and thus integrated. It does not appear in daily life unless some huge stressful situation triggers it.

But what if it isn't integrated, but still active? If the Moro is still present and easily elicited in the child's body, the child is going to be easily startled. Children like this have a hard time modulating their behavior -- everything throws them for a loop, so they can't focus and attend, especially in a noisy atmosphere.

So what I do in the clinic is introduce activities that elicit the Moro response, over and over, and have the child work through it, until the child's nervous system integrates it, and it is no longer the child's initial response to stress. Voila! A calm, reasoned approach to life, instead of a startled, primitive one.

Another problem is the fact that she never crawled. So we can do lots of play that involves crawling. This integrates the two halves of the brain to work together, which organizes her brain and body, strengthens up her trunk and shoulders, improves her vision, and prepares her hands for fine motor skills by separating out the thumb from the rest of the hand. Now she can sit better, because she has trunk support, she has better vision, so she can see what she's doing for close work, and she has more control over her pencil.

See how sensory integration works?

burritoful said...

Thank you for your very insightful, informative post. I see a lot of things that are affecting her ability to attend, but how to you suggest to meet those needs? Besides reflex integration during therapy sessions, how have to you addressed her needs in terms of environment? Have you done much parent/teacher education? I'm curious as an OT new to working within the school setting. Thank you!

Anonymous said...

Looks like you deleted my previous comment.