A few weeks ago, I started working with a really cute four year boy whom I could see was in trouble the moment he arrived for our first session. He did not acknowledge my greeting, and ignored his mother's entreaty to look at me and say hello.
After passively allowing his mother to take off his shoes and jacket, he wandered into the treatment room, found some bean bags, dumped them onto the floor, and lined them up. Before I could intervene, he had grabbed a toy tennis racket, positioned it just so on top of the precise row he had made, and stomped hard with both feet, damaging the playing surface.
When his mother and I told him to stop, he completely ignored us. I could see that he hardly knew I was in the room. His mother said that this was typical behavior for him, and that despite being four he could not talk very well. I quizzed her in depth about sensory issues, but she denied that she had ever seen any symptoms of defensiveness.
I tried to place him on all fours so I could test his postural reflexes, but he kept falling over and crawling away, back towards the line of bean bags.
He did let me put him on a large therapy ball, so I looked at his protective extension responses. Protective extension means that when the body is falling, the arms and legs will automatically shoot out in order to protect the head. His were absent. When the ball rolled forward, his head hit the mat. He was so shut down that he did not respond.
Next, I set up the trampoline, and invited him to jump. He tried, but could not maintain his balance while standing on it and kept falling over. His mother held out her hands, and he jumped for a moment or two while holding on to her, then climbed off.
I put him on my back to see if he could hold on to me. He could not. When I leaned to the side, he started to topple over. This meant that he was not righting himself in response to my movements, so the weight of his head was pulling him over sideways.
His balance! What jumped out at me during our interactions was that this little boy had a very unreliable relationship with gravity. He could not right his head, so his ability to keep upright when he tried to use his body was limited. His legs and trunk were too weak to stabilize him effectively when he was on an unstable surface, and there was no reflex in his body to protect his head when he fell.
I also knew, from his lack of attention span, his clumsiness, and from his mother's report that he refused to do any prewriting or craft activities at school, that he couldn't see very well. Poor vision is common in children with balance issues, partly because the vestibular nerve, which controls balance, also affects the movement of the eyes, and partly because the fine motor coordination of the eye muscles depends on a stable base of support from the spine. If a child is weak and unstable in his core musculature, his eyes will be weak as well.
Our eyes tell us where we are in relation to everything else, and if we don't have reliable vision, our behavior is going to reflect that.
I also saw that he was quite easily startled, and that his heart would race at the slightest provocation. This caused him to go directly into overdrive and become disorganized, so I focused some of our activities on training his nervous system not to set off alarm bells in response to ordinary, unthreatening experiences.
I asked his mother to buy a large therapy ball, and play some of our games with him at home. I also suggested that her husband give him piggy back rides, dancing and bending over, so he that he could work on improving his head righting and strengthening his arms and legs. She bought him some whistles and bubble toys.
When he came in for his fourth session, he was like a different person. It was amazing! Speaking in full sentences and making eye contact, he told me all of the games that he was looking forward to playing. He was completely present, engaged, and motivated. He played jokes on me, watching intently for my reactions, and laughed along with me. His balance was so much better that he was able to play some really complicated games on the trampoline, catching bean bags while jumping at full speed, and aiming them at targets.
I've been seeing him now for about five weeks. He has progressed from scribbling to drawing faces, stick figures, trees, and houses on the chalkboard. He can have real back and forth conversations. He no longer lines up his toys at home or in the clinic. He displays a wicked sense of humor, and loves to make me laugh. He has become much more affectionate with his mother, and has started to initiate conversations with the other mothers in the waiting room. His parents took him to a family gathering recently, and everyone was astonished at how open, friendly, and talkative he had become.
Now that this child can rely on his body and eyes to give him accurate information about where he is in space, to keep him stable and strong against gravity, and not to startle at everything he encounters, he is ready and able to participate in, and enjoy, his life!