Wednesday, October 26, 2011

A Life in the Balance

The way in which we perceive the world directly determines how we respond to it.  Here is the story of a little boy I started treating at the beginning of the school year.  He was uninterested in other people, lined up his toys instead of playing with them, and had almost no expressive language.  Despite how impaired he seemed initially, he made an immediate, remarkable turnaround when some simple improvements were made in his neurological and sensory functioning.

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.

During the last few minutes of the session, I gave him some whistles to blow.  The sound was unbearably loud and shrill, so I made an exaggerated face, cringed, and covered my ears when he blew them.  To my surprise and delight, this made him laugh.  

Hooray!  He was in there!  I just had to figure out what was preventing him from being able to fully inhabit his body, explore his world freely, and want to interact with others.   Since his mother claimed that he was not tactile or auditory defensive, which is the first thing I always assume is causing the child to tune out the world, it had to be something else.  What could it be?

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.

No wonder he didn't want to play!  He could not trust his body to keep him from falling.   He could not rely on his eyes to tell him where he was in space. 

Our second and third sessions centered around deepening his breathing, developing protective extension, improving his balance, strengthening his trunk, legs, feet and toes, and stabilizing his eyes. Strongly rhythmic music helped organize and contain him and hold his attention while we played.

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!

Wednesday, October 19, 2011

The Role of the Sensory Integration Therapist

A few weeks ago, a reader asked me how exercise could help a child who could not function at school.  Last week, I talked about how the sensory integration approach works.  This week, I thought I would continue the discussion by explaining what sensory integration therapy has to offer, and talking some more about how we go about accomplishing our objectives.

A sensory integration therapist's role, as I see it:

To improve motor planning and problem solving skills, which the child can then generalize to all learning.

To improve balance and equilibrium responses, so that the child has a reliable, dependable relationship with gravity.

To reduce or eliminate defensive, aversive responses to sensory experiences, so that the child is not bothered or distracted by sound, smell, touch, or light.

To improve neurological functioning by integrating the presence of primitive and postural reflex activity,  so that his movements are not dominated by the involuntary lowering of his muscle tone or involuntary flexor withdrawal when he tries to use his body.

To improve the child's ability to maintain the appropriate level of alertness and arousal for learning in a classroom setting.

To improve the child's ability to filter and discriminate sound.

To increase the length and flexibility of the child's attention span.

To maximize the child's ability to explore and interact with his environment freely and confidently.

To enable the child to self soothe, self regulate, tolerate frustration, solve problems, work independently, and socialize appropriately.

To provide the child with a strong, stable, resilient, flexible  body, and maximize fine and gross motor coordination and age appropriate skills acquisition.

To improve spatial awareness, visual perceptual, and visual motor functioning.

To give the child the inner resources to meet an unfamiliar challenge or obstacle with zest and confidence, by allowing him  to prove to himself, over and over, that he can solve problems and rely on himself.

In addition to these things, a sensory integration therapist can help the child function in class and on the playground by adapting his environment, providing him, his teachers and caretakers strategies to maintain his ability to be present and available for learning in class, prescribing a sensory diet, and by teaching life skills like shoe tying, using utensils, handwriting, telling time, bouncing, catching, and kicking a ball, jumping rope, and any necessary activity of daily living.

Why do sensory integration therapists use suspended equipment?

Children whose nervous systems have not matured along with their chronological ages behave differently than others.  They don't function well at school, because in some areas, they are developmentally behind the other children.  They can't consistently meet the grownups' expectations for comporting themselves, internalizing the rules of the classroom, or keeping up with the academic demands of school.  They can't sit quietly and do their work, they can't contain their impulses, they get into altercations, they talk out of turn, they can't get their work done in class, their work is messy and disorganized, they take up far too much of the grownups' attention.

 Or they do keep it together at school, but then can't manage their behavior once out of the public eye, having one meltdown after another at home.  Perhaps the child is obviously quite intelligent and capable, but in a classroom setting, seems lost and not very bright.

  Some of these children are driven to move and seek sensation, and will have a hard time sitting still.  They are constantly on the go, have a short attention span, and can't walk in a straight line because they have to spin themselves on every streetlight and jump on and off every curb that they pass.  They throw their bodies off of the highest walls they can find, crash into other people, give hugs like rabid bears, throw a ball a hundred miles an hour to someone standing two feet away, unintentionally break crayons and toys, and can't stay organized or get anything done in a chaotic atmosphere.

Others avoid interacting with things and people, sitting quietly, not bothering anyone, but not participating or learning, either.

For the first child, who needs a lot of intensity and endangers himself in order to get it, the suspended equipment can give it to him. With the therapist's direction, the swings can provide high intensity in a safe, controlled, contained way.   Over time, the child will stop seeking, because he no longer needs the huge amount of input to feel at ease in his body.  He also learns to control his impulses and solve problems, because if he does not slow down and think things through while interacting with the suspended equipment, he will fall.

For the avoidant child, working with a therapist on the suspended equipment is an efficient, highly effective way to improve motor planning, gain confidence and strength, and develop a good relationship with gravity.  The swings also affect the part of the inner ear responsible for alertness, so that over time, the child's ability to stay present is improved.

The therapist can also provide suggestions for making homework manageable and for navigating other problem areas in the child's life.

Wednesday, October 12, 2011

How Does Sensory Integration Therapy Work?

A reader left me a great question in the comments after I described a little girl who was struggling in her daily life. She asked how exercise could solve this child's problems.

A. Jean Ayres, who founded sensory integration therapy, was an occupational therapist and developmental psychologist whose work was based on the theory that learning problems and behavioral issues were caused by faulty processing of sensory information.

  According to Dr. Ayres, learning is a function of the brain.   If we improve the brain's ability to perceive, remember, motor plan, and solve problems, and to perceive sensory information correctly and respond to it accordingly, this skill can be generalized to all learning, including academic learning.  By having the child participate in specific movement experiences which integrate and strengthen an immature, inefficient nervous system, sensory integration therapy can, over time, correct the underlying issues that prevent the child from succeeding in school.

What we know, and how we learn, is through the brain. When we are babies, we train our brains to learn by moving through and exploring our environments.  As we sit up, turn over, reach for things, creep, crawl, cruise, and walk, we teach our bodies, and our eyes and hands as they work together, to do what we tell them to do.   We learn to discriminate, so that we can attend to what is important and  filter out what is not.  We learn to struggle for what we want to achieve, and not give up until we succeed.  We develop vision, balance,  core strength, equilibrium, hand eye coordination, and fine and gross motor control. We integrate the workings of the senses as they take in information, the brain as it perceives them, and the body as it acts on them, so that over time, the brain and body evolve into a unified, graceful, efficient whole.

Until a child is about six, virtually all learning, and all understanding, is based on his physical interaction with the environment.  This is why it's so important not to restrain children in playpens, strollers, and carseats, park them in front of televisions and computers, and force them to sit still.  It impedes their development.

As a sensory integration therapist, my concern is how the child's body is functioning.  When I evaluate a child, I am looking for how well the child responds to the demands I place on him and on his body.  This will give me direct insight into the child's difficulty functioning in the classroom.

How long can the child sit still and attend to the task at hand without losing focus?  Does he need frequent movement breaks?  Does he complain about fatigue, make conversation instead of engaging with the test materials, or otherwise try to divert my attention?  Does he lie on the table or rest his head in his hand when he is working? Does he rub his eyes?  Does his hand hurt because he is gripping his pencil too hard? Will his hands coordinate together when he cuts with scissors?

Can the child hold on to me if I put him on my back, or are his legs too weak to grip?  Does he move his head back to  midline if I lean to the side?  If I push him, will he fall, or do his core strength and equilibrium enable him to stay strongly upright?  If I place him over a large ball and tip him forward, do his arms shoot out to protect his head? Is he able to balance on one foot?    Can he run up and down stairs without using the rail for balance?

Does he startle and pull away when I touch him?  When I put him on all fours and turn his head, will he stay stable, or will his arms and back lose their tone and collapse?

When asked to do an unfamiliar task, can the child mentally form a motor plan and execute it without too much difficulty, or does he get lost and frustrated?

Can the child make eye contact with me?  Is he interested in pleasing me and in my reactions, or is he indifferent to me?  Does he have a sense of humor? Can he chat, or does he monologue?  What does he do if another child or therapist enters the testing area?

What is the child's breathing like?  Is he a picky eater? Can he sleep through the night?  How does he behave when he wakes up in the morning?  Does he have enough energy to get through the day?

Does the child get overly excited when he is stimulated, or does he shut down when confronted with intense or unfamiliar sensations?

Assessing how the child's body works, and how it habitually responds to the demands of daily life, is crucial to understanding what underlies the child's learning and  behavioral difficulties.  The body is the foundation for the brain.  If the foundation is shaky, and does not offer adequate support, the workings of the brain, and the eyes and hands, will suffer.

A child who is living in a body that falls out from under him when he wants to use it, won't do what he tells it, and doesn't keep him strongly,  sturdily, upright, is living in a body that does not support the work of his brain, eyes, and hands.  A body that won't keep him effortlessly upright when he sits in a chair or on the floor, won't keep him safe from falling while running on the playground or allow him to keep up in gym class, won't filter out background noise and movement, startles and flinches at the slightest provocation, won't correctly inform him about where he is in space, and constantly tells him that sounds are too loud, smells are disgusting, fruits and vegetables are yucky, paint, glue, and clay are nasty, and his clothes are tight and scratchy, is not a body that will allow him to navigate the complicated, demanding, exhausting world of school without a tremendous struggle.  His internal disorganization, weakness, unreliable sensory processing, and poor balance will be directly reflected in his behavior.  He will be either acting out, attempting to communicate his distress, or he will be tuned out, in an attempt to leave his body.  Neither one of these responses is appropriate for classroom participation, and  prevent him from being able to learn and to formulate and express his ideas.  A child who lives in this kind of body is "out of synch."

My job as a sensory integration therapist is to provide the child with a strong, stable, reliable, resilient body and a brain that perceives and responds accurately to the information conveyed by the child's senses.

In addition, I must educate his parents and his teachers about how to best support him, so that his environment is conducive to learning.

Wednesday, October 5, 2011

Peter Pan Was Wrong

 Here in America, we seem to have taken being sensitive to children's feelings into account to such an extreme that we have allowed them to take over.  Being kind and polite to small children is certainly important, but we have to be careful to maintain the role of the grown up while doing so.  It's not only all right for the grownups to assert their authority, it's crucial to a child's sense of security. 

It would be better for everyone if the grownups would just make the decisions and act on them instead of always seeking the children's input and approval. 

A few weeks ago I started seeing a little boy who was referred by his school for difficulty functioning in the classroom.  His IEP noted that he had a great deal of trouble transitioning between activities, and that he was very bossy and stubborn.

His father brought him to his first therapy session.  As is my custom, after we introduced ourselves and got our paperwork in order, I asked the father to come into the treatment room with us.

The little boy's father knelt down, assumed an expression of worry, concern, and apology, and asked his four year old boy, "Is it all right with you if daddy comes in?"

With that one short sentence, he had undermined my authority and let the little boy know who was really in control.

Not surprisingly, the child then proceeded to act exactly as if he was the one in charge of the therapy session.   He would not take off his shoes.  He would not lie on the mat.  He would not lie on the therapy ball. He would not jump on the trampoline. He would not kneel.  He would not go on all fours.

 He rudely informed me, after being told that I wanted to talk to his father for a bit, that I had exactly one minute to do so, then began counting so loudly that conversation was impossible.  When I instructed him to sit down in a chair, he asked, "Why should I?"  and proceeded to roll around on the floor.  He threw things across the room, and tried to break my toys.  After that first encounter, I was sweaty and exhausted.  I could see it was going to be a long, long year.

The next time he came to the clinic, he was accompanied by his mother, a very young, soft spoken British woman.  When I asked her to come with us into the treatment room, she held out her hand, said to the little boy, "Let's go!" and he promptly followed.  When we entered the treatment room, she said, "Shoes and socks off, diddums!" and off they came.  When it was time for him to lie down on the mat, she said, "Time to lie down on the mat!"  and he did.   He cooperated with all of the testing, played some games with me, and we all had a lot of fun.

Do you see what I'm getting at here?  This little boy's father, who is a loving parent and means well, thought that he was being polite and taking the child's feelings into account when he asked his son's permission to join us.  But what he didn't understand was that a four year old has hugely different emotional needs than he does.  A four year old doesn't really know what to feel about, or how to analyze, a lot of what swirls around him.  He just wants to feel safe, for the expectations for how he should conduct himself to be clear, and for the grownups to behave in a reasonable fashion.  When the grown ups want him to reassure them that they have his permission to be in charge, it's unsettling and confusing, to say the least.

When you continually ask a small child whether it's are all right with him for you to be the grown up by asking him if what the adults expect him to do is OK with him, what you don't get in return is a happy, secure child.  What you get instead is a child who continually acts out, because he being told, over and over, that he is more powerful than the grownups.  This makes him feel unsafe and insecure, and his actions will reflect that.  He will keep pushing and pushing, hoping that the grown ups will contain him, and because they have told him that he is in charge, he will respond accordingly by running the show.

I am here to tell you that your life will be easier if you stop checking in all the time and asking for the child's permission to take charge. The grownups are supposed to be in charge, and the children want it that way.  It's too confusing for them otherwise.  Children don't want to be the ones running the show! They don't want to have dominion over the adults.  They know that they are small, don't know best, and need protection and direction.  They want to be able to trust the grownups to be strong enough and smart enough to contain them, to make and act upon appropriate decisions on their behalf, and to keep them  safe from harm. {By the way, despite all evidence to the contrary, teenagers feel the same way.}

This mother, although she is so  young and soft spoken, has it just right.  She, not her son, is in the driver's seat.  When he is in her presence, he can relax and stop ordering everyone around.  He knows that in her own sweet, quiet way, she can contain him and keep his world in order, so he doesn't have to try to do it himself.

You can avoid a lot of fights, behavioral problems, and heartache if you follow a few simple rules when dealing with small children.  Be clear and reasonable in your expectations, don't ask a child if he wants to do something that he has to do, and don't ask if something is OK with him if he doesn't actually have a choice about it.  Don't say, "Do you want to brush your teeth?"  Don't say, "Brush your teeth, OK?" Say, "It's time to brush your teeth."

 Don't ask the child, "Is it OK if the doctor gives you a shot?"  If you think I'm being funny, I'm serious.  I once evaluated a six year old boy and told his father that he would benefit from a course of sensory integration therapy.  His father turned to him and asked him, " Would you like to come here for occupational therapy?"

How secure do you think this child feels if he knows he can't trust his father to be the grown up and make those kinds of decisions for him?  The adults should NOT be seeking the children's input for things about which they should have no say.  Going to therapy is not the child's decision to make.   Asking for his input tells him that the grownups can't or won't take care of him properly by making important decisions on his behalf.

The more you can order your child's world, be in charge of the decisions, keep it structured and predictable, and keep him contained, the more secure and happier he will be.