Wednesday, February 23, 2011

Helping the Auditory Defensive Child

When a child's body is neurologically wired to operate in fight or flight mode, the brain interprets loud or high pitched sound as threatening and noxious.  So the child is going to respond by becoming disorganized or by acting out, hoping that he will be removed from the situation that is causing him so much distress.

If a child runs aimlessly around in his classroom, and is oppositional, disorganized, confused, or combative, or shuts down in a noisy atmosphere, the noise is too much for him and he doesn't know how to tell you what's wrong.

  Other signs that a child is adversely affected by sound:  covering his ears, yelling at other people to shut up {one child I know used to slug his brother at the dinner table because he couldn't bear the sound of other people eating} chewing on things other than food, hyperfocusing in an attempt to leave his body, or trying to hide.

What causes auditory defensiveness?  There are several possibilities.  One is a history of ear infections.  The inner ear is responsible for the initial filtering and dampening of sound, and if the physical mechanism is impacted due to scar tissue or a residue of pus, the sound can actually build up in the child's eardrum and become painful.

As someone who spent most of the 70's in a fetal position, with my fingers stuck firmly in my ears, I can sympathize.  I'm a bit auditory defensive myself.   Going to rock concerts, which I did from time to time in order to please my friends, was never fun for me.  I hated the sheer volume of noise, which felt like a physical assault.   The whine of the electric guitars made me feel as if a dentist was drilling directly into my eardrums.   The entire experience was always one of pain and misery.  I tell parents and teachers now that expecting an auditory defensive child to learn in a noisy environment is like expecting him to be able to concentrate at a construction site.

Another reason for auditory defensiveness is poorly integrated postural reflexes.  These reflexes, when they are working properly,  are what give us our effortless uprightness against gravity, and set our muscle tone.  When the tone is too low,  the muscles in the inner ear, which dampen sound, are not strong enough to do their job.

I've had children in my practice who have  run out of their classrooms and onto the street, thrown things, punched their classmates,  and tipped over their desks in response to being forced to sit in noisy environments.

If your child doesn't seem to hear you when you are speaking to him, or his teachers report that he doesn't understand what is being said, it could be that he's tuning out voices, or that he simply doesn't have the ability to distinguish between foreground and background sound and can't pick your voice out from among all the other sounds in the room.

There are several ways that sensory integration therapy can help a child with auditory defensiveness.

One is by improving ability of the inner ear  to do the job of filtering and dampening sound.  We do this by providing the child with intense movement experiences.  Movement affects the workings of the inner ear, which in addition to filtering sound, is responsible for monitoring where we are in space.  As one system improves, so does the other.

Occupational therapists with additional training can prescribe special filtered music that trains the ear and brain to be less sensitive to sound.  This music can be very helpful to children who have trouble attending in noisy environments.

Delays in the the child's neurological development can cause all kinds of difficulties in the child's ability to use his body and process sensory information correctly, including sound sensitivity.  Sensory integration therapy works on improving the way that the nervous system functions.  A therapist who can employ specific techniques for integrating primitive reflex patterns can often make dramatic changes quite quickly in the child's sensitivities.

In addition to what I do in the clinic, I often recommend that the child be treated by an osteopathic practitioner who specializes in manual therapy techniques.  There may be problems with the child's internal structure that are preventing ears from functioning correctly, and manual therapy can be remarkably effective in normalizing the child's internal workings and improving the child's behavior.  Unfortunately American osteopathic training does not emphasize manual techniques, so if you are interested in finding a manual therapy practitioner for  your child, you may have to do some research to find one who has completed additional training.

At school, an auditory defensive child can wear noise canceling headphones or earplugs, chew gum, and take breaks from the noise when needed.  I try to arrange when possible for the child to be excused from eating in noisy cafeterias, and for him to be given a pass from participating in indoor recess or gym when it's obvious from his behavior that it's too much for him.

A smaller, quieter, more structured classroom is a better fit for a sensory defensive child in general.

I advise parents not to expect the child to be able to tolerate concerts or to endure long stays at noisy family gatherings until the problem is corrected.

I am often asked if the problem is permanent.  It may or may not be always present, but with appropriate intervention, it should diminish.  Sometimes children grow out of their defensiveness and sometimes sensory integration therapy can eradicate it completely. Having good coping strategies in place, like something to chew on and keeping a stash of earplugs in his backpack, helps the child feel more in control.

Wednesday, February 16, 2011

Auditory Defensiveness, the Hidden Behavior Problem

If your child is having tremendous difficulty comporting himself at school, is aggressive towards his classmates, can't participate in noisy classrooms, either going off by himself or  acting out, and in general behaves in ways that are difficult to comprehend when he is in a noisy environment,  the chances are very high that his ears are hurting him and that he has no way to let you know that he is suffering. 

Consider these scenarios, taken from my files:

1.  An exceptionally beautiful, creative little girl, who should be the most popular girl in school, but instead tends to keep to herself.  She does not interact or socialize with her classmates during lunch, gym, or recess.  While the other children are happily and noisily chatting and laughing with each other as they sit around a table and draw, cut, and color, she sits a bit off to the side, head down, and does what is required of her, but does not join in the conversation.  She refuses to accept any party or play date invitations on the weekends, preferring to spend her time alone in her bedroom with the door closed.

2.  A bright, handsome little boy who is labeled emotionally disturbed.  He cannot comport himself at school or in public.  He is verbally and physically aggressive, sarcastic, oppositional, and constantly spoiling for a fight.  His OT sessions the previous year with a different therapist were a disaster.  The therapist had to spend most of his treatment time trying to help him contain himself in the busy clinic.

{This year, he comes to OT at a time when he and the therapist work together alone.  He is affable, cooperative, and works hard.}

3.  A little boy who is the bane of his gym teacher's life.  Normally, he is a total delight to be around, charming, sweet, and funny.   He is a polite child who does well in school, but  his behavior in her class has everyone in an uproar.  He interrupts her frequently, is oppositional and rude, disrupts the games, and slugs his classmates.

4.  A little boy who always enters the gym {at 3:30, the busiest time of day in the clinic} making a face like an angry grizzly bear.  He won't make eye contact or say hello.   He does not respond to the therapist when she calls his name, but wanders around sulkily, arms crossed over his chest, picking up balls and toys and throwing them aimlessly.

When he does allow himself to interact, he says an emphatic no to every activity suggestion proposed to him, shaking his head and sticking out his lower lip.  At school, he is constantly getting in trouble for throwing things, talking out of turn, and being silly, especially during arts and crafts, when the teachers play music in the background, or when the children work in groups, building block structures together on a hard linoleum floor.

{A few weeks ago, he came at a time when he and the therapist were working alone.  He was cooperative, playful, motivated, and full of ideas about how to challenge himself.}

5.  A little boy is observed at school one day in his noisy, busy classroom.   The children work on the activities of their choice in small groups, sitting around small tables.  Instead of choosing an activity and being seated, he runs around the room, unable to sit still, follow directions, or to engage in purposeful activity.  He is constantly reprimanded for knocking the other children's projects off the tables.

{At the OT's suggestion, he was switched to a smaller, much more structured, quieter classroom, and immediately began to demonstrate goal directed behaviors.}

6.  A little girl whose parents experience her at home as supremely creative and intelligent, unusually physically coordinated and daring, feisty, funny, witty, and loving, comes home with this report card from her preschool:  Below average performance on most academic subjects.  Does not appear to understand what the teacher is saying and is frequently observed watching the other children for cues.  Cannot play games like Simon Says.  Sits by herself most of the time, chewing on her hair or on a sleeve.  Does not initiate any activities in a school where children are encouraged to be self directed.

7.  A charming, affectionate little boy who is the sweetest, most loving big brother imaginable to his baby sister, observed one rainy morning during indoor recess: He runs aimlessly around and around the periphery of the room.  He then picks up and starts throwing a Frisbee, aiming it directly at the backs of his classmates' heads.  When the Frisbee is confiscated, he picks up a plastic disc, runs up to his classmates, and whips the disc at them from behind, causing them to cry out in surprise and pain.  When this is taken away, he returns to running around and around in circles, until he finds a ball and begins to throw it into the center of the room, again carefully aiming it at his classmates' backs.

 His teachers report that when the children are lining up in the hallway, he will often suddenly tackle the child next to him and slam him up against a wall.

8.  A 43 year old man who suffers from severe anxiety.  He avoids parties and restaurants because it's too difficult for him to make conversation.  His wife reports that when they are sitting quietly at home, reading or watching television, he frequently turns to her and says, "What's that noise?"

9.  A very sweet, smart, friendly little boy who is reported as having a very flat facial expression at school, and who can never get his work done in class.  His teacher's policy is to allow the children to be self directed and do what they need and want to do during class time, as long they get their lessons learned and their assignments finished, so the classroom is noisy and busy during writing time.

10.  A bright, charming little boy who flat out refuses to eat lunch in the school cafeteria, no matter how hungry he may be.  His teachers think he is a bit dim, because he rarely participates in class.  He is consistently pale, mopey, and red eyed at the end of the day.

What do all of these people have in common?  They are all extremely sensitive to noise, and they can't cope in noisy environments.  Some of them respond by tuning out and shutting down, and some of them respond by acting out and doing anything they can think of in an effort to be removed.

If your child becomes disorganized, disruptive, oppositional, aggressive, or highly anxious in chaotic environments, becomes overwrought at live performances,  hums, covers his ears, grits or grinds his teeth, or chews on anything he can get his hands on, or or gets distracted by every voice and sound that crosses his path,  chances are good that his ears are not filtering and dampening noise effectively and that he is confused and even in pain as a result.

In my next post, I'll talk about auditory defensiveness, some of its causes, and what sensory based OT has to offer to an auditory defensive child  -- or grownup.

Wednesday, February 9, 2011

Managing Circle Time

Circle time can be extra challenging for children who have a hard time in school.  Sitting on the floor with backs unsupported is very difficult for low tone kids.

There should be a variety of sitting options for circle time. Since no one wants to be singled out, I suggest that there be a few chairs around the perimeter of the circle at the beginning of the school year.  The teacher can invite the children to try both sitting in them and sitting on the floor, and then deciding which they prefer.   Eventually, the children who need them will go on using the chairs, and the rest of the children will choose the floor, and no one will notice or care who sits where because they have all tried all of the options and made their choices.  If this is truly not possible, then having the child sit with his back against a solid surface, like the wall, is the best choice.  Or perhaps a few floor chairs could be kept in a cubby and made available.

A child who has difficulty self regulating, or who tends lash out when others are in his personal space, will do best sitting on a piece of furniture, which defines personal space, next to an adult.  These children will be happiest with their backs covered.  A chair is good.  Placing the chair up against a solid wall would be better.  Sitting on a chair in a niched corner would be best.  Something to occupy the child discreetly and  quietly would be very helpful here.

Do you tend to sit in meetings and utilize fidget toys to keep yourself present?  Do you perhaps bend paper clips, doodle, roll up the paper from the straw in your drink, fold dollar bills into origami, spill sugar on the table and draw in it with a finger, or play with a rubber band?  Or do you take a craft project, like knitting or needlepoint, with you when you have to sit for a long time?  It helps, doesn't it?  Children need to be able to do this as well.

I always send a little bag of fidget toys, generally a collection of little stretchy animals, in to the classrooms of the children I treat for the teacher to hand out as appropriate.  One teacher told me that when she notices my friend starting to zone out during circle time, a little stretchy frog discreetly pressed into her hand is enough to keep her focused and present.  A child who chews a lot could benefit from a plastic drinking straw or some fishtank tubing to chomp on to keep steady.  {Chewing is a sign that the child either needs to move his body or that the room is too loud.}  What would be really wonderful is if the children had little sewing or needlework projects they could work on while they were sitting.  Do you listen better with busy hands?  I know I do.  I always bring my crocheting to board meetings.

 Teachers, if you are consistently having a hard time keeping the children in your classroom engaged during circle time, it's because you are expecting them to stay still when they need to move.

 To prevent having to expend all of your energy on disciplining the children instead of teaching them, you can try making sure that long stretches of sitting down time are preceded by some movement activity and perhaps a drink of water, so that the kids can maintain their alertness.   Remember, movement is what activates the brain and drives development forward!

 When children are restive and you are unable to engage them, if they are not hungry, thirsty, or needing to use the bathroom, they need a brief movement break. If you tell the children that you see that they are having a hard time sitting still and say it is time for a quick movement break so that they can activate their brains,  you will be helping all of the children recognize when their alertness levels are starting to flag, and teaching them some strategies to maintain a good arousal state for learning.
Something else that I would like to see change in the classroom is forcing the children to sit "Criss Cross Applesauce" during circle time.   I have been to several classroom observations where the teacher flatly refused to continue until all of the children, including my little friends, who can't maintain an upright posture while in that position, were sitting like this.

Can you sit that way?  I can't. People in Western society, who spend almost all of their time in chairs and in cars, have lost the ability to squat or to sit comfortably on the floor.  If you observe most preschoolers sitting on the floor with their legs crossed, their spines are quite rounded.  This is an unhealthy way to use the spine, and leads to back problems as we get older.   I have vivid memories myself of sitting on the floor in kindergarten and feeling how hunched and rounded my back was and how miserable I felt.  We should not be teaching our children to use themselves badly!  As we get older and become more accustomed to slouching, something we learn in school when we are forced to do things we are not ready or able to manage, we cause ourselves real damage.  Schools should not be perpetrating this on the children in their trust.

A few better options:  teaching the children to sit on their heels, allowing them to lie on their bellies with their elbows propping them up, or providing them with a firm cushion, like a meditation cushion, or zafu.

It's an unfortunate truth in American society that we have lost our attention spans, and it's true in the classroom as well.  I have been to many classroom observations where an activity, especially in a lower grade, went on for too long.  Is circle time just going on for too long?  Is it too close to lunch?  Are the children having a hard time comporting themselves because they are tired of sitting still, hungry, thirsty, or have to go to the bathroom?

Some keys to success: keep circle time short, keep the lesson engaging and the children's participation active, provide postural support and discreet fidget toys to those who need them, and don't force children who really can't manage the physical proximity to sit close to their classmates.

Wednesday, February 2, 2011

Why Can't My Child Behave During Circle Time?

Which do you prefer in a restaurant, a banquette or a table in the middle of the room?  Banquette, right?  Ever wonder why? It's because your back is not exposed to people walking or moving behind you, so it's easier to let down your guard and  focus on the meal and conversation.  

A sensory defensive, hypervigilant child can't truly concentrate with his back exposed, which is often the case during circle time.

Circle time is often one of the most difficult school related activities for the children I treat. Over the years I have seen so many children fail to meet the grownups' expectations when they are required to sit quietly and attend while on the floor.  They can't pay attention, they move around, they speak out of turn, they lie down, they tune out,  they lash out.

Why are they acting out during such a seemingly innocuous time of day?

Circle time often means sitting very close to the person next to you, with no furniture to help guard and define the boundaries of your personal space. Children who are tactile defensive generally don't like to sit in close proximity to others, especially to other children, who are less predictable, and therefore potentially more threatening, than adults.  I have often seen tactile defensive children suddenly, and with no warning, strike out at classmates who were sitting too close by.  It's like petting a cat who suddenly startles and scratches.  The light touch receptors gets overloaded, a switch gets tripped,  the fight or flight part of the brain instructs the system to defend itself against an attacker, and... pow!

  Another circle time issue I have observed over and over: two children get into an altercation while sitting next to a sensory defensive child, who immediately joins the fray.  Again, it's that primitive part of the brain getting tripped, and the child not having yet developed the restraint to be able to override the primitive response.

Children who don't have good extensor tone or a strong trunk have a terribly difficult time sitting unsupported on the floor.  If you observe a child sitting on the floor with his legs in front of him, and his arms extended behind him to support his upper body, he's working so hard to keep himself there that there's not much energy or attention left over to devote to the day's lesson.

If a child simply can't sit still during circle time, moving and changing his position constantly, chances are he's very uncomfortable and is seeking a way to hold his body that won't be effortful and/or painful to  maintain.

Children with sensory issues don't possess good regulation of their arousal and alertness levels.  Their engine speeds are often too low, and they struggle to stay present and tuned in during class.  Often, when you put them so close to the ground, gravity beckons, and they're gone.  This is especially true if they're not good breathers, eaters or sleepers; their bodies are chronically short on oxygen, fuel and neurotransmitters.

  Judging from my observations over the years, circle time is not very exciting, especially to an under reactive child who requires more intensity than others to maintain his engagement and arousal in a classroom setting.  Generally circle time consists of a lot of talking and no movement, so a child who needs to move, and a certain amount of excitement in order to keep himself tuned in, doesn't have much luck on the floor.

Have you ever been to a movie or a live performance that went way over your head or was just really, really, boring?  Did you tune out, daydream, or even fall asleep?

Auditory defensive children often unconsciously block out voices and language, so if they are sitting on the floor, struggling to remain upright, a bit short of sleep, oxygen and nutrition, and don't really comprehend what's happening... can you blame them for not being fully present?

In my next post, I'll talk about some of ways I help the children I treat manage circle time.