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.

Wednesday, September 21, 2011

The Hurrieder We Go, the Behinder They Get

The habitual use of strollers, car seats, carriages, playpens, and strap on baby carriers forces a child into the role of  passive observer instead of allowing him to be an active participant in his surroundings.  This interferes with learning, delays his neurological development, and negatively impacts language, balance, motor control, socialization skills, vision, and academic performance.

I truly believe I would have many less clients if people got rid of their strollers, carriages, playpens, and car seats, encouraged their children to walk, carried their babies and toddlers on their hips, and put away their electronic devices while with their children.

I have a friend who lived in Europe for many years. He married a woman who grew up on a farm in rural Bavaria and they settled in Munich.  I visited when their first daughter was five months old, and was fascinated to see my friend's wife getting ready to take her baby out for a walk one afternoon.  Instead of opening the front closet and hauling out one of the elaborate carrier devices I was used to seeing in the States, she went to her bedroom, opened her dresser drawer and fetched a long, wide cotton scarf.  She sat the baby with its legs around her hip, wrapped the scarf around the child's bottom, tied a knot, brought it over her opposite shoulder, and slipped the knot around to her back.

She did use a stroller, but only if she had a lot of shopping to do or had to go a long distance.  Otherwise she carried her babies tied on her hip in her home made sling, or allowed them to walk.  I remember many mornings walking in the park that surrounded Schloss Nymphenburg, waiting for the little girl, who was about a year and a half old on my next visit, to look up from her explorations of pebbles and dirt and join us, but since we were not in a hurry, we were able to let her satisfy her curiosity.  We remarked one morning at how toddlers are like little artists or scientists, they are so absorbed and fascinated by the minutiae of their world.

This child's mother, like her own mother, who had raised five children with no outside help, was an expert at one handed cooking and housework.  She habitually carried her babies on her hip as she cooked, cleaned, and tidied her apartment.  One morning, as I sat down at the kitchen table, she carefully leaned over sideways and served me a cappuccino that she had  brewed with one hand literally tied behind her back.

Both babies are young adults now.  They are excellent students, charming, accomplished, and intelligent, and despite having spent so much time in a small apartment in a big city, they are effortlessly athletic and graceful.

I was a fairly new OT back then and wasn't working with children, so I did not understand what a difference it makes in a baby's development to actively cling to its mother as it is carried versus being passively strolled.

I've said this before, but it bears repeating:  for a child to be able to "hang in there" in daily life, the child must literally be able to hang on.  By riding on her mother's hip, gripping her mother's body between her legs, my friend's daughter was being conditioned to do just that.

In direct contrast, a stroller does not condition a child to do anything but slump passively.

Think about all of the modern equipment available these days for carrying babies, toddlers, and small children.  Almost all of it is designed for the grown ups to be able to ferry the child quickly and conveniently from place to place, exactly as if the child were a cat in a carrier.  The child is placed inside, strapped in tightly to prevent it from moving, and is passively conveyed from one location to the other.  Thus we can quickly get wherever it is we need to go, and if the child is tired of trying to escape, it will simply give up and stay put, and not bother us when we get there.  We can also avoid almost all interaction with the child since he is facing away.  This allows us to text, talk, surf, IM, and do our errands in peace.

I see this all the time in Manhattan:  nannies with children fastened into carriages and strollers, browsing in Filene's Basement and chatting on their cell phones while the developing youngsters in their care passively stare out at the rows of clothing on the racks.  Or I see working mothers in suits and heels, absentmindedly pushing a child in a stroller while absorbed in their Blackberries.

In contrast, being carried is such a multi sensory, multi directional, active experience. When a human walks, the body rotates in many directions all at once.  The baby, holding on, bobs up and down, back and forth, side to side, with each step.    All the while it is being carried, since it is wrapping its legs around and holding on tight, it is also stretching, strengthening and developing endurance in the deep muscles of the legs responsible for posture and balance, and readying the outer layers of muscles for walking.

 When the baby rides on a hip, it has to hold its head, neck, and trunk up against gravity in all different positions, righting itself continually as the person carrying it turns, twists, and bends.  The spine and trunk are continually challenged and strengthened. The child learns how to maintain its stability and balance in all planes, and develops the trunk strength necessary to support sitting, breathing, fine motor control, and eye hand coordination.

The child's neck muscles develop the strength necessary to support the close work of the eyes, and visual skills, like depth perception and binocular vision, are developed and practiced as the child learns to see things from all different perspectives.  The muscles in the child's eyes become strong and stable as he bobs up and down and watches the world go by while fixing things in his gaze.

And, most important, a child who is carried on a hip is eye to eye with the grownup, the exact right level to look at each other and carry on a conversation.  The baby practices making eye contact, reading expressions for emotional cues, and developing his receptive and expressive language.   He learns to attend to what is being said to him, and to develop and internalize the social skills required for conversation.  He becomes accustomed to, and comfortable with, intimate contact and intimate conversation.

Strap a child down, prevent him from moving, force him to be passive, and you condition him to be passive.

Keep a child moving, don't strap him down or impede his movement, carry him on your hip and talk to him, and you give him the tools he needs to be strong, resilient, active, curious, and healthy.

Wednesday, September 14, 2011

Boys Will Be Boys

Normal male behavior is often incomprehensible to women.  We who are in charge of small children should try to be aware that when boys are violent, loud, messy, obstinate, competitive, and otherwise "not nice," they are simply being boys. 

I have a bright, personable eight year old boy on my caseload who was referred for handwriting and other minor academic delays.  He's doing really well these days, but his mother reports that his teachers complain that he has "anger management issues."   I was surprised to hear that, because despite some sensory defensiveness,  which we are addressing successfully, this child doesn't strike me in the least as having any social difficulties whatsoever.  He is affectionate, flexible, good natured, has a strong sense of humor, and interacts well with the other adults and children in the clinic.  He is also a talented, driven, exceedingly passionate athlete.

 I asked his mother what the school was telling her, and she said that the teachers feel that he cares way too much about the outcomes of the games that are played in gym or at recess.  I asked if his caring extended to hitting, swearing, throwing things, refusing to concede points, excessive arguing, disrespectful behavior to teachers or classmates, or otherwise acting out.  No, was the response.  He just gets very excited, turns red, and yells more loudly than the other children.

Anger management issues?

Here's what I have observed:  he does insist on turning every clinic activity into some kind of competition, which can be a little tiring for a middle aged lady such as myself, but isn't that normal for a boy?   Once when he was playing with a much younger, less skilled child, I took him aside and asked him to please hold back and let the other boy score some shots.  He behaved in a very gentle, classy manner throughout the game, and I was frankly impressed by his restraint and kindness. 

He likes to play games in which he competes with me, and when we face off,  he assumes a look so concentrated and fierce that a little thrill of fear and awe runs through me. It's a bit unsettling.  He reminds me of Dave Stewart,  my favorite lead off pitcher from baseball's greatest team ever, the Oakland A's circa 1988.  {Favorite closer: Dennis Eckersley.} But although he is determined to win, he does not cheat, nor does he tantrum if I score a point against him.  He simply revs himself up, talks a little trash, and competes twice as hard.  His level of sportsmanship, in my clinical opinion, is perfectly acceptable for such a young child.

I wonder why the people in charge of this little boy's life feel the need to educate him out of his greatness.  He is highly, unusually competitive, but isn't that a trait that will carry him far when he is out in the big bad world?   If he does become a professional athlete, or even just goes to school on an athletic scholarship, his coaches should expect nothing less from him.

 People in Manhattan are not used to athletes.  We are, for the most part, things like bankers, lawyers, businessmen, therapists, and artists.  We generally behave, for the most part, like city dwellers, who value exquisite manners and a soft spoken, polite demeanor.  Consequently, the grownups, who are not looking at the big picture, are telling him that the very thing that makes him unique, and that gives him an enormous edge over others, is not an acceptable part of his personality.  Did Babe Ruth's grammar school principal suggest to his parents that he needed therapy because he was overly competitive?  What about the people who raised and educated Bobby Orr?  Barry Bonds?  Joe Namath? Roger Clemens? Claude Lemieux? Michael Jordan?  I am sure that even as very young boys, they wanted and needed to be the best, and as far as I can determine, no one sent them to psychologists to re-educate them and make them more socially acceptable to others.

Normal human behavior varies tremendously, from country to country, culture to culture, family to family, person to person.    Unfortunately, we as a society are delineating what is acceptable and desirable behavior into ever narrower parameters.

Let's not force children whose personalities and character traits fall outside of these narrow norms to behave only in ways that we can understand, or that the culture of their schools deem acceptable.  Let's not shame them or make them feel that they are bad because they are different.  And let's be especially careful not to demonize normal male behavior.  It's perfectly normal for boys to swagger, trash talk, yell and scream, enjoy violence, hit each other, and be viciously competitive.

Wednesday, September 7, 2011

How to Get Your Child to Sit Still

I have a piece of code embedded in my website that tells me why people visit my blog.  Almost every inquiry is the along the same lines:  My child can't sit still.

There may be other reasons preventing the child from being able to attend, but first and foremost, a child who is unable to sit still and focus is a child who needs to move.  

Children cannot be taught how to sit still.  They cannot be instructed to sit still and be expected to follow through for more than a few moments.  Sitting still is not a cognitive task like spelling.  It is an inherent physical ability that depends on a great number of factors, like balance, strength, mental alertness, the amount of exercise the child has had recently, sufficient breath control, nutrition, and rest, and mature neurological functioning. If these things are not solidly in place in the child's body, the child won't be capable of sitting quietly and being available for learning.

Recently I had to say goodbye to a little boy I had been treating for several years.  He was doing beautifully and ready to graduate!  Amid the tears and hugs, his mother said something that caught me completely off guard.  She said, "So much of what we learned here was counterintuitive."


At this little boy's school, a high premium is placed on the children's ability to be "steady."  They were expected to manage their own behavior, to sit still upon command, to internalize and follow the rules, and to be quiet and respectful and correct in what they do and what they say to each other at all times.

This little boy couldn't come close to being able to do all that.  He was impulsive, clumsy, and primitive.  He bit and hit instead of being able to "use his words," and when he did use words, they were often not acceptable either in volume or content.  He rarely initiated any activities, especially when the room was noisy, could not keep his hands to himself during circle time, nor meet the grownups' expectations regarding the social and academic demands of the classroom.  I thought he was very bright, but no one at school seemed to think so, judging from the carefully neutral, unenthusiastic reports from his teachers.

His mother explained that she and her husband had tried to teach him to follow the schools' expectations by reminding him, over and over, to "be steady."  They reasoned that to help him sit still, he had to be taught how to sit still.

Then they were referred to OT, and instead of encouraging him verbally to control his body, I hardly spoke to him at all.  Instead, I quietly provided one intense movement experience after another on the suspended equipment, encouraged him to scream as loudly as he wanted and to jump and crash as hard as he needed, and convinced his parents, after much cajoling, to take him outside to play in the mornings before school began.

To their amazement, on the mornings when they got him to school twenty minutes early and played tag with him in the schoolyard  {many of the other children in his class started coming early as well and joining in} he was able to go directly to his seat and stay focused all morning.

There were other things we did, of course, to improve the functioning of his nervous system and reduce his sensory defensiveness, but the more I could convince his parents to keep him active, the better his behavior both in and out of school.

His mother said, "We didn't realize that in order for him to be able to be still, first he had to move!"

Living in the city and lacking lawns, yards, and natural habitats, we habitually spend our time indoors.  We forget how necessary it is for children to move their bodies and explore their environments freely.  It's not healthy for babies and toddlers to be constantly strapped into strollers and car seats and play pens and forced to be passive.  It impedes their physical, emotional, and cognitive development!

Humans are biologically designed to hunt, fish, plant, gather, chop wood, carry water, walk long distances, keep watch for predators, and to use our bodies and hands to build and make things in order to survive.  We were not designed to sit in chairs all day, and the bad posture, obesity, depression, poor health, and chronic pain suffered by so many of the people who drive themselves to work and sit all day long in artificial light, year after year, is telling.

It's not realistic to expect a child to sit still all day long, rarely get any exercise or time outside, eat a lot of sweets and nutritionally empty processed foods, and then be present and focused and available for learning.

The ability to sit still for long periods, control impulses, filter distractions, maintain flexible attention, and focus on high level skills like reading, writing and solving problems demands a high degree of internal organization, postural stability, and excellent respiratory functioning.  Without these things firmly in place, the child's body has a limited ability to support the work of his brain, eyes, and hands.

In order to "be steady" mentally and emotionally, a child  first has to be physically steady.  In order for a child to be able to "hang in there,"  a child literally has to be able to hang in there.

The only way for children to be able to mature and develop their nervous systems, improve their  motor planning, strengthen their core muscles, and maximize their balance and coordination, all of which are vital to learning and attention, is through movement.  Do you want your young child to excel?  Forget the enrichment classes, which I consider a waste of time and money, and take him outside.  I'm not talking about Saturday morning soccer practice.  I'm talking about going to the park, playing on the swings, slide, merry go round, teeter totters, playing tag and statues, having a catch, playing Frisbee, messing around in the sandbox, climbing on the jungle gym, making snowmen, sledding, skating, roller blading, swimming, riding a bike or scooter, hopscotch, jumprope, etc.

 In order to do and be their best, children need a lot of unstructured time to play outdoors. They need to be able to coordinate themselves with their heads and bodies in all kinds of different positions and situations.

If your child has a hard time sitting still, try this:  give him lots and lots of intense exercise and time outside every single day, drastically reduce screen time, make sure he gets plenty of sleep, and minimize sweets and nutritionally empty foods, substituting whole, fresh, organic, unprocessed foods.   Turn off  your electronic devices when you're with him and give him your full, undivided attention.  If you're nervous about not giving him all the enrichment classes, here are some ideas: play lots of classical music at home, read to him regularly, provide craft activities,  and do things together as a family.

If he is still having problems, there are most likely underlying causes  such as sensory defensiveness, an under responsive vestibular system, or allergies that an occupational therapist who specializes in sensory integration issues can help you uncover and correct.

  Let me know how it's going.