Thursday, May 10, 2012

Who Needs Sensory Integration Therapy?

In my last post at Minds in Bloom,  I help teachers identify who in their classrooms would benefit from  sensory integration therapy.

Thursday, May 3, 2012

Why Some Children Pay Better Attention at School

This week on Minds in Bloom, I talk about the necessary components of the ability to pay attention in the classroom:

Wednesday, April 25, 2012

The series at Minds in Bloom continues.  This week  I give advice to classroom teachers on how to teach handwriting.

Wednesday, April 18, 2012

Recess and PE Are Crucial to Academic Success

Go here to find out why recess is a vital part of education!

Wednesday, April 11, 2012

Good Sitting Equals Good Learning!

Go over here to see what I have to say about posture and learning...

Tuesday, April 3, 2012

Helping Children Sit Still in Class

I'm guest blogging over here for a few weeks...

Thursday, March 8, 2012

Getting the Most out of Sensory Integration Therapy

Want to know how to get the best out of your relationship with your child's OT?

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Wednesday, February 15, 2012

To Sleep, Perchance to Dream

I briefly treated a little girl earlier this school year who unfortunately did not make much progress while participating in occupational therapy.  She missed many sessions because her mother could not persuade her to put on her coat and shoes and leave the house to come to the clinic.  Most days were met with severe temper tantrums, with the child refusing to allow her mother to dress her or to eat breakfast.  When she did come to OT, she would not let me get near her.  Any attempt to help her take off her coat and shoes or to engage her in any play was met with hysterical tears and crawling under her mother's chair.  Therapeutic brushing helped somewhat, but it was still a walk on eggshells to even be allowed into her personal space.  She was over three years old, but had almost no language.  When she wanted to express herself, she could only cry, "Mer!  Mer!"   She could not even say no.

She made no progress with the speech therapist, either.  I sat the mother down after a few weeks and asked about the little girl's diet and sleep patterns in order to get a better sense of what was behind her behavioral difficulties.  It turned out that this mother was letting the little girl go to bed when she did, which was generally around midnight, and waking her up at seven thirty the next day. No wonder the child was delayed in her motor and speech development, and always so resistant! She was chronically sleep deprived.  Unfortunately, the mother, a recent immigrant from a culture that does not operate on fixed schedules,  did not follow my suggestion that the child be put to bed much earlier so that she could get the twelve hours of sleep she needed.  

A few weeks later, the child was removed from my caseload due to a scheduling conflict.  She continues to work with the speech therapist, and continues to make no progress.

How much sleep should a child get?  Toddlers and preschoolers should get about twelve hours of sleep.  School aged children should get about ten hours of sleep.  High school students should get about eight or nine.

Less sleep than this on a regular basis can cause a host of problems, including a compromised immune system,  delays in language acquisition and neurological development, socialization and learning issues, anxiety, poor attention span and frustration tolerance, emotional fragility,  impulsivity, and poor self regulation.

Many of the children I treat are not very good sleepers.  They have trouble transitioning to bedtime, they have a hard time falling asleep once they get in bed, they wake up during the night, and they are crabby, irritable, and hard to get going in the morning. 

If your child habitually wakes up tired, cranky, and hard to get going, he is either not getting enough sleep or the sleep that he does get is not resting him properly.

Unfortunately, modern life interferes with circadian rhythms and healthy sleep patterns.  We no longer spend our time out of doors using our bodies for hunting, gathering, and planting, going to bed with the chickens and waking up with the roosters.   Electric lights mean that we  no longer need to obey the natural rhythms of the sun and moon, retiring when it is dark and being naturally awakened by light.  Staying up late to work or read before the advent of electricity was uncomfortable, a strain on the eyes, and an enormous outlay of effort and expensive fuel.   Since the advent of the light bulb and cheap electricity, it is thoughtlessly easy to stay up long past the time when we should be in bed.  

Most children sit inside all day at school and then go home and sit and watch television, play video games and do homework until it's time to go to bed, so they don't really get physically tired enough to allow their brains and bodies to slow down.  On the weekends, many of them are seduced by the addictive power of video games, computers and television, and stay inside on the couch when they should be outside running around and playing.  Add to this the tremendous amount of pressure children are under these days to adhere to rigorous academic standards and social behaviors that are often beyond their developmental abilities, being over scheduled with too little down time to relax and play, and you have a perfect recipe for insomnia.

In order to fall asleep easily, the brain must be quiet and peaceful, with no stressful thoughts racing through it, and the body must be tired and relaxed.

Do you ever take vacations that involve lots of outdoor fun, like skiing or swimming?  Ever notice how you can barely keep your eyes open at night after dinner, how happily exhausted you feel, how you can hardly wait to tumble into bed, and how rested and refreshed you feel in the morning?  A day full of physical activity is the best way to ensure a healthy night's sleep.

A child who gets plenty of outdoor exercise and eats nutritious food will have a much easier time of it transitioning to bed and sleeping soundly than a child who has been inside all day long watching television or playing video games and eating processed foods pumped full of chemicals, fat, salt, and sugar.  

If you want your child to get a good, full night's sleep on a regular basis, he has to go outside to play every single day.  I recommend that a child who does not walk to school be taken to the playground for half an hour or so before the bell rings and be given an opportunity to run around and play on the equipment before school begins, and again on the way home.  Can you arrange for a few other mothers to join you?  The children can have a quick soccer game, jump rope, or a game of freeze tag or statues.  If exercise and movement has an energizing effect on your child, make sure it happens early enough in the day so that he is happily tired when it's time to sleep.

For an anxious child, who can't stop his mind from racing,  exercise is doubly important. { I can speak from experience here:  whenever I am under a lot of stress, the only way for me to cope successfully is to tire myself out enough during the day so that I can sleep at night. }

In direct contrast to television, which imposes a state of mindless relaxation, {which is why we call it "vegging out" in front of the TV,} computers and video games engage the waking, thinking part of the brain, making it difficult to relax and drift off.  In order to allow the brain to slow down enough for the body to follow,  computers and electronic devices should be turned off a minimum of two hours before bedtime.

Some foods and substances are excitatory to the nervous system and should be avoided in the evenings.  Sugar, caffeine, sodas, and highly processed foods tend to increase alertness and arousal and to rev up our engines.   

A full stomach before bedtime can prevent restful sleep.  Dinner should be finished by a minimum of two hours before bedtime.  Bedtime snacks should be light and healthy: a little yogurt with naturally sweetened jam, a whole grain cracker with almond butter, a small handful of nuts and dried fruit, a half of a banana.

A child who needs a tremendous amount of structure and predictability in order to function would benefit from a bedtime routine consisting of the exact same things in the exact same order at the exact same time every evening.

A warm bath with Epsom salts and a few drops of essential oil {valerium, sandalwood, chamomile, and bergamot are all good choices for promoting sleep} is very relaxing before bed.

Bedding and pajamas should be made of natural fabrics and washed in unscented laundry soap, preferably one from the health food store with a short list of ingredients.  Avoid fabric softener sheets, which are full of nasty chemicals.

If your child is not allergic, down pillows are the best. 

Points to consider:  Is the room adequately ventilated?  Is the room temperature too warm?  {In New York, I have to keep my bedroom windows open all year long because the heat, which I can't control, is suffocating.}  Is the air too dry? Is the room dark enough? {Leaving a bright light on while the child sleeps may cause visual problems and should be avoided.}  Is there too much visual stimulation?  {Too many toys and objects in plain sight are overwhelming and distracting when it's time to sleep.}  What is the noise level in the room?  Could the child benefit from ear plugs, a white noise machine, or some soothing music?

Remove all televisions and electronic equipment from the child's bedroom.  Bedrooms should be just for sleeping if at all possible, so that the child associates that particular space only with bedtime.

Some children like very heavy blankets and find the weight reassuring.  An anxious child might like to play sandwich before bedtime:  Place a sofa or heavy cushion on top of him while he lies on his belly on the floor or on the bed.  That is the bread.  He is the filling.  Put condiments on him {"Here is some catsup!"} by pressing firmly in a downward direction all along the length of his back and legs either with a therapy ball or with your hands.

Anxious children are often not such great breathers, so I often recommend that bath time include playing with bubbles or whistles.
This one looks like fun.

I'm a big, big proponent of books and reading, and a bedtime story and a snuggle is a wonderful ritual.  This is something to look forward to and can motivate the child to get into his jammies and get teeth his brushed so he that can hear the next chapter.

If your child is a snorer and his breathing during sleep is labored and irregular, he may have sleep apnea.  This is a condition in which the child's airway becomes obstructed while he sleeps, which prevents him from breathing.  This causes interruptions in the child's sleep, does not allow him to sleep deeply, and interferes with his oxygen intake, which in turn affects his brain functioning.  A visit to an ENT and a sleep study, if recommended, may be in order.

Chronic ear infections also make it difficult to fall asleep due to the pain.  If your child has a very high pain threshold, he may not be letting you know what the problem is until his ears start draining.

If your child is on a therapeutic brushing program, I highly recommend that he be brushed as a part of the bedtime ritual.  The deep pressure will help him with the transition to bed.

In Manhattan, I see babies and small children being strolled and rolled around  while their parents and nannies ignore them and chat on their cell phones and play on their Ipads and Blackberries.  Is your child resisting bedtime in the hopes of getting some much needed attention and physical affection?  Before strollers and car seats, we used to carry children on our hips and talk to them.  Now we isolate them and immobilize them for long, long stretches every day.  Judging from the desperate hugs I get from many of the children I treat,  not only is this interfering with their neurological and language development, we are depriving them of sufficient human touch, ratcheting up their anxiety levels.

Are there things going on in your child's life that are genuinely worrisome?  Children are extremely sensitive to what is going on around them.  If there is a problem and the adults are stressed out, the child will pick up on it.  Simple explanations and reassurances, along with hugs and kisses, are always a good strategy to calm an anxious mind.

Wednesday, February 1, 2012

Inside Moves, Part Three

More ideas about playing inside when the weather does not permit. However, I urge you to brave the weather and take them outside anyway, even when it's freezing out  -- kids don't seem to mind the cold nearly as much as we do!

Hullabaloo is a fun game that preschoolers enjoy.  You could probably make your own version.  The instructions are to hop, crawl, spin, jump, skip, or twist  to a specific square among a dozen or so spread out on the floor.  The squares are different colors and have pictures on them.  If you make your own version, you can increase the difficulty by making the movements more challenging and by having children solve problems to find their squares by posing the directions as riddles.

Hippity hops are large balls with handles on them that the child sits on and bounces to move forward.  They are great for providing lots of input and for improving balance and increasing trunk and leg strength.  You can make an obstacle course for the child to bounce through, and challenge the child to propel himself forward, backward, and sideways.

Peanut balls can be used for sitting and for movement.  At the clinic, I have children ride them like horses up and down the hallway.  They are superb for working on leg strength and trunk balance while providing lots of input.

Balance board adds a dimension of challenge to games that involve tossing and catching.  A child can stand on the balance board and toss a ball against a wall and catch it, toss bean bags at targets, or play catch.

Nerf balls have lots of indoor possibilities.

 Simon Says.


 The game red light yellow light, green light, which is another way of playing statues, is a great way to spend a rainy afternoon.  It's a perfect combination of activity and stillness.  Speaking of which, how about being the DJ for a game of freeze dance?

Does your child know how to jump rope?  Here are some rhymes to get her started.

Foam  rollers are great for many activities.   A child can kneel on two of them {one under his knees, one  under his hands} and roll across the floor.  Two children can use them as swords {my rule in the clinic is that they can hit the other's sword as hard as they like but not aim for the body}.  They can also be used to balance targets on for shooting practice.  

Chinese jump rope, which promotes balance, sequencing, motor planning, and endurance, can easily be played inside.  When I worked at a little clinic in Brooklyn, I would sometimes have the neighborhood girls come and play with the children I was treating so that they could teach them the moves that were popular on the playground.  The games could have gone on for hours.

Stilts can be challenging and fun.  After mastering the basics, the child can walk along a designated course and try to pick up objects and toss them at targets without falling off.

When everyone is happily tired out, it's time to break out the art supplies and crafts.  A stash of scissors, construction paper, beads, feathers, sequins, modeling clay, paints, chalk, rubber stamps, pipe cleaners, and anything else that catches your fancy is great to have on hand when the weather is bad and everyone is bored and antsy.

Wednesday, January 25, 2012

Inside Moves, Part Two

More ideas about staying sane while staying indoors.  {If the weather at all permits, please, take your children outside to play!}  

therapy ball is invaluable for a young child who needs a lot of intensity but insists on maintaining control of the activity.  The child can sit and bounce to his heart's content, with the added bonus of strengthening up the intrinsic musculature around the spine and working the eyes.  The correct size allows the child to sit with hips and knees at 90 degree angles.  The therapy ball can used for homework, eating dinner, or sitting while watching television or working on the computer.  The child can play catch and shoot targets from the ball, as well.

large therapy ball is great for all kinds of play activities at  home.  An excellent activity the child can do independently is to drape himself over it and roll back and forth, landing forward onto his hands and then rolling back onto his feet.  This develops protective extension responses, which are frequently lacking in low tone children.   He can also spin himself around in a circle using his hands and feet on the floor.   Another great game to promote strengthening and vision is to hold the child by the legs while he lays across the ball, have him walk forward on his hands to pick things up and toss them at targets, then walk back.  You can use foam alphabet letters and spell words, or use Handwriting Without Tears wooden pieces and build letters.

Games that require the child to use his body with his head in different positions are very challenging and alerting.  I have children bend over and shoot at targets through their legs, sing "Head Shoulders Knees and Toes", and play Twister.

I have a long tube made out of stretchy fabric, purchased at a fabric store, that the children love to crawl through.  Drape it over sofa cushions for an obstacle course.  Put stuffed animals inside, and have the child rescue them, or have him push a therapy ball through.  Two adults can also pick the child up and swing him back and forth while he's inside.

An indoor tunnel is a great workout, especially for a child who did not crawl I  toss toys inside for the child to rescue, or pieces of a puzzle which he can then put together.  You can gently roll the child back in forth inside, or have him roll himself across the room.

Roll the child up in a blanket like a burrito, and then unroll him by holding onto the end and unfurling him.  If he enjoys deep pressure, bury him in sofa cushions while he lies on his belly and then roll the therapy ball on top of him.  This is very calming.

Piggy back rides are as therapeutic as they are fun. This is a great way to improve endurance, strengthen up the child's flexor muscles, and to work on head righting, which is often weak or absent in children with poor balance.  While the child is clinging to your back, put on some music and do a dance, dipping and leaning from side to side.  Shake your hips and spin around in a circle. The child should be able to wrap his arms and legs strongly around you and hold on to  you without assistance.  If he can't, that's something to work on.

 If he is not righting his head and is falling off when you lean over, dance in front of a full length mirror so he can use his reflection to keep his head in midline.  Or another adult can provide a visual target by holding something interesting for the child to look at on the opposite side.  {When you lean to the left, the target is moved to the right, and vice versa.}

Old fashioned calisthenics are great for building strength and endurance, and for turning restless, antsy, oppositional children into exhausted, compliant ones.  {I refer to this tactic as fatiguing them into submission.}  Running and marching in place to music, deep knee bends, jumping jacks, push ups, planks, and sit ups are all great.  If there is room, military style frog crawling under and around an obstacle course of chairs set up around the room is fun and a very good way to improve brain functioning. 

Wrestling is a great, high intensity indoor activity.  Let the child pin you, but make him work for it.  Keep it as low to the ground as possible.  Or I will get on my hands and knees and challenge my friend to do the same and try to knock me over by pushing me steadily or slamming into me with his booty.  This is an excellent activity for a child who constantly squirms around in his chair or doesn't like to wear underwear.

Booty walk: Sit on the floor with your legs straight out in front of you and your arms across your chest.  Walk yourself across the room, keeping your bottom on the floor and your legs straight in front of you, by leaning slightly and using the muscles in your behind.  Race the child across the floor, or start on opposite ends of the room and meet in the middle, then booty-walk backwards.   {Jane Fonda did this in her exercise videos.}

A pair of foam bats can be used for indoor fencing or for sparring.  {The ones in the link are flimsy, and don't last long.  You could probably get a pretty good custom made pair at the local foam or futon shop.}

The child can practice somersaults, go crab walking, and do wheelbarrow walking with you.  

roller racer is a great way for the child to improve trunk rotation and upper body strength.

Set up a water filled basin with a magnetic fishing game, {easily purchased at the 99 cent store} and have the child lie on his belly with his head over the edge of a bed or coffee table and fish from that position.

Install a chin up bar, and have him get in the habit of hanging and doing chin-ups whenever he walks by.

Many more great ideas here.

To learn more about how movement affects learning and development, I recommend this book.

{And I surrender to the inevitable: there is always the Wii.}

Wednesday, January 18, 2012

Inside Moves, Part One

I can't urge parents strongly enough to make sure that their children get outside to play every single day.  It's critical to their health and to their neurological development.  A body that is not strong, stable, and healthy does not adequately support the work of the child's brain, eyes, and hands, and can't be counted on to keep him effortlessly upright against gravity.   A weak, unstable body makes it difficult for the child to sit, to be present and alert and able to pay attention, and to learn.

If a child can't sit still, it's because he needs to move. A child with sensory processing or attentional issues especially needs a great deal of gross motor activity, the more intense the better.  Movement is what focuses and organizes the brain and body, and drives development forward.

 Playtime should be outdoors whenever possible.  But when circumstances prevent you from getting the child to the playground, here are some suggestions for providing movement and intensity indoors, in small spaces.  

If the child has difficulty focusing on homework, one of these activities can be used as a quick movement break to increase focus and attention.

All homework should be preceded by intense exercise, a drink of water, and a protein rich snack.

Trampoline:  Jumping is a superb high intensity exercise and a very high quality rebounder is not too expensive.  {Even a medium quality trampoline will take a surprising amount of abuse.}  There are so many fun games to play while jumping.  I use a trampoline a lot in my work and encourage parents to invest in a trampoline for home use.  Children love it.  It is a powerful way to work on joint stability, balance and endurance.   It deepens respiration and promotes lymphatic flow, cleansing and detoxifying the system.  It's also excellent for vision.   Most of the children I work with have weak eye muscles, and jumping while aiming and shooting at targets is a great way to stabilize their eyes.

Some ideas for playing on the trampoline:

1. Put on some lively music and have a jumping/dancing party.

2.  Set up some targets and have the child toss beanbags or little stuffed animals at them.  If the child is able, have him jump while you throw his ammo to him, catch it, then turn and shoot, all while jumping. {If he can't catch, hand him the animals while he jumps.}  I use play bowling pins or cardboard bricks as targets.  You can also use large numbers or letters, a Nerf Hoop, a hula hoop, or make a tic tac toe board out of oaktag and colored tape.

2.  Play catch while jumping.  For a very young child, a big Nerf ball or an OBall are good choices.  For an older child, a large playground ball, like a foursquare ball, is fine.

3. Have the child bounce and catch a ball against the wall while jumping.  This is quite challenging.  You can make it even more challenging by standing behind him while he jumps and having him turn his upper body to toss the ball back at you, then turn to the other side and catch it, then bounce it at the wall again, while he is jumping.  Upper body rotation encourages integration of the two halves of the brain, improves bilateral coordination, and solidifies dominance in children who tend to be indiscriminate in hand use.

4.  Play balloon volleyball while jumping, either with racquets or hands.  This is great for visual tracking.

5.  Blow bubbles to the child as he is jumping and have him pop them.

6.  Play horseshoes while jumping.

7. Have the child copy your movements, like hopping, bending, twisting, waving his arms, jumping from side to side, jumping feet apart and together,  clapping,  while he is jumping.

8.  Do the Freddie.

Bosu can also be used in similar ways to the trampoline.  There are many videos and articles available on the web that outline exercises and activities that can be done on it.

A Sit n Spin is a great, compact toy for a toddler who needs to spin.  Older children can use an office chair.  Spinning is  very high intensity and is good for children who never seem to tire or get dizzy.

An inexpensive scooter board is fun if there is room inside your home.  The child can lie on it and propel himself around, or you can spin him around in a circle while he holds on to a rope or a hula hoop, or you can spin him around by the legs.    Here are some ideas for games.

{Next week:  even more ideas for indoor fun!}

Wednesday, January 4, 2012

Twenty Four Reasons Why a Child Can't Sit Still

1.  The child does not get enough exercise.  Children require huge amounts of movement, preferably outside, every single day.  Movement and exercise is as essential as food for children in order to stay organized, develop and  mature their nervous systems, improve their coordination, strength and motor planning, and to be healthy!  So many of us live in cities now and have just forgotten how vital it is for a child's health and development to go outside and play.  Bring the child to the playground for half an hour, or whatever you can manage, before school starts, and let him play on the equipment, or have a game of touch football, statues, or tag.  If this is truly not possible, buy a trampoline or have him play an exercise game on his Wii.  And if his teacher takes away recess as a punishment, you must insist that she find another way to help him manage his behavior.  He is acting out because he needs to move more, not less!

2.  The child has poor postural stability, low muscle tone, and a weak trunk and spine.  This makes sitting physically exhausting, uncomfortable and painful.  Circle time is especially grueling since sitting unsupported is such hard work.

3.  The child's chair/desk at school does not fit.  I can't tell you how many times I've walked into classrooms and seen children whose desks literally come up to their necks while their chairs are so high that their feet are dangling on the floor.  Could you sit and do your work like that?

4.  The child is tactile defensive and his clothing bothers him. Or he is sitting in too close proximity to others and his alarm system is clanging away, instructing him to flee.

5. The child is sitting with his back exposed and people are walking behind him, again setting off alarm bells.  He should be sitting with his back to the wall, preferably in a corner.

6.  The child is auditory defensive and his ears hurt.  A child who can manage in a quiet, low stimulation atmosphere but can't control his behavior in a noisy environment is probably suffering mightily in all of the chaos.  Or he may not understand the teacher's instructions if she is talking over many chattering voices.  A good clue about auditory defensiveness:  a child who runs around the perimeter of the classroom, acts out, and can't engage in any goal oriented behavior when the room is noisy.

 7.  The child is a poor breather.  Shallow breathing sets up the body for fight or flight, and it's very hard to sit still when every cell in your body is urging you to get up and check for predators.

8.The child has undetected visual problems.  It's exhausting and frustrating to try to attend to close work if you can't see what you're doing.  His eyes may be so unstable that he is seeing double, or seeing floaters, or visual images are shimmering.  Or the light in his classroom might be bothering him.  In Manhattan many children are expected to sit all day long in inside classrooms with no natural light or outside ventilation.  I get headaches just thinking about it.

9.  The child's inner ear is not functioning well.  The inner ear tells us how alert/upright or at ease we should be in response to movement.  {Roller coaster: very alert and upright! Hammock: very drowsy and relaxed.}  If the child's inner ear is not registering movement very well, it's not telling the body to sit up and attend.  The child is driven to move in order to provide the intensity he needs to stay upright and aroused.

10.  The child's nervous system has not matured along with his chronological age.  This means that primitive movement patterns, which should be dormant, are instead active and present, dominating the way the child responds to his environment.  Primitive reflex patterns lower the child's muscle tone automatically when he turns his head and body in certain positions. This interferes with, among many other things, his balance, equilibrium, and vision. Or things that would not even register to us, like a dog barking in the distance, can throw the child's system into a startle, making it hard for him to stay grounded.

11.  The child's metabolic processes are not functioning well.  Does the child have undetected food allergies, difficulty sleeping, leaky gut syndrome, candida, heartburn?  Is the child constipated?  Is he subsisting on a diet of refined carbs, sweets, and processed food, and so is inadequately nourished?  Children need lots of high quality protein and complex carbs to fuel their bodies for learning and attention.

12.  The child does not get enough sleep, or the sleep that he does get is not resting him properly.  Can he transition well to bedtime?  Does he get ten or eleven hours every night?  Is there good ventilation in his bedroom?  Are the lights off in his room?

13. The child may be too young or too immature to be in a classroom.  In my clinical opinion, most three year old boys would be much better off waiting another year or two before starting school.  They simply don't have the emotional or neurological maturity to be handle all of the rules and expectations of the classroom.

14.  The expectations of the classroom are too much, and the  child feels lost, inadequate, and confused.  Four year olds should not be expected to learn to write.  They simply don't have the internal stability, attention span, or visual discrimination required for such high level work yet.  Let them wait until they are developmentally ready.  One of the very best schools in Manhattan, the Rudolph Steiner School, does not start the children writing until they are seven. Their children have beautiful handwriting and are exceptional scholars.

15.  The child is hungry, thirsty, tired, or has to go to the bathroom.

16.  The child is over scheduled.  Children need lots of down time to recharge their batteries and connect with their creativity.  A child who has two or three activities every day after school and on the weekend is expected to be "on" way too much.  Cut back to just an activity or two a week and use the time instead to take him outside to play.

17.  The child is spending too much time in front of screens.  This is especially true if the child can't transition well to sleep after spending time on a computer.  Is the child watching or playing games with excessively violent content?   Strictly limit time spent in front of televisions and computers and use the time instead for creative pursuits {crafts, painting, writing stories, playing a musical instrument, dancing, etc.}.  Turn off the computer a minimum of two hours before bedtime, or, better yet, allow the child just an hour or two on the weekend.  It's just not realistic to allow a child to spend all day Saturday and Sunday watching TV, playing video games, and eating frozen waffles, and then expect him to be alert, relaxed, grounded, able to sit still for hours at a time, and ready to learn on Monday.  Don't you feel more clearheaded and able to manage at work after you've taken a brisk walk?

18.  His parents are going through a hard time, or don't get along.  Strife at home will upset any child's equilibrium.  If parents are stressed out,  rarely home, argue a lot, or are going through their own issues, it will show up in the child's behavior.

19. The child's parents don't teach him to respond to adult redirection, so he thinks that obeying grownups is optional.

20.  The adults who care for the child spend inordinate amounts of time on their electronic devices during their time together, or otherwise ignore him.

21.  The child is expected to sit still for too long.  I have so very often observed classrooms where very young children were expected to sit for long periods without getting up, being given a drink of water, or anything to eat.  And if the child has endured a long bus ride to school, he is at a disadvantage before he even walks into the building.

22.  The child is bored.  Many reasons why this could be  -- the grownups don't have a realistic idea about the child's attention span, the activity is too difficult or too easy, or the child expects everything to be like television or the computer: loud, lots of chatter and images quickly passing by, lots of novelty.

23.  The child has sustained structural damage due to a fall or other accident, poor handling, or birth trauma which affects cranial nerve function and would benefit from manual therapy.

24.  The child may have issues with body/brain chemistry.