Wednesday, September 29, 2010

Making Handwriting an Automatic Skill

In my last post, I talked about some of the reasons why a child who is bright and articulate can't commit his thoughts to paper in a way that reflects his true abilities.  Today  we'll look at ways to work with children to make writing completely automatic so that that their minds and bodies are free to think more deeply and write more fluently.

 The more completely automatic the child's knowledge of letter formation, the more his mind is able to think about what he wants to say, instead of being stuck in the mechanics of how to write it down.  If your child is still thinking to himself, "Which way does the hook turn on the J?  How do I remember which one is b and which is d?  How does that Q go again?" He's not going to be able to let his thoughts flow through his fingers and onto the paper.  He has to attend instead to the problem of  just getting those marks down, and there is little room left in there for creativity. 

 This is even more the case if he has a dysfunctional pencil grasp and has a difficult time controlling the pencil successfully or suffers hand pain after writing for more than a few moments.

Unfortunately, most schools don't teach the mechanics of handwriting these days.  Teachers are not taught how to teach handwriting during their training, and I have had more than one teacher, who required that their children write every day, tell me that there was no room in the curriculum to teach handwriting!  

What happens instead these days is that the teachers pass out the workbooks and the children are expected to fill them out on their own and then turn them in. 

As no one is actively modeling and monitoring how the child is writing, he will most likely come up with some eccentric habits in how he forms letters.  Generally what I see in the clinic is that the child starts many of his  letters from the bottom, he takes several strokes to write a letter that just requires one or two, he mixes up capitals and lower case, he can't remember which of the lower case letters are taller and so will make an l the same size as an i, or an h the same size as an n.   He will have to stop and think about how to write some of the less common letters, and in which direction to turn the asymmetrical ones like J and P.  He will have a hard time leaving enough space in between the words.   He will ignore the lines on the writing paper and his words and numbers will float all over the place with very little organization.

If the child writes very slowly, concentrating on the act of writing instead of thinking about what he wants to say, he can keep his work legible, but when he starts to speed up, it all falls apart.

The only solution to this is to reteach the child the alphabet, emphasizing correct habits of placement, spacing and letter formation.  This means starting every letter and number from the top; making capitals, numbers and tall letters all the same height; writing letters with tails that go below the line, etc.

  The only way to reteach the child to write correctly is to drill, drill, drill.  Like learning to play a musical instrument, the only way to improve is to practice every day.  Short, mindful sessions are the key.  Especially for a very young child, practice sessions should not exceed five minutes.   Always precede the session with some movement {jumping jacks, a jog around the block, a trip to the park, a spin in an office chair} and a drink of water.  This will help the child focus.  So will a lollypop or a piece of gum.

If you are undertaking this at home, buy yourself some Handwriting Without Tears materials {instruction books, handwriting texts, slate, and double lined paper} and follow the instructions.  It's all there for you.

 If you live in an area with a good selection of pediatric occupational therapists, you may want to hire someone to work with your child.  Make sure that the therapist has taken the HWT training and shows you how to practice with your child at home in between sessions.

Make sure the child is sitting at a table where there is good lighting, he can sit with his feet flat on the floor, and the table is low enough so that there is free movement for his arms.  He may do better with a slant board.

I suggest starting with the capital letters and going on from there only after the child has mastered them completely. I won't go into the specifics of how I teach each letter because it's all laid out in the Handwriting Without Tears books.  Just follow the instructions.

When you see that he can write the capital letters of the alphabet automatically, with no hesitation or mistakes,  starting all of the letters at the top, have him copy some words that you have written and see if he is still hesitating before writing or starting some letters from the bottom.  If he is, he needs to drill further.   It is still not completely automatic.   Drop him back to just writing the alphabet.

 When he is able to copy the words you have written with no hesitation or mistakes, try spelling some three and four letter words for him and see how he does.  If he is still struggling, drop him back to copying words you have written and try again in a day or two.

It's easier to wait until all of the capitals are mastered before you move on to lower case.  The capitals are all the same size and all start at the top, which is less confusing.  {Two lower case letters, d and e, start from the middle.}

You can be creative in teaching the letters.  Have him write them by dragging a forefinger through shaving cream, confectioner's sugar, hair gel, chocolate pudding, etc.  Roll them in  Play-Do.  Buy a pack of foam letters and float them in the bathtub.  I strongly recommend the Handwriting Without Tears wooden pieces for preschoolers.

When he can write the words you spell with no mistakes,  have him write words that you dictate without spelling them.  When he is successful at that,  try writing a little story together and have him record what you both say.  Or you can play a game of Hangman or Mad Libs.   And thank goodness for Harry Potter  -- most of the older children I treat will happily write Harry Potter words for hours.  One little girl loved to write Harry Potter fan fic with me; we would spin endless silly yarns about Hagrid losing control of his Blast Ended Skrewts and all of the havoc they would create in the forest around Hogwarts, or we would make up stories about Tom Riddle and James Potter as schoolboys.  She learned to write as fast as she could think in short order.

If your seven or eight year old is struggling with print, you may want to switch him to cursive.  Many children do much, much better with cursive than they do with print, since the "flow" of cursive suits their hands and eyes better.   Handwriting Without Tears also has has a first rate cursive program.   It uses vertical cursive, which is much easier to write and read, there are no superfluous loops or ornamentations, which makes it easier to learn, and all of the connections are carefully taught.

If your child has trouble holding a pencil, I recommend making sure that he does craft activities and plays with toys that emphasize pinch between the thumb and forefinger.  Lite Bright, Operation, Jenga, and pop beads are good.  So are beading activities, weaving potholders on a little loom, leather lacing, and sewing.  Get rid of big markers and fat crayons and only have small nubs of chalk and bits of crayon, which will force the fingers to hold them in a strong pinch.

Or check out these adaptive grips.  {I don't require a child to change his grip unless I see that he really can't control the pencil very well, or he complains of hand pain.}

Wednesday, September 22, 2010

Why Can't My Child Express Himself in Writing?

Very often, when a child is referred to me for handwriting problems, the parent tells me that the child is very bright and articulate and has lots of ideas, but simply cannot get his thoughts down on paper:  "He will write a sentence or two when the rest of the class has written three or four paragraphs."

In order for a child to be able to write well, the act of writing itself must be completely automatic.  If it isn't,  the child will not be able to compose fluently, even though he has great ideas and can articulate them perfectly.  The cognitive, perceptual, and physical underpinnings {eye/hand coordination, visual acuity for close work, trunk and shoulder stability, fine motor control, attention span, visual memory and discrimination, and knowledge of letter formation} must be firmly in place in order for the child to be able to express himself to the best of his ability in writing.

What does it mean for the child's writing to be an automatic skill?

For those of you who remember what it's like to learn to drive a car, when you were first starting out, it was a stressful, exhausting task.  There were a million details to keep in mind every moment you were behind the wheel.  You had to focus continually on the coordination of your hands and your feet to steer, signal, shift gears, accelerate, and brake.   You had to remember to look in the rearview mirror every few moments and take into account all of the other cars on the road before you could turn, change lanes, or park.  You had to plan how you were going to to respond to traffic, make split second decisions, and remember all of the specific traffic laws.  Holding a conversation or thinking of something other than what you were supposed to be doing while trying to keep track of all of that would have been impossible, because doing it took every ounce of your concentration.

After a few sessions of practice, though, your body took over the details, and braking, shifting, signaling, accelerating, and steering became automatic.  You no longer had to think about it.  Suddenly, without any conscious effort on your part, your body was smoothly coordinating the gas, the brake, the steering wheel,  and the turn signals.  Your eyes began to automatically check the rear view mirrors.   You and the car were one, the car was responding to your commands, and it wasn't terrifying and exhausting anymore.  You didn't have to think about it!

  How did this happen?

 Repetition coupled with conscious thought eventually sent the skills you were practicing down to the lower lobe of your brain, the cerebellum.  This is the part that is responsible for automatic tasks, so when it took over, you didn't have to think about all of those things anymore behind the wheel.  Your conscious brain was freed from having to work at coordinating your body while driving, and then it was easy to have conversations, or to think about other things.

Any physical task we undertake to learn is mastered in the same exact way.  The forefront of our brains, the grey matter, is initially responsible for  coordinating our thoughts with our actions.  The more the task is repeated, the further it is sent to the lower parts, which eventually take over, and the task becomes automatic.  Any impairments in the above mentioned underpinnings {for instance, poor eye hand coordination, delays in visual perception or fine motor planning} will stand as an obstacle in allowing the cerebellum to take over completely.

For a child to whom writing has not become a completely automatic skill, the part of his brain that should be free to think about what he wants to say is caught up in trying to remember how to form the letters or is busy trying to coordinate the work of his hands and eyes.  I see this quite often. I ask the child, "write a capital letter A," and his pencil will hover uncertainly over the paper for a few moments before he begins.    If he can't remember how to write the letters, and must focus his attention on just that part, there's not a whole lot of grey matter available for him to come up with an organized, articulate, cohesive essay.  {Or for that matter, to solve the problems in his math homework. } The activity itself is such an arduous task that order to comply with the adults' demand that he write something, he's going to get the minimum quantity down,  just to get it over with, then breathe a sigh of relief.  He doesn't have the energy or ability as yet to be free to focus on the quality.

  Sometimes poor handwriting is one symptom in a whole constellation of problems. Other times, it's just poor pedagogy {schools are just not doing a good job of teaching handwriting these days} and can be resolved with some extra work on the basics and short, concentrated daily practice sessions.

If your child is doing well in all other aspects of school and life but has bad handwriting, he just may need to learn correct habits of letter formation and do some work on spacing, sizing, and organization to bring him up to speed.  If you suspect that this is the problem, you can try purchasing some Handwriting Without Tears materials, go over how to form the letters correctly, and work on drilling your child until his habits of letter formation are completely automatic.  {If you are putting a disproportional amount of time and effort into it, and it's not getting better, I suggest an evaluation by an OT specializing in sensory integration, and a visit to the neurobehavioral optometrist.  What this suggests is that those underpinnings need some work.}

What if a child is exceptionally resistant to writing?  If a child really has a difficult time of it, it's quite possible that he has a convergence issue with his eyes and can't see what he's doing very well.  He could be struggling just to focus on the paper.  Again, he's using up the part of the brain that should be functioning to formulate and express his thoughts in order to control his eyes and hands.  If the child rests his head on his non dominant hand and turns his head to one side while writing, this is a signal that his eyes are not functioning together properly.  A visit to neurobehavioral optometrist is in order.

Another reason a child won't want to write is a dysfunctional grip.  Many children these days who didn't get enough tummy time as infants, or who spent time in walkers in strollers instead of crawling, didn't develop sufficient shoulder stability or trunk strength to support the fine motor control in their fingers.  They hold their pencils in such a way that their entire hand and arm must be involved in the formation of letters.  This is awkward and often painful, so the child will have quite a limited ability to tolerate the activity.

In my next post, I'll talk about some of the kinds of things I do to help kids practice until they attain fluency.

Wednesday, September 15, 2010

Homemade Solutions for Attentional Difficulties

You can go a long way towards improving a child's ability to cope by eliminating toxins from his environment, making sure he gets the nutritional support he needs, and gets plenty of sleep and exercise.

1.  Take your child to the playground for a quick workout before school starts and make sure that he gets daily vigorous exercise.  If your child is not getting outside to play every single day, this could account for at least part of the problem if he is having a hard time sitting still.  

Children need to move, to work on coordinating their minds and bodies, to use their hands, and to solve problems.  Sitting passively in front of a television or video game is not an appropriate way for the child to spend more than an hour or two, at the very most. If your child is inside due to weather problems, have other options available besides the TV or computer.  Play board games or cards, cook together, make a craft project, or build a fort out of sofa cushions.  And put away your cell phone or Ipad  -- no texting or surfing the web while you're playing with him.  Give him all of your attention when you're together.

2.  Make sure your child has a regular bedtime, and that he is getting ten or eleven hours of sleep at night.  A bath with Epsom salts, which draws out toxins, can help with the transition for a child who has trouble falling asleep.  So can eliminating computer time right before bed.  Call a halt to all computer use at least two hours before bedtime.

See that the child's room is well ventilated, and that he is not wearing synthetic pajamas or sleeping on synthetic bedding.  Keep the visual stimulation in the place where he sleeps to a minimum.  No TV or video games in the bedroom.  The less electronic equipment in there, the better.  Keep radios and alarm clocks on the other side of the room, away from the the child's head.  Turn the lights out.

3. There is such a profound link between nutrition {or lack of it} and behavior.  Eliminate or minimize junk food.  Reduce your dependence on prepared foods, take out, and frozen food. Cook from scratch.   If you don't know how to cook, get someone to show you how to do a few basic things.  {An opportunity for a little mother/daughter-in-law bonding, perhaps?}  You may find that you enjoy it  -- cooking is creative and life giving!

Try reducing, or eliminating altogether, gluten and white foods like white flour and dairy, which can cause allergic reactions, and salt and sugar, which rob the body of essential nutrients and interfere with brain function.  Incorporate grains into your diet that don't contain gluten and have a high protein content, like quinoa, amaranth, and buckwheat.  Make sure your child's diet has an abundance of good fats {from fish, avocado, eggs, extra virgin olive oil, nuts and seeds} and reduce or eliminate transfats, which also interfere with brain function.  Try to provision organic food when possible.  Give the child small, frequent snacks that are rich in lean protein and complex carbohydrates.

4.  Reduce or eliminate the use of chemicals in the child's environment.  Use only natural substances to clean your home.  You can clean just about anything with vinegar and baking soda.

5. Have your child evaluated by a neurobehavioral optometrist to check for eye coordination problems.  If you can't see what you're doing, especially for close work, it's very hard to sustain attention.

6. Reduce or eliminate things that excite the nervous system:  sugar, caffeine, {in many sodas and in chocolate}  MSG, {in many packaged foods}artificial colors and sweeteners.  Avoid foods that contain artificial sweeteners and colorings.  Especially avoid aspartame.  Check labels  -- lots of foods contain it these days, including things that aren't necessarily sugar free.

Better yet, try not to feed your child food that has labels! 

7.  Help the child learn to deal with stress by using breathing exercises {I am a big proponent of bubbles, blow toys, and whistles, which require sustained exhalation, improving respiratory capacity in a playful, functional way} and simple yoga postures.   Many special needs children are not great breathers, so any work you do on the breath is helpful.  Shallow breathing makes it hard for a child to pay attention by starving his brain of oxygen and putting him in a chronic fight or flight mode.

8.  Make sure the child drinks plenty of water.

9.  Consult with a nutritionist who works with special needs children about eliminating foods that aggravate behavioral issues, and ask for recommendations for supplements that supply trace minerals or other essential fatty acids or vitamins that your child's diet does not currently supply.  If your child is a super picky eater, chances are good that he is nutritionally compromised, which will definitely impair his ability to function.  Some children may have leaky gut syndrome that interferes with learning and behavior.  This is a possibility to consider if your child has chronic digestive or bowel related issues.

10.  Work on improving the way the nervous system functions by participating in brain/body coordination activities like Brain Gym, yoga, martial arts, and sensory integration therapy.  If your child is sensory defensive, ask his OT for ways to reduce overly sensitive vision, hearing and skin.  If your child seeks out sensory experiences, like spinning, crashing, or jumping, instead of constantly restraining him, make sure he gets plenty of whatever it is he needs by supplying him with a safe alternative.  Talk to his occupational therapist about setting up a sensory diet at home and at school.  Sound therapy can be very effective in reducing noise sensitivity and helping the brain learn to attend better.

11.  If there is an osteopathic practitioner in your community who specializes in manual therapy techniques, particularly cranial osteopathy, I strongly recommend an evaluation and a course of treatment, especially if your child had a traumatic or a Csection birth.  A traumatic birth can set up physical problems in the body which interfere with, among other things, breathing, balance, vision, immune functioning, and self regulation.  I send many of the children I treat to an osteopathic practitioner here in New York.   Sensory integration and manual therapy together can be an extremely powerful way to bring about rapid improvements.

12.  There is a great possibility that your child has some issues with delays in the integration of primitive reflexes.  Check out  this website for a wonderful explanation of how primitive reflexes that are still present in the system and dominate the child's neurological functioning can interfere with learning and behavior.  Ask your child's OT about exercises to integrate the reflexes.

13.  At school, make sure that the child is not sitting with his back exposed.  A corner, where he can be niched, is best.  At circle time, he should be seated near the teacher with a support for his back, either in a chair  or with his back against a wall.  He should have an inflatable cushion, like a DiscoSit, available. A piece of theraband tied around the legs of his chair will also give him something to help keep him sitting still while providing deep input.  He should have movement breaks, things to chew on, water, and discreet fidget toys available when he is having a hard time keeping his arousal levels up.  If it's difficult for him to eat his lunch in a noisy, chaotic cafeteria, would it be possible to have the school arrange for him {and the other children with similar noise sensitivities} to eat in a quiet classroom?

Wednesday, September 8, 2010

Why Did My Child's Behavior Get Worse After He Started OT?

When you prime the pump, the first thing that comes out is mud.  If your child's behavior gets worse before it gets better after he starts therapy, actually, you're probably on the right track.  

Sometimes when a child starts sensory integration OT, things happen that you don't expect.  It's important to remember that big changes in a child's nervous system are going to manifest in all kinds of behaviors, and many of them are unfortunately not adorable.  Often, a child who is plagued by defensiveness, and has been hanging on by a thread, tuning out, and shutting down, will be able to let go enough after a good OT session to allow himself to know how he's really been feeling.  This will allow him to move through it and let it go.  {In other words, he'll have a meltdown.}

This is particularly the case if you have a child with a very high pain threshold.  A child who does not register pain is a child who is very shut down, and when he ceases to be shut down, anything can happen.  Meltdowns, regressions, and unpredictable, disorganized behaviors are all very common and to be expected when a child begins sensory integration therapy.

If your therapist has recommended starting several direct interventions, for instance, therapeutic brushing, music therapy, and sensory gym all at once, changes in behavior are inevitable.  We are bombarding the child with intensity in an effort to get his nervous system to shift the way it takes in and processes information, and a few bad bumps along the way are part of the process.  It's not a good idea to request the OT to back off, even if things seem out of control at the moment.  The more intensity, the stronger the intervention, the more effective and lasting the changes.  Hang in there!

Many children, after their first time in the sensory gym, especially those who avoid movement, may be strung out and exhausted.  They may cry, be disorganized, look pale and have no energy, or just want to skip dinner and go to bed. This is normal. If your child has a good relationship with his therapist and has had an enjoyable session, working hard, having fun, and challenging himself, but then has a strong emotional reaction afterward, remember that it's all part of the process and please don't ask her to change the program.  Again, the sensory defensive child has been suppressing a lot of misery.  It has to go somewhere as it exits the body.  And remember, he's doing it where it's safe to let it go.  Wouldn't you rather have him do it at home, in private, than out in public?

On the other hand, if the reaction is not emotional but physical, that's something the OT definitely needs to know.  If your child spends the evening throwing up, sweating and shaking, or has a terrible headache after his time in the sensory gym, that's a sign that there was more input than he could handle during the session, and you should definitely let the therapist know so that she can scale back accordingly.  But if he's just cranky, disorganized, or has a meltdown, think of the therapy as a big broom that is sweeping out much of the misery, negativity, and discomfort that the child has been holding.  It's very uncomfortable to live with sensory defensiveness and try to maintain some semblance of good behavior when you're coping with the noise, chaos, and demands of school every day, which are perceived as an assault.  It's a relief to acknowledge it and let it go, but small children lack the emotional or verbal sophistication to tell us what is happening inside or to titrate it in any way, and can only cry and let themselves lose control as a response.

Children who are wrapped up in their sensory defensiveness are people whose true personalities and abilities have yet to emerge.  I have a few little boys in my practice at the moment who started out being timid, avoidant, compliant, passive little creatures, who suddenly have started becoming sassy, assertive, fiercely independent, and frankly mischievous.  In other words, they are behaving exactly like six year old boys!  It takes some getting used to, to be sure.  Personally, I find it delightful and enjoy it, because it means that I'm being an effective therapist!  Try to roll with it.  Although the former child may have been easier to live with, it's the latter qualities that are going to help him cope the most successfully with that cold, cruel world out there.

I heard a funny story from one of my teachers, Sheila Frick, who was one of the founders of an OT camp for special needs kids.  After one little boy came home from his session, his mother called her, furious.  Her passive, avoidant, lumpish ten year old had woken up early the morning after he returned, gotten himself out of bed,  dressed himself, eaten a bowl of cereal, and ridden his bike down the road to visit a friend.  She was baffled and frightened at this sudden, unexpected change in him and wasn't sure how to interpret the fact that he had gone off by himself.  He had behaved exactly like any ten year old boy on a summer day, but she wasn't anticipating such a different child than the one she had sent to camp a week earlier, and didn't know how to respond to the new paradigm.

If you are having genuine difficulty coping with your child's changes and feel your buttons getting pushed on a regular basis as he becomes more assertive and independent during therapy, I can recommend an excellent book, Parenting From the Inside Out.   We all have our triggers and blind spots, and this book teaches us how to recognize the source of our negative emotional responses to our interactions with our children, and how to repattern our dysfunctional communication patterns.  If your reactions to the child's changes are problematic, however, a few sessions with a counselor might be in order.

If you have experienced dramatic, unexpected changes in your child's behavior after OT intervention, I would be very interested in hearing about it in the comments.

Wednesday, September 1, 2010

When The Wheel Doesn't Squeak, But It Still Needs Grease


Welcome back to my blog.  I had a lovely summer.  Most of the children I treat were on vacation, so I had lots of time to write articles!  I hope you had a nice one too  -- and I hope your children played outside every single day, and ate lots of delicious summer fruits and vegetables.

 I continue to have a few openings for both preschoolers and school age children in my pediatrics practice in Manhattan, so please email me if you are interested in having me work with your child.

I thought I would begin the school year with a timely topic:  recognizing those children who tend to escape our notice, because they're so quiet about their problems, and making sure they get the help and support they need before they fall too far behind.

The mother of a little boy I treat is just dreading the beginning of the school year.  She is very frustrated at having to deal with the bureaucracy of the public school he attends, which is refusing to provide him with any extra assistance, although he clearly has sensory issues.  The reason?  His method of dealing with his sensitivities, which are severe, is to shut down.  He is very quiet, never acts out, never makes the slightest bit of trouble for anyone, just folds himself up into a silent ball of misery at his desk and leaves his body.

No one ever suspected he had any issues until near the end of first grade, when someone noticed that he was way behind in reading, although he is very bright and has a strong work ethic.  The school put him in a short term intensive reading program, which helped catch him up to his classmates, but when the program ended he wasn't capable of continuing to keep up or to retain the gains he had made.

He was then evaluated by one of my colleagues, who found plenty of issues to treat, but told his mother that her child wouldn't qualify for services through the New York City Board of Education, since he didn't demonstrate any learning disabilities or delays in his visual motor or visual perceptual functioning.  His issues were purely sensory:  a high degree of auditory defensiveness, a chronic low arousal state, and depressed vestibular functioning.  His sensitivity to sound is so severe that his mother told me that he looks ill at the end of the school day  -- ghastly pale with red rimmed eyes.  He often can't manage to eat his lunch in the noise and chaos of the cafeteria, so on top of everything else, he has to cope with hunger and low blood sugar all afternoon.

Although this child is quite capable of learning, he has been so far prevented from demonstrating his true abilities because his sensory defensiveness, which dominates most of his responses to the noise, chaos, and confusion at school, makes learning and retaining information a huge challenge.

His mother was gearing herself up to talk to the school psychologist about making accommodations for him, like sitting him near the teacher, making sure he had movement breaks, and trying to get him a quiet place to eat his lunch.  She didn't think she would get very far.  It appeared, from the school's point of view, that if a child is not actively behaving in a way that disturbs the class, but sits quietly, there is no problem.  No problem means no need for an IEP, and so no special accommodations are required.  And certainly no mandate for occupational therapy.

If you have a quiet, withdrawn child who creates no problems other than functioning well behind his abilities, chances are good that he is sensory defensive, and his method of dealing with it, unlike a hyperactive child whose issues are so easy to pinpoint, is to disappear. In order to prevent a child who presents like this from slipping through the cracks, you're going to have to advocate for all of the things he will need, along with the added challenge of convincing the people in charge that there is a real issue here.

  Just like his classmates who act out, a withdrawn, low arousal child would benefit from sensory integration therapy.  At school, just like his brethren who can't keep still, he needs movement breaks, things to chew or suck on, sips of water, fidget toys, a seat near the teacher, an inflatable cushion to sit on, a pair of ear plugs, a slant board, and all of the accommodations that are made for the ones who are more obvious in demonstrating their distress.

How can we go about educating the system, and ourselves, to be more on the lookout for these children and provide them the help they deserve?