Wednesday, April 27, 2011

Giving Them What They Need, So They'll Give Us What We Want

Recently I had a bit of a run in with the mother of a little boy I treat.  His teacher had complained, yet again, that he simply could not sit still in class.  When she called to tell me about it, I asked her, yet again, if she was taking him to the park to run around and play for 20 minutes before school began and again in the afternoon before it was time for homework.  She became very irritated and told me that there was simply no time in her day for it, and to stop asking, because it wasn't going to happen.  I told her, "I understand that you are all very busy, but he will never be able to meet your expectations unless you first give him what he needs."

I took a really interesting class many  years ago called "How Does Your Engine Run?"   The women who developed the program had devised a whole way of thinking about how alertness and arousal levels are dependent on the state of body, and how sensory defensive children tend to be either underaroused or overaroused, with not much in the middle. This makes them largely unavailable for learning or for exploring and socializing in an age appropriate way.

We learned all kinds of strategies for helping the children's "engines" to idle in the middle range, so that they were in the just right state for learning.  I left the course with a whole new appreciation for how the state of my body affected my brain and emotions, and thus my reactions and behaviors. I saw how I could manage my own engine speed to increase my alertness, or to soothe myself when I was overstimulated or out of sorts, and have more control over my responses and my ability to stay present and focussed in meetings and classes.

I like the engine analogy. If you drive a car, you know that in order for it to respond beautifully, it needs premium fuel, water, air in the tires, regular tune ups and oil changes, and intact brakes.  If you  take care of your car's basic needs, you can expect it to handle well, get good mileage, and do what you want it to do:  start up reliably, stop promptly, steer responsively, idle quietly, rev up quickly.

Car engines are less complex than children, it's true, but in order for children to be able to function at their best, they, like car engines, need certain basic things.

The first thing a child needs to function at his best is premium fuel. If you put the cheapest gas in the tank of  your car, would you expect it to handle well?  Many of the children I see at the clinic are fed a steady diet of second rate food, like french fries, chicken nuggets, white bread and cold cuts, toaster waffles, sugary cereals, cookies, soda, and chips, and their behavior reflects it.

Your car needs the best fuel you can provision in order to handle well, and so does your child.  Premium fuel means fresh fruits and vegetables, whole grains, lean proteins, water instead of soda or juice, and saving processed foods for an occasional treat.  Children are not at their best when they eat a lot of refined carbs.

Please make sure that your child's breakfast and lunch don't come prepackaged.  Protein bars and granola bars are full of unpronounceable ingredients and sugar and are not a good substitute for whole, fresh, unprocessed food.   {One dad, who does most of the cooking for his family, calls packaged food like granola bars "Saturday food," which I think is a great idea.}

Premium fuel, especially on a school day, is a solid breakfast with lots of protein, a nutritious, unprocessed lunch, and a high protein after school snack, so that they can focus on their homework.

Children should not be drinking soda, enhanced, flavored waters, or lots of juice, which predisposes them to obesity, heart disease, and diabetes.

Some kid friendly ideas for a good breakfast:  string cheese, a hard boiled egg, a handful of nuts and dried apricots, a smoothie made with yogurt and frozen berries, nut butter and banana on whole grain toast.  Steel cut oats with maple syrup and walnuts is delicious and rib sticking, and can be made in advance and quickly heated up the next morning.

Some ideas for non junk food after school snacks:  fruit kebabs with a cinnamon yogurt dipping sauce, quesadillas, Wasa bread and cheese, guacamole with whole grain chips, canned salmon, cherry tomatoes, cut up raw vegetables and dip, ants on a log {celery stuffed with peanut butter and sprinkled with raisins}.

In order to to function well, children need lots of sleep.  From the age of three until they are seven, they should be getting a minimum of 12 hours a night, and seven year olds still need at least 11.  If they don't get that much, their attention, concentration, and behavior suffer.   If your child has trouble falling asleep, he needs to be outside more, and television and computer time should be drastically reduced.  Turn off the computer a minimum of two hours before bedtime, and if you don't already have one, institute a regular bedtime routine with story time and a snuggle.

Anxious children have a particularly hard time transitioning to sleep.  To decrease anxiety, make sure they get intense exercise during the day. Have them play with blow toys to improve their respiration.  If your child is tactile defensive and is on a therapeutic brushing program, try brushing before he changes into pajamas.

Some children respond very well to heavy, weighted blankets.  The deep pressure makes them feel relaxed and secure.  You don't need to buy a special weighted blanket.  Old fashioned wool blankets are quite substantial.

  A warm bath with epsom salts before bed is soothing.  You can also experiment with essential oils.  Lavender, valerian, and cedarwood are said to be good for relaxation and promoting sleep.  {Sheets and blankets have been traditionally stored with lavender in Europe for centuries.}

Sugar, caffeine, and food additives are excitatory to the nervous system and so should be eliminated at least two hours before bedtime.  {Or if I had my way, altogether.}

 In order to be able to perform optimally, a child needs regular time outside, and lots of exercise.  I'm not just talking about soccer practice on Saturday mornings.  Children should be outside every single day in every weather, preferably doing things that require their heads to be in all kinds of different positions and give them all kinds of different movement experiences, like swings, slides, teeter totters, merry go rounds, bicycles, scooters, skates, etc.  Activities that require using balance and motor planning and challenge the child's coordination are the best.

I would also recommend making the child's environment as non toxic as possible.  Ditch the scented products, don't wear shoes inside the house, and replace your cleaning products with baking soda and vinegar.  Don't nuke his food, which should be organic when possible, or if you must nuke,  don't nuke it in plastic.

What else?  I would say that in addition to these basic things, they need lots of affection and quality time with the people they love  -- turn off your Crackberry and your cell phone when you're with your children, please.

In order to feel safe and secure, all children need firm limits and patient, loving discipline.  They need a sense of responsibility and things to which they can aspire.  They need toys that encourage their imaginations and challenge their eye hand coordination, and they need books that make them think about the world and teach them wisdom.

 Make sure your child knows he's part of a strong, solid tribe.  Spend regular time with the child's aunts, uncles, grandparents, and cousins.  Have dinner together as a family every night, and talk to each other.  Turn off the television and the telephone while you're at the table.

What else does your child need to succeed?

Wednesday, April 20, 2011

My Secret Weapon Revealed!

A commitment to following through with a home program can make a huge difference in a child's ability to function.

A couple of mornings a week, I see children at a little clinic in a very poor neighborhood in upper Manhattan.  My treatment room is the size of a walk in closet, and instead of a beautifully equipped sensory gym with a large assortment of swings, a zip line, a ball pit, a climbing wall, a slide, and a loft, which is what I have available to me at my practice in Greenwich Village,  I have a couple of collapsible tunnels, a small assortment of therapy balls, a little portable mat,  a few puzzles and toys, a chalkboard, and whatever else I can scrounge from my own stash.

However, despite the lack of equipment, I have been able to help make remarkable changes in some of the children I treat, because I have a secret weapon up there: their mothers.

I've had some amazing turnarounds at that rickety little  clinic, sometimes getting better results than I do at the sensory gym, mostly due to the children's mothers following through at home.

For instance, I recently started seeing a four year old boy who was referred by the district because he was having so many problems adjusting to preschool.   I must confess that when I met him and his mother, my heart just sank.  He looked like a thundercloud made flesh, he was so unhappy in his body.  And his mother, who looked like she was still in high school, wore low cut, skin tight clothing and was pierced and tattooed everywhere.

My initial impression was that he seemed unreachable and unapproachable, and that she was scattered and not very bright.  {Which only proves that first impressions are misleading, and that you really can't judge a book by its cover, etc.  And I should have looked past that, and noted that he was beautifully groomed and dressed.}

This child was so sensory defensive that he was practically feral.  Any time anyone came into his personal space, he screamed "NO!" and either lashed out with his fists or folded into himself and crawled under furniture.  School was not going well at all.  He threw things, hit, bit, kicked, hid, and would not participate in any activities.  Because of his tactile defensiveness, he could not bring himself to touch glue or paint, and his ears were so sensitive that music class was a disaster.  When he was upset, which was often, when he wasn't lashing out, he would hit himself, smacking himself hard in the head with a fist.

His mother told me that he fell frequently.  When he wanted something from the floor, instead of bending his knees and squatting to pick it up, the way toddlers and small children so beautifully use their bodies, he had to drop down on all fours, or else he would collapse onto the ground and sit with his legs on either side of him.

When he wanted to pick something up, instead of using his finger tips, he used his hands like paws, and raked.

He had some language, but not much, and what he did have wasn't especially intelligible.

That first day, about 20 minutes into his treatment, he got so overstimulated that he punched me.

The second time I treated him, his mother casually mentioned that she had gone to Target in search of a collapsible tunnel like the one I had, but they were out of stock.  "You want to do things with him at home?"  I asked, surprised.  She said she wanted me to give her a list of things to do with him every day.

I pointed out that he was quite weak in his legs, which made his balance poor, and that he needed to crawl a lot, not only to integrate and strengthen up his pelvis, but also to stabilize his shoulders and help his hands be ready to hold a pencil.  I suggested that she put him on her back and give him piggy back rides without holding on to him, so that he would have to grip her with his arms and legs.  This would give him some much needed joint stability, so that he wouldn't fall so easily.  "Put on some music and dance with him on your back," I said.

We put him on a therapeutic brushing program, and gave him lots of blow toys.   His mother bought a couple of therapy balls and duplicated the activities we did in his sessions.   I urged her to keep him outside as much as possible.  I suggested that she take him to a park and have him go on the swings, and, since he liked to spin, to twist the chains.

Since he tended to isolate himself, I taught her some basic FloorTime techniques, and asked her not to punish or threaten him when he was being obstinate, but to attempt to be patient and to remember that his sensory defensiveness and balance issues caused him a lot of distress.

I then spoke to his teacher, taught her how to brush him, and asked her to please stop trying to force him to learn to write his name, since {like all four year olds} he was nowhere near ready developmentally to do that.  He was still only scribbling, could not duplicate a straight line or curve, and had not developed a three point pinch.  I also requested that be be excused from attending music class, since it was so painful to his ears.

He's been coming to OT for about ten weeks now, making slow but steady improvements, beginning to be interested in the toys and doing some exploring.   Last week, though, when they arrived, instead of hiding behind her, he walked into the clinic ahead of his mother, and grinned at me.  Instead of forcing me to walk on eggshells while gently coaxing him against his will into the treatment room, he bounced right in and started talking to me a mile a minute.

 As we settled down to work,  his mother lifted up one of his pants legs, and showed me where skin on his knee was darkened and scuffed.  "That's from crawling!"  she told me.  She had devised all kinds of crawling games at home, like putting his favorite toys under the sofa, so that he would have to frog crawl on his belly to get to them.  She was playing with him on the therapy ball, doing all the foot activities, all the brushing, all the piggyback rides, tons of crawling, and spending time at the park every single day.

She reported that he had stopped falling.  He was starting to use his legs to squat, instead of dropping to all fours or collapsing.  And he was participating much, much more at school.  He did not hit himself once during our session, and instead of hitting me and screaming when I started to remove his shoes so I could work on his feet, he helped to pull them off.

This child made his remarkable turn around so quickly because his mother was committed to helping him decrease his sensory defensiveness, which she did by diligently following through on his therapeutic brushing, and to improving his respiration, balance and strength, by doing the exercises and activities she learned in our sessions.  Nothing she did was very complicated, she accomplished everything in a tiny little  Manhattan apartment, and she was creative, improvising and expanding on what she had learned,  making  it challenging and fun.

If your child is seeing an OT, ask your therapist for activities you can do at home to improve his balance and strength.  If you invest in a few small, inexpensive pieces of equipment, like a therapy ball and collapsible tunnel, and spend a few minutes every day working on core strengthening, you can make his therapy go much faster.

And make sure he gets outside every single day to play!

Wednesday, April 13, 2011

Jay, a Case Study

 I had such a remarkable turnaround this week with a little boy that I started seeing last month that I thought I would share it with interested readers.

A few weeks ago I wrote about a little boy who habitually entered the clinic and proceeded to zoom around from room to room.  No one and nothing could stop him.  When his parents rebuked him, loudly and sharply, he didn't appear to hear it.  If he was physically restrained from running into the back of the office area to check out the treatment rooms, as soon as he was released, he was off again.  The only way to get his attention was to physically hold him down and force him to make eye contact while speaking loudly and sternly.

My take on his behavior was that he was so sensory defensive, he was unconsciously  searching for predators.  His reptilian brain {the most primitive, reactive part} was constantly warning him that danger was afoot, and so he was driven to go on a reconnaissance mission every time he entered a new environment.  The grip of that inner force was so strong that nothing could penetrate.

I got a phone call from his speech therapist a week or so after I started seeing Jay, who wanted to know if I could help her manage his behavior better.  He was unable to sit still or cooperate with her in any meaningful way.   During his therapy sessions, he threw himself on the floor, crawled under furniture, tried to run out of the room, picked up anything he could find and hurled it, broke things, screamed, cried, kicked, and hit.  Aside from his sensory issues, it was obvious from the way he behaved with his speech therapist, with me, and at school, that he considered obeying grownups to be completely optional.

I commented that I had never experienced such disorganized behavior from any child who did not also have a diagnosis on the autistic spectrum, and the speech therapist agreed.  This child, however, was clearly not autistic in the least.

 I identified some sensory issues and some environmental issues that needed to be addressed before he could be expected to behave in an organized way.  He was quite clearly tactile and auditory defensive.  His balance wasn't very good.  He had not spent much time crawling, which is essential for developing a strong, sturdy, neurologically integrated body.  It was apparent, just looking at him, that his eyes didn't work together well, so perhaps he was seeing double, which is certainly anxiety provoking, especially in a busy classroom or on a Manhattan street.  His nose was chronically stuffy and he wheezed, which meant that his breathing was shallow and inefficient.

Environmental issues were a big part of his problem.  His diet consisted of mostly of chicken nuggets and french fries, washed down with soda.  He did not spend any time outside other than to get from place to place.  There were also issues at home about things like anger management, setting appropriate, consistent limits, and having a regular bedtime.

I suggested to the speech therapist that she start his sessions with therapeutic brushing  {there was an OT onsite who could teach her the protocol}  have him play with blow toys, incorporate movement whenever possible, and to give him lots of heavy input into his joints, like jumping on a trampoline, or putting him on the floor and rolling a big therapy ball over his body.  I told her to set the bar really low for a while and not expect too much in terms of the difficulty of the tasks she set out for him.  Children often act out when they are overwhelmed and don't know how to do what is expected of them.  This is particularly true, I find, for children who are wrapped up in their defensive responses.  They don't have enough cognitive energy available for much else.

 I also encouraged her to have a zero tolerance policy for unwanted behavior.  She had begun to just ignore the behaviors she didn't want, but I have found that with a child who does not respond to adult authority, calm, firm, consistent redirection, in combination with physically containing him to prevent him from running off, is more effective.  A child like Jay, who feels so unsafe and whose behavior is so out of control, has to know that the grownups are in charge.   He can then begin to let down his guard and depend on the grownups to protect him.  {My analyst colleague would add that he will know that the grownups are strong enough to prevent him from doing anything too terrible.}

I taught his parents the therapeutic brushing program, explained that he would behave better if they did it, and crossed my fingers that they would carry through at home.  I sent a brush to his school so that his SEIT, {a special education teacher who works with an at risk child one on one in the classroom} could brush him.   I told his father that his behavior would improve considerably if he were given regular time outside, especially at a playground with swings and a slide, and his father promised that he would make sure it would happen every day.

In my therapy sessions, I worked on integrating postural reflexes and improving his balance and core stability.  We did lots and lots of breathing work, using whistles and blow toys.  It was not easy.  The first couple of weeks were quite exhausting as he challenged my authority again and again, had many tantrums, and had to be restrained from climbing under furniture or running out of the room.  One day he came in so restless and unable to focus that after brushing him, I took him into the hallway and told him that we were going to run a race.  That worked wonders.  We ran and ran and ran, and he kept begging for more.   When he was finally tired enough to agree to change activities, we got lots of things done.  He gave me a big hug when it was time to go.

The next time he came to see me, he started to wander back into the office area.  I said, "Hey, Jay, you're not allowed back there," in a normal tone of voice.  He stopped and came right out.

What made it possible for him to finally hear me?

I believe it was a combination of things.  The brushing reduced his tactile defensiveness enough so that he wasn't wrapped up in his internal fight or flight mode and could attend to what was happening outside  of his body.  The blow toys, which I sent home and encouraged his family to have  him play with, improved his ability to breathe, further reducing his anxiety.  His father had indeed made it a point to take him outside, which he reported made bed time a breeze, so Jay was well rested.  The authority figures in his life were all making sure that he behaved in a manner that met their expectations, which made him feel secure.

Later that afternoon I got an email from the speech therapist letting me know that Jay had been participating a hundred percent in their sessions and had not had a single behavioral issue for two weeks.

His SEIT reports that he is participating much better at school, his behavior is more organized, even in the noisy classroom, and his tantrums have reduced considerably.

We're still not out of the woods yet, but these small changes have made a remarkable difference in this little boy's ability to function.

Wednesday, April 6, 2011

Treating Tactile Defensiveness

Treating tactile defensiveness will vastly improve a child's ability to learn, explore, play, and socialize.  A tactile defensive child is in survival mode much of the time when he should be feeling at home and happy in his body and with the world.

Many problematic behaviors can be attributed to tactile defensiveness.  A few of the classic signs are complaints about clothing, especially tags, elastic waistbands, and the seams in socks, refusing to touch certain textures like lotion, glue, or liquid soap, lashing out when others are too close, wiping off kisses, tantrums over being groomed,  poor ability to transition between activities, being controlling or rigid in personality, not being very physically affectionate {or insisting on being hugged as tightly as possible} habitually fisting the hands,  and refusing to walk barefoot and/or preferring to walk on tiptoes.

Tactile defensive skin is overly sensitive and is wired to a part of the brain that alerts the system to danger.  It has little ability to filter out unimportant sensations, like the feel of clothing, and can't easily distinguish between what is neutral and what is a threat.  This puts the child on high alert in situations where there is no reason for it.  Is Grandma zeroing in for a hug or for the kill?  The child's nervous system is telling him that danger is approaching and to defend himself, even when she has a loving look and her arms open wide.

  Ever had a spider crawl on your skin and have an extreme panic reaction?  Ever had a fever and just want to wear your softest jammies because your skin was so sensitive that your clothing felt prickly and awful?   That's what tactile defensive skin feels like much of the time.

Tactile defensive children generally don't do well with change, especially with sudden, unexpected deviations from daily routine.  They have a higher than normal need to control what is happening around them and tend not to be very mentally or emotionally flexible.  The reason for this is because so much of what comes their way during a typical day is interpreted by their nervous systems as threatening, noxious, and painful.  They have to expend an enormous amount of energy coping with unpleasant perceptions and sensations that a normally functioning nervous system would not even register, so they don't have a whole lot of mental energy left to be able to roll with the punches.  Transitions are especially difficult for them, more so if the child is not expecting one.  He doesn't adapt to novelty well, and so he can't easily shift gears.  A child who habitually responds to life with a resounding "NO!" is struggling with sensory defensiveness.

 In school, the amount of energy the tactile defensive child must expend coping with the sensations of the classroom, which he perceives as an assault, often leaves little left for learning or socializing.

I've never seen any research about this, but I have often thought that untreated tactile defensiveness, because it is so anxiety provoking, forces the child to self soothe with stereotyped behaviors and rituals, which then develop into obsessive compulsive disorder, or OCD.  The reason I say this is because I have spoken to many, many parents over the years whose children, when they were very small, demonstrated classic symptoms of tactile defensiveness that no one knew how to diagnose or treat.  As the children got older and their self soothing behaviors became more and more ritualized, compulsive and bizarre, they were diagnosed with OCD.

 I have also worked with dozens of small children over the years who had OCD like behaviors {compulsively picking at clothing, pulling sleeves over hands, facial tics} that promptly extinguished when they were put on regimens to treat tactile defensiveness.

If your child is exhibiting signs of tactile defensiveness, or is unusually rigid and controlling, seeking out a good sensory integration therapist and having your child evaluated and treated for sensory processing difficulties can make an enormous difference in the child's ability to function.  The therapist can show you how to administer a program to reduce tactile defensiveness.  The protocol was developed by Patricia Wilbarger, an occupational therapist who has contributed a great deal to the body of knowledge about treating sensory processing disorders.  It consists of firmly and slowly brushing the child's skin with a specific surgical brush in a specific way, followed by a series of joint compressions.  The deep pressure overrides the fight or flight response that is constantly being triggered by light touch. Over a period of time the protocol will shut the inappropriate responses down completely, normalizing the way the child takes in and processes sensory information from his skin.   I have been using her techniques for many years in my practice and have had wonderful results.

Here are a few recent examples of the changes that the Wilbarger protocol has brought about for the children I treat:

After about a month of therapeutic brushing, the little girl I mentioned last week, who kept to herself all the time at school and spent all of her time at home alone in her bedroom, suddenly began to join in when her sister had friends over to play.   She stopped keeping to herself so much at school and started interacting with her classmates.  Instead of habitually turning down invitations for playdates and birthday parties, she began to initiate invitations herself.   Her nanny told me that she has begun to slip into her sister's bed at night for some pillow talk and a snuggle.  Now that's making up for lost time!

The little boy who was so anxious and picked at his clothing  stopped picking, stopped hiding in the corner, and started joining in with the other children at school, using all of the craft materials, and willingly painting and gluing along with everyone else.  He also, for the first time, had a wonderful vacation visiting his older cousins.  Instead of hanging back and clinging to his mother, he fearlessly played all of their rough and tumble games with them,  challenging himself to keep up.

A little boy who refused to ever go barefoot and would have a panic attack when required to take off his shoes is now completely insouciant about his feet, pulling off his shoes and socks with ease at home and in the clinic.  His attention span, which was almost non existent at school, is now age appropriate.

The little girl who insisted on going bare legged and commando dressed herself the next morning after the protocol had been started, choosing a pair of corduroy slacks that she had previously refused to consider, and wore them to school.

Another mother just reported that her son had mostly stopped trying to control everyone and everything at home, and was amazingly loving and cuddly instead of being standoffish and rigid.  She said he was like a different child.

The little boy who was highly aggressive at school, who joined in every altercation and lashed out whenever anyone got too close, was so out of control that during the spring, the administration threatened to ask his parents to find a new school for him unless they got him some help.  He was put on the Wilbarger protocol, and it was carried out all summer.  At the start of the new school year,  I called his new teacher to check on his progress.  She was surprised that he was in occupational therapy, since his behavior was now no different than that of the other children in his classroom.

For a child who has difficulty touching a variety of textures, I recommend messy play. {This is often easier just after the child has been brushed.} In the clinic, we play with cornstarch mixed with water, shaving cream, Funny Foam, artificial snow, Flarp, {I buy mine at Michael's} tubs of kidney beans mixed with little toys for the children to dig around for and pour from container to container, Play-Doh, finger paints, and Moon Sand.  If you, his friends, and his siblings play with gusto, he will be persuaded to join in.

If left untreated, tactile defensiveness can seriously interfere with a child's quality of life.  We can grow out of some things, it's true, and some sensory issues lessen in severity as the child matures,  but I have seen adults who have very unhappy lives because their tactile defensiveness prevents them from having loving relationships.  They want to be good partners, but the pain, anxiety, and revulsion that intimate touch evokes in them makes it impossible.  They also tend to need to control their environments and have a hard time being flexible.  This affects not only them, but everyone around them.

If you know of an adult who has tactile defensiveness issues, a consult with a sensory integration therapist can be tremendously helpful.  The Wilbarger Protocol works well on adults, too.

For more information on sensory defensiveness, I recommend the book Too Loud, Too Bright, Too Fast, Too Tight, by Sharon Heller.