CASE STUDY |
(The client's name has been changed to honor the family's request for confidentiality. All other details of the case are factual.)
Deanna Petros
8 Year-old
with Motor Development Delays
and Immature Social-Emotional Development
Deanna is an active eight year old girl with many motor challenges. Her mother decided to bring Deanna to HANDLE after reading Sensory Integration and the Child, by A. Jean Ayres. Specific concerns included motor planning, fine and gross motor skill delays, lots of extraneous unproductive movement, and difficulty remembering and sticking to a task. She did not yet have established laterality-- that is, there was indecision as to whether she was right or left handed. Her teacher writes: "She appears physically agitated, being unable to sit still at all. She has wiggled her chair almost to pieces." And, she went on, "Deanna is a very tactile child. She still has a tendency to mouth and chew on things. She enjoys physical contact:: rough housing, 'being a chair' (crawling under the big pillow in our room and asking other children to sit down), leaning on me when we stand in a circle, etc. She doesn't have the same consciousness of physical boundaries as other children her age...."
Emotionally, Deanna had a lot of frustration, stemming not only from all her physical challenges but also from social challenges. It was hard for her to connect with others and so she spent more time alone than with friends. Her teacher writes that she is "emotionally volatile... She can be dramatically exuberant, tirading, woeful, and has had occasional tantrums at school during which she cried, shouted, and kicked. ... Once she has interpreted an event it becomes fixed in her mind and she has great difficulty in hearing what another has to say. This can make problem solving a challenge."
Reported history from Deanna's mother revealed a normal, full-term pregnancy, a natural birth, and no complications. As a baby, Deanna had a strong suck and was breastfed for one year. She had fairly severe colic and was inconsolable for about half a year. White noise and driving helped to calm her. She sat up and crawled at an early age, but did not begin walking until 14 or 15 months. Walking downstairs was a very difficult task for her, and once she fell down. Toilet training was late (age 4), and tying her shoelaces is still challenging.
In the area of sensory stimulation, there was evidence of irregularity in processing. For example, hair washing and brushing, and nail clipping were great challenges, yet her mother reported that for a long time Deanna seemed hyposensitive to sensations, such as cold and pain. There was a supposed hearing loss, yet Deanna could pick up small noises or conversations you wouldn't think she's listening to. She is sensitive to light, requesting "Turn the light off" as soon as she wakes up in the morning. She hates spicy food of any kind, preferring bland tastes like bread.
Deanna had frequent ear infections when young, with the complication of high fevers and seizures. She had tubes put in her ears at the age of four, but they fell out within days. The family did try to keep antibiotic treatment to a minimum, however. Deanna had, and continues to have, chronic respiratory infections.
Deanna's sleep also is problematic. She thrashes in her sleep, throwing the covers awry, creates a "nest" for herself in her bed, and finds it hard to get up in the morning. She loves wild rides and getting dizzy, and would spend half her time spinning and swinging if she could. She does not have a natural sense of rhythm and is not interested in sports of any kind.
Deanna was very cooperative at the beginning of the assessment, just swiveling a bit in a swivel chair. By the end of the two our session, she was non-compliant, needed to engage in expansive movement, as well as lying on the chair, the table, etc. Throughout the session, she was not really able to sit up straight in any situation that called for that. Her level of tolerance for frustration was very low, and she was not willing to try things she thought were too hard.
On the first task, which involved tracing some figures, and on subsequent tasks where some drawing was required, Deanna's lines were notably very wobbly and shaky. She leaned over her worksheet and rotated the paper on these eye-hand coordination tasks. When Deanna wrote her with her eyes closed, she did not lean over the paper. She did not remember her phone number; and wrote her 3's and 4's backwards (eyes open and closed).
On another visual motor integration task involving picture completion, Deanna at first laid her head down on her arm. While doing this task her thumb was not in contact with the pencil. Deanna quickly closed two of the pictures without attention to the details she was supposed to copy, and drew two extra points on a star.
Deanna demonstrated difficulty sustaining visual focus. Her responses on a task of binocular convergence were so disorganized that it was hard to even complete the task. She virtually could not track with her eyes in isolation from head movements, except for a few seconds when she did track the light from a pen light.
Another area in which Deanna exhibited notable immaturity was that of reflex inhibition, or differentiation of motor response. On fingertapping there was a huge amount of overflow, or extraneous movement, in the hand which was to remain still.
Asked whether she knew what she was supposed to do on one page, she did, but when asked to state this is one word ("copy"), she refused even to attempt to find the word.
Deanna succeeded in repeating strings of three and four nonsense syllables. With the introduction of a fifth syllable and "k" sounds, Deanna was challenged. She was, however, able to repeat a thirteen word sentence correctly and answer three questions about it, albeit with much swiveling, lying down and some non-compliant behaviors.
On a structured midline crossing task Deanna became confused about which hand was doing what. And conversation basically stopped her from continuing to perform the learned motor pattern, or rather, she stopped the task and devoted her attention to the conversation. Writing her name and phone number with both hand simultaneously, Deanna did mirror writing, i.e. instead of both names reading from left to right, they both started from the midline and went outward, so that the left name was backwards with backwards letters. On bilateral manual work with eyes closed, Deanna demonstrated great difficulty maintaining form constancy (for circles and triangles) and relative position in space.
Deanna's reported history along with her behavior and performance during the assessment present a clear picture when noted on the interdependent and interactive systems chart used at HANDLE. It becomes obvious that areas of major weakness for Deanna are vestibular functions, tactility, proprioception, muscle tone, and kinesthesia, all of which are closely interrelated. The wobbly, shaky lines, her leaning and lying down on the table and chair, inability to sit up straight for visual tasks, and lack of interest in any sport indicated weak muscle tone, as did the poor sphincter control inherent in her light sensitivity and late toilet training.
Deanna's teacher's comments are very revealing about proprioceptive issues - she crawls under a big pillow and asks other children to sit on her (this helps her to feel her body), and "she doesn't seem to have the same consciousness of physical boundaries as other children her age... " (she leans on the teacher in circle times). The fact that she thrashes in her sleep, throws the covers off, and creates a nest for herself are further clues to this important sensory weakness, and also her performance on the eyes-closed bi-manual form drawing.
Tactilely, Deanna is hypersensitive to some things and hyposensitive to (or perhaps blocking perception of) others. She has poor kinesthetic feedback from her muscles and bones and joints, which is related to her lack of a sense of rhythm. This was a major factor in her difficulty to perform the fingertapping task, in which it was hard for her to find certain fingers and repetition of the pattern did not make it easier.
Some of Deanna's weakness in social-emotional skills stem from these neurodevelopmental weaknesses. People with low muscle tone and poor kinesthetic and proprioceptive feedback sometimes do not identify or remember what different facial expressions of emotions feel like, and do not recognize them on the faces of others. Clearly, Deanna is experimenting with various emotions ("tirading", "woeful", "exuberant"), but she may be demonstrating inappropriate responses to her feelings. Deanna's tactile irregularities also make it difficult for her to share space with other children, whose movements may be threatening to her both for proprioceptive and tactile reasons. Combined with other idiosyncrasies in her behavior, and it is not hard to see why Deanna has few friends; children can be brutally unaccepting of behavior that is different from the norm.
Weaknesses in all of the above listed systems are clues to weakness in the very crucial underlying vestibular system. Other information that also points to vestibular impairment: chronic ear infections when younger; craving for spinning, swinging, etc.; difficulty getting up and going in the morning; the disruption to her auditory processing caused by the introduction of the "k" sound in nonsense syllables; and, a large red flag, the inability to perform visual tracking.
Immature reflex inhibition (overflow movement) is another significant element in Deanna's emerging neurodevelopmental profile. This immaturity is preventing her from becoming completely lateralized, and thus from fully integrating the functions of her right and left cerebral hemispheres. Another aspect related to weak interhemispheric integration was Deanna's immaturity of development with respect to the midline, evidenced in part by her mirror writing on the chalkboard. (We develop from the head down, and from the midline out. With both hemispheres integrated, we should be able to write with both hands going left to right; Deanna, when challenged, reverted to an earlier reflexive tendency.)
With so many challenges, it is no wonder that Deanna was having tantrums, crying, shouting, and kicking. She is a bright child and she is understandably frustrated.
Deanna and her mother were guided through a set of exercises and activities designed to strengthen her specific weak systems, notably the vestibular system, tactility, muscle tone, and proprioception. Also included in her program were activities to encourage maturation of her visual functions for tracking, convergence, and reduction of light sensitivity. Several activities to enhance differentiation (reflex inhibition) completed the initial set of suggestions in her customized program. Advanced activities for interhemispheric integration were not introduced at this phase, as Deanna's more basic systems needed to be strengthened first. Some activities to enhance this function were introduced at the first exercise check, as soon as Deanna had learned how to perform the initial set of activities.
Deanna has been seen twice for fine-tuning of her program in keeping with her progress since her first exercise check. Her mother and teacher are observing her progress and plateaus in order to determine if and when further follow-up is needed.
Two months after beginning the program, Deanna's mother reported being extremely happy with the progress, saying, "This has really changed my life, too." Deanna is also aware of and happy about the changes. As added benefits to the improvements in those behaviors that were initial concerns, Deanna has even learned to swim. And recently when Deanna joined her mom at a contra dance class (requiring good proprioception, muscle tone, vestibular function and interhemispheric integration), Deanna's performance prompted mom to ask, "How does it feel to be in control of your body?"
Three months after she was seen, Deanna was continuing to do well, and many others have noticed and commented upon her progress, even other children in her class. Deanna's list of activities was streamlined to a short-term maintenance program of six basic exercises to be performed only three times a week.
