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.)
Skyler Roman
Six Year Old Boy with Asperger’s Syndrome and Hyperactivity
Six year old Skyler was an explosive child. Volatile and unpredictable, Skyler could experience intense torrents of emotion that would surface suddenly and without apparent cause. In these moments, he would tense his body, thrash about and throw himself to the ground, saying things contrary to fact, such as “My name is NOT Skyler.” He would sometimes engage in head banging or other forms of self-abuse, such as pinching, pulling at his neck, bending his fingers backward or poking himself in the eyes. He had also begun spitting.
Skyler’s parents were already versed in the language of dysfunction and diagnosis. On Skyler’s intake history, they indicated the following; auditory perception/processing dysfunction, attentional disorder, conduct disorder, general learning disability, developmental delay, and hyperactivity. They were also troubled by that fact that Skyler exhibited little in the way of eye contact.
Skyler’s excessive activity, coupled with his dramatic behavioral displays, had earned him the label of ADHD. He had been taking Ritalin and Prozac. No one as yet, however, had identified the condition that most appropriately encompassed Skyler’s behaviors, Asperger’s Syndrome.
Skyler’s mother was sick for the first two trimesters of her pregnancy with him. Skyler was a full term baby, but his was a “dry birth” following 18 hours of labor. No complications were noted, however, and he appeared to have a good sucking reflex. When Skyler was six weeks old, his mother switched from breastfeeding to bottle-feeding. Many brands of formula were tried because most seemed to cause Skyler to throw up excessively.
Skyler met his developmental milestones on a somewhat erratic timetable. He began walking, or rather running, at nine or ten months old, but his speech was delayed. He sat up within the appropriate age range, however his crawling was minimal. Moreover, Skyler did not crawl in the standard cross pattern fashion that works both sides of the body and brain hemispheres in a balanced way.
Skyler’s gross and fine motor coordination were both poor. At six years old, he was still not proficient with tasks such as getting dressed or using utensils, and he was unable to alternate feet while climbing or descending stairs. Grooming routines were onerous for him and his parents, as he was unduly bothered by clothing and distressed by hair washing, hair brushing and dressing.
Railings had been put up around Skyler’s bed to keep him from falling out. Needing someone in bed to help him fall asleep was problematic because his nighttime thrashing made him a difficult sleeping companion. Skyler could spin for long periods of time without getting dizzy and he could go on, seemingly forever, swinging or revolving on a merry-go-round. His dining repertoire consisted primarily of milk and peanut butter and he refused all fruits and vegetables. Moreover, he would not eat in front of others. Consequently, he would not eat at school.
Each of these concerns, as presented by Skyler’s parents, yielded a glimpse into the sources of Skyler’s social and behavioral difficulties. To complete the picture, Skyler was observed and assessed at The HANDLE Institute.
The first observation, made even before Skyler entered the evaluation room, was that there was an asymmetry about Skyler’s head. It was as if one side had been pushed forward and one side backward. This was not something that his parents had recognized, nor had other professionals brought it to their attention.
At the time of Skyler’s evaluation, he had been off of all medication for a month. While waiting in the lobby, Skyler had discovered a book about King Kong, and had been completely ensnared by it. Despite being allowed to bring it with him, Skyler had to be coaxed into the evaluation room and physically guided to avoid bumping into things along the way. He required prompting from his parents to speak to the evaluator, and it was noted that speaking seemed difficult for him.
Skyler’s father commented that dinosaurs were a fascination for Skyler, indeed a fixation. Skyler’s inclination to fixate became evident during the evaluation as he was observed scrutinizing the King Kong book, turning the pages one by one, analyzing the picture, then acting out the positions and expressions of the characters. Skyler’s father explained that Skyler was also known to fixate on words or phrases, repeating them many times over.
As the assessment began, it quickly became apparent that Skyler would not be able to perform many of the standard evaluation tasks most six year olds were capable of. The first, tracing around a diagram of animal shapes to untangle them from others, he began but stopped, as the jumble of lines promptly confused him. Blue paper was substituted and he tried twice more to trace the animals, with only slightly more success the third time.
As he worked through this task, Skyler drew with his right hand, but appeared to neglect the left side of his body entirely. His pencil grasp was a fist and he had mixed success with writing his name throughout the evaluation. At one point, Skyler was asked to match two simple drawings, identical except for the directional aspect. After an initial success, he had difficulties with the second and third drawings and began guessing, appearing to be genuinely uncertain. As he pointed to the figures he used his left hand, and his right hand remained totally inactive.
As the evaluation progressed, Skyler lost interest and had to be persuaded to continue. Specific tasks were bypassed and priority was given to those most pertinent to Skyler, the evaluation of auditory and visual functioning.
The auditory assessments validated the auditory processing and perceptual problems reported by Skyler’s parents. He was unable to repeat a sequence of more than four nonsense syllables. Nor could he repeat a sentence or answer some basic questions about the sentence he had just heard. A careful look at visual functioning suggested problems here as well. Skyler was able to peer through a tube with one eye, but he could not point to an object with both eyes open. He was also fully unable to track an object with his eyes.
As the assessment came to a close, the climate of the evaluation changed as Skyler’s attention continued to be drawn to the King Kong book. Although the evaluator was challenged to engage Skyler through play, much was learned about Skyler during this time. In turn, this knowledge was fused with Skyler’s history to produce his comprehensive neurodevelopmental profile, providing insights into the obstacles that Skyler was facing.
Asperger’s Syndrome is a form of Pervasive Developmental Disorder, which can include poor social understanding, all-absorbing narrow interests, uncoordinated motor movements, speech and language idiosyncrasies and difficulties with non-verbal communication. Although this is a befitting descriptor of Skyler’s condition, the label provides little to shed light on the underlying weak systems giving rise to the behaviors in question.
Instead, it became clear that a primary contributor to Skyler’s poor adaptation was a vestibular system that was functioning far less than optimally. The inner ear, of which the vestibular system is an integral part, supports our ability to filter and process sound, our sense of balance, the dynamic use of our eyes to track, the sense of our bodies in space and it also allows regulates muscle tone--the state of readiness in our resting muscles. Skyler’s auditory challenges, ability to spin without dizziness, balance problems, and inability to track visually were all indicators of vestibular dysfunction.
When weakened through damage or disease, the vestibular system can send unreliable signals to the brain, eliciting inappropriate behavioral responses and spurring the development of learning problems, both of which were present in Skyler. Through its effect on the reticular activating system, the vestibular system also effects both general focusing of attention and activity level. Skyler’s difficulty in shifting focus was notable, as the evaluator had to work diligently to attract Skyler’s attention to the assessment tasks. His zeal for spinning and tendency toward hyperactivity were Skyler’s strategies for activating his weak vestibular system, thus keeping himself alert.
The sense of proprioception, emanating from the muscles, ligaments, joints and receptors associated with the bones, and integrally related to vestibular functions, gives us our unconscious awareness of the body in space. Skyler liked to jump, as his jumping placed impact on his joints that helped him to feel his body. The fact that Skyler was prone to falling out of bed, needed someone with him to fall asleep and engaged in head banging indicated that Skyler’s proprioception was highly impaired.
Cross pattern movements, such as crawling, aid in developing the neural pathways between the two hemispheres of the brain. When this connection is inadequate, there is difficulty in getting the two sides of the body to coordinate. Skyler’s interhemispheric integration was markedly deficient, as evidenced by the fact that he had, at six years old, trouble alternating feet when maneuvering stairs and he had not yet selected a dominant hand.
Indeed, it appeared that as Skyler used his right hand, he accessed the left side of his brain exclusively, and conversely with his left hand and right hemisphere. These weak interhemispheric connections can also be implicated in some of Skyler’s emotional instability, his language deficits and his general learning difficulty. It is necessary to use both sides of the brain to balance logic with emotion, as well as achieve optimal proficiency in language and learning. Skyler’s performance in the visual component of his assessment also signifies a lack of binocular vision (another area compromised by irregular interhemispheric integration), helping to explain why eye contact was absent in Skyler.
Skyler’s parents reported that he had many tactile sensitivities with respect to clothing and grooming. Also, the possibility of undiagnosed food allergies seemed a strong likelihood, given his very definite food preferences and avoidances. Most suspect are milk and peanuts, the two foods that he craved.
With all of these factors in play, weak connections between the two sides of the brain, vestibular disturbances, poor proprioception, visual and auditory deficiencies and tactile and food sensitivities, it is not difficult to see why Skyler often exploded in frustration. To strengthen the weak and irregular systems, thus opening new opportunities for living and learning, a comprehensive therapy program was designed and presented to Skyler and his parents for implementation at home. Nutritional suggestions--easily absorbed vitamin drops and flax seed oil--were made to support the strengthening and building of neural pathways and general health as Skyler moves and progresses through his HANDLE program.
Skyler’s family and teachers began noticing subtle changes in Skyler very early into his HANDLE program. In the first week, his teachers commented that he was relating better with the other children. At Aikido class he was able to perform jumping jacks along with the other students.
After following his program diligently for one month, Skyler began to blossom socially. His bus driver noticed his great smile and “bubbly happiness.” Delight, openness and sociability began pervading his general mood, and his verbal repetition had lessened considerably.
When he and his parents checked in for their first follow-up appointment, Skyler ran in with a huge grin and reported that he likes pizza. He was trying new foods, had been taking his supplements, and had begun eating at school on a daily basis. He had learned to fall asleep without someone else in his bed.
At a school conference, about two months into their program, Skyler received an excellent report from his teacher. His tantrums had diminished greatly. Skyler was calm in class, focusing and paying attention, and was spending less time obsessing. He appeared to be choosing a dominant hand. Furthermore, Skyler was initiating dialogue with the other children. His social awareness was growing as he demonstrated reciprocity in conversation and facility in selecting appropriate social responses.
By this time, Skyler was completely weaned from peanut butter and milk and enjoying a wide variety of foods. He saw his first movie in a movie theater and discovered that he likes popcorn!
Five months after his assessment, it was clear that Skyler would be well equipped to participate in a regular kindergarten classroom the following September. His emotional turbulence had settled and an outgoing and vibrant Skyler was emerging.
Following their final appointment, we (HANDLE) received a card from the Roman family. On the front was a picture of Skyler smiling at the camera. In it, Skyler’s parents expressed their gratitude and told us of Skyler’s continuing successes. It was with pleasure that the HANDLE staff observed the Romans’ dedication to their HANDLE program, watched Skyler’s personality unfold, and listened each visit as the family reported on Skyler’s splendid progress. We, also, are gratified at our hand in giving Skyler an opportunity to live, love and learn to his greatest potential with joy and happiness.
