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.)
Tamara Harris
7 Year Old Girl with Learning Differences and Anxiety
Tamara came to the HANDLE Institute at seven years old. She was a bright, articulate, compassionate and fun loving little person. She was also struggling mightily in her first grade classroom.
Emotional reactivity and difficulty managing transitions were longstanding issues for Tamara. However, these became especially problematic when she started formal schooling. Her first grade days were punctuated with tears, and occasional show-stopping tantrums, as she could become overwhelmed by the sights and sounds of the classroom. The fast pace of the school day proved especially distressing for her and she would sometimes retreat into an imaginary world of her own. Stress was evident as she tore papers into tiny bits or chewed her hair at her desk.
Tammy’s thinking was, at times, inflexible. She could get “stuck” on certain ideas, seemingly stubborn to those trying to help her. Once stuck, she had a difficulty devising solutions to her problems until she was able to distance herself from them with time. Attempts to control her environment to reduce her anxiety were construed as oppositional by her teacher.
As if tantrums were not enough to isolate Tammy socially, her driving desire to touch things and others caused problems with her peers. “Busy hands,” always on the move during instruction, made her appear as if she wasn’t listening and fleeting eye contact made reading social cues difficult for Tammy.
Despite her intelligence, Tamara was beginning to fall behind her peers academically. Of primary concern was her writing ability. Gifted with an active imagination, creating stories and songs was a source of pleasure for her. However, committing them to paper was excruciatingly slow and physically painful due to the death grip with which she held her pencil. Even rotating the pencil in her hand to shift from the graphite to the eraser was a task for Tammy. She would typically drop the pencil and pick it up again to gain access to the eraser.
She often flat-out refused to write. When she did write, legibility was difficult as her writing was wrought with letter reversals, uneven spacing and poor letter formation. As the rest of the class began incorporating accurate spelling into their writing, Tammy didn’t seem able to break away from the phonetic “invented” spelling techniques that were taught to her in kindergarten.
Reading and math were not as problematic, but she often invented distractions during work time as she could not read or work at near point tasks for very long. Weak motor skills and disorganization lead to additional frustration. Although her teacher appreciated her exuberance and cheery smile, Tammy was described as a highly distractible and sometimes difficult child.
Tammy entered the world in the usual way, and was an easy baby. She became independent at an early age, and her curiosity was evident. She met her developmental milestones early, walking and speaking in multi-syllabic words by nine months. She appeared to be developing beautifully.
However, as Tammy progressed through toddler hood, hints of a developmental derailing began to appear, only to be recognized by her parents in retrospect. Since Tammy was their first child, they did not realize that her inability to dress herself, inconsistent success with toilet training, inability to peddle her tricycle, indifference to books and puzzles and formidable tantrums regarding her car seat were signs of anything more than Tammy’s temperament.
Although her general disposition was upbeat and happy, Tammy could reach emotional extremes. “Terrible twos” lingered into three, four and five. Tammy’s mother recalls her preschool teacher commenting that, at any given moment, Tammy was either the happiest or unhappiest child in the school.
“Marching to her own drummer” was the theme of her kindergarten year, and it was recommended that Tammy repeat kindergarten to be given some extra time to mature socially and emotionally. Given an August birthday, this seemed like a reasonable idea. Although her second year of kindergarten was much smoother, the academic demands of first grade set off a downward spiral of poor conduct and poor scholastic achievement.
Wanting help with a child that they knew to be caring and kind, Tamara’s parents sought the advice of a child psychologist, as well as the school. Hoping for insight into the motivation behind Tamara’s behavior, they instead received recommendations for drugs, remediation and behavior modification. Rejecting all these approaches, they to began to look for alternatives in education when an ad for The HANDLE Institute caught their attention. They attended a Community Information Night to hear more. Tamara’s mother comments, “I learned more about my daughter in this group presentation than I had in six hours of private consultation specifically focused on my daughter.”
Tamara was evaluated at the Institute in late March. In contrast to the IQ testing she had previously endured, she thoroughly enjoyed the assessment process at HANDLE, as the evaluator played upon her sense of humor and love of a good challenge. Tammy performed well on many of the tasks and demonstrated deficiencies in others. Vestibular (inner ear) irregularities surfaced quickly, including the need to move frequently in a rotating pattern, and nystagmus coupled with a sense of dizziness when using her eyes to track.
When asked to don a pair of glasses with one red lens and one blue lens, Tammy’s view was red in one area, blue in another. In rather rapid succession, Tammy saw the white objects in the room as alternating from red to blue, indicating a visual irregularity known as alternating suppression. Additional tests revealed that the visual functions of tracking and binocularity were not operating optimally for Tammy. Her eyes tended to move in a jerky fashion throughout the tracking test and they tired easily when focusing at near point. An auditory sequencing task indicated a decrease in processing upon hearing specific sounds, and it was noted that she retained last segments best.
Overflow movements of her fingers, head and mouth were detected and a whole body response, which should have been integrated several years earlier, were observed. Tammy lost track of her writing when her eyes were closed and she was unable to internalize, through muscle memory, a simple repetitive, movement pattern. Additionally, the assessment revealed a weakness in the integration of the two hemispheres of the brain.
A complete profile of Tammy’s neurodevelopmental strengths and weaknesses was developed using her reported history and reflections on her general behavior and performance of the assessment tasks. Areas of concern were identified.
Several factors were suspected to contribute to Tammy’s difficulties. Central were multiple ear infections and associated high fevers causing weakness in the vestibular system. The vestibular system supports and regulates audition, balance, dynamic use of our eyes, feeling at ease with our bodies in space (proprioception), and having an appropriate state of readiness in our resting muscles. Tammy’s history of motion sickness, as well as problems with balance, proprioception and visual functioning confirmed speculation that the vestibular system was faulty.
For Tammy, this translated to physical awkwardness and she displayed timidity in the performance of motor activities. Consequently, she avoided many typical childhood games, retreating instead to the safety of solo fantasy play. In this, she missed important opportunities for social learning and did not stretch herself to enhance vestibular functioning as most children do naturally through play.
Among other causations, Tammy did not spend a significant amount of time in the crawling stage, a crucial period for the development of strong integration between the two hemispheres of the brain. This weakness was contributory to the many emotional shifts that Tammy experienced, and was holding her back from reaching her full learning potential.
Tammy also had unresolved tactile hypersensitivities, many of which interfered with normal grooming. Her parents reported an aversion to tickling, and roughhouse play almost always ended with her physically striking out in a manner inconsistent with the intensity of the game. It was not uncommon for Tammy to hit or act aggressively toward other children as a preschooler. She was particular about what she wore, seeking out comfortable clothing rather than fashionable ones. Socks often came home in her backpack rather than on her feet.
Tactile and kinesthetic irregularities were also found to impair Tammy’s ability to express her thoughts in writing. She had difficulty sensing where her hand was and what movement it had made unless she monitored each movement visually. If she paid close attention to her hand, then she became frustrated at losing the ideas she had wanted to capture.
A weak suck reflex as an infant, coupled again with vestibular weakness, interfered with the healthy development of her visual functions. Academically, she sometimes lost her place while reading, her eyes tired quickly and she had a vexing practice of reversing letters and numbers. The systems supporting vision and her sense of position in space were not strong enough to support reading, math and general organization in an efficient way. Visual inefficiencies also caused Tammy to be somewhat oblivious to her surroundings. This, coupled with reduced muscle tone, diminished her ability to interpret facial expression and body language so integral to social interaction.
No wonder Tammy was struggling, and was frustrated by her difficulty to prove herself despite all the wonderful qualities she possessed. How could her learning and behaviors improve before these root problems were identified and treated?
Tammy and her parents were taught a program specifically designed to address each deficiency in her neurodevelopmental profile. The program was dynamic, changing over time to accommodate Tammy’s progress, and incorporating many treatment techniques.
Feeling validated for her struggle, and eager to have things going better for her, Tammy began her program immediately, and cheerfully. Tammy progressed through her program, building and strengthening neural connections toward the ultimate goal of functionality.
For Tamara, the downward spiral that began in first grade slowed, then stopped, and then gradually shifted direction. Tears and temper tantrums began to diminish. By the end of first grade, she could read for longer periods of time and, consequently, her reading skills began to flourish. By summer, the child, who previously cried at the prospect of getting her face wet in the tub, was jumping off of the diving board and swimming. She learned to ride a bike without training wheels, and an 800-mile car trip was noticeably devoid of pit stops for carsickness. With the foundation set, she and her parents decided to give the local public school another try in the upcoming fall.
Starting second grade has been a new beginning for Tamara. She claims that, "second grade is a lot calmer," but clearly it is she that is calmer. Well integrated into the rhythm and routines of her day, school is a much less stressful place for Tammy. Hair chewing and paper tearing are no longer recreational pass times. Instead she is listening, reading, writing and computing. Writing is still her biggest challenge, and so she continues with specific HANDLE activities to strengthen this skill.
In the words of her mother, "Coming to HANDLE was the bright spot on an otherwise dreadful first grade year. She is doing fabulously in second grade. She's poised for growth socially, emotionally and academically; working hard to catch up - and doing it! I've been watching closely as she puts the pieces together, and peace of mind has replaced worry for me as a parent. So, as I watch Tammy ride her two-wheeler down the street yelling, 'Look Mom, no hands,' I think of (HANDLE) with a small curse and huge Thank You."
