This understanding of sensory integration led to interventions to help these children. Sensory Integration Therapy focuses on correcting, improving, and/or compensating for sensory integration disorders, much as special education therapy focuses on Learning Disabilities, and speech-language therapy focuses on Language Disabilities.
We now have a greater level of understanding of these learning, language, and sensory-motor disabilities. Yet, all too often, the underlying problems are missed until the level of frustration experienced by the child or adolescent, the parents and family, and the school and teachers results in emotional, social, and family problems. Sadly, even more frequently, educational, health, and mental health professionals focus on the emotional, social, and family problems as if they were the primary issue, missing the fact that they are really secondary to underlying neurological problems.
Let me illustrate. Recently, I evaluated a four-year-old boy because his parents thought he needed to be on medication or in psychotherapy. They also asked for parent counseling to help them handle their son better. He was a “monster” at home and at nursery school. Clearly, they were overwhelmed.
His parents found themselves angry at his immature and explosive behavior. He would not dress himself, insisting that Mother dress him. He ate with his fingers. He did not play well with other children, acting bossy and insisting that they do what he wanted. No child would play with him. His favorite activity was to sit in the swing in his backyard and swing “forever.”
His pediatrician told his parents to set firmer limits and to expect better behavior. His teacher was angry because he was so disruptive. He never listened to instructions and never did what he was supposed to do. The parents felt guilty that the pediatrician and teacher blamed the boy’s behavior on their parenting. Yet, they did not know what else to do. Father often suggested that maybe, if Mother were more strict, their son’s problems would clear up.
I was struck with how nice this child appeared when seen alone. Then, I observed him in his preschool program. In school, I could see what the teacher and parents described. He rolled around on the floor, often rolling up to another child, touching or hugging. That child would pull away, and the teacher would yell at the child I was observing.
When they had circle time, he walked around the room, refusing to sit in the circle. When playing, if another child brushed against him, he pushed the child away. I noticed how poorly he walked and ran, how clumsy he was with the blocks, and how immature his drawings were. By the end of this full-day program, he seemed tired and irritable, crying at any disappointment.
Knowing of Sensory Integration Dysfunction, I arranged for an evaluation by an occupational therapist. The underlying disabilities with motor coordination, tactile sensitivity, and vestibular insecurity were documented. Occupational therapy, not medication or psychotherapy, was started.
This child did not need to “change his behaviors.” We needed to understand his behaviors and what they suggested as the probable underlying reason for the behaviors. We needed to remember that behaviors are a message, a symptom—not a diagnosis.
If professionals do not see below the surface problems and understand the underlying causes for the problems, interventions do not work. Unless the underlying problems are addressed, the emotional, social, and family problems will not improve. Our task is to not react to the behaviors with the same frustrations and feelings of failure that the child experiences. Our job is to understand the behaviors. Only with understanding can we know how to help.
As a professional who sees many children and adolescents with learning, language, and sensory integration problems, I see clearly that critical to any progress is helping parents understand the underlying neurological problems. Without their knowledge of the brain difficulties and the resulting school and life-skill problems, they cannot understand or help their son or daughter as much as they want to.
There are good books for parents on Learning Disabilities and Language Disabilities. My frustration has been that there has not been a good book for parents on Sensory Integration Dysfunction, now known as Sensory Processing Disorder.
There is now. Carol Kranowitz has done an excellent job of taking complex material and presenting it in a way that can be understood—and used. Parents who read this book will understand motor-planning problems, as well as tactile sensitivity and vestibular-proprioceptive difficulties. The format of the book goes beyond this understanding, offering creative ideas on helping the child or adolescent handle the challenges within the family, with peers, and in school. She helps parents understand what help is needed, and how to get this help.
Knowledge is empowering, and The Out-of-Sync Child empowers parents to be the successful and productive parents they want to be. Thank you, Carol, for writing this book. Many families and their children will benefit.
—Larry B. Silver, MD
Clinical Professor of Psychiatry
Georgetown University Medical Center
February, 1998
ACKNOWLEDGMENTS
Primarily, I am profoundly grateful to the late A. Jean Ayres, PhD, OTR, whom I never met but shall revere forever. Her work has touched and moved me to do all I can for children with sensory problems.
I also thank all those who made the first edition of this book possible:
Occupational therapists Lynn A. Balzer-Martin, Georgia deGangi, Sheri Present, Susanne Smith Roley, and Trude Turnquist.
Early childhood specialists and advocates T. Berry Brazelton, Barbara Browne, Donna Carter, Michael Castleberry, Elizabeth Dyson, Stanley Greenspan, Jane Healy, Anne Kendall, Jack Kleinmann, Patricia Lemer, Larry Silver, and Karen Strimple.
“SI parents” Chris Bridgeman, Catherine and Ron Butler, Deborah Thommasen, Linda Finkel and Vivek Talvadkar, Jacquie and Paul London, Mary Eager, and Denise McMillen.
Teachers and students at St. Columba’s Nursery School in Washington, DC; Lynn Sonberg and Meg Schneider of Skylight Press; Sheila Curry Oakes, my first Perigee editor; T.J. Wylie, illustrator; and my family.
For this second edition, my everlasting love and thanks go to Lucy Jane Miller, PhD, OTR, FAOTA, who has gently guided my thinking and raised my level of understanding about sensory processing. Additionally, I thank these marvelous professionals for their wisdom and support:
Occupational therapists Marie Anzalone, Paula Aquilla, Erna Blanche, June Bunch, Anita Bundy, Sharon Cermak, Ellen Cohn, Valerie Dejean, Marie DiMatties, Winnie Dunn, Anne Fisher, Sheila Frick, Kimberly Geary, Tara Glennon, Barbara Hanft, Anne Henderson, Diana Henry, Lois Hickman, Jan Hollenbeck, Catherine Hostetler, Genevieve Jereb, Lorna Jean King, Nancy Kashman, Moya Kinnealey, Jane Koomar, Lawrene Kovalenko, Aubrey Lande, Shelly Lane, Barbara Lindner, Zoe Mailloux, Teresa May-Benson, Heather Miller-Kuhaneck, Myania Moses, Elizabeth Murray, Patricia Oetter, Beth Osten, Diane Parham, Charlane Pehoski, Norma Quirk, Sharon Ray, Judith Reisman, Eileen Richter, Roseann Schaaf, Colleen Schneck, Sherry Shellenberger, Jill Spokojny Guz, Shirley Sutton, Stacey Szklut, Sandy Wainman, Rondalyn Whitney, Julia Wilbarger, Patricia Wilbarger, Sue Wilkinson, Mary Sue Williams, Janet Wright, and Ellen Yack.
Developmental optometrists Sanford Cohen, Kenneth Lane and Charles Shidlofsky; nutritionist Kelly Dorfman; physicians Fernette and Brock Eide; psychologist Sharon Heller; speech-language pathologists Laura Glaser, Joanne Hanson, Janet Mora and Kathleen Morris; other influential individuals including Julie Starbuck, Temple Grandin, Stephen Shore, David Brown, Mark Zweig, and my current editor at Perigee, Marian Lizzi.
I am eternally in your debt.
—Carol Kranowitz
Bethesda, Maryland
Summer, 2005
INTRODUCTION
For twenty-five years, I taught at St. Columba’s Nursery School in Washington, DC. Most preschoolers loved my classes involving music, movement, and dramatic play. Every day, small groups of three-, four-, and five-year-olds would come to my room to play, move, and learn. They happily pounded on drums and xylophones, sang and clappe
d, danced and twirled. They shook beanbags, manipulated puppets, and enacted fairy tales. They waved the parachute, played musical follow-the-leader games, and flowed through obstacle courses. They swooped like kites, stomped like elephants, and melted like snowmen.
Most children enjoy such activities because they have effective sensory processing—the ability to organize sensory information for use in daily life. They take in sensations of touch, movement, sight, and sound coming from their bodies and the world around them, and they respond in a well-regulated way.
Some children, however, such as Andrew, Ben, and Alice, did not enjoy coming to my classroom. Faced with the challenge of sensory-motor experiences, they became tense, unhappy, and confused. They refused to participate in the activities, or did so ineffectively, and their behavior disrupted their classmates’ fun. They are the children for whom this book is written.
In my teaching career (1976–2001), I worked with more than one thousand young children. Outside of school, I taught music classes for kindergartners in my home. I choreographed children’s dances for community performances. I conducted dozens of musical birthday parties. I was room mother, Cub Scout den leader, and team manager for my own sons’ school and sports groups.
Many years of working with children taught me that all children like lively, interesting activities. They all want to join the fun—yet some don’t take part. Why not? Is it that they won’t—or that they can’t?
When I began teaching, the nonparticipants puzzled me. Why, I wondered, were these children so difficult to reach? Why did they fall apart when it was time to join the fun?
Why did Andrew buzz around the room’s perimeter while his classmates, sitting on the rug, sang “The Wheels on the Bus”?
Why did Ben tap, tap, tap his shoulders when the musical instructions were to tap, tap, tap his knees?
Why did Alice flop onto her stomach, “too tired” to sit up and strike together two rhythm sticks?
At first, these children annoyed me. They made me feel like a bad teacher. They also made me feel like a bad person when their inattention or disruptive behavior caused me to react negatively. Indeed, on one regrettable occasion, I told a child that turning away and covering his ears when I played the guitar was “just plain rude.” That day I went home and wept.
Every evening, while preparing dinner or engaging with my own sons, I would muse about these students. I couldn’t get a handle on them. They had no identified special needs. They weren’t unloved or disadvantaged. Some seemed to misbehave on purpose, like sticking a foot out to trip a classmate, while others seemed to move without any purpose at all, in an aimless or listless manner. Little about their behavior could be classified, except for a shared inability to enjoy the activities that children traditionally relish.
I wasn’t the only one who was stumped. Karen Strimple, director of St. Columba’s Nursery School, and the other teachers were equally puzzled by the same children. The children’s parents were often concerned, especially when they compared their child’s behavior with that of their other, more “together” offspring. And, if caring parents and teachers were frustrated, how must the children themselves feel?
They felt like failures.
And we teachers felt that we were failing them.
We knew we could do better. After all, since the 1970s, St. Columba’s had been mainstreaming into its regular school program a number of children with identified special needs. We were extremely successful with these children. Why were we less successful teaching certain “regular” kids with subtle, unidentified problems? We wanted an answer.
The answer came from Lynn A. Balzer-Martin, PhD, OTR, a St. Columba’s parent and a pediatric occupational therapist. Since the 1970s, Lynn had been an educational consultant for our mainstreaming program—called Inclusion today. Her primary work, however, was diagnosing and treating young children who had academic and behavior problems stemming from a neurological inefficiency—then called Sensory Integration Dysfunction.
An occupational therapist, A. Jean Ayres, PhD, was the pioneer who first described the problem. About fifty years ago, Dr. Ayres formulated a theory of Sensory Integration Dysfunction and led other occupational therapists in developing intervention strategies. Her book, Sensory Integration and the Child, presents a thorough explanation of this misunderstood problem and is required reading for anyone interested in grasping its technicalities.
Sensory Integration Dysfunction, now known as Sensory Processing Disorder (SPD), is not a new problem. It is a new definition of an old problem.
SPD can cause a bewildering variety of symptoms. When their central nervous systems are ineffective in processing sensory information, children have a hard time functioning in daily life. They may look fine and have superior intelligence, but may be awkward and clumsy, fearful and withdrawn, or hostile and aggressive. SPD can affect not only how they move and learn, but also how they behave, how they play and make friends, and especially how they feel about themselves.
Many parents, educators, doctors, and mental health professionals have difficulty recognizing SPD. When they don’t recognize the problem, they may mistake a child’s behavior, low self-esteem, or reluctance to participate in ordinary childhood experiences for hyperactivity, learning disabilities, or emotional problems. Unless they are educated about SPD, few people understand that bewildering behavior may stem from a poorly functioning nervous system.
Dr. Lynn Balzer-Martin, like other students of Dr. Ayres’s work, was trained to recognize and treat sensory problems. Her growing concern was that many of her clients were not sent to her for a diagnosis until well after they had run into trouble at school or at home, at the ages of six, seven, or eight. She was anxious to identify children at younger ages because the brain is most receptive to change while it is developing.
Preschoolers, whose nervous systems are still developing rapidly, stand a good chance to benefit from therapeutic intervention. Lynn knew that if SPD could be detected in three-, four-, or five-year-olds, these children could receive individualized treatment that would prevent later social and academic impasses.
The challenge was to find a way to identify preschoolers with SPD, because the available standardized tests are inappropriate for the “little guys.” Lynn conceived of a quick, effective screening to see whether very young children had the neurological foundations necessary for developing into well-organized people. She asked us if we were interested.
Were we interested?!
Thus, everything came together at once. We wanted to learn more about our worrisome students. Lynn wanted to try out her screening idea. The Katharine P. Maddux Foundation, which already funded our flagship mainstreaming program, was urging us to develop more projects designed to improve the physical, mental, and emotional health of children and their families.
Lynn’s first goal was to educate us about sensory processing and then, with our help, to devise a screening program that would be developmentally suitable for preschoolers.
The screening process would be fun for the children. It would be simple enough for many schools to duplicate. It would be short, yet thorough enough to enable educators to distinguish between basic immaturity and possible SPD in young children.
Most important, it would provide data that would encourage parents to seek early intervention for their children with an appropriate professional (such as an occupational therapist, physical therapist, or sometimes a psychologist or speech/language pathologist). The purpose of early intervention is to help children function better—even beautifully—in their classrooms, in their homes, and in their daily lives.
In 1987, with the support of the school community and with my eager assistance, Lynn instituted a program at St. Columba’s in which all 130 students undergo an annual screening. We began to guide identified children into early intervention therapy. And we began to see immediate, positive, exhilarating results as these children’s skills began to improve.
Under Lynn’s guidance, I st
udied and learned everything I could about the subject. I learned to screen the children and to compile data gleaned from teachers, parents, and direct observations. I learned to make sense of some children’s mystifying behavior.
As my knowledge increased, so did my teaching skills. I learned to help my co-teachers understand why these children marched to a different drummer. I gave workshops at other preschools and elementary schools to train educators to recognize signs of this subtle problem. I added activities in my class that promote healthy sensory-motor development for all children.
I rejoiced in the strides that children such as Andrew, Ben, and Alice made soon after they began occupational therapy. Incredibly, as they acquired more efficient sensory-motor skills, they relaxed, became more focused, and began to enjoy school. Now, when I went home at the end of the day, it wasn’t to weep—it was to celebrate!
While my expertise grew, I learned that explaining SPD to parents requires time and skill. When children who were screened showed clear evidence of dysfunction, Karen and I asked their parents to come in to observe them in the classroom and on the playground. Then we would sit down for a private conference to discuss our observations.
In these conferences, we described Sensory Processing Disorder and why we suspected it as a cause of their child’s difficulties. We explained that the problem is treatable. We said that while older children and even adults can improve with treatment, early intervention produces the most dramatic results. We tried to allay parents’ fears, assuring them that SPD did not suggest that their child was mentally deficient, or that they were inadequate parents.
We understood that this information inevitably filled parents with anxiety, questions, and misapprehensions. Often, they dashed to their pediatrician, who, unfamiliar with SPD, mistakenly dismissed it as a problem that the child would outgrow.
The Out-of-Sync Child Page 2