Within every child lies a natural yearning to learn. We have to look beyond what we can see to realize each child’s potential.
Andrew sat next to his favorite teacher in the whole wide world! He wished he did not feel so nervous each time she paid attention to him. He liked her, he just did not like to read or write and unfortunately these two tasks travel with her. She smiled warmly at him, opened the book on the page she would like for him to read, and asked him to start reading the first sentence. She praised him for a good effort and calmly pointed to one word in the sentence, he needed to pay attention to again. Andrew started to sweat. He could see where she was pointing, but the trouble was that when he looked at the word, he still saw what he saw and heard what he heard in his mind. He had no idea how to sound the word out differently. In an effort to cope with his sympathetic over-arousal and anxiety, he focused intently on the very first letter, and as a coping strategy, he took this first letter and guessed at the rest of the word. He breathed a sigh of relief when it worked! Now on to the next sentence…………..
Sarah was sitting in the desk next to Andrew. She could easily decode the letters to any word and frequently got praised for her efforts, but she was not able to recall any detail from the passage she just read. Sarah really tried hard and wished all stories could be read to her. When someone else reads, she could relatively easily comprehend the detail and follow the story to retell it later, but this same skill was elusive to her when she had to decode herself.
Paul did not enjoy reading for pleasure and would hardly pick up anything to read if it was not his schoolwork. He felt uncomfortable when he read, but he was marked proficient in reading. If only he could do as well in math! He thought he could do OK, if someone told him what the expectation was and he could remember what to do, but each time he had to read the word sum himself, he got lost in the detail of the words and could not figure out the steps to follow in order to achieve the right answer.
Mary loved her reading and her math, if only the teacher could let her get to the answers her own way. She almost always got to the right answer, but the teacher rarely agreed to the way she arrived at the answer. To follow the step sequence required was simply elusive to her, even when the teacher repeatedly told her that her way would be easier in the long run.
Gregory is OK at reading, but he absolutely, positively hated to write!!! Each time he saw a pencil or pen, the heat rose in his body and he could feel himself steaming! Sometimes, in an effort to not feel this response in his body, he simply does nothing and suppresses that feeling so deep down that no one noticed what he was going through. It made it easier just to “chill out” and simply act like he did not care. He had overheard adults say that he simply did not want to try, that he was “lazy” and “not motivated”, but he did not respond to hearing this about himself. He simply withdrew into himself even more and let others do the worrying. He wrote simply to “get it over with” and his writing did not reflect the wonderful ideas and stories he exchanged with his peers when he could just “talk” and not have to write!
The stories are multiple and within the range of these 5 students, there lie a myriad more varied profiles, as students with learning difficulties come in all shapes and sizes. The intelligence is intact, and available, though somehow the skill does not grow and produce the fruit everyone would like to see. School is not easy, but it is expected to travel this road, even when feeling anxious, dissatisfied with themselves, rarely feeling productive and slowly, but surely developing a self identity of a struggling learner that will likely never fit in the top of the class. The effect of struggling to learn is devastating on self-esteem. Some students find outlets in sports, art, or music. Others become so perfectionistic that all has to be just right in such a regard that hours are spent on homework, honor role is achieved every year, but the cost on the developing self is very high. The continuous anxiety about school performance spills over in other areas in life and the student socializes less, finds more solace in hours of video gaming, or after years of achieving being on the honor role, simply gives up. Coping and compensating just become too much, as the demands of each year increases.
Evaluation, assessment and term benchmarks all do a great job of highlighting what is going well and what is influencing the learning and this is greatly helpful. But the truth to each of these profiles lie deeper and start with the development of the central nervous system (CNS) during the first 5 to 7 years of life. At our center we developed a developmental pathways model for struggling learners and it is a phase trajectory for assessing students and upon which intervention is targeted by way of a variety of different programs.
The Developmental Pathways Model
This phase consists of the actual foundation of development from utero and towards the age of 2 years. During these beginning years, our development focuses on emotional regulation and sensory modulation. (the ability of all our senses to work together in harmony within an even homeostasis) In the beginning, we have primary movement patterns (reflexes) that have to be integrated as we develop the different motor systems to take over in the long run. How we register and process information through our different senses are also crucial aspects of development in these early stages.
Regulation / Modulation is very dependent on our autonomic nervous system (ANS). When the baby gets very excited, they become over-aroused as the sympathetic branch of the ANS gets over-activated and with over-activation comes disorganization. The parasympathetic system (inhibitory influence) balances out this over-activation. As the sympathetic nervous system revs up, the parasympathetic is activated to calm the ANS, and this meeting point is different for different profiles. There is a “just right” position that creates the balance, the homeostasis we need to pay effective attention and learn. Many books use the example of the sympathetic nervous system being our foot on the gas pedal in a car, while the parasympathetic system acts as the brake pedal. Some students really struggle with this foundational difficulty. As we grow, this balancing system is to grow and mature with us, so we could become increasingly more skilled in the ability to exercise self-control and apply emotional inhibition to stressful situations.
This foundational regulatory piece in the ANS is also the foundation for another executive skill and this would be the understanding of the passing of time and the ability to pace myself through my work. So many misunderstandings and power struggles occur over the student’s misconception of how long something is going to take them away from a preferred activity. For the adult 5 minutes are a short time and not such a big deal, but for a student who does not understand time, it is “forever”. And as the adult knows the child’s cognitive skill is not impaired and they certainly understand language, the “behavior” is assessed as being willful, manipulative and sometimes self centered. Not so!
We need a whole chapter to discuss reflexes, but for this writing let us restrict our focus on only the ATNR (Asymmetrical Tonic Neck Reflex). Basically, this is observed in a baby when he lying on his back in the crib and you turn his head to the right, there will be a tendency for the right arm and leg to extend (straighten), while the left arm and leg tend to flex (bend). This actually helps the baby to get into a rolling position. This reflex impacts greatly on our ability to cross midline and use the left and right sides of the body simultaneously even while doing separate tasks, maintaining similar timing and rhythm. Think about cutting with scissors. The right hand may be doing the cutting of the circle, while the left hand is supporting the turn of the paper at the same time. When you see a student at a desk lying on, or tilting his head towards his straight left arm that is spread out across his desk, while he flexes his right arm to effect a writing position, you may question if this reflex has not been integrated effectively in earlier years. If your assessment were correct this would cause the student to have to work harder than their peer to complete the same task resulting in earlier fatigue, and loss of focus and concentration. This particular reflex plays an important role in setting up the pathways for interhemispheric integration (the efficiency with which our brain is able to communicate across the right and left hemisphere), the ultimate skill for effective and sustained attention to a task.
During these earlier years of setting up the foundation, registration of information, through our different senses, is a crucial part of development. We have 12 cranial nerves in both hemispheres that have to gain information from the environment through eyes (visual), ears (auditory), body (proprioception), touch (tactile), smell (olfactory), and gravity (vestibular). Each of these systems has different receptors in the brain that has to be activated in order to develop according to the performance demand. In order to read, the student has to be able look at each letter, discern each shape through the focus of both eyes, and sound out the word within 5 to 20 milliseconds after seeing the word. In writing this process continues and includes the ability to understand spacing between letters and words, staying on lines while writing, to name a few. If the visual system is not registering information correctly, the student may be seeing double, and have to suppress one eye in order to point more exactly at the word, but this changes their central line towards the eye being used. Some struggling readers perceive that the words might be moving or “floating” as they read (influence of the vestibular system). Others may have a hard time copying from the board to the paper. In math they may not read the symbols for addition, subtraction, multiplication or division in the problem question and do the exact opposite of what is required, or they may be seeing reversals of letters and symbols. Others may learn to decode, but speed and automaticity remain an issue, as their brain cannot visually close a symbol that they only saw in part (visual closure), disenabling them to become automatic in their decoding skill.
We all have encountered the act of phonics in reading. The ability to sound out what they eyes are seeing, relies heavily on our auditory system. If our inner ear is “hearing”, but not processing all the bits of sound, then we will not be able to use our listening to sound out the words effectively. What we are “hearing” is different from what our typical peer is hearing. Our vestibular system has to keep us upright, our neck extended while we are reading and also assist our eyes to move across the page as we read and not lose our place as we move from line to line.
Our tactile and proprioceptive systems are very involved in the writing process. We have to register the exact position of the pencil / pen in our hand and “feel” how we are moving it across the page in a subconscious way, leaving our minds free to focus on the structure and content of our writing.
We are only discussing the tip of the iceberg as each system deserves a chapter of it’s own. If a student is struggling with any of these foundational difficulties and we are expecting them to perform at grade level, we are asking them to cope and compensate for what they do not have. In order to do this, they have to work harder than their peers, creating bypaths in the brain to accommodate for what they do not have. This leaves them with no other recourse than raising their anxiety, which in turn impacts on the sympathetic nervous system and can create over-arousal, leading to disorganization. Others may “shut down” on us, as they want to avoid this feeling of over-arousal that threatens to make them feel out of control. All of these foundational areas are interlinked and of course within these developmental areas we find multiple different profiles, each deserving an assessment that would determine their exact profile.
Now we would focus on how the toddler would be organizing him or herself with regards to the information that has been registered and processed. All of the abovementioned systems would have to work together in an organized way. This working together also has to occur in a timely manner, so all could proceed efficiently and smoothly. In occupational therapy terms we would be discussing motor planning (praxis) and timing skills. Through play and early problemsolving experiences the developing child gains ideas, initiates and sequences through them, while fine-tuning the development of skill. This occurs both in the cognitive and physical realm. If the little one wants to have a cookie and mommy is not around, he would have to figure out a way to get to that cookie that is currently out of his reach. He would have to plan a motor idea and perhaps pull a chair closer (cognitive idea). How to get his body up on that chair with the exact spatial distance, planned ahead, to gain access to that cookie, requires motor planning and visual spatial skills.
These early problem-solving experiences rely on intrinsic motivation to put a plan in place, then sequence and execute the plan in order to get the desired result. This includes the important building block of sequencing that has to occur both in the body as well as in cognitive skill to truly gain automatic and efficient executive skill. Not only does it impact on the students ability to plan their homework or activities, but prioritizing what they want to write and when they want to write, all the while adding detail without losing sight of the overall theme. We also need sequencing in order to effectively comprehend information or stories presented, as each layer of information builds the scaffold to the next layer.
Students frequently get assessed for being able to sequence cognitively and also being able to use sequence in language. But this simply is not enough. Some students can talk really well, and also “fool” the adult into thinking they have this skill conquered, but if you video this particular student in play and you mute the video on the second play back, you will see disparities such as the same motor movement repeated numerous times (poverty of motor planning), and when the students starts talking they stop doing altogether. Or when the student focuses very hard on the doing, they have to stop talking. Productivity is affected when the balance between cognitive and motor skill is not achieved. Students with this difficulty may also have difficulty with gestural information in a social sense, which in turn may result in not picking up social nuances or the hidden meaning behind what they are reading or listening to. More severe forms of this difficulty can be observed in students who rely mostly on cognitive skill, developing profiles that could include the following: difficulty processing emotions; seen as rigid and controlling; relying on their literal interpretation of situations; insufficiency in developing cognitive flexibility to entertain different thoughts and ideas; difficulty with social skills and later vocational performance.
Before we leave this phase, we have to pause a moment to consider timing. We can teach a child to do a jumping jack, but if they cannot do this jumping jack in timing with their peers in PE class, they will not feel successful and productive. Though timing skill starts at the body coordination level, it has a profound effect on later educational skills. The student has to look and listen to the teacher at the same time. In order for the brain to make sense of the information, both hemispheres have to coordinate the visual and auditory information, which only works optimally if the information reaches the pre-frontal cortex (executive center) at the same time. If the visual information (teacher demonstration) reaches the cortex ahead of the auditory information (teacher narrative), it would cause confusion in the brain, making it difficult for the student to keep sustained focus on the new information. Frequently the student would decide to forfeit one source of information for the other, resulting in partial sensory information, causing cognitive overload, as the brain now has to work much harder to make sense of the instruction. Of course the student is unable to maintain this level of functioning, becomes distracted, lost in his or her own world, or simply shuts down, while seemingly still looking at the teacher. The timing between the different systems is crucial.
In order to decode reading material, the eyes have to complete one saccadic (eyes shifting from one point to another) eye movement from left to right about 11 to 18 character letters before fixating to get ready for the next eye movement. At the point of eye fixation, the phonemic analysis (sounding out) has to occur within 5 to 20 milliseconds in order to productively read in an effective way with automaticity. Again, the timing between the visual and auditory systems is crucial for decoding reading material. Writing also adds the hand movement, thought structure, language, capitalization, planning and remaining focused on the target theme. Timing plays an extraordinary role in holding all of these functions together in such an amazing way that we could use all of these skills exactly at the same time! No wonder written expression will be the most difficult developmental task a student will ever have to do.
Auditory attention is another skill that depends on timing beyond what was already described above. While our right ear takes information mostly to our left-brain, which focuses greatly on reading, language, logic and organizational skill, our left ear roams the environment to pick up detail that may be important to attend to. The brain simultaneously gains information from both ears at the same, automatically discards what should not be paid attention to and the student does not become distracted from the learning taking place. If the timing of both ears is not simultaneous it causes a hyper focus in either the background or foreground, making it increasingly difficult to sustain attention and not be drawn into being “side-tracked”.
Lastly, working memory is the memory we use every day to multitask, taking in new and novel information, while also retrieving what we already know from long-term memory, to add to the new learning. It is a very important system in the brain for new learning and our working memory span is very reliant on the visual-spatial as well as verbal information reaching our brain at exactly the same time.
Students with difficulties in areas of phase 2 frequently find new and novel situations anxiety provoking. This could vary in different profiles, but the teacher comes in every day with new and novel information to build on information already learnt. Each day at school is a situation of anticipated anxiety leading to difficulties with sleeping and eating patterns, prolonged enuresis (wetting bed at night) and difficulties with separation anxiety when they have to be away from caregivers.
This would be the final phase of assessment and intervention. Once the foundation is more solid and the student is able to build structure for skill development in his or nervous system, we are now able to consider what we can actually observe in productivity. Phase 1 is about entering the data (registering and regulating information) into the computer (our brain). Phase 2 is about organizing the files in the computer for automatic retrieval, and efficiency in a timely manner. Phase 3 is the printed copy showing what the data came up with (executive functions). At this phase we focus on handwriting, writing essays, reading, math, as well as organization, planning, goal setting, pacing through learning activities, attention, sustained attention, working memory. Many families are anxious to start seeing results in this area very soon and most school programs do not consider the developing building blocks of phase 1 and 2 any more as these areas are not considered “educational”. This is quite unfortunate as the students are mismatched in their needs, as teachers keeps exposing them to material related to phase 3 and the building blocks of phase 1 and 2 are not in place. Students know they are struggling, but their insecurity and anxiety grows as they realize they are fighting a battle, but they feel hopeless in fighting the unknown. They do not have another body to compare to and no idea how they are supposed to feel, had they been developing typically. Many school systems also do not recognize the continued anxiety some students are facing because the students tend to not show their emotions due to self-protection, but of course this compounds the learning issue. Of course we have all witnessed the “out-of-control” profile as well. We simply cannot imagine what a struggling learner is going through when they have an agile mind, have sufficient IQ, yet they cannot gain access to the skills they need to show others what they know.
Social emotional development is affected by the student’s identification of himself or herself being a struggling learner. This is compounded by being pulled into certain groups, clearly identified as “strugglers” or in some cases, being pulled out of their classroom of peers in order to see a special teacher for additional support. The responses to this social-emotional roller coaster are varied, from withdrawal of the learning process, becoming the class clown to divert attention away from this issue, or becoming the classroom bully, or as noted above, needing to be “perfect” in order to feel good, putting an inordinate amount of pressure on themselves. These are only to name a few, but perhaps the reader can recognize these patterns in students they may know.
After many years of studying the students we work with, we thank each one of them and their families for being able to figure out that an assessment can never be a “one size fits all”. We had to find different tests for different reasons and as we do not have to diagnose as occupational therapists, we developed functional assessments based on different diagnosis. Each assessment follows this developmental pathways model and adds pieces that are unique to certain diagnosis. The “regular” developmental pathways assessment is functional for any developmental delay, and sensory processing disorder. We also developed different functional assessments for autism spectrum disorder, attention deficit disorder, attachment disorder, reading and writing disorders, as well as pre-school assessments. There are more to come, but these are the functional assessments we are focusing on thus far.
It is important to have neuropsychological testing to determine as best possible what a diagnostic category would be. The addition of our functional assessments in support of the neuro-psychological evaluation explains the “why” for each developing student brain. Each of our assessments includes a social-emotional section that explains different behaviors in a student profile to the best of our ability. Functional assessments enable us to plan intervention from the “bottom up”. This means that we start from the most base origin we can find and strengthen the foundation as strong as possible in order for the skills to be taught by the teacher to fall on fertile ground and not to disappear, falling through the cracks.
We also have a process called “demystification” that we apply after we met with the family on the results of the report. This is when the student will meet with us to go over the results of the testing. Teenagers are especially known for not seeming interested, but they do listen. For some it would be the first time that someone provided them a reason as to why they felt the way they do about learning and it usually provides sufficient motivation to go through the program as a partner in the process. It prohibits as much as possible, the sinking feeling of yet another program they have to invest in. If the previous program did not work, why should this program hold the key? The process of demystification is determined by profile and age range.
We follow the “bottom up” approach, starting at the level of regulation/modulation as well as sensory registration (Phase 1). Our occupational therapists frequently use sensory processing techniques with access to suspended equipment and a range of gym-type equipment. We also include reflex integration from a variety of sources of training (Masgutova method, Sally Goddard, Rhythmic training). If the student struggles with auditory-vestibular integration our activity program will be assisted by the Tomatis method, an intervention applied through headphones. The Tomatis headphones has both air and bone conduction, which enables the sound to come through the ears, though also through the bone conductor causing vibration from the head through the spinal cord, creating a strong impact on vestibular receptors. The music consists mainly of Mozart (stimulation through the sympathetic nervous system), Gregorian chants (calming through the parasympathetic nervous system) and Strauss waltzes to enact upon the timing of motor activity. The music is modified with multiple parameters layered to impact on “surprising” the brain causing the nervous system to fire more frequently, increasing activation and processing.
Depending on the individual profile, we may include speech language pathology as well and target goals would range from speech, communication, and language to reading. This phase may consist of up to 3 intensives of 10, 12, or 13 days each, consisting of 2 to 5 hours intervention per day with each intensive, again determined by the profile, as well as the distance of travel for the family. When families come from other states or other countries and they cannot be followed up as frequently, we tend to do 4 to 5 hour intensive programs to gain the most of their time here and follow up with home based intervention until the family could come back to our center again. In-between the intensives we usually plan weekly sessions with either occupational or speech language therapy or sometimes both. On some occasions we add weekly sessions of DIR/Floortime sessions to target emotional development and processing. As noted above, anxiety can become quite strong in some student profiles, causing them to be very frustrated or mildly depressed by their seeming inability to perform the way they would like to. On some occasions these intense emotions causes a developmental delay in emotional maturity and they need an outlet to work through these emotions.
DIR/Floortime consists of 6 emotional developmental milestones and the application of different Floortime techniques to mobilize the student forward. Dr. Stanley Greenspan originally developed it for the world of Autism Spectrum Disorder, though the developmental hierarchy is based upon typical socio-emotional development and in recent years have been applied to multiple different diagnostics and student profiles. Socio-emotional delays prohibit the student to effectively show the skills they may be gaining through the program. Paying attention to both skill acquisition and socio-emotional at the same time supports greater efficiency in showing outcomes in functional learning behavior.
The weekly sessions include sensory processing principles, though other programs may be added as well depending on the profile. Balametrics is a visual-vestibular protocol that, together with the auditory-vestibular stimulation of Tomatis training, strongly impacts on the building blocks for reading and writing. Quickshifts is another sound based headphone program that is applied for 20 minutes within an hour session to assist a “shift” of attention to a targeted behavior, such as bilateral integration, regulation, oral-motor etc. Astronaut training is another visual-auditory-vestibular protocol that also targets on reading and writing. Visual-spatial activities such as using the Infinity Walk (walking in figure 8 patterns around two objects, while keeping they eyes fixed on a specific target at eye level) is great for many aspects of development, and especially great building blocks for both math, reading and writing.
Some families invest in using a Forbrain at home for about 10 minutes each evening. This device consists of bone conduction feedback to the student’s ear while reading aloud through a microphone. Bone conduction is 10 times faster than air conduction and enhances the sounds emitted by the voice, easing the process of reading or speaking. This device can also be used in-between intensive programming.
Phase 2 would also consist of at least two intensives and weekly services and could include similar programs as phase 1, though the goals would be more advanced. The Interactive Metronome Program is a major focus during this phase as it really acts as a bridge between sensory registration to the pre-frontal cortex for executive functions. The program consists of wearing headphones through which an auditory stimulus would be heard. The student wears hand triggers and has access to foot triggers. The therapist plans a series of exercises based on an initial long form test to target timing and anticipation speed, while also working on timing regulation before or after the beat. The clap on the hand triggers and tap on the foot triggers, through various different motions is registered through a computer and the student’s responses are calculated within milliseconds. The Interactive Metronome Program has been thoroughly researched to have impact on reading, writing and math (www.interactivemetronome.com) And for those students who also struggle with sports and PE; the impact on the motor system greatly supports coordination and timing in the body.
Phase 1 and 2 are building block phases, though we could already start seeing the results expected in phase 3. For some profiles, we may accelerate the different phases and go a much shorter route to get to phase 3. This would depend upon the initial assessment and the strengths and challenges of each individual profile. Phase 3 could include all of the above-mentioned programs, though at a more advanced, executive level. For speech, reading, spelling and writing goals we might do more extensive microphone work to refine listening, pronunciation, discriminating different vowel combinations, memory, comprehension and more.
We frequently like to include computerized programs, such as ReadOn. This is a remarkable program that works specifically on the integration of the visual and auditory system to impact on decoding, spelling, working memory, visual and auditory attention and comprehension. Another computerized program we may suggest would be Cogmed, a well researched active working memory program, another great compliment to especially math, though reading as well.
Combinations of different specialties such as occupational therapy and speech language therapy could be targeting spelling, language, written expression, as well as handwriting during this phase.
Our program is comprehensive, though not overwhelming. Each of these programs have a reputation of it’s own; yet it is the hierarchy of typical development that drives the choices at any given time. The program is mobilized one step at a time with commitment from family, student and therapy team and the holistic approach considers the best possible outcome for different directions at a given time.
Students do not have to look at being life long strugglers in the learning process. Neuroplasticity research has given us the scientific base whereupon we expect change, if we do our due diligence to assess each student to his or her best capacity. We are grateful to families that stood by us over the past 17 years to develop this unique program. Without their trust and commitment, we would not have been here.
Maude Le Roux, OTR/L