Alexis was 7 years and 10 months old when she was referred for help. She was in Grade 2 and had been diagnosed with ADHD, as well as auditory and visual-motor perceptual dysfunctioning by a psychologist, neurologist and occupational therapist. She had also received vision therapy.
In spite of some scatter amongst the scores of an IQ test, she still managed to fall within the superior range of intelligence. The school described her as a strong-willed child who struggled with a very short concentration span, and who was unable to sit still and listen or focus on her work due to distractibility. They considered her to be a very clever girl who was not reaching her potential.
On a modified Conner’s Rating Scale, her teacher gave her the highest rating of 3 (‘Very much’) for restlessness/overactive; excitable/impulsive; disturbing other children; failing to finish things/ daydreaming; constant fidgeting; temper outbursts/unpredictable behaviour; and a rating of 2 (‘Substantial’) for quick and drastic mood swings and frustration if demands are not instantly met. The neurologist had prescribed Ritalin and her teacher was very supportive of this.
During the evaluation, Alexis’ mother expressed the wish that Alexis could get along better with her friends and be less selfish and jealous. Alexis wanted to be able to concentrate better and complete tasks before going on to the next one, but showed a developing low self-esteem with her doubts that she would ever be able to do this or please everyone.
Background information
After a normal, easy pregnancy, Alexis’ birth had some complications. She was a big baby, weighing 4.21 kgs. After 3 hours of labour, she showed signs of distress so was delivered with the help of forceps. She had passed and inhaled some meconium in utero, which was suctioned from her lungs.
However, her APGAR scores were 8 and subsequent development was incident free, except that she did not have much movement stimulation as a baby. Her mother was content to leave her in her cot or carry her around in a baby chair for most of the early months. As long as there was something to look at, Alexis seemed to be happy to be mainly immobile.
She achieved normal motor milestones (crawling and walking) and early language development. After experiencing colic during the first three months, she was a healthy child with no ear infections or other significant illnesses.
From toddler days, she showed an ever-increasing liking for movement and constant activity. She enjoyed wild roundabout rides as well as running and jumping, and spent long times walking on her hands, which she mastered at 5 years. She also liked rocking on her school chair – backwards, forwards and sideways and did occasionally fall over. She went through phases of being clumsy, and got numerous bruises on her legs from bumping into chairs, walls, doors and even people. However, she was a slow starter in the mornings, showing little urgency to begin the day, and often spent a long time just gazing at herself in the bathroom mirror.
She was not an extremely restless sleeper but liked company in bed. She covered her head with her blankets when she slept. She was very sensitive to light and disliked sunlight, torchlight or waking up in the morning with her bedroom light burning.
She had a very sensitive scalp and thought that her fingertips were also very sensitive to touch – hating having her fingernails trimmed. She was extremely ticklish and disliked having anyone pretend to tickle her. Her favourite foods were salads and french fries or fish. She was not very fond of meat and particularly disliked the texture of chicken and some vegetables. She was very conscious of smells and seemed to be more sensitive to odours than most of her friends and family members.
Observations
Alexis did not move very much during the evaluation but soon expressed a liking for eyes-closed activities because she said that her eyes get tired very quickly. She showed some uneven saccadic movements when asked to follow a moving object with her eyes and also said that it made her dizzy. Her eyes could not converge easily at close distances either.
Low muscle tone was suspected when she displayed an untidy handwriting and also showed a preference for having her body supported by the chair or the desk. Her mother further supported the conclusion of low tone by commenting that Alexis was often rebuked for “slouching’.
She showed a dominant right hand and right eye and it seemed that her left brain hemisphere processed information more rapidly than the right. She used a technique known as ‘cognitive override’ to cope with demanding tasks. For example, she quickly used counting to help her master a finger tapping task.
When given an auditory task, Alexis had some difficulty accurately recalling syllables and she also forgot some details from a sentence read out to her.
Conclusions
Alexis’ sensitivity on her scalp and fingers and her ticklishness are indications that her sense of touch is irregular. This, coupled with a hypersensitivity to smell and light, can be very distracting to a child in a classroom. Her need to move, difficulty processing certain sounds, issues with visual tracking as well as her lowered muscle tone showed that her vestibular system was weak and unable to support the many functions for which it is responsible.
Her slow adjustment to the morning and her tendency to bump into things pointed to a weak sense of proprioception. Alexis’ vision was still compromised, in spite of vision therapy. Her light sensitivity and problems with tracking and convergence caused her to experience dizziness and headaches, and she preferred eyes-closed activities because they give her eyes a chance to rest. Because of poor proprioception, however, she found it necessary to depend on her eyes, which became increasingly strained.
Alexis needed a great amount of energy to sustain her weakened systems during the day and her short temper and frustrations were making it hard for her to maintain interpersonal relationships. One reason why she found it difficult to attend to language and directions from others is that their words interfered with her own thoughts through which she was directing her movement.
In spite of the problems Alexis was experiencing with so many irregular systems, she had been compensating well. She was thus using her superior intellect to her advantage, but she did not have the underlying support systems for focussing and sustaining her attention flexibly and for completing tasks. These were leading to distress in her relationships with schoolwork as well as with friends and adults and ultimately to her failure to realise her potential.
Recommendations
The program designed for Alexis concentrated on activities to strengthen weak underlying functions and to enhance the connections among the various functions. Her program included several activities to strengthen her vestibular system. These, as well as the special massage that was recommended to reduce Alexis’ hypersensitivity to touch, were also targeting her muscle tone issues, to help strengthen this crucial function.
Other simple, non-taxing activities were suggested to strengthen her visual functions and reduce her light sensitivity, without stressing her weak vestibular system or relying on muscle tone and differentiation of eye movements from head movements. One of these was drinking through the “loopy straw” with its many loops and small diameter. Alexis was also encouraged to supplement her diet with omega-3 fatty acids, to ensure myelination of those neural pathways which the exercises were creating and strengthening.
Follow-up
Alexis’ initial assessment took place in September. By late in November, her mother reported encouraging progress. Alexis was beginning to make friends with girls with similar intellectual interests as her own as was coping better socially, with less aggression. She also showed an improvement in her manners and behaviour at school and home.
According to reports from the school, she was sitting still and finishing her work, and this improvement was substantiated by the school awarding her certificates of excellence. They no longer thought Ritalin was necessary.
Alexis is continuing her ILT programme. It is gratifying that the improved ability to focus and sustain tasks has already helped to reverse her lowered self-esteem. She now feels proud of who she is and is rapidly forgetting that she was ever labelled as having ADHD and related learning problems.