Danny is now a 6 year old boy diagnosed with Pervasive Developmental Disorder – Not Otherwise Specified in Autism Spectrum disorder in December of 2009. He was noted by his family to be very “busy” and was observed to be quite disorganized during visits with therapists. It seemed as though one of Danny’s biggest obstacles related to his lack of ability to self regulate. Danny seemed to switch between two extremes of being very engaged in activities in his environment and seeming to retreat into his own little world in which he would develop a blank look on his face and would be content at “stimming” with various sensory modalities or using his own body to move in repetitive ways. Often times Danny presented as a child who rarely stopped buzzing in whatever activity he became engaged in. His parents noted that it was if he couldn’t “help himself” when he walked into a room and just HAD to touch things and explore. Although Danny was “busy”, he rarely paid attention to others and showed limited eye contact and social referencing. Sitting still quietly was an unattainable dream for them, especially because they were avid church goers and felt embarrassed to have others look at them and judge their apparent “lack of parenting skills” when observing Danny and some of his inconceivable behaviours and fixations. I originally met Danny in July of 2010 when he was 4 years, 9 months old.
One of Danny’s parent’s major concerns related to Danny’s highly emotional nature and frequent tantrums. He was noted to be very “stuck” on his routine and did not do well with transitions and changes to his routine. Danny’s parents noted that these daily tantrums seemed to be often related to transition times, but sometimes they were puzzled by Danny’s extreme blow ups for no apparent reason and they were often at their “wits end” when trying to deal with him. He was noted to often become aggressive with his mother by hitting or kicking her or would fall to the ground and start hitting his head. Falling asleep and staying asleep was a challenge for Danny and they had begun trying melatonin with him to try to help him sleep. Danny was also reported to experience problem related to his sensory processing of information and was especially noted to be sensitive to loud sounds and touch. He was not a fan of engaging in any type of messy play such as with playdoh, goop or wet sand and was noted to be a very picky eater. His parents also reported that Danny has an extremely high pain tolerance and does not respond normally to when he hurts himself (he was noted to not cry very often unless he was having an emotional meltdown instead of actually being physically hurt). In addition to this, I had reason to believe that his vestibular system was also not sensitive enough as Danny did not show a normal Post Rotary Nystagmus Response to rotary input (he did not show any movement of his eyes back and forth as a result of spinning input). It was no wonder that Danny seeked out all kinds of movement including spinning, because he was likely just trying to feel something!
Other areas of concern for Danny were related to his clumsiness and lack of fine motor skill development. He was noted to show an immature grasp of his pencil, constantly switched hands in activities, showed poor bilateral integration skills, difficulty with motor planning skills and difficulty with finger isolation and use of the skilled side of his hands in activities instead of using his whole hand. While he demonstrated fair use of language and expressive speech, his words were often “jumbled together” when he was talking or when he got overly excited about something. Danny also often engaged in echolalia when engaging with others, and it was quite challenging to have a back and forth conversation with him.
When I engaged Danny in testing for retained primitive reflexes, he scored as having a moderately retained Tonic Labyrinthine Reflex (TLR) forward and backwards, Spinal Galant, Symmetrical Tonic Neck Reflex (STNR), Babkin Palmomental and Sucking reflex. He also showed as having a mildly retained Asymmetrical Tonic Neck Reflex and grasp reflex.
Upon meeting and beginning to assess Danny, I started showing Danny’s parents how to complete 3 of the passive rhythmic movements with him due to Danny’s problems with self-regulation and extreme emotionality. I showed them the passive rocking from the feet, rolling of the bottom from side to side and passive stimulation of the ribcage. Danny was noted to enjoy these movements and during the first session, when I showed his parents these movements and they practiced them, Danny showed a noticeable change in his arousal level. When he had initially arrived in the room that day he was very busy and seemed unable to stay in one spot for very long. After the input, which lasted about 6 minutes total, Danny engaged easily in activities with me for the remainder of the visit, with a calm and attentive demeanor. His parents reported a week later that Danny really seemed to like the movements and that they seemed to be helping him to fall and stay asleep, something he had always struggled with!
The passive RMT movements helped significantly with my testing of Danny’s skills as I noted one morning he was quite attentive and cooperative during our testing session and his mom had reported that she had engaged him in some RMT before they came to see me. She noted that this was now part of their morning routine, and she found a huge difference in Danny’s composure and ability to comply if she stuck to this routine. I also noticed that there was a noticeable change in his behaviour without the input as during another visit in which I had planned to engage Danny in assessment, he was very hard to control. His mother reported that they had not complete the RMT movements with him the night before or that morning. After engaging Danny in a few minutes of RMT before continuing our testing session, he showed noticeable changes in his arousal level and was able to attend to what I wanted him to do. I learned a lot about the direct power these movements can have on a person’s arousal within a short period of time, and that without the input (and while still being “early” in the process of connecting up parts of the person’s brain) this can revert the person back to the prior ways of functioning and disorganization. Clearly the connections were still building with Danny, and it had only been about a month since he began engaging RMT movements for a few minutes a day. I had initially taken a somewhat cautionary approach with advising Danny’s parents in completing these rhythmic movements with Danny as I didn’t want Danny to become even more emotional, so as to scare him about these new movements. Danny’s highly emotional nature and sensory sensitivities, coupled with his problems with processing sensory information in general, made him seem like a “time bomb” waiting to go off, so I suggested to his parents that “less is more” and to build up the movement input with him gradually. I also emphasized that the movements should never be “forced” on him, but that he should be accepting of the input.
In August of 2010, I showed Danny’s parents how to complete the hand massage program from the facial reflex course because I was hoping this would help Danny with the integration of his grasp reflex and I was hoping that this would help Danny with his performance in fine motor activities and also with his pencil grasp. I also added in the rocking on hands and knees to help with his grasp reflex as well as his retained STNR. His parents were also shown how to complete the facial tapping on Danny in order to help him with speech production through integration of his sucking reflex. A couple of weeks after I showed Danny’s parents how to complete the facial tapping, I noticed during my session with Danny that his speech was a lot more intelligible, he showed a lot less echolalia and was able to carry on a basic back and forth conversation with me.
In September, Danny’s mother reported to me that Danny had gone to get a haircut recently with limited problems! She and his teacher noted he was doing ok with transitions at school, but still was noted to be quite “busy” and had difficulty sustaining his attention on tasks. I visited the school to show his educational assistant first how to complete the 3 passive rhythmic movements with Danny and then later on in the Fall, how to complete the rotation of the head from side to side and windscreen wipers. I explained to his assistant that the head rotation aimed to help make more connections in Danny’s vestibular system and visual system and also could help Danny with maintaining his attention and alertness (along with the other passive movements). I also explained that the windscreen wipers could help Danny improve his coordination and timing skills through the stimulation of his cerebellum. I also tried the longitudinal rocking from hands and feet with Danny and he showed considerable trouble with coordinating his body to engage in this movement and became very frustrated. We decided to leave this one out at the time, and to continue forward with the other movements on a daily basis at school if possible. His mother reported that his hands seemed like “new hands” as she noted that Danny was now able to do things he had never done before such as opening bottle tops by twisting, and engaging in other functional fine motor activities. I also noted that it seemed as though Danny had “more muscle tone” in his hands and they seemed to be stronger and more able.
Danny missed much of December due to sickness, and when I checked back in late January of 2011, his teacher reported that she no longer had concerns with Danny’s self-regulation or compliance to engage in activities in the class. He was also noted to show better coordination of his scissors to cut and was able to achieve a static tripod with minimal help. Danny had been on a break from active occupational therapy intervention during the Spring, and when I checked back in with his teacher in June, she expressed concerns with Danny’s impulsiveness and inability to sustain attention in the class. She expressed that he showed many inconsistencies in his learning and ability to demonstrate his knowledge and this seemed to vary based on his level of engagement. His educational assistant reported that she had not had much opportunity to engage Danny in regular RMT movements due to a lack of available space to use at the school. I anticipate that this might have been a direct causal link in the concerns noted about Danny’s behaviour.
When I recently checked in on Danny’s progress in regards to his transition to grade 1 this past October, I was pleasantly surprised by his behaviour and reports by his teacher and educational assistant. No concerns were noted with Danny’s self-regulation in the class, he was following the routines well, was noted to be able to sit at his desk to complete work with some assistance from his educational assistant to help him know what to do. He showed good ability to print most letters in upper and lower case legibly and with appropriate spacing, showed good motor planning skills, average visual motor integration skills and visual perceptual skills, good in-hand manipulation skills, cutting skills, etc. I was very impressed with Danny’s progress and transition to grade 1 and will plan to follow up with his parents to continue showing them more RMT movements to complete with him once I have the chance to re-assess him for retained primitive reflexes.