by Maude Leroux | May 25, 2018 | Reading
Photo by sean Kong on Unsplash
In the last blog we discussed the impact of the visual system on the reading process, more specifically, decoding. There is always much talk about phonics when it comes to reading decoding and it is likely the most talked about feature discussed in current literature. Sally Shaywitz wrote in her seminal book: “Overcoming Dyslexia” that the pathway of phonics is really good for the novice reader who are learning to read, but in order to accomplish reading efficiency, we would need the high speed pathway from the occipital lobe (vision), through the temporal (auditory and timing) and to the pre-frontal cortex for meaning. It is a confluence of developmental skill that creates a proficient reader.
The first aspect to consider in the auditory contribution is if she (or he) is actually registering the sound in the inner ear. Sound occurs through a variety of frequencies and is also embedded in the under and overtones within the speaker’s voice. The listener would need to discriminate the actual sound to be repeated and create an imprint of this particular sound in the auditory cortex. When the listener encounters the same sound again, it could then be anticipated by memory. Coinciding with having difficulty with phonics, parents and clients will frequently also describe additional features of difficulty with sound. One example would be that family members could note that the struggling reader would be called 3 times by name before responding to their call. She would need to “shut down” the auditory system in order to focus on a task. On such occasions family members may schedule a hearing test, which many times result in hearing being “normal”. Hearing is frequently not the issue in phonics (unless there is a medical condition), but it is more likely the registration and processing of the auditory stimulus that can cause trouble. The pathway to the auditory cortex might be disturbed in it’s processing and the actual sound may not make it to the cortex for analysis.
For a client with difficulty in this area, it would be difficult to know if the sound she hears is the same sound that the speaker produced.
Audiologists who specialize in auditory processing disorder (APD) would have much more to say about this area of function. Fact remains: the child needs to register each specific sound with it’s own frequency and intensity on the basilar membrane of the inner ear (Organ of Corti) to create a tonotopic map, which is repeated in the cochlear nucleus of the subconscious brain, and then finally again in the cortex, where the identification between the sound and symbol can be analyzed for the first time. For a client with difficulty in this area, it would be difficult to know if the sound she hears is the same sound that the speaker produced. When she sounds out a different sound than expected, the teacher would repeat the sound, which would be confusing to her. She knows something is wrong by the words of the teacher (that can be understood in context), but isolating the sound she can only reproduce what she is “hearing”.
Another factor to consider is that the efficient reading pathway is mostly located on the left side of the brain, as is most of language. Since sensory information from the right side of the body travels mostly to the left side of the body and vice versa, it makes sense that the right ear would have to be the leading ear in this process. It would be quicker and far more efficient. In fact, our right ear is supposed to be the leading ear in listening and language, as our left ear is always scanning the environment in order to gain information from around us. In most clients tested for reading difficulties at our center, we would find that they use their left ear as the leading ear, causing a processing speed delay as the information has to first travel to the right brain and then back to the left brain. In most of these cases, we also find a coinciding auditory sensitivity, either in the past or present, as for some reasons (perhaps developmental delay?) the client had to maintain high vigilance to the environment in order to gain control over stimuli. Literature have yet to uncover more about auditory sensitivity, but it is a real issue for many family members as they observe hands over ears, especially when younger and later simply avoiding loud and boisterous social engagements. This is not to say that every client with a decoding issue has this difficulty, but it certainly coincides in a high percentage of cases.
When the teacher reads a story, the child can tune a listening ear to create context from the teacher’s language, using cognitive skill to compensate. But the same child can have great difficulty decoding “nonsense” words and even when decoding appears to be good, spelling may be a difficult, as the same sound to a different visual symbol does not make sense. Homonyms are especially difficult in spelling and it would behoove the family to seek more thorough evaluation particular to the auditory system.
Families can have this difficulty tested from the ages of 6-7 by an audiologist specializing in this area of APD. Bear in mind that accommodative strategies would be different from remediation therapy. Fast Forward has shown some success in remediating reading proficiency and would be a valuable therapy to consider. I found the most success in using Tomatis Sound Therapy (www.tomatis.com) as it also combines the vestibular process as well. Our auditory and vestibular systems share the same cranial nerve in the brain (CN8) and the added bone conduction in Tomatis support the faster processing speed. Using the Forbrain is also an additional tool that we use in conjunction with Tomatis Sound Therapy. (www.atotalapproach.com)
by Maude Leroux | Apr 13, 2018 | Reading
For the next 4-5 blogs we will focus on different aspects of acquiring reading skill. Reading is an acquired skill in the brain and not something that we are born with. It comprises of the ability to decode symbols of information as well as comprehending the words with meaning to make sense of what we are reading. Decoding is the “technical” part of reading and is comprised of the following aspects:
- The ability to see a string of letters from left to right in a sequential order requiring visual skill.
- The ability of the auditory system to be able to sound out what the eyes are seeing (phonics).
- The ability of the visual and auditory system to time together in split second second timing to gain automaticity, speed and reading fluency.
All three components are developed in the brain during early development, first requiring each system’s separate development and then ultimately the systems have to integrate together. Decoding can impact on reading efficiency in different ways:
- Some persons clearly struggle with decoding and it is an obvious difficulty that is witnessed by the observer.
- Other persons would appear to decode fine, especially when reading story books of their interest, but struggle greatly when it comes to factual text books, finding themselves reading the same text over and over.
- Others would be able to decode sufficiently, supporting the process with their intelligence, but would never be seen to pick up a book to read for pleasure.
Many families will note to us that their child can decode very well, but cannot comprehend what they are reading. If their listening comprehension is intact and they have sufficient command over language in other contexts, it does not make sense that it would only be in reading that they could not comprehend. We have to consider more closely what the different components of decoding skill are and assess each separate function in order to determine why reading has such an impact on a person’s learning ability, especially when intelligence is intact. For this writing let us briefly focus on the different visual skills involved in the reading decoding process.
In order for the eyes to see the letters it is supposed to decode, we require acuity and ocular motor skill. Acuity is tested through an optometrist, though ocular motor skills frequently are not. There are ciliar muscles around the eyes that have to be synchronized in order to create this efficiency. The eyes have to work together to see exactly at the same point on the page (binocular fusion). Both eyes have to be able to rapidly move from one point to another very quickly (saccades). And both eyes have to be able to fixate together at the end of a saccadic eye movement in order to give the auditory system time to sound out what was seen.
Decoding also requires a very precise synchrony between the visual and vestibular system in order to gain efficiency. The development of the Vestibulo-Occular Reflex (VOR) is an important piece of development in this instance. We have to be able to intricately coordinate the visual pathway of stable vision with peripheral vision in order to affect the momentum of the eyes. Some persons with reading difficulties will note that for them it feels like the words are moving and they need to “catch up” to the individual words. The eyes also need to develop visual perceptual skills such as:
- Form Constancy – no matter the font, it will be recognized for the letter it is. Visual discrimination will assist in seeing the differences in each letter to be able to read it.
- Visual Figure ground is an ability to pay attention to the foreground (letters in black) against the background (the white page). For some persons it feels like they are seeing white “rivers” instead of focusing on the black print. When a reader is fluent in decoding they also employ Visual Closure. This is seen in the ability of the brain to “close” the letters we are scanning through on a written page. Fluent readers do not look at each letter anymore.
- Visual memory is required to remember different letters, words, and patterns to form Word Attack skills.
Another skill would be Visual Sequential Memory that recognizes the different sequences in words in a certain order. Some persons are observed to reverse letters, sounds and words and have to “de-reverse” in order to make sense of a word. We will discuss this more under laterality later.
Each of these skills need to be assessed on it’s own in order to determine efficiency. These areas can be influenced by therapy and need to be considered when confronted by a struggling reader. There is no reason anyone, no matter the age, can learn to read as it is an acquired developmental skill, not a specific brain injury. Decoding training requires skill and expertise and is not going to be changed if we are simply taking someone in a separate room to read “at their own pace”. In the next blog we will discuss the involvement of the auditory system.
by Maude Leroux | Mar 20, 2018 | Autism Spectrum Disorder
This is the third and last blog (for now) I am writing with regards to behavioral vs. relational approaches in intervention. We have covered essential ground in these past months and we want to take these thoughts even deeper at this time. I spoke at the ICDL conference hosted by the amazing Rebecca School in New York this year. My talk was on this very topic of symbolic thinking. I showcased and reflected on a number of seminal cases over the past years. In preparing for this talk, I was once again struck by the children who taught me and was pondering the use of “high” vs. “low” functioning Autism. I will illustrate through a special girl that I have come to care for dearly.
I have been working with a lovely girl (we will call her Amy) for multiple years now, though we have been working in a very non-traditional way. The family lives too far from our center to visit, but our Floortime player lives closer to them. We designed a program where she would visit the home once monthly for 3 hours each time, video record at least 2 hours and edit the video. I would then review and narrate on the material before it was finalized and sent back to the family. I do this practice for many clients and therapists across the globe, but Amy took this work to a deeper dimension. We always add a disclaimer on the video to not watch the footage with the child present. Well, in this case, this notion was not followed and we only realized this 3 years into the process.
The videos were numbered and upon one visit, Amy mentioned a number to her mom and mom immediately located the number of the video. Amy fast tracked to a certain place in the video! Long story short, these videos became a lifeline for this growing young girl. When Amy became a pre-teen, she would start requesting mom when it was time to have our play partner (Janine) visit her. Amy would plan the visit to show Janine different pieces she wanted to have on video. At this time, I was providing Amy with a little “life” lesson at the end of each narration, where I was talking directly to her. I had never met her, but she knew my face, my voice and she referenced me as Ms. Maude.
She would then say on the video “show Ms. Maude” or simply “Ms. Maude”, as Amy experiences great challenges verbally expressing herself. After we did Tomatis sound therapy for one year, she started vocalizing and saying many more words, so we recommended voice lessons, which mom promptly started. Since then, she has performed in local concerts arranged by her voice coach, as she finds it much easier for her to express through song. When Janine visits, Amy would do a number of things to lead us along within her mind to a topic she wanted clarity on. She would sing a certain verse, go through the house and point at different pictures, open her wardrobe and point to certain clothing and, as the time goes, we are then able to piece her communication together.
Our first discovery of this was when she wanted to explain her feelings of embarrassment when her mother corrected her in front of her peers regarding the height of her pom-poms during a cheerleading performance. She wanted me to talk with her on the feeling of embarrassment! And so many other feelings followed: rejection, disappointment, envy, her need to have what others have, etc. Many nights, Amy would fall asleep by the sound of my voice. (Please let us not make this about me, it was all her.)
We did meet once in later years and she simply could not really connect, though we all knew she was acutely aware of me. Her connection with me was through video. She could rewind and review videos for hours in order to make sense of her emotions as she is not expected to respond and is in complete control as to how much she was able manage at a certain point. In her own way, she was connecting different files in her mind and has been able over the years to connect many emotional dots for herself.
Amy is much more social today in her own way, even though she continues to struggle with verbal expression. I hope to one day work with her mom to write up her case study. She helped shape my process of understanding how much autistics do have the capability of symbolic emotional thinking. She persevered and struggled through and found a medium that she could use with which to communicate. Her mother is an amazing woman, who “feels” her daughter’s needs – Mom’s response to Amy is directly linked to Amy’s ability to follow through.
I am hoping this case speaks to you as it did to me. Autistics are symbolic, we have to help them to find a way to express in safety and security. If we only see the surface, if we only consider their atypicality as “different” from ours, we are missing the soul underneath. We are causing these very big emotions to remain suppressed, unanswered, providing a message that what they feel is not important. How would it feel to never have your emotions validated? Is it not safer to simply remain in your own world, do things by rote memory as it does make life easier, but not to be enjoyed for who you are? Each autistic has an inner sense of themselves, they are no different from you and I. We have an obligation to them to dig much deeper.
I know this was long, but a final thought as we conclude: The pendulum always swings to and fro. Right now, behavioral therapies are enjoying a great time of acceptance as it is the only model that is covered by insurance. As time goes by, more and more parents will realize that behavioral therapies do not lead to complex social thinking and, as this is a basic essence of life, they will start to question legislature for providing only 1 option of care for their child. When that day comes, I really do not want to be the person sitting in that seat that has to answer to a group of angry parents. Many years will go lost before this really happens, but it is inevitable.
Coming back to discussing high vs. low functioning autism, we really have to think about what we are saying. Are we saying “low” functioning because from the outside they appear to look more impaired, or perhaps have a lower IQ, or a slower response rate to intervention? Any of these will provide professionals an excuse to not need to dig deeper and find the real person underneath. Is it true that these options can exist? Of course it can, but it should not be a reason for us to assume by judging a book by its cover. Everyone deserves the right to be “known”, just as all of us have the right to make known what we want others to know. As professionals, it is our job, our work, to find the missing link that will provide the key to the inner world of each client in our care.
by Maude Leroux | Jan 31, 2018 | Autism Spectrum Disorder
Part 2 of fundamental differences between behavioral and developmental approaches in Autism Spectrum Disorder.
I am currently on a 7-day course on blending attachment theory with sensory processing theory in a very practical way. I am looking at videos of children and reflecting on our kids at the center. It feels good to not be the presenter and simply taking the time to listen, reflect, and add to what I already know. To my staff’s dismay, though secretly they enjoy it, I am again thinking of changes I would like to make!
But the topic of attachment is fascinating. It starts in utero as the baby is also exposed to what the mother is exposed to. The baby starts the sense of smell quite early and listens to the mother’s voice by 5 months, though some books say 4 months. They cannot understand the language, but they can get the cadence and prosody of the mother’s voice, which conveys mostly emotional tone and this occurs with bone conduction through the spine as it ripples into the womb. Once the baby is born it is that emotional tone they seek when they burst into this sudden change from fluid to air and there the love affair visibly continues in earnest. I do not think anyone could have hardened heart when watching a mother nestle the baby’s head in that special place just under her shoulder. From this time through the entire lifespan, it is this mother that we bury deep in our subconscious no matter the environmental circumstances.
You can teach social manners, but not the complexity of social skill.
We have come a long way from believing that children on the spectrum do not share this same yearning. There is so much literature discussing the importance of the co-regulation occurring naturally between mother and baby and how this bonding keeps affecting other relationships in our lives. Some families noted the difference in their child from the first month of life; other say it happened after about 18 months, though most agree that co-regulation has always been difficult. As the child’s autonomic nervous system does not provide the adaptive response they need in order to cope, their behavior becomes difficult to read, causing the parent to feel disarmed and alarmed at their seeming own inability to follow their natural instincts. They “lose” their ideal baby to feeling dismissed, rejected and also incompetent, thinking it is about their parenting. They search for help and family members say all kinds of unhelpful things though they mean well. “Do not worry, they will grow out of it” or “I raised you this way, so you should be doing this” and other “helpful” hints. Still the mother struggles to establish a co-regulation with her baby. She visits the doctor and voices her concern about the child’s difficulty to be engaged in a co-affective behavior. Her instinct tells her something is wrong, but she is also afraid that she could possibly be to blame. The doctor states “to give it time”, “he is just a boy, they take longer to develop”. The mother feels again that maybe she is over-reacting and that she must stop feeling anxious.
If there is an emotion children on the spectrum share it is anxiety and it is this anxiety that rules their adaptive response. They also cry out for attention as other babies, but due to their difficulty adapting to the environment, the mother cannot find the right sensory pathway to assure her child of her love and care. As the mother’s anxiety rises, her child feels her anxiety quite intensely. Trewarthon gave us the term “intersubjectivity”, which considers an innate ability that seeks strength from the mother child bond. Think about when you are looking at your significant other and you know exactly what they are thinking and the look from your partner tells you they got it too. Research with one-month old babies and mothers engaged in “motherese” (that special baby talk) showed that exactly the same places in both the mother and baby brain lights up as they “talk” their own language.
Anyone working with children on the autism spectrum will know that they are keenly aware of any amount of tension in the room. They remind me of the deer I love to watch in Kruger Park. As they bend their necks to drink water, their ears are forever moving, checking the environment for danger. In their primal brain, they live in an eternal cycle of fight, flight and freeze. Children on the autism spectrum are just as vigilant of their environment as those deer. The difference is that they are supposed to grow into making sense of their environment. They should feel secure enough to mature into understanding that the environment holds no threat; that there is no danger. A loving secure base in the mother would have provided them this ability had sensory adaptive systems not gone awry. It has to feel painful to experience this disruption of such a primary “right” of development. Mothers continue to search for the answers and techniques that would allow their child to seek their loving arms.
Why am I going into this detail? If this mother-infant bond is good enough to set the stage for all typically developing children in order to grow and mature, it is no less necessary for the child on the autism spectrum. Relationship is the essence of growth and research has shown that this first bond also fosters brain growth. The child on the spectrum is as much in need of relationship as any other typical peer. Their vigilance with regards to discerning threat however, overshadow the relaxation they can find in their mother’s arms, and when sensory thresholds are over-activated, the first response is to use a short circuit to the limbic Amygdala (low road), which does not allow for logic to enter into the equation (high road). Of course there are different ranges of profiles on the spectrum, but the needs remain the same.
So this is my concern: What are we teaching children on the spectrum about relationship within the behavioral method? Is relationship about performance (the task) or is it about creating a love bond that would form the foundation of being social and developing empathy? Why are behavioral therapies so sadly lacking in developing social-emotional skills? This is a question, not an attack. This is a core deficit of Autism Spectrum Disorder and it does not appear to be enforced nor developed by behavioral techniques. The answer lies in re-establishing the mother-child bond and fostering a joy between them that can overcome the Amygdala short circuit, and build the intrinsic motivation that will create the willingness to want to be a part of our world. You can teach social manners, but not the complexity of social skill. Sadly they are not equal in attaining quality of life. To be social-emotionally skilled is to start with the bonding relationship and to use this secure base in developing the child into a fuller, more conscious person that does not have to live with fight, freeze and flight all of their lives.
by Maude Leroux | Dec 30, 2017 | Parenting
There is something about the end of the year that is slightly nostalgic as I reflect on different Christmas events in the past, especially contemplating times when I was home with family in sunny South Africa. Sometimes I experience loneliness in the midst of people and the hustle and bustle around me. I was sad on Christmas Eve, but the church service at 4 in the afternoon perked me up and quiet enjoyment followed. On Christmas day I watched a 5-year old boy (we will call him Paul) waiting expectantly for Santa to arrive. This honor was bestowed on my husband and his “ho-ho-ho” really had me smiling as he entered the room in full gear, his green eyes sparkling as always! I know the feeling I feel is a strong bond of love for a man that I have been with since I was 16, and I thrive on the mutual trust and expectation we have of each other. I know this is what every child should be able to aspire to.
I watched the emotions on Paul’s face and picked up a range of at least 4 emotions, if not more, within 2 minutes. He was excited, joyful, though also a little scared, perhaps anxious. He was feeling these emotions and dealing with all of them simultaneously. As his breathing rate became faster, he made an active decision to overcome this tinge of anxiety and go with the anticipation of the moment. He took the risk of approaching Santa and started talking with him. One minute later, he was sitting on Santa’s lap, shyly talking about having been “naughty or nice”! I observed the resilience, the willingness to overcome, and the inner drive that came from high interest to see what Santa had brought for him.
There are 3 very important developmental facts that were brought to light in this very short incident, which are repeated moment after moment every day of our lives. These are necessary elements that assist us in making sense of our world, and enable us to cope with the different challenges we face every day.
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- Different emotions cause different sensations in our body, but they all center around the autonomic nervous system with a balance between over and under arousal. In the early developing years, we give in to the needs of our body most of the time. Our emotional responses center around the Amygdala, which is involved in deciding whether to flee, fight or stay. As we develop and grow, our ability to gather meaning from a situation can be used to cognitively override our emotions, enabling us to continue engaging in the moment. We “know” that if we overcome, there would a reward on the other side. This “knowing” is the result of multiple different experiences that allow us quick access into our hippocampus (memory), which supports retrieval of emotional associations from past experiences. Every typical youngster feels the stress and challenge of growing up and understanding different emotions. Children who struggle with developmental delay experience added difficulty and are more prone to being avoidant of feeling different emotions, robbing them of wonderful experiences that could have assisted them in feeling more safe and secure. They tend to want to avoid feeling the sympathetic over-arousal that different emotions can bring and forfeit the ability to simply go with a feeling of joy, which will ultimately lead to more successful experiences. Paul felt each of these emotions and due to his ability to reflect on past experiences; he was able to pull through. Many potentially wonderful experiences have been marred with negative associations of the past. Their memories are fraught with feeling “out of control” and this essentially becomes their retrieval. This is even more true in children who witnessed and experienced trauma in their lives.
Children who struggle with developmental delay have an even harder time and are more prone to being avoidant of feeling different emotions, robbing them of these wonderful experiences that can form the scaffold of the next experience.
- The symbol of Santa is both strange, but good. He lives in the North Pole and spends all year making gifts with his elves. At 5, Paul knows deep down that Santa is not real, but he chooses to go with his fantasy as it suits his purpose for this time. The ability to make sense of fantasy vs. reality is a big milestone in children’s lives. For some, the reality they live in makes it better to stay in fantasy, never truly connecting in their relationships. Others cannot get into fantasy as they have difficulty imagining, operating with abstract thought, and visualizing in their minds what is not there in reality. They remain concrete, almost rigid, and experience great difficulty to understand past, present, and future, making it difficult to overcome developmental adversity.
- Lastly, our first mother is the symbol of our first love connection, which made everything “right” and provided us with an anchor to overcome. This first relationship can be symbolized in many different ways (heart sign, teddy bear, blanky, binky, bottle of milk, to name a few). These different items remind the developing mind of the nurture and care of the mother’s heart and within this experience of nurture and consistent parenting, Paul builds his own caring heart within. This scaffolds the later development of empathy and the willingness to please others. Of course many experiences, including developmental delay, can upset this process, but it does not make it less true. My symbol of an anchor has become the Cross and knowing that whenever I “mess up” and make wrong choices, I am safe in the knowing that He is standing in for me. For me, He gave the symbol of a mother so we could understand His love for us.
There is so much more to say, but I am getting quite lengthy again. My wish for each parent and therapist is to reflect on these little nuggets and to consider how one would teach these very fundamental growth areas of the brain? Considering the previous blog I wrote on behavioral vs., relational abilities, what curriculum can we possibly create to build these capacities? Positive experiences, “overcoming” experiences need to replace the older, “feeling out of control” experiences. Can we check this on a tally sheet of 3 out of 5? Or do we use the tool created for all of us to enlarge our world and understand our experiences: Play?! If being able to reflect upon your life, your experiences, this past year, have meaning for you, can you consider what life would be without this? Let us be playful this Season, let us experience joy to replace past hurts, let us stand together in this world of abundant emotions!
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