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RMT and Autism - Brian's Story

1/20/2012

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Brian is a 4 year, 2 month old boy who had received a diagnosis of moderate to severe Autism when he was 2 years, 6 months of age. He showed significant problems with self-regulation, was showing no joint attention, significant delays in his verbal and non-verbal skills, aggressiveness with peers, as well as delays in his play skills and attention skills.  He was also observed to show a significantly high activity level as he was observed to constantly seek out movement input and was rarely observed to “sit still.”

When I first met Brian, he was 3 years old and was invited to participate in our school readiness group for children with Autism.  There were 6 children in the group, and Brian was by far the most challenging to deal with. Brian would come into the group with a huge smile on his face, clearly excited about being there to have fun, but this smile would quickly fade and turn to tears or screams. He very much had his “own agenda” of things he wanted to do and things he wanted to play with, and if anyone interrupted him or did not fit in with his agenda, this resulted in extreme behavioural fits or meltdowns. Brian was able to say only a handful of intelligible words and the rest was garbled gibberish, to which, no one, including his primary caregivers understood. If Brian wasn’t understood the first time he made an attempt at communicating, he would instantly become very frustrated, often screaming and crying uncontrollably. Brian did not seem to use gestures such as pointing or bringing someone over to something he wanted.  His grandparents, who were his primary caregivers noted that his meltdowns would often last for hours, and the only way they found to “console him” was to put him in his high chair to cry his head off until he was too tired to cry anymore. Brian would not share with others and often hoarded toys, to the point that he would be seen carrying at least two toys around the group room at all times. Brian was observed to be quite aggressive with other children to get toys and to push them out of his way where he was playing and he would often come running from across the room to hit or push another child. Transitions were also very challenging for Brian. To put it lightly, everyone in the group was very aware of what Brian was doing or where he was at any given time due to the potential threat he could pose to safety of others as well as the general activity level of the room.

Brian was known as “the screamer” as, even when no specific demands were placed on him, he would scream in discontent for no apparent reason. At the time, he was the single most concerning child I had seen thus far, and I desperately wanted to help him with his self-regulation. After the end of the school readiness group, his name came up on my list of children to see for an occupational therapy assessment. I experienced some mixed emotions about this as I knew he would be challenging to work with, but I desperately wanted to help him with his self-regulation and sensory processing. The first time I met with Brian and his grandmother in mid November of 2010 (who was one of his primary caregivers), was very chaotic. I had setup one of the large rooms with a platform swing, trampoline and other fun activities with the goal of having fun and building some rapport with Brian. I had not expected to place really any demands on him, and was taken aback as he became highly emotional during our visit, including crying, and screaming and jumping up and down. It highlighted to me just how significant his problems with self-regulation were at the time. I had tried to have him lie down on a mat so I could show his grandmother how to complete some of the passive rhythmic movement training movements with him. He refused to lie down, seeming unsure of what I was going to do to him. After explaining what I wanted to do, I went out to get another staff member so I could demonstrate to his grandmother and have her practice engaging in the passive rhythmic movements. Once I began engaging my co-worker in the passive rhythmic movements, Brian came over and lied down beside her and started kicking his feet, seemingly in an attempt to demand it was his turn! He stayed lying on his back for a period of a few minutes, in which I was able to show his grandma the passive rhythmic stimulation from the feet, passive stimulation from the rib cage and passive rolling of the bottom from side to side. He was so dis-regulated that when I engaged him in the passive rhythmic stimulation from the feet he kept crying and engaged in drawing on a magnadoodle board which was held up in front of him, shielding me from his view and he rocked back and forth. Before we had this magnadoodle board in place, it was if seeing me at his feet was too much stimulation for him. His grandma agreed to engage Brian in the movements for a few minutes total daily. I emphasized the importance of starting off slow with the movement input due to the potential to cause some increases in moodiness and I also expressed my concerns that he was an already very moody child with lots of regulation problems. I explained that I had hoped that this input from these passive movements could significantly help Brian with his self-regulation by stimulating his Reticular Activating System to help with sending calming input to his brain. I also explained that some increased moodiness that we would likely see as a result of implementing this movement input, was a sign that his emotional brain was building new connections and maturing.

When I called his grandmother a week later to ask about how things were going with the rhythmic movement training movements, she reported that things were going very well. When asked how long she was completing each of the 3 movements for, she replied that she was completing about 15 minutes for EACH movement just before bedtime! I advised her that this may be too long to start with and that she should think about engaging him in up to 5 minutes per day total to start. When I saw Brian later that same week, he had a wonderful visit with me. He was observed to engage in lots of pretend play, showed good eye contact and referencing and even shared toys appropriately with me! He still showed some difficulty with transitioning out of the room when it was time to leave, but it seemed less of an issue than previously. I had attempted to see Brian in December that year before the Christmas holidays to follow up with the rhythmic movement training movements, but Brian was noted to be sick on and off and I wasn’t able to coordinate with the family. *Please note that the RMT program always recommends that "Less is More" because there can be a lot of emotionality stimulated by these movements because of the connections being stimulated with the emotional part of the brain - the limbic system. 

I followed up in early January of 2011 in regards to how Brian was doing and how the Christmas holidays were going. His grandma reported that he was a different child, as she reported that he was not screaming nearly as much as he had been before, Christmas went really well for him and he was using many more words to communicate than he had ever had before! When I visited with him for the first time in the New Year, I was blown away by his ability to engage and interact with me for a period of about 40 minutes. He showed the ability to engage in a game with me with good turn taking, engaged in cooperative play, and I was able to understand his commenting on things he was playing with. He was observed to get upset at the transition time when he had to leave, but was noted to recover quickly. His grandfather reported that he can “last” (cooperate with others and play well) for about 40 minutes before having a meltdown and beginning to scream and cry like he used to. His grandfather also reported that Brian’s ability to communicate had drastically improved, that he was now persisting on finding a way to communicate his point with his grandparents instead of having a meltdown if they didn’t understand him the first time. Brian was noted to point at things, bring his grandparents to things or find other ways of getting his point across without become frustrated as before. He was also noted to be able to interact with other children successfully without engaging in hitting or pushing behaviours. Brian was noted to become very excited, in a good way this time, as he was reported to be more interested in the “norm” (for example, he wanted to help his grandparents in daily activities and was interested in playing like other kids did). His grandfather reported that Brian was now trying a much larger variety of foods (he was previously noted to be a very picky eater). One of the biggest changes in Brian was noted to be around his ability to self-regulate for certain periods of time (before he was never noted to be able to control his regulation level to be calm, happy and attentive). His grandfather happily reported that Brian was one of the best behaved children at a Christmas party they attended and that everyone was astounded at his behaviour; commenting that something had changed drastically with Brian and they wondered what it was. He noted that many people asked if they had drugged Brian or were curious as to what “miracle” they had worked with him!

As it turned out, Brian became an unusual and astounding case study of sorts due to the long amount of time that his grandmother had engaged him in the passive rhythmic movements and the drastic changes which were noted in him! I never would have suggested completing this amount of time on the movements this soon with an individual like this, but it was truly amazing to see the effects that this amount of stimulation had evoked within a very short period of time. It seems as though this input really helped to “reorganize” Brian’s brain and really significantly helped him with his self-regulation, but also helped with putting into place the building blocks to enable him to develop his language abilities. Not only this, the strong stimulation to his neural chassis seemed to significantly help him to be able to attend to things and decrease his impulsivity. His limbic system was significantly impacted by the passive rhythmic movement stimulation and his emotions seemed to mature somewhat over this period of a month and a half.

I showed Brian’s grandmother how to complete some more rhythmic movements with Brian such as encouraging him to actively roll his bottom from side to side as well as windscreen wipers to help further stimulate his cerebellum to make new connections thereby helping with his speech development, coordination skills, etc. I also showed her how to engage him in rocking on hands and knees to help him with his motor skill development and possibly retained STNR, as well as facial tapping to help him with his facial reflex integration. I also showed her home to complete the sensory hand program with Brian, to hopefully help him further with facial reflex integration as well as improve his fine motor skills. I also showed her how to complete the rotation of the head from side to side to further stimulate and mature Brian’s neural chassis.

In February of 2011, Brian was noted to show a lot of emotionality and assertiveness in visits with myself and his speech and language pathologist, which we took as a good sign of his developing sense of self. He was also noted to continue to struggle with self-regulation at times as well, but this was fleeting instead of being a continuous and ongoing problem involving long meltdowns! Brian was noted to show a good awareness of real versus pretend in March and was also reported to have become a much better sleeper, as he was noted to sleep through the night and also sleep in his own bed. Brian entered daycare around this time and he was observed to generally interact well with the other children and was noted to have adapted fairly well to routines and structure of the daycare environment.  I was particularly impressed one day when observing him really want to play at the playdoh table but it was “full” so he had to wait until there was a place for him to join the table. He stood there for about 20 seconds, watching the children play with the playdoh, then proceeded on to another play area on his own without a fuss! This is something he would have totally blown up about in the past! A few minutes later, from across the room he noticed that there was a spot available at the playdoh table, and he proceeded to throw his toys he was playing with and made a run for the empty spot!

I haven’t had that much involvement with Brian in recent months, as he was noted to be away at his cottage for most of the Summer and had recently started an intensive behavioral intervention (IBI) program for children with Autism this Fall. He was noted by his grandparents to be doing very well in many areas. They noted that he is now completely toilet trained and is starting to eat more of a variety of foods. She also noted that Brian is talking in full sentences and is now enjoying activities such as sitting down to colour and playing games.  He was noted to be engaging in pretend play and more cooperative play with other children and was noted to be currently learning to print and starting to read.  Brian was noted to be on a gluten/casein free diet some of the time by his grandparents and they noted that gluten and various food dies, etc. seem to have an effect on Brian’s behaviour. Concerns were noted by the IBI program staff related to Brian’s behaviour at the program such as hitting and biting as well as general non-compliance and dysregulation.

When I recently visited Brian at the IBI program to re-assess his skills, I was deeply impressed by the boy I saw and engaged with. He was much more articulate with words than when I had seen him last and was able to talk with me in a back and forth communication, asking appropriate questions and interjecting with comments. He was able to wait his turn and transitioned fairly easily between most activities. He showed a drastic improvement in his visual motor integration skills and scored in the above average range for visual motor skill development! Before this, Brian was engaging in exploratory colouring and very basic imitation of lines. He showed a good awareness of counting and colour concepts and fairly good fine motor ability to engage in activities using mini tongs to pick up items and use in hand manipulation to move a button from his palm to his fingertips. Despite the fact that Brian is still showing some problems with regulation and behaviours, I am deeply impressed by his progress and attribute much of this progress to the stimulation he received from the rhythmic movement training program. I do believe that there are likely many factors that have helped Brian, and a big one also seems to relate to his sensitivity to gluten, casein and red dye and his grandparents have cut out these things in the past 6 months. 

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RMT and Autism - Danny's Story

1/19/2012

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The following is a story about one of my clients. The client's name has been changed to protect his confidentiality. His mother consented to sharing his story on my website to share the results of RMT with others. 

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. 

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    Heidi McLarty is a Pediatric Occupational Therapist with a passion for remedial treatment activities which provide the most bang for your buck! In other words, they are very effective, simple to implement and teach others, AND best of all, they don't cost a small fortune! Not quite free, but pretty near because of the applicability of this work with a whole bunch of different individuals, with different conditions! The main link here is that we are dealing with the brain and nervous system, which we now know is plastic. That's a very exciting and valuable bit of info that we NEED to take advantage of. 

    Heidi plans to continue to create lots of "ripples" in the therapy world! Reflex integration is one of the most valuable tools she hopes many more will add to their toolboxes in the near future!
    *Please note: Heidi has obtained client's verbal consent to post the case study stories she has posted here. Names have been changed to protect client confidentiality.

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