Thursday, October 22, 2009

Match, Repeat and Emote

This past summer I attended a wonderful workshop by James McDonald, PhD. His latest book is Communicating Partners and it demonstrates his technique of how to increase communication skills in non-verbal or lo-verbal children. The gist of his method is to engage the child in an activity by imitating the child's sounds and gestures and then adding meaningful words and phrases about the activity itself. The example of an activity that he uses is to rock a sleeping doll in it's cradle. The outcomes that Dr. MacDonald has experienced for the past 30 years is true speech and social interaction from the child.

The clinic I work at (Building Bridges Therapy Center, in Plymouth, MI) sponsored Dr. MacDonald and encouraged our parents to take part in family sessions with him while he was in residence. One of my non-verbal clients, Jack, was part of this, and we began to see increased interaction. More than that, we saw a way "in" to a highly challenged child.

As the weeks went by, goals came and went, and we therapists sometimes forgot to use the match and repeat method. But Jack is so challenging, that I continued to make this therapy my number one form of treatment for him.

Jack will answer to his name and display joint attention for a few seconds. He can speak multiple words at a time (not necessarily sentences), but is mostly lost in his own experience. His primary interest is in stimming with his favorite object. It is possible to get Jack's attention by putting him into a Belkin suit and demanding his presence. With a great deal of pressure and persistence he can be made to work in this mode. However, he does not like it, and he screams and whines to make sure that the therapist knows this.

Right after the workshop with Dr. MacDonald, I tried to hone my skills in the new practice with Jack. He responded fairly well, but he still screamed his ear-splitting screams, making it all a lot of work. The resistance I received was so strong as to make me question continuing this approach.

Then I tried something a little different. Jack came in and went to our big, green bench swing near the mirror. I gently pushed him back and forth. He spoke some words, I repeated. We made faces, we even had an amazing eight "sentence" interchange. After that, we kept swinging, while I said words like "happy", which he repeated with a smile. This lasted 8-10 minutes, then he was done and ready to run around the clinic aimlessly like a wild guy.

I took his hand and we went to a cabinet to get a worksheet. He grabbed one of my card decks. We sat at the table, I took the deck and placed it aside, telling him it was time to work. (I don't typically take things from kids.) He protested, tried to grab it back and looked like he was going to have a meltdown. Without even thinking about it, I held him tightly, rocked him and then began to emote for him. I very calmly said what I thought he was thinking. "I want the cards. What do you think you are doing? Gimme those. Who do you think you are? Those are my cards. I am very unhappy about this." and on and on. We stayed this way for 4-5 minutes with me holding him. He squirmed and protested but did not melt.

The remainder of the session went much the same with breaks every now and then for him to play freely. At the end, he went out to his mother, protesting (but not screaming) to her. She had a favorite transition object (we had agreed on) to catch his attention. We got his shoes on and got him out the door. The transition object was a God-send. He had worked hard enough. No one wanted a meltdown at this point.

It was a very difficult session, I was going by the seat of my pants the entire way. But it felt like a success for both of Jack and I. We had conversations, shared our feelings and played. There were no meltdowns. That's a lot for a feisty, non-verbal guy who is buried inside.

(Followup one week later: Jack's mother reported that he had had a very good week with behavior. His session this week was memorable in that he was happy the entire time. No melt downs, no transition issues. Let's see if this is a fluke or it continues to hold...)

Monday, October 19, 2009

ADHD Overfast Response to Tapping

When I have children with ADHD get started on an IM program, I automatically adjust the tempo to 63 beats per minute rahter than the standard tempo of 54. Why, they almost always over-anticipate the beat with the standard tempo and so miss clapping or tapping in rhythm. But when I change it to 63, most find their sweet spot and can perform admirably. IM's recently released bibliograpy of temporal studies points to research that came to the same conclusion. Check it out. That paper and others are found at this site. Here is the citation:

Hilla Ben-Pazi, Ruth S. Shalev, Varda Gross-Tsur, and Hagai Bergman. (2006). Age and medication effects on rhythmic responses in ADHD: Possible oscillatory mechanisms? Neuropsychologia 44: 412–416

This question came up for me recently. Does ADHD meds suppress timing? In this case, the meds are Adderall. I see a 6 year old girl who had excellent scores on IM prior to starting Adderall. Afterward, her score fell into the severely deficit range. Interesting. The above study found that there was no difference in timing skills for those on Methylphenidate (i.e. ritalin). I'd love to see a study on Adderall. Adderall is a combination fo amphetamine and dextroamphetamine. It has a known side effect of appetite suppression.