Building the Brain

Why do certain kids have an incessant need for — or aversion to — stimulation? And how can they get rid of the problem?

“Real learning” is often assumed to be reading, writing, and arithmetic. But developmental experts assert that the first mode of learning is actually movement: each distinct pattern lays the foundation for higher-level cognitive skills, like comprehension, expression, or critical thinking.

Crawling, for example, is the precursor to reading and writing. As Baby crawls, looking ahead and alternating hand and leg movements, he learns to focus from a short distance while developing an understanding of vertical and horizontal planes — critical for reading and writing.

One fascinating study (Delacato, 1963) showed that ethnic groups who never put their babies on the floor due to dangerous or freezing conditions — like Eskimos or certain African tribes  — developed no written alphabet; their communication was exclusively verbal. These findings strongly support a link between development of the horizontal plane (through tummy time and crawling) and the ability to use a writing system.

The Guttmanns develop treatment plans using these principles of neurodevelopment: the belief that every developmental experience — rolling, crawling, sitting — forms the blueprint for a brain pathway. If a child hasn’t sufficiently and successfully engaged in several of these stages, this can either (a) indicate an underdeveloped central nervous system or (b) result in impaired development, potentially causing trouble integrating stimuli.

“Through movement, a child reaches automaticity for basic sensory integration — dealing with everyday noises, textures, movements or imbalance,” explain Roizy. “Without this, he can’t possibly move on to higher level skills. He’s too busy dealing with the sensory overload; he doesn’t have room for anything else. He’s living with constant radio static in his ear.”

Because movement and learning are so interconnected, Friedy and Roizy view physical activity from the youngest age as absolutely critical. They’ve labored to make movement programs standard in schools, but have met resistance.

“When we approached the Board of Education and other agencies, we were seen as ‘just therapists,’ ” says Friedy. “Parents hold the key to making — demanding — such changes.”

Moving Past Babyhood

It’s not surprising that therapy at Hands on OT revolves around movement. Their exercises attempt to recreate lost stages or eliminate immature patterns, like primitive reflexes.

“A baby is born with numerous reflexes — Moro (startle), rooting, sucking, and many more,” explains Roizy. “These are supposed to integrate — turn ‘inactive’ — within a year and be replaced by higher-level postural reflexes, which enable the head to align in relation to body movements.” When they don’t integrate, the child’s development can be seriously hampered.

Chaim, for example, was referred to Hands on OT at age nine by his rebbi, who reported reading difficulties and illegible handwriting. Upon evaluation, Friedy and Roizy discovered that Chaim had retained a cluster of primitive reflexes. Among them was the asymmetrical tonic neck reflex (ATNR), where a baby turns his head to one side and the limbs on that side straighten, while the limbs on the opposite side bend or flex.

Each time Chaim turned his head to write, his arm instinctively extended and his fingers loosened their grip on the pencil. To compensate, he’d tighten his grip on the pencil, tensing all his muscles. Furthermore, since he’d never developed mature postural responses, Chaim’s eye movement was unstable — a condition not conducive to reading or writing. Expending so much energy on just getting his hand to write, he could hardly pay attention to what he was actually writing.

Treatment for Chaim involved a repetitive series of targeted movements designed to inhibit primitive reflexes. By consistently replicating infant movements — but ensuring they were practiced and controlled — Chaim’s body learned to elicit and then inhibit that disruptive primitive reflex cluster.

Hands on OT treatments are never confined to the therapy room. Parents and caretakers are an essential piece: the sisters strongly encourage both mother and father to attend the initial evaluation, and 75 percent of treatment plans are home programs, with parents implementing the exercises.

“We’re treating families,” says Roizy. “We look at dynamics, the whole picture. Parents often tiptoe around the issue, avoiding tension at all costs.”

Shlomo* is a classic example of this phenomenon. Five years old, and a habitual thumb-sucker, his parents described him as “extraordinarily clingy, immature for his age, petrified of new people and places, and extremely opposed to transitions.” Outside his home, Shlomo would become so anxiety-ridden and uncontrollable his parents began limiting their outings.

The sisters quickly identified Shlomo’s underlying sensory issues. And with each therapy session, they encouraged his parents to challenge him.

“We do a lot of hand-holding,” Friedy says. “Parents are so afraid of meltdowns that they’re reluctant to take the child out of his comfort zone. But we need to make sure that happens, to confirm that treatment results carry over to regular life.”

At the same time, Roizy warns, the ante must be upped gradually — particularly for children with sensory integration issues. “Some parents want to dive in full-force, exposing their child to all kinds of stimuli. That would be killing him, it’s like asking him not to breathe.”

From the Womb

Most clients arrive for evaluations at age eight or nine, a reality Friedy terms “predictable.”

“That’s when academic demands get too high. That’s when the child starts breaking under pressure. That’s when school begins insisting that parents do something.”

It’s unfortunate, since most of these kids could’ve benefited from early or preschool-age intervention, years before their limitations translated into poor self-esteem or social problems. “Parents should be aware of red flags,” says Roizy. “Early intervention can preclude so many issues.” What’s more, it usually yields faster, better results, minus any social stigma.

When it comes to neurodevelopment delays, there are three critical periods: gestation, birth, and the first years of life. If some or all of these stages were compromised, parents must be especially on guard for developmental problems.

Pregnancy’s impact is grossly underestimated, the sisters assert. “The first trimester is crucial,” Roizy says. “Major organs are formed, cells are migrating and replicating rapidly. Because the placental barrier hasn’t been established, whatever you imbibe or inhale — cleaning agents, excessive caffeine, medicinal drugs — transfers directly to the fetus.”

One pregnancy no-no is stress: several longitudinal studies have shown a correlation between high stress levels during pregnancy and behavioral problems in the resulting children (particularly males). Elevated stress levels were also linked to feeding issues and metabolic diseases.

Another mandate for expectant mothers: get moving. The unborn baby’s all-day womb-bobbing is vital for his sense of balance. Though empirical research is inconclusive, women on extended bed rest or those carrying multiples — with limited uterine space, the twinnies can’t jounce around much — should look out for balance and motor delays.

“We’re not trying to scare people,” Friedy clarifies. “Parents should feel empowered to determine if their child is predisposed to neurological immaturity — so they catch it on time.”

The next major player in a baby’s development is the birth process. The nature of your child’s birth, the Guttmanns say, can affect her development. Was it smooth and quick? Complicated and hair-raising, stretching on for days? Caesarean delivery — while at times necessary — has been linked to allergy, breathing, and digestive issues, among others. In addition, birth injuries or trauma may potentially lead to neurodevelopmental delays.

Last on the list are the first years of life, the most adorable — and rapidly changing — stage. Did Baby reach milestones on time? Did he exhibit normal sleeping patterns? Did he experience high fever or seizures or require a hospital stay?

The answers to these questions yield valuable info about a child’s predisposition to delays. “Many children who had a difficult birth or didn’t crawl will do fine,” Friedy qualifies. “But if all three stages were jeopardized, the child is at high risk for delays, and parents should know.”

Beyond awareness, if the difficulties were pregnancy or birth-related, parents should try to prevent additional issues by making sure their child fully experiences every motor stage.

Sensation or Spoof?

Friedy and Roizy are grateful to be able to give back to their own: their clientele represents every tristate Jewish community and beyond. But in their 15 years of practice, a disturbing pattern has emerged: learning and movement programs — many with dubious supporting research — claim to effect immediate, lasting change in children with a wide range of problems, and vulnerable parents become hypnotized at the possibilities.

“Parents constantly call us, asking, ‘Can you do such-and-such program on our child?’

“We say, ‘Why are you asking? Is your child even a candidate?’

“As a mother, I know the desperation we feel in doing anything and everything for our child,” Friedy says. “But with so many differing methods being presented as ‘the solution,’ parents get filled with hope without knowing the sources behind them.” Asking questions and challenging providers of alternative approaches, Friedy asserts, is every parent’s entitlement — and responsibility.

That’s not to say none of these programs have value. “We’ve earned certification in nearly every program out there, and we believe many are beneficial,” Friedy stresses, noting that she and Roizy implement some programs as part of a broader treatment plan. “They just have to be used correctly, and on the right child.”

Proper training is key, as some movement programs may elicit harmful reactions in children with cerebellar damage or a history of seizures. If the concerns go beyond integration, and there may be neurological, psychological, or behavioral sources, therapists must know to refer out.

Intensive “fad” programs may focus on upper-level cognitive skills, ignoring the underlying issues. Parents may see exciting academic changes, like improvements in reading or comprehension, while the untreated original source of the problem — possibly poor reflex integration or a neurodevelopmental delay — expresses itself in other areas, like over-reactivity or emotional regulation, accompanying children long past graduation.

What’s more, even successful changes may crumble under stresses like puberty, illness, or marriage.

“Many parents come in crying, ‘We thought we were done! A year later, we’re back to square one!’ ” Roizy relates. “When you build new pathways without repairing the broken ones, progress is fragile. It takes a minimum of nine months to rewire the brain and consolidate changes.”

What does “rewiring” the brain really mean?

As you read this article, new brain synapses, or connections, are being created each second, in a phenomenon known as neuroplasticity. The problem starts when there’s a neurochemical imbalance, like too much stress-producing cortisol. When that happens, you might be building new pathways, but the quality is poor. “It’s like a tree,” Roizy offers. “It may sprout lots of branches, but if the branches are weak, they’ll break in bad weather.”

To avoid this, the sisters attempt to rewire the brain: create strong synapses that endure in the face of stress. They do this by addressing lower-level issues (e.g., reflex or sensory integration) rather than skipping to reading, language, or processing skills. They also address chemical imbalances through techniques that release neurotransmitters such as serotonin and dopamine, the relaxing hormones.

The sisters’ message? “ ‘Do no harm.’ Not every program is for everyone. We want to empower parents to research, ask questions — and discover the appropriate resources for their children.”

Behind the Reading Problems

“Appropriate” is the operative word. While Pinchas, Meryl, and Shaindy all presented with reading difficulties, their subsequent treatments were highly targeted — and unique.

Pinchas came for academic reasons, but during the evaluation, his parents reported a slew of emotional and behavioral problems, including anxiety and sleep difficulties. When demands got too tough, he’d shut down, and fights with siblings and peers were constant. He’d received vision therapy for eight months and completed a well-known neurotechnology program, but the results didn’t last.

Friedy and Roizy immediately saw that Pinchas had low muscle tone: he couldn’t sit straight without full back support. They also noted poor reflex integration, and sensory integration issues in the visual, vestibular, auditory, and olfactory systems: he was hypersensitive to background noises and certain smells.

“As long as Pinchas was in a full-support chair, his eye movement seemed okay. In any other position, he immediately tired of reading,” Friedy relates.

Vision therapy had done its job, but it didn’t address the vestibular component: having to read in a not-quite-ergonomical classroom desk, or while standing. Pinchas was too busy stabilizing his head and eyes to work on processing words.

The sisters began treating Pinchas intensively, three times weekly for several months. They used specific movement exercises to improve postural control and foster communication between the visual (eyes) and the vestibular (head).

They also implemented an auditory-augmentative system: while executing each movement, Pinchas had to listen to different sound frequencies. At the beginning, he was terribly bothered, asking to turn it off, but with each session, his body became more desensitized — until he learned to tune it out completely. The systems had begun working together.

“When you read, you are (a) seeing the words (b) sounding the words (silently) and (c) visualizing the concept,” Roizy points out. “Our goal was for Pinchas’s body to synchronize all three systems.”

Within six weeks of treatment, Pinchas’s teachers noted improvement in mood, attention, and motor control: he was able to sit straight and do more before getting tired. His parents reported a happier child who didn’t “shut down” as often.

After three months, his sleeping had improved, and he’d begun expressing himself more verbally — the result of being more organized and calm on lower levels. He even began reading for pleasure at home.

By nine months, Pinchas’s reading had improved by one grade level, along with comprehension and spelling. Eventually, the sisters recommended a neurotechnology program to further develop automaticity in these areas.

Twelve-year-old Shaindy, on the other hand, presented with no sensory issues. Her primitive reflexes were mostly integrated, but her postural reflexes were underdeveloped, and communication between brain hemispheres was poor: she had trouble with tasks that required crossing the midline (an imaginary line down the center of the body), like writing A’s and T’s, tying shoes, and most relevantly — reading.

Since the issues were less involved, the sisters felt comfortable establishing a short home program of targeted head movements. Once they saw real improvement, they recommended vision therapy to further refine eye movements.

Meryl, in contrast, was not a candidate for vision therapy — though her parents initially assumed so. Nine years old, and a diligent student, she’d recently begun having reading and writing issues, particularly when taking tests.

“Reading was very slow,” Roizy recalls. “Once Meryl finished, she had good knowledge of what she read. But if she had to write about it, she’d lose her way.”

Meryl’s parents also reported significant overreactivity at home: constant mood swings and impulsivity. She suffered from severe motion sickness and was afraid of heights; she shied away from age-appropriate sports like jump rope. Her posture was highly fixed, and she had rigid, unrelaxed movements.

Testing revealed Meryl had a classic reflex integration profile: she’d retained a primitive reflex cluster, with adverse results. Most detrimental, perhaps, was the still-active Moro (startle) reflex.

The Moro, meant to disappear by four months, is Hashem’s survival gift to newborns, who cannot yet process sensory information. When faced with sudden position shift, abrupt temperature change, or loud noise, the infant responds with a startle: he flails open, curls into a fetal position, then begins to cry loudly.

Eight years later, Meryl was still affected by the Moro. In her constant state of hypervigilance, anything unfamiliar triggered a fight-or-flight response, with cortisol (stress hormone) levels at a sustained high. Desperate to control her environment, she lived with perpetual anxiety and made impulsive decisions to protect herself.

“Children like her vacillate between hyperactivity and extreme fatigue,” says Roizy. “It’s tiring to be on guard all the time.”

Another primitive reflex still alive and kicking in Meryl, the tonic labyrinthine reflex (TLR), resulted in unstable eye movement and irregular muscle tone — hence the reading problems and stiff posture. A third unsuppressed reflex, the ATNR, affected pencil grip and hand-eye coordination, making written tests impossibly challenging.

Treatment for Meryl was straightforward: intense reflex integration exercises at home overseen by her committed parents, promoting hormonal balance and improving Meryl’s emotional regulation.

After six weeks, Meryl’s parents reported she was “less reactive, more even-keeled, more able to talk about her feelings.” Four months later, her posture became less rigid and her movements more fluid; she seemed more comfortable in her own body. By seven months, Meryl’s reading showed improvements, and she began scoring better on short-answer exams. She expressed interest in riding a bike. Most incredibly, for her afikomen, she requested a diary. “We never dreamed she’d ask to write!” her parents said.

For the sisters, Meryl’s case was particularly gratifying. “Meryl’s parents were consumed by her overreactivity — and its effects on other siblings. When you help a child like Meryl, you’re changing the whole family dynamic.”

The Heart of the Matter

Friedy and Roizy are uncompromising when it comes to research: any treatment approach lacking overwhelming evidence is subject to skepticism and scrutiny.

“When we attend a certification course, the presenters go a bit crazy,” Friedy laughs. “We don’t let up with the questions. We really want to understand.”

The dynamic duo also insists on measurable treatment goals: they conduct regular standardized evaluations to ensure the placebo effect is not at play. (“We never rely exclusively on parental reports.”) They’re also working to network with interventionists with access to cutting-edge functional MRI technology, which shows neurological activity in real-time.

“Until ten years ago, there was no way to gauge brain changes quantitatively,” Roizy says. “You could evaluate therapy progress only through academic performance, functionality, or behavioral changes. These MRIs are truly game-changing.”

The sisters’ therapy sessions are similarly scientific and refreshingly methodical. But it’s not logic alone that helps children bridge developmental gaps. Behind the analytical eyes and scientific brains of two gifted girls from Boro Park lie big hearts and a keen understanding of kids.

“It’s so hard to look at a child as a body and brain, and not just as the yummy tzaddik’l he is,” Friedy says. “But realize — you are your child’s only true advocate. By asking the right questions and getting the right interventionist, you’ll know you did the best you could.”

All client names of Amy Guttmann and Evelyn Guttmann, OTR/L, have been changed.

Finding the Right Messenger

The Guttmann sisters offer valuable guidelines for securing an effective interventionist.

Don’t be afraid to ask. This person is going to work on your child’s brain — you can challenge him! Have an initial phone conversation before the first evaluation to see if they’re a good fit. Ask specific questions, including the following:

• What is your training?
• What is your area of expertise?
• How many years have you worked in this area? (Should be three to four years, at minimum.)
• How do you plan on treating my child’s issues? The therapist should be able to outline a clear treatment plan. You never want to hear “Trust me,” or “I’ve been doing this for 40 years, I know what I’m doing.”
• How will you establish my child’s baseline, and how will you measure progress? The therapist should describe her initial evaluation process and then her methods of gauging progress.
• If you are calling about a specific program in which the therapist claims to be trained:
  • How will Program X address my child’s issues?
  • Can I get a copy of your certification in this program? Some therapists use bootleg copies of programs, not having actually attended the live training, which is an imperative component.
• How will we, as parents, be involved? Parents should always be part of the intervention process. Numerous studies have proven the importance of parental involvement for carryover of change to real life. If the therapist downplays your need to participate, stay away.
• What kinds of issues do you not treat? Specialization is a hallmark of mastery and professionalism. Professionals must be sure their treatments are appropriate and targeted and know when to refer out. If a therapist claims to do it all or responds defensively, stay away.
• Can you provide references? Warm recommendations are a good sign. But you shouldn’t rely on them exclusively. Make sure you are satisfied with the therapist’s replies to your questions — both the content and the tone.

Red Flag One-Liners of a Potentially Ineffective Therapist:

• “I guarantee I can change your child.” Only G-d can guarantee things. A more appropriate statement would be: “I’m going to use approach XYZ. I’ve seen success with it in the past, and I’ll do my utmost to help your child.”
• “If you see a regression, come back for a boost.” When a therapist correctly addresses the underlying neurological issue and rewires the brain pathways, the changes should be permanent. There should be no need for additional treatment — even after stress, sickness, or puberty. If a “boost” is required, either the therapy was a mismatch, or it should have been more intensive.
• “Everyone can benefit from this.” Sure, if you’re talking about yoga. But certain exercises can trigger seizures or tics in susceptible children, and a properly trained therapist will know that.

(Originally featured in Family First, Issue 406)