Sensitivities to touch may be environmental (e.g., fleeing from contact of furniture; discomfort from clothing touching child), other-initiated (e.g., withdrawal from mother hugging child; avoidance of being in groups of children), or self-initiated (e.g., avoidance of touching textured objects). The child may respond aggressively by hitting or kicking, or by physically retreating (e.g., hiding under furniture). Emotional responses including hostility, aggressive behavior, and high irritability are not uncommon.

Andrew would not permit others to touch him at all, including his family. If touched by another person, Andrew responded by pinching, biting, or kicking. At school, he was a severe behavior problem and would scream and kick when touched. Once these behaviors had occurred, Andrew could not be calmed for long periods of time. He often withdrew into places where he could avoid being touched, such as under a table or in a corner of the room, after which it would be very difficult to get him out of his hiding place. Andrew did not like other people to be too close to him and when in groups, Andrew would kick, bite, and scream. Tactile defensiveness was also observed in Andrew’s inability to tolerate having his face or hair washed. All of his clothing tags had to be cut out routinely. On one occasion, the tag was left in a new shirt by accident. Andrew began fidgeting with the tag, scratching his whole body. Over the course of the morning, he began to rip his clothing off and could not be controlled.

Andrew’s tactile problems are representative of a child with severe tactile defensiveness. Although Andrew’s problems are not solely attributable to his tactile disorder, it affected his capacity to develop appropriate interactional skills, attention, and self-calming. His severe tactile defensiveness needed to be addressed as a major component of his classroom and home management program.

Using guidance from the occupational therapist at school, Andrew’s parents found that his behaviors at home and school were much better when they instituted play times throughout the day that involved pleasurable contact with them. Before school, his mother rubbed lotion on his body using firm touch, emphasizing his palms and soles of his feet. Sometimes Andrew would use a surgical scrub brush and brush himself on his arms and legs while he and his mother sang songs together. His parents also found that if they gave Andrew some focused activity to do before school that involved heavy objects, it made a difference. Some examples of these activities included having Andrew helping them move chairs to the breakfast table or carrying his heavy back pack filled with a thermos, bean bags, and books on his back while he “checked” the house to see if all the lights had been turned off. After school they instituted a rough house play time with Andrew that involved deep pressure to his body. He particularly liked swinging on the tire swing outside and crashing his body into soft things like a large gymnastic ball that his mother would roll toward him. They thought of many creative interactive games using the concept of giving him heavy pressure to his joints and skin. For example, his mother and Andrew would kneel on opposite sides of a large foam “wall” and try to push the other person over. At the end of the day, Andrew needed time to settle himself down and responded well when his parents did soothing activities involving deep pressure. He loved lying back to back with his father while they sang songs and played with flashlights on the wall in the darkened bedroom. He also enjoyed sitting in a bean bag chair with his feet buried in a bin of dried beans or with a heavy quilt wrapped around his body while they read stories together.

Michael was evaluated by an occupational therapist to determine if there were any sensory integrative problems underlying his sleep difficulties and motor incoordination. Throughout the testing, Michael was very fearful of being physically moved and touched by the examiner and, consequently, refused to attempt many tasks. An interview with the mother confirmed Michael’s hypersensitivities to touch and movement. He hated having his face washed and avoided messy activities, such as finger paints. He was very picky about the textures of clothing. In group situations, he tended to withdraw into hiding places (i.e., under a table or inside a tent) and became very irritable when in close quarters. He resisted being hugged and held, but would tolerate cheek to cheek contact with his mother on occasion. In addition, Michael avoided movement experiences, such as swings or slides and was very cautious about heights and climbing. He preferred to initiate movement activities rather than being moved by others. Sometimes he enjoyed making himself dizzy but became fearful if he moved too fast.

The treatment program was directed towards alleviating his tactile defensiveness and sensitivities to movement through activities that Michael could self-initiate. The tactile activities emphasized firm deep-pressure. He particularly enjoyed wedging himself between heavy mats, covering himself with pillows, and jumping into bins of plastic balls. Some of these activities were modified for use before bedtime to help Michael develop self-calming mechanisms.

Very often the child with either tactile defensiveness or tactile hyporeactivity will exhibit a lag in motor development because of their inefficient use of touch in exploring objects. Frequently, children with tactile dysfunction have low muscle tone, contributing to poor sensory support for movement experiences. For instance, one may see the child sitting half on and half off a chair or sitting with the arm caught under their body with no apparent discomfort. It is important to note that the same child may exhibit both elements of tactile hyper and hyporeactivity to tactile experiences (e.g., crave deep pressure contact on hands but an aversion to light touch or certain textures on palms).

When an infant is underreactive to tactile input, they may appear very passive and content to be left alone. Often the baby does not cry during physically painful medical procedures. A low activity level is often observed. When these behaviors are observed, it is important to differentiate the child’s responses from other medical problems or a severe cognitive delay which can resemble these behaviors.

Discomfort at tactile experiences becomes heightened as the child grows older and encounters more challenging and varied tactile experiences. For example, the child must accommodate to the touch of playmates and adults other than mom and dad’s familiar touch. Although the child’s own parents may have found ways to approach and touch their child in ways that feel acceptable to the child, other children and adults have not made this accommodation. As a result, the child’s tactile problems may appear worse.

As the child enters the second year of life, independence and mobility allow the child to flee from uncomfortable tactile experiences or to approach and touch those that are pleasurable. Some parents begin to notice that their child seems unusually active as they move from one unpleasant tactile experience to another. Some children are observed to mouth or bite toys, seeking hard deep pressure in an area of the body that can more easily adapt to incoming tactile sensations. The child often prefers intense deep pressure activities, such as rough housing with mom or dad.

Preschool and school-aged children with tactile hyper- or hyposensitivities often display fine motor difficulties because they lack the tactile discrimination to handle and manipulate objects within the palm and fingertips for refined use. Tasks, such as drawing with a pencil or buttoning are very difficult. The child may always look at their hands when they are manipulating objects. Mouthing of toys may still be present. There is often an avoidance of touching new textures with a preference for firm, hard toys. The child may have a strong preference for certain types of clothing, complain about clothing tags, and dislike having hair and face washed. More advanced tactile discriminative skills, such as stereognosis (i.e., detection of objects by feel alone) and graphesthesia (i.e., identification of letter or number drawn on a body part while vision is occluded) are usually delayed as well.

Play difficulties are common among children with tactile hypersensitivities. Destructive or aggressive play occurs frequently when the child is required to play with other children in close proximity. The child may touch other children with force even when trying to be gentle. If given a choice, some children withdraw from other children or find spaces to play that provide them with tactile security, such as a corner of the room.

Infants with vestibular hypersensitivities typically show an intolerance for low-to-ground positions (e.g., prone or supine), a strong preference for upright postures, low muscle tone, slowness in developing motor skills, delayed balance, and/or fear of irregular or unexpected movement (DeGangi & Greenspan, 1988). When the infant is underresponsive to movement in space, the infant seems to crave movement and may become very fussy and demanding unless the parents provide movement stimulation for them. Once the baby is more adept at moving about, he or she may rock vigorously while sitting or on hands-and-knees. The infant may seek swinging for long periods of time and particularly enjoy rough housing with parents.

Vestibular processing problems in the child may take the form of hyper- or hyposensitivities to movement. When the child is gravitationally insecure—that is, fearful of movement experiences with a strong preference for movement activities near to the ground, there is often an accompanying separation anxiety disorder. The child relies heavily upon the parent to provide safety in new situations, such as helping them to find a place to play where other children won’t bump into them, causing them to fall. Since the child with gravitational insecurity usually dislikes playing on playground equipment, one usually sees the child with this problem standing close by an adult when outside or preferring to play with small manipulative toys. The child’s play in large space is very constricted, playing in a small area, even when engaged in play with cars and trucks on the floor.

When a toddler is underreactive to movement stimulation, different issues emerge. Toddlers are notorious for their desire to test limits and attempt activities that allow them to master new motor skills. The child who is underreactive to movement often challenges parents by climbing onto dangerous surfaces, jumping from unsafe heights, or trying a movement activity that exceeds their motor capacity, such as climbing high on a jungle gym. Often the child who is underreactive to movement is fearless and constantly tests limits. They may crave movement activities and become very upset when restrained from continuing to swing, climb, or spin. Parents often report that on days where the child is unable to engage in such movement activities, the child becomes very irritable, tantrums frequently, and has difficulty with sleep.

In addition to gravitational insecurity and vestibular hyporeactivity, the preschool and school-aged child with vestibular problems often has problems in postural control, balance, and sequencing and coordination of movement. The child may have poor equilibrium reactions in different body positions. When sitting at a desk, the child may be fidgety with extraneous body movements due to weak trunk stability. When asked to engage in activities, such as walking on hands in a wheelbarrow walk or climbing a trapeze bar, the child may show weakness of the trunk and neck. As a result of weakness at the shoulders, the child may have poor distal prehension, holding small objects with the pads of the fingers rather than the fingertips. It is not unusual for the child to have ocular-motor problems as well, such as difficulties looking up from their paper to the chalkboard and back again to their paper.

Vestibular dysfunction is often observed in combination with bilateral integration problems, particularly in children who have postural deficits. Bilateral motor integration involves the ability to coordinate the two body sides and develop lateralization (Magalhaes, Koomar, & Cermak, 1989). Children with problems in this area frequently do not establish a hand dominance by school-age. Frequently the child will interchange hands with no consistent preference for one hand. Bilateral assistive skills where one hand acts as a specialized hand and the other as an effective stabilizer are difficult. For example, simple tasks, such as buttoning and scissor cutting are delayed. Reciprocal bilateral movements, such as skipping, jumping, or alternating the hands in a drumming pattern are difficult. Oftentimes the child lacks precision in hand function and cannot sequence hand movements. The child may lack symmetry and control in large body movements. As a result, the child is often very clumsy and stiff in gross motor tasks, such as rolling and walking since these movements require coordination of the two body sides. The child lacks flexibility in rotating the trunk, and there is also a strong resistance in crossing the body midline. Consequently, the child may turn the entire body when required to cross the midline rather than rotating the trunk. Table 9.4 presents many of the traits of children with vestibular problems.

In this next section, details about the different types of movement disorders are described.

The gravitationally insecure child demonstrates an extreme fearfulness of moving in space. Children with gravitational insecurity typically have a strong preference for upright positions, avoid rotational movement patterns, such as rolling, prefer close-to-ground positions (i.e., W-sitting posture), “lock” the body and neck in rigid postures to avoid movement stimulation, and tend to avoid movement activities. Not only are they fearful of body movement in space, but they resist any change in their body which they may perceive as threatening. Movement that is imposed is particularly upsetting to the child. The emotional response that accompanies gravitational insecurity is associated with a sudden change of head position, a displacement in the body’s center of gravity, or the feet suddenly leaving the ground. As a result of insecurities in moving in space, children with gravitational insecurity tend to be emotionally insecure also. They frequently display fearfulness of new situations, rigidity, and a resistance to change. It has been hypothesized that gravitational insecurity may be due to poor modulation of otolithic inputs (Fisher & Bundy, 1989). In infants one may observe a strong preference for sameness in routines with crying and agitated behavior when routines vary, a strong need to be held and carried constantly, and a fearfulness of certain body positions (e.g., back or stomach). Some individuals experience an intolerance for movement and experience considerable autonomic discomfort during movement activities. The child may also exhibit gravitational insecurity as well. Typically the child feels nauseated and dizzy, particularly during rapid movement activities, such as spinning. It is not infrequent for such an individual to experience motion sickness in a car or boat ride. It is hypothesized that the individual with intolerance for movement is hyperresponsive to semicircular canal stimulation (e.g., spinning) (Fisher & Bundy, 1989). Since gastrointestinal symptoms are common, vestibular-vagal connections are also involved. Sometimes a person with intolerance for movement has visual motion sensitivity and feels autonomic responses while watching spinning or swinging objects, or watching motion pictures that assimilate movement or flight in space (Fisher et al., 1986).

The primary problem underlying a vestibular-postural problem is inadequate postural control. The neck and trunk muscles provide stability in movement, and their development provides the foundation for postural control. If the proximal musculature is not well developed, the child is often unstable in maintaining body postures, has poor balance, and may have poor fine manipulation and locomotor skills.

It is rare for a child to have a motor planning problem without difficulty in the tactile or vestibular system. Treatment for children with vestibular-based motor planning problems should first focus on vestibular awareness, therefore, vestibular stimulation activities should precede motor planning tasks in a therapy session. Postural and other motor problems associated with the vestibular-based motor planning problem should be addressed in the treatment process as well.

Step 1: Ideation: In this first stage of motor planning, the child with vestibular-based dyspraxia will have difficulty initiating purposeful movement. The child needs to link the feeling of enacting the motion or action with the concept of what actions lead to task completion. The therapist may move the child through the action while describing what is happening. By using vestibular stimulation in a very specific way, the child can attach meanings to the action. For example, a child may not be able to motor plan how to push himself on a scooter board. The therapist may hold the child’s hands and contrast fast and slow movement on a scooter board in a game, then vary other task characteristics, such as holding a hoop versus the therapist’s hands, or riding down a ramp or inside a tunnel. Each of these variations of the same action will help the child to conceptualize the motor action that is required to propel through space on the scooter board. Motor planning activities should be varied according to sequence, ordering, position, and timing.

The child may not be able to choose a motor task at first because he does not have a concept of what he is able to do with the different toys and materials. The therapist may select a simple planning task, and then model how to do it. For example, the therapist may demonstrate jumping off a platform into a large bin of balls, a task that offers both challenge and success. If the child shows fear or is unable to complete the action required, the task should be modified to assure that the child can succeed. Sometimes children are more interested to try a difficult task if they have experienced moving through the motions. Once the child has engaged in the task successfully a few times, it is important to then vary the task demands slightly to present a new challenge. In this way, the child must learn to self-correct himself and to execute new movement patterns.

Step 2: Planning the action: Before the child can plan out what he wants to do, he must be prepared to act. He needs to be motivated to do the action, therefore, it is important to find activities that excite the child and solicit his interest and involvement. The first step in learning to plan an action is to be able to experience it and to verbalize or conceptualize what needs to happen. Once the child has enacted the action with a model or the therapist’s assistance, he needs to understand what the end goal will be and how to get there. Selecting activities that give sensory feedback throughout the sequence helps the child to construct a plan. For example, if an obstacle course is used, the child may crawl through an opening in a large foam tunnel, then pull himself on the scooter board by holding a resistive rope, and lastly, swing while pushing over the large sandbag man. Each of these would have distinctly different sensory inputs that would help him mark each event in time and space.

Verbal mediation is an important aspect of learning to motor plan. The therapist may help the child to articulate what he is doing to help him link language with motor actions. Verbal commands from the therapist while the child engages in a sequenced task help to organize the sequence for the child. Once the child has consolidated his actions with verbal guidance from the therapist, he should then be helped to articulate what he is going to do next.

Sandra’s favorite play activities were playing pop-up pals, rolling balls, twirling or swinging string, dragging fake pearls on the tile floor, listening to music, looking in mirrors, and watching Sesame Street videos. She loved music and would jump up and down or wave her hand while she listened. She appeared interested in making sounds with objects. For example, when she hit the string of pearls on the floor, she created different types of sounds. She carried the pearls about with her, almost as a source of comfort like “worry beads.” Sandra would spin dishes, dump objects, or throw toys. She was fixated on strings and would go to great lengths to find them, pulling threads out of a rug to put in her mouth. Mr. and Mrs. T. reported that she had few imitation skills and no symbolic play. There was little turn taking ability although her father stated that he could get her involved in a reciprocal game of rolling the ball. Wandering occurred almost constantly. Sandra would mouth toys and would try to eat or chew on books. Sandra was most connected with another person during singing activities. She also enjoyed hide and seek and peek-a-boo games. Sometimes she would pinch others, especially if she was angry or jealous when her older sister was sitting with her mother.

Sandra was a picky eater with definite food preferences. She had just begun to use a spoon or fork. When she did not like the food or was finished, she would throw the plate or cup on the floor or against the wall. Usually, Sandra would handle or feel the food with her fingers before eating it. During mealtimes, Sandra was whiny and had a hard time sitting still.

Sandra experienced a range of sensory hypersensitivities. She would cover her ears when she heard unusual sounds, such as an animal noise or the videotape rewinding. Sensitivity to light was noticed when she would squint vigorously when outside in sunlight. Sometimes Sandra enjoyed being held but she didn’t hold onto her parents when they hugged her. Instead, she would bury her hands under her body and act as if she was just putting up with being hugged. She didn’t hold onto a person’s hand when being led someplace. She loved swings, riding in a stroller, and jumping in the crib. Motor planning problems were noted in certain situations. When coming downstairs, she would scoot on her bottom rather than holding onto the rail and walking. Sandra enjoyed visual stimulation, such as looking in mirrors, watching reflections and shadows, and creating visual effects with a swinging string. She also loved music and making sounds with objects.

Motor development was reported to be on course. Sandra walked at 13 months although her parents stated that she was more content to sit than move about. She smiled at 4 months and engaged in games like peek-a-boo as a young baby. Communication, play, and social–emotional skills were delayed for Sandra. Her parents suspected that she might be bright. For example, she understood where things were in the house and appeared to remember events.

Both parents were unsure about the future for Sandra. They had been told that she would probably need “special education services forever” from various doctors. They had just begun the process of identifying her problems and had been focusing on her medical diagnosis. They felt that Sandra had potential and that she was smart, but did not know how much she would progress.

During testing for cognitive and language skills, Sandra mouthed all of the objects presented to her. She only stopped mouthing when her mother cautioned her, “Not in your mouth.” When she manipulated objects in her hands, she often rubbed them on her face, and at times, waved her arms back and forth across her body, or flapped her hands while holding the toys. Sometimes Sandra seemed angry or frustrated, throwing things on the floor or refusing to cooperate. She especially liked the red ring on the string and anything that was shiny like the mirror, bell, and spoon. Most of her sounds were vowels, squeals, or grunts. Although testing at this age for children on the spectrum can be unreliable, her overall functioning was about at the 8 month level with scatter to 13 months. Her best skills were fine motor and simple problem solving. Language and social skills were the most difficult for her.

Our focus at the beginning of treatment was on the integration of sensory integration therapy and child-centered play. Sandra became easily overstimulated by being in close proximity to her parents, and constantly ran away from her parents as we attempted the child-centered activity. Another important part of the early work was to help her parents to become comfortable with this approach, as both preferred a highly structured, teaching kind of approach with Sandra.

This case depicts the importance of respecting how the parents feel as they cope with their child’s diagnosis and what it means for them and their child. It was important for me to respect the grieving that each parent experienced, allowing them time to adapt while providing opportunities for them to express their concerns and supporting them in ways that helped. Integrating this piece into the treatment was just as important as providing practical guidance, sensory integration techniques, and child-centered activity in helping Sandra become more related to the people and object world.

Although Ali seemed to have an easy temperament, she was too easy, passive in receiving the world and needing her parents to bring the world to her. There was clearly something more behind her “easy” temperament—most likely a chronic state of sensory overload and emotional overload. She was slightly behind in her development, and because she had problems tolerating touch and movement, and was not exploring the world, I suggested that it might be useful to provide Ali with some input to help her with these areas. Mrs. B. did not want to hear that her daughter might have problems. I expressed my interest in seeing Ali at our next follow-up visit at 2 years, and urged Mrs. B. to feel free to call me anytime if she had any concerns. I was aware that my feedback to Mrs. B. might have alarmed her, shattering her view that she had a “normal” baby. I wasn’t sure that she would come back to see me, but before it was time for the 2 year visit, Mrs. B. called me, feeling urgent that she get help for Ali.

Mr. and Mrs. B. reported that Ali was unable to tolerate other children being near her, even at a distance. She seemed in terror of their activity level and noise. Ali could not stand to be touched, making daily tasks, such as dressing and bathing a nightmare. Despite this, she wanted to be held constantly for comfort when distressed. It seemed that the only kind of touch that she could tolerate was static– being held but not stroked. She would touch objects, but only on her own terms. She avoided movement activities like swings that most children her age enjoy. She was bothered by noises, noticing sounds that most persons don’t normally notice. She would become extremely distressed by vacuum cleaners, sirens, bells, or toilets flushing. Ali was showing many of the characteristics of a child with sensory defensiveness, but it was accompanied with severe anxiety as was evidenced by her strong emotional reaction to group situations and leaving the house.

When I saw Ali for testing at 2 years, she could not sustain interest in toys, playing only briefly before losing interest altogether. She was very cautious in exploring the toys, generating play only when cued by her mother what to do. While holding a doll, her mother prompted her to point to the doll’s body parts. Ali was not able to initiate or organize any symbolic actions with the dolls, things like feeding the doll which most 2 year olds can do. Although her cognitive and language skills were within age expectations, Ali’s play was restricted to labeling objects or defining the objects’ properties (i.e., what color it was) and she wouldn’t play unless her parents organized it for her. Ali was experiencing a significant motor planning deficit, attentional problems, difficulties organizing reciprocal interactions, and problems using language for communication.

Here was a child who, at age 2 years, was still clinging to her parents, fearful of exploring the world, and unable to organize even the simplest of play. The task of engagement with others was seriously compromised by her fear of social approach by others, her sensory defensiveness to touch, sound, and movement, and her limited capacity to sustain interest in persons and objects. Although she clung to her parents, her attachment to them was highly anxious. She had not learned to negotiate the basic task of engagement and intimacy with them. She had created a state of being merged with her mother that was unpleasant and intolerable for her mother. Mr. and Mrs. B. found themselves pushing Ali away when she clung to them. It appeared that Ali was not yet ready for the task of separation and individuation.

During the assessment I asked Mr. and Mrs. B. to step out to the observation booth so that I could see how well Ali could separate from them and soothe herself. Initially Ali was very upset and cried, but she comforted herself by standing against me while holding her blanket. After a few minutes, she became interested in playing with toys, and began interacting with me around them. It appeared that Ali had some capacities to separate and when she could do this, she was better able to construct purposeful and organized play and reciprocal interactions with me. It seemed that Ali and her parents were stuck in a conflict—Ali wanted her parents to soothe her, but they resisted this task—pushing her away and until Ali felt that her needs for closeness were met by them, she would persist in this position—to cling, cry, and insist on being “one” with her mother. The severe sensory defensiveness was one of the reasons that Ali experienced caused her to be stuck in this dynamic.

When we began the child-centered therapy, Mrs. B. expressed feeling conflicted about the way in which we would be working. She had seen a psychologist before coming to see me who counseled her not to pick Ali up when she cried. In our first treatment session, Ali cried vigorously, wanting to be picked up, clinging to her mother and asking repeatedly to “go home.” I suggested to Mrs. B. that she allow Ali to self-initiate and indicate what she needed. She was asking mother to nurture her, to hold her, and comfort her. I explained to Mrs. B. that Ali needed to feel comforted by her mother in a basic way, like a young infant, and she needed to experience this before she would become self-reliant in soothing herself. Mrs. B. was upset by Ali’s distress and did not want to hold her. When she held her, there was a pained expression on mother’s face. She felt that all she did was hold her and did not think my idea would work. I suggested that when we practiced the child-centered therapy, Mrs. B. would learn how to read Ali’s cues, to respond in ways that Ali needed, while at other times she could set limits (e.g., “no holding right now, I’m cooking dinner”). When I asked her what bothered her so much about holding Ali, she expressed that Ali was feeling abandoned by her. This was probably a very real experience for Ali because Mrs. B. expressed that she did want to escape from her child. Mrs. B. talked later in the session about wishing Ali was different—singing and playing like the children she heard through the wall in the next room. She also told me that she was uncomfortable being observed by me while she interacted with Ali. I was struck by how she wanted the ideal child who others would admire, yet it was difficult for her to share how painful their relationship felt to her.

In the following week, Mrs. B. reported that she had had a good week with Ali. They went to several outdoor events and new places without Ali becoming distressed. Despite this positive change, Mrs. B. expressed how helpless she felt when Ali became distressed and how vulnerable Ali must feel. That week in therapy, Ali wanted to be held the entire time, but she didn’t cry. She listened to the children in the next room and even laughed as they sang songs. She experimented making loud sounds by kicking a chair. We ended the session playing a game of hide and seek with a toy to begin working on separation using a neutral object.

Over the following weeks in treatment, Ali remained clingy to her mother in the waiting room. Her crying and distress improved, but she continued to use her mother as a calming object, stroking her mother’s hair. Mrs. B. reported that Ali was beginning to use transitional objects like a toy or blanket, however, sometimes her selection of an object was odd like carrying an onion around with her. She used these objects to stay calm in new situations. We had intermittent success in the next few weeks—a play date at another child’s house that went well, then Ali screaming on another play date. Her parents were angry at her that she was this way, seeming to expect a quick fix. Mrs. B. was distressed that Ali was so dependent on her. Mrs. B’s own parents did everything for her as a child and she wanted Ali to be more independent. To respond to Mrs. B’s wish for Ali to become independent, I suggested that she give Ali jobs to do like turning on the light or picking out a toy to play with as they entered a room which would also serve to organize her.

Within a month of the start of treatment, Ali began to readily approach me. After picking out toys that she wanted to play with, Ali would rock in a chair, climb the ramp and look in the mirror and engage in other movement games like chasing a large ball, but she did not interact with any toys. Gradually she began to play with various toys at my office during the child-centered play, selecting things she could throw. I put out koosh balls, heavy bean bags, and other safe medium to throw that would provide her with tactile-proprioceptive input. Sometimes Ali would become overly exuberant and wild, throwing koosh balls around in her play. Because of the level of dyspraxia that she experienced, I would sometimes model things like a simple symbolic play scenario. If I showed her how to do it, for example, feeding dolls with play doh, she could imitate me and seemed to enjoy enacting these schemes. However, whenever I introduced a doll into play, Ali would react as if it were real. For several weeks we had to have the doll just present in the room to get her accustomed to it.

The child-centered therapy was completely different at home. When her parents practiced it. Ali would want to hold an object that was unsafe or she would stop playing after only a few minutes. I was aware that both Ali and Mrs. B. needed me to contain their relationship. It seemed that Ali tested her mother by expressing unsafe or impulsive urges. Her parents also expressed a lack of pleasure in being with Ali and could only experience more positive interactions in my presence.

In the upcoming months, Ali gradually stopped asking to “go home” when out on excursions. She began testing limits more by running off or putting things she shouldn’t into her mouth. She was going to a play group with 2 children and doing well, but when she fell apart, Mrs. B. interpreted it as a major setback. Mrs. B. felt that other mothers viewed her as a bad mother and that something was seriously wrong with Ali for her to behave this way. Mrs. B. expressed strong feelings of isolation, depression, and hopelessness. She worried that Ali would always be this way. It pained her that Ali avoided people. She thought about quitting her job and moving away. Her only contact with others was seeing me or the play group once per week.

In addition, there was enormous strain on her marriage. Mrs. B. would call dad whenever she had had it, wanting him to come home immediately. It was clear that containing her own distress was difficult for mom. Likewise, her wish to escape only heightened Ali’s anxieties. Mrs. B. felt that she had no friends to talk to and relied totally on her husband. I was becoming aware how Ali’s problems mirrored mother’s internal world. Mrs. B. felt depleted by Ali. She desperately wanted a close friend but had no energy to meet people. She reflected with me about how she was outgoing and had many friends as a child. She felt that she was like the child on the playground who nobody wanted to play with. As Ali progressed, I was aware how Mrs. B. was becoming increasingly more depressed, isolating herself more and more, just like Ali. We talked about Mrs. B. getting help for herself which she was able to do. As she began seeing a therapist and felt a bit better, Mr. B. began talking with me how he had been enduring the emotional burden of supporting his wife and how he, too, needed a break.

The struggle for me as a therapist during this early stage of treatment was the difficulties the parents had in engaging with their child in a nurturing and loving way. Instead, they pushed her away when she approached them, feeling suffocated by their own child, and wishing to escape from her. They felt like they were held hostage by their own daughter. They never experienced what other parents of toddlers could do, the opportunity to observe their child moving away to master the world. As a result, there was a lack of differentiation between parent and child. Ali developed an overdependence on her parents, and as we explored what this meant for Mrs. B., it became apparent how Ali reflected mother’s internal object relations. Mother and child were merged in an anxious and disorganized attachment pattern. For Mrs. B., her child seemed to mirror an aspect of herself that caused her great pain. When she looked at her child and saw that she was imperfect, she reflected that others saw her as an incompetent mother. Mother and child were merged as one but in a position of distress and narcissistic injury rather than a warm and loving attachment to one another.

From the child’s standpoint, Ali was a child who was clingy and viewed the world as unsafe and unpredictable. She was unable to move away and separate from her parents or explore the object and person world because of extreme tactile, auditory, and movement sensitivities and motor planning difficulties. She watched the world and viewed it as a scary place which only fueled her anxieties. She didn’t know how to engage in pleasurable interactions with her parents and other children, and instead, kept her parents close to her to organize and calm her. Her needs were that of a very young infant, not a child of 2 years.

Despite the lovely changes in Ali’s social behaviors, her behavior at home became increasingly worse. She was becoming more rude to her parents and doing outlandish behaviors to express her anger at them. She smeared feces all over the bathroom and yelled that she was angry. She said rude things to her parents, then when reprimanded, she would mock them back—“Well, you’re being rude!” When her parents tried time out with her, she would have a huge tantrum. Both parents felt that none of the limit setting worked and felt that 90% of their interactions with Ali were negative. This surge of oppositional behaviors coincided with her increase in social skills. It seemed that Ali’s oppositional behaviors were related in part to the fact that she never learned to negotiate the task of intimacy and engagement, and when she did finally learn to separate, it was with extreme anxiety. Instead, when she engaged with others, it centered around distress and anger. Ali did not know how to assert herself in positive ways. She seemed to be operating at two ends of the continuum—moving from a clingy, fearful child to intense, negative engagement.

During this period, it became more apparent the difficulty that Ali felt in self-calming. She often sought high intensity when engaged with anyone, not just her parents. She would say things like “I just want to be wild,” “I can’t stop myself.” In individual treatment sessions with me, she often submerged herself in the bubble ball bath inside my pup tent, screaming and laughing almost hysterically, wanting me to watch her as she did this. Often she would talk to the balls as if they were real, after which she would seem amazingly calm. In the pup tent she would exclaim things like “Stop, don’t do that!” to the balls.

Ali entered first grade that year in a specialized setting for children with learning and emotional problems. Over this year, we saw how she became overwhelmed with task or situational demands. Her response to requests to do things usually resulted in her becoming defensive, anxious, or avoidant. If she felt she couldn’t do something, she could become bossy or rude. She tried to control the activity by changing the rules to do it her way, or insisting that she could do it even when she couldn’t. We tried to encourage non-competitive activities to give her success in trying new things. I found that what worked well was structuring activities or selecting medium that allowed her to have varying levels of competence from simple to complex (e.g., art, dramatic play, construction toys). Once Ali organized herself, she often took cues from others to modify her responses or to model after them. If I gave too much direction early on, she would balk or becomes anxious. Finding ways to help her to take instruction from others was a major goal as she entered first grade.

Part of my work with Ali at this stage included consultation to her classroom teacher and the occupational therapist at school. I encouraged her teachers and therapist to have a familiar adult help her during transitions in activities, particularly when she had to go into a new situation or be with unfamiliar children. Unstructured activities were very difficult for Ali because of her dyspraxia, word finding difficulties, problems with visual–spatial perception, reading social cues, and executive functioning. For example, it was very difficult for her to walk down the hall on the way to the classroom or the lunch room. Open-ended situations like free play, recess, or field trips were very stressful for her. She wasn’t sure what to do or say. In these situations, she was apt to become a passive observer, show her distress by comforting herself (e.g., sucking on a finger), or by becoming silly (e.g., pretending to be a roaring monster). I suggested to her teachers to give her little assignments during these more open-ended times. For example, when walking down the hall to an activity, they asked her to carry something to be a helper. In large, noisy gatherings, such as the lunch room, we had her sit by the wall at a small table with only a few children, then had her leave the lunch room to a quiet space.

In the individual therapy, I focused on how to problem solve and sequence her thoughts. Ali needed help with being organized and figuring out how to do things on her own. We worked on how to connect ideas logically in a sequence, in understanding the link between actions and consequences, and to evaluate her behavior when problems arose. When we talked about problem situations, she had good skills in thinking through a solution, but enacting the solution in the midst of the problem was difficult for Ali, particularly because she tended to become loud, silly, overstimulated, or disorganized. What seemed to work best was enacting problems through dramatic play and presenting her with problem situations to solve, or prompting her to stop and think through what to do next as she worked through the sequence. I also used visual aids, such as pictures or writing down the steps in a sequence as I helped her to figure out the best way to approach the task, thus playing to her strengths as well. She did well when given a specific verbal script or series of pictures to guide her in taking action. I used videotaping and comic script formats as additional mediums.

The playground was very challenging for Ali. She would usually stand back quietly and watch the other children. By the time she figured out how to enter their play, the children often had moved onto something else. Many times other children didn’t invite her into their play because of this. It helped Ali to be paired with other classmates for projects, allowing her to get to know them in more structured activities. She also did well when cued on the playground of how to get started in play. She responded very well to a behavioral program that we did during that year—the playground program. This program first rewarded her for simply getting out of the car and watching the other children, then rewarding her for standing next to the equipment, and gradually working towards going on equipment without other children nearby to ones with children on it. Moving freely between pieces of equipment on the playground was hard for her, so giving her a sequence of what to do helped. The playground program also focused on her building connections with her mother, using walkie talkies where she could keep a connection with mom at the playground. For example, I suggested that when they used them, mom could ask her things like “See if there are any pine cones under the tree” or “count the number of children you see with white shoes on and report back to me.” We played race cars and remote control airplanes that Ali could move across the field. In her neighborhood, we had Ali deliver flyers to house doors for the county council on a regular basis. We gave Ali a map of the neighborhood and had her do neighborhood watch activities—count number of pink houses, number of green cars, number of barking dogs, and record it in her notebook. We did a similar program around walking into school by herself, having mom first walk her to the front door, then up to the big bush midway up the walk, and eventually having her walk by herself from the drop-off car lane. I also suggested that Ali be given something to carry when they were walking together outside, holding hands only in the parking lot or when crossing a street.

I tried to make the treatment as naturalistic as possible for Ali, we visited Pizza Hut one time to work on her hypersensitivities and fears of noise in this type of setting. Walking up to the trash can was scary for her to throw her trash away or going into the bathroom because of the automatic toilets. We talked ahead about what would happen that she would order pizza, sit with me in the booth, then we’d throw our trash away, and go to the bathroom. With each juncture, she exclaimed to me “I did it,” “I can do it.”

Ali seemed to enjoy school and showed a strong desire to learn, but would become easily upset when she made mistakes. She would say things like “I’m angry” when she couldn’t figure out how to do something. She seemed to do best if she saw another child solving the problem so that she could model after them. This worked better than if suggestions were made to help her. She was very responsive in my group if paired with a verbal child who could provide her with ideas. It didn’t work to focus on her statements of why she was angry. I found that giving her time and space to reorganize calmed her more and my ignoring these comments. She would generally come around within a few minutes, but if I joined her around her statements of anger, she would escalate quickly. Following these outbursts, I would simplify the activity and get her redirected in a productive activity like an art project or play scenario. I often suggested to Mr. and Mrs. B. to try this strategy, but they claimed it never worked for them.

Despite the good progress that I was seeing in Ali, I was struck by how Mrs. B. needed to hear over and over again what was going right for Ali. She seemed not to believe me when I told her how Ali was doing well in group and individual therapy. When I gave her concrete examples, that is, how Ali showed wonderful insight and empathy toward the other girls in the group when she was calm, she wouldn’t believe me and wanted me to say more. Throughout this year, there were some sessions with Mr. and Mrs. B. that they felt completely demoralized, saying—what was the point, nothing worked, and no one understood. I told them that it was Ok to be disappointed and angry with me that I hadn’t been able to make a big enough difference. Some of the ideas I offered to them may have been too difficult or not possible for them to do. I reiterated that I would stick by them and would not abandon them. Their anger at professionals, including me, had been mounting. They were frustrated that no one understood Ali and what her problems were. They were disappointed that professionals had not been successful in making a enough change in their daughter and that no one was addressing the real problem. Mr. and Mrs. B. did not want to acknowledge that Ali might be reflecting the anger of the household and needed to displace it to me and other professionals.

In several episodes of this story, our dolls were taken hostage by pirates and thrown into the dungeon inside the ship or thrown into a dark cave in some remote secluded place. Her doll always escaped and ran for help while my doll remained helpless and scared. In the end, her doll would save me from the dark dungeon by fighting off the pirates. Throughout the episode, the parents didn’t notice the children’s disappearance and were unconcerned for their safety. Ali seemed relieved for me to experience and understand what she had been struggling with for years, her fear of the outside world, lack of protection, and abandonment.

Over the years in my work with Ali, she often carried transitional objects as a way of comforting herself when out and about in the world. As a toddler, her comforting objects were a lemon, a bicycle helmet, and a paint roller and tray, all odd and hard objects, certainly not very cuddly. In the school years she latched onto Weazer, a doll she found at a yard sale that was very dysmorphic and reminiscent of the objects in Toy Story. Its hair was cut off and what was left was dyed pink. There was a light bulb on the scalp; metal bars jutting out for shoulders, and a hideous looking face. She brought Weazer with her everywhere and to her therapy sessions. Often Weazer was integrated into our play, and frequently I was cast in the role of Weazer’s mother. Could I love this distorted doll?

By the time Ali was 10 years old, she began carrying a large stuffed black labrador retriever with her, something that persisted for several years. It looked quite odd to see this dog on a young adolescent’s lap in the waiting room, so I asked her to bring the dog in a back pack so that it would look more socially appropriate.

By the time Ali was 16 years old, her play with the paper dolls stopped, but she became interested in writing stories at home. They were long plot-less stories about rap stars containing vulgar language. Her mother was deeply troubled by this, but I suggested that she allow her to write for a short period each day (i.e., 30 minutes) to give her an outlet for tension release. Ali reported to me that she “had to do this” and if she didn’t, she felt enormously stressed.

Ali had no friends until she reached high school. She attended a private school for students with learning disabilities and eventually developed a few superficial friendships with the kids in her class. Until that time, her only social relationships were with her family members and me. She seemed to have no desire for friends. In her interactions with me, she remained physically stiff and awkward, walking and moving like a robot. Her eye gaze was odd, looking askance and not scanning to look at my face or others’ emotional displays for feedback. In the social skills group that she participated in for many years, she sat there stiffly, not initiating any conversation unless prompted by questions. In contrast, when I saw Ali before the group in individual therapy, she would be quite spontaneous and relaxed with me, but as soon as we walked into the waiting room or group therapy room, she froze up. It seemed that the stimulation of more than one person in the room was overwhelming to her. I wondered how much her inefficient visual scanning and tactile defensiveness put her physically on guard and resulted in a shut-down state.

When Ali turned 18, she went to community college as an art student. Over the next few years, I saw Ali intermittently, usually around incidents when she had done something very impulsive. On one of these occasions, she decided to cut all her hair off. When she came down to breakfast in the morning, her parents were shocked to see her hair hacked off and later found the hair strewn about in the bathroom sink. Mrs. B. was extremely upset and felt that once again, here was another reminder of Ali’s poor judgment and manifestation of her distorted body image. I reframed the incident for her, suggesting that Ali didn’t know how to assert that she wanted to have a new hair style. They took her to a hair salon and reshaped the hair, but it was in such bad shape that they had to get a wig for her to wear. Surprisingly, Ali liked the wig stating that it felt good on her head.

Other incidents of this sort happened in the upcoming years, but despite this long journey, Ali was able to leave for college in her junior year, live on-campus, and make friends with the girls on her dorm floor. She had become serious about studying art and liked living independently. From time to time, she calls me to let me know how she is doing. In one of our recent sessions, she said to me, “You know who you are to me. You’re like a second mom.” How lucky I was to know her.