Self-Stimulation: Dr. Hammer Responds
by Dr. Ed Hammer, Professor, Department of Pediatrics
Texas Tech Health Sciences Center in Amarillo
Reprinted from the Volume 2, Number 1 issue of News From Advocates for Deaf-Blind, a tri-annual publication of the National Family Association for Deaf-Blind.
From the Editor: The general consensus is that blindisms (mannerisms or self-stimulation behaviors such as excessive rocking, head swinging, finger flicking, eye pressing, etc.) are bad. Enlightened parents and professionals understand that these mannerisms detract from a normal appearance and, with the goal of averting future social problems, they move quickly to quash them whenever they crop up. There isn't much concern about why kids do it the rocking, the finger flicking, the eye pressing only that they stop doing it. If a blind child responds well to firm consistent measures, the why probably doesn't much matter. But the why may be significant for blind children who don't respond and very often these are the children who have additional, often severe, disabilities.
This article and the one that follows A Parent Discusses Self-Stimulation tackle this troublesome topic from the premise that to the child in question the purpose of these behaviors matters very much, indeed. (Both articles, by the way, are reprinted from issues of the News From Advocates for Deaf-Blind newsletter.) Some readers may find the conclusions enlightening and informative, others may find them disappointing and off base. Whatever the reaction, I think the point is well taken that the ">It's bad, stop it" approach won't cut it when working with blind multiply disabled children in the often complex task of balancing the need to learn and the need to develop socially appropriate behavior. Let's begin with what Dr. Ed Hammer has to say on the topic:
1. Can stims be developmentally appropriate for a child at a certain time?
I am always hesitant to give answers as blanket responses about behaviors. These behaviors come from a child and each child is different from the next child. What I might say about one child might very well not be appropriate for the next child. With that caution in mind, I'd like to talk about the brain, the mind, and the person.
We are all born with a central nervous system (the brain and the nerves) that is not complete. It takes about 12 years for the central nervous system to be finished. In those 12 years, there is a specific progression that takes place that completes the central nervous system. How does this happen? Well, the central nervous system completes itself. It does so by (1) growth, (2) development, and (3) maturation. It does so by feeding itself from internal sources and from external sources.
External sources include stimulation of sensory receptors by light, sound, touch, smell, pressure, or movement. Internal sources include completing nerve connectors (synaptic bridges) and growing insulation to protect sensory and motor pathways (myelinization). It organizes this progression by the maturation of the brain from primitive systems, through mid-brain organization, to higher cortical functions. Not only must the central nervous system build itself, but it must do so with the available body that the person has. Thus, for the infant who has a very immature central nervous system, there are not synaptic connections present to allow him to talk, walk, sit up, or do much of anything independently. As a child grows, nerves begin to mature and development may be observed.
At these times, there are self-stimulating behaviors that are not only developmentally-appropriate but also required if the child is to mature toward independence. An example is the child who is learning to use the oral motor area (mouth, tongue, and throat). Putting the lips together helps the baby learn to suck in order to receive milk and to control the tongue. But that action also permits the baby to make front sounds such as 'm', 'b', and 'p'. Babies practice making those sounds. They also get lots of encouragement from mothers for making the 'm' sound. When the baby is alone, you can hear the 'm' sound even when the baby is not nursing. It might be called practice, but it is also a stim.
When the central nervous system is hungry for information that helps it progress, there are behaviors that answer that need. These may be called stims, but they are very important building blocks toward mature behaviors.
Interestingly, the stims follow a similar progression as the maturation pattern: from primitive through mid-brain to the cerebral cortex. In our culture, we are only interested in looking at higher cortical functions in terms of learned behavior (speech, reading, writing, abstract thinking). There is a whole world of learning that is limbic (primitive arousal) and associational (mid-brain coordinating) in nature. Unfortunately, we do not train professionals to work in these areas.
When a child is impaired, the impairment may effect the way the system needs stimulation or the amount that is needed. Some stims may come from efforts of the central nervous system to jump-start the next level of maturation, growth, or development. For this reason, it is speculated, stim behavior in children who are impaired may be more exaggerated than for the child who is not impaired. The need is present; the behavior is for a purpose. The challenge is whether we can understand the underlying process. Remember, when the process is in place, learning the skill is a piece of cake. But when the process is not in place, the central nervous system compensates to find the stimulation it wants and needs. Impairments are process breakdowns.
2. How do you know if these are developmentally-appropriate or one of those stims that causes the child to withdraw into himself and disappear?
Did you ever ride down the street thinking to yourself about how you would like to yell or tell someone else off and then catch yourself talking to yourself out loud? Do you remember how embarrassing it was when you looked over at the next car and noticed the person looking at you as if you were crazy? I think this question is close to that situation.
So what if your child rocks when he needs to orient himself in space? Which is more important: what the child needs or what someone else will think about the child (or you, the parent) if they see the child do something off or eccentric? If the child has a sensory hunger, then it needs to be fed. If it is not fed and thereby allowed to be incorporated into a more complex behavior, the child gets stuck in the developmental progression. I think you are really asking, 'What if the child gets stuck in one of these stim patterns and does not come out of it?' Well then the child is not receiving the types of opportunities that encourage incorporation of movements into complex behaviors. Get that started and the self-stimulation behavior will change.
There was a time when the field believed in a critical period of development. That is, if the child did not experience a certain behavior or pattern at a critical age, then the opportunity was lost forever. That is not true. A person always gets another chance. The central nervous system is far more sophisticated than to ignore opportunity. So if a child gets stuck, the risk of just disappearing into oneself is not the issue. It may be the fear, but it is not the issue. The real issue is to try to understand the hunger and feed that need.
3. Is it valid to think of a stim as a motor communication?
Of course it is a communication act if it tells the other person something. When a child is wet, hungry, or angry, there are nonverbal (e.g., non-cortical) ways to signal that to another. If the communicative loop is somehow modified, then other communications that are simple motor acts serve the same purpose. If I hold up my hand toward you with the palm facing you, it means stop. If I do not have the word stop in my vocabulary, I might turn away, look away, close my eyes, or throw up on you to tell you to stop. Look for the motor act that is consistently telling you something and try to find the meaning that is being conveyed.
With premature babies, we know that they have very consistent movements that signal approach, avoidance, or potent withdrawal. These are all motor acts that are learned very quickly by even the most premature babies. Certainly these are communications. Are they stims? Well, to someone who does not read these behaviors they would appear as a stim behavior, but to those who know every little movement has a meaning all its own, they are powerful attempts to convey a message. Somehow we have automated the way we look at language development as if it were on some railroad track chugging right along. For the person who does not have a clear track to run on, it is necessary to look at the modified ways a person communicates. See, I don't think in terms of stim or not stim. I think in terms of metaphor, that is, what is this person trying to tell me.
4. Is it appropriate to encourage these stims and try to mold them, or is it better to redirect this behavior?
I do not think you can encourage a stim behavior. It is a need of the person and is not enhanced by encouragement from another. However, there used to be a program called toy play that addressed this question very clearly. Toy play was a program that encouraged the extension of a stim behavior by making it a socially-appropriate behavior. For example, a child flicks his hand before his eyes to pattern light. You could put a bracelet with bells on the child's arm. When the child shook the bells he would activate a clapper switch attached to some type of light source (something you know he is interested in because of his self-stimulation). The child learns through exploration that he/she can control the light source. Others can interact with him in this game. Different kinds of light sources can be introduced such as toys that incorporate lights with sound or vibration. The bells can be changed to produce different sounds. The behavior becomes more purposeful and outwardly directed. The child expands his interactions with his environment. The new behaviors also may be perceived as more socially-appropriate. Flicking can be decreased while still acknowledging the sensory need.
As a behaviorist, I am guided by the dead mans rule which says that dead men have no behaviors and no behaviors put the behaviorist out of business. What you want to do is to go to where the child is and let the child take you where the child needs to go. Along the way, you shape in the socially-appropriate behaviors that will lead to independent living and working.
There is an old myth that needs to be laid to rest. This myth is that children must somehow qualify for services. That is, if the child cannot perform to some set of standards, the child is not worthy, receptive, capable (fill in the blank with your own experiences with prejudice) of the wonderful services offered. Let's get rid of this idea. Let's begin to share with each other that we are all pioneers and learning from the child. The professional has a history of how to do some things, but the professional does not know this child any better or have any more magical secrets than the parent who has learned to let the child flick to get to sleep at night so the whole family can rest.
I think the first chore is to learn to work together and not get freaked out when there is some behavior we cannot immediately control. Use whatever behavior there is to go where the child wants to go. I always admire those who venture into problem solving using their training but learning from the situation how to program for the individual. We must always learn from the child.
To answer the question more directly, you use the stim and redirect it by molding it at the same time. The molding is, however, in my experience, best directed toward incorporating the behavior into a larger, more complex behavior (i.e., rocking into moving, flicking into oral motor competence, crying into speech sounds, etc.)
5. If the movements that professionals call stims or blindisms serve a purpose, are they really stims?
Back when I started in this field, there were major efforts to investigate and identify the blind personality, the psychotic personality, and any other disability personality that could be imagined. What happened was a field that began to think in stereotypes. There is no such thing as a blind personality, or any other disability personality. Fortunately, we have matured as professionals and target more relevant issues in our research. However, the field is still focused on cognitive functions; reading, writing, abstract thinking, or overall normalization meaning that the impairment does not impact on the person.
The impairment is going to impact on the person in the way that a person responds to the experience of the impairment. This does not lead to a disability personality but it affects how that person handles information. For a professional who is trained to look at higher cortical functions only, then any limbic driven or associationally-dominated actions are viewed as aberrant. The stim tells us something if we can just figure out what it is saying to us. I choose to view this stim as a sensory hunger, a way the central nervous system asks for some help in organizing information and making sense out of the world. It does not bother me for someone to call the pattern a self-stimulatory behavior or a stim, as long as we respond to the need, the hunger, and the attempt to organize information by the child.
6. If we can classify the childs stims into categories (like tactile, gustatory, vestibular, etc.) why can't we get a handle on what the sensory input is that he is seeking and just supply that to him?
Oh, if it were that simple. It is always difficult for parents who realize that they are walking into the field in the middle of things. Maybe there is some comfort to feeling that everything is known and that practices have been in place for years and years. It does not take too long to figure out this is not the case. In many instances, we are just beginning to understand children who are impaired. The progression of knowledge goes from theory to study to validation to practice.
Most of the field concerned with disability is at a theory level with some studies popping up. There are several pioneers in the field who have attempted to move from theory to practice. The best known were a husband and wife team in England, Karel and Berta Bobath. They studied neuro-developmental techniques that pertain to this question. They were highly successful, but in America the Bobath's work is still viewed as experimental or marginal.
Another person who studied this area was Jean Ayres from Southern California. Ayres believed that limbic and associational motor expressions could be integrated into more cortical functions. Her approach is also considered lacking by some in the field.
I like the work of Berry Brazelton, a pediatrician formerly on the faculty at Harvard University. His work then was considered unfounded and appealing to the popular press. Brazelton, who is originally from Waco, Texas, used the work of a man named Wolf to read the limbic and associational cues from infants to assess their needs and development. I doubt that it will occur in my career span, but someday these theories will be synthesized into a better understanding of the roots of learning and the patterns of behavior in children who are impaired.
A lot of the information is available, but the synthesis is lacking. Heidilese Als, who is presently at Harvard, has a major grant from the United States Office of Special Education and Rehabilitation Services (OSERS) to study Brazelton's work as it can be applied to children who are disabled. You may want to write to her to keep up with the progress of her early childhood institute.
7. If we assume that these stims are ways to seek input, how can we explain that these same movements are being used by the child as a means of output (expressive communication)?
The movements you are calling stims are not the input part of the equation. The stims are the output side. The input side is some sensory hunger or need. We need to look at the whole equation: input, processing, output. What if the stim is something hazardous like the child beating his head against the floor? I could not understand that behavior as a self-stim until I saw a child who beat his head against the floor because he had developed glaucoma after his cataract surgery and no one knew of the pressure on his eyes. The head beating was a problem but not near the problem that the glaucoma presented. The input side is what needs to be understood. Unfortunately, the output side is visible and receives the most attention.
(back) (contents) (next)