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Hydrocephalus Education & Behaviour for Teachers

The Child’s Point of View

Not all children with Hydrocephalus will present as ‘a behaviour problem’. When problems do arise, however, it is important to realise that there may be underlying causes that need to be addressed, and these may not be obvious at first. A child with ‘behaviour problems’ is often a child who is experiencing a problem and is tackling it as best s/he can.

For example, the problem may be due to:

A physical condition:

  • A shunt blockage or infection;
  • Migraine (but a severe headache should always be taken seriously and investigated);
  • Low energy levels (some visibly ‘perk up’ after a snack); Hypersensitivity to noise (e.g. laughter, clapping, lawnmowers); Hormonal changes (precocious puberty, PMT);
  • Food intolerance (diet may be implicated in about five percent of children with behavioural problems).

Adverse social experiences:

  • Bullying (they may be targets for taunting and abuse as they are often more immature than their peers;
  • Social exclusion (cf ‘Does he take sugar?’);
  • Communication difficulties (poor ‘listening’ memory; reticence in responding to a request for personal views, explanations etc., although appearing to be very ‘verbal’);
  • Well-meaning over-protection (they may become used to thinking themselves incapable of certain tasks).

Delayed development of:

  • Temporal concepts (difficulty predicting ‘what will happen next’);
  • ‘Filtering’ systems for environmental information (difficulty differentiating ‘relevant’ and ‘irrelevant’ information, resulting in anxiety, a lack of self-confidence, and a reluctance to abandon familiar routines, because what is ‘familiar’ is ‘safe’);
  • Stress-tolerance (resulting in frustration that sometimes only ‘boils over’ in another, different setting, especially if there are also communication problems);
  • Self-monitoring systems (learning to ‘wait’; to stop and think before acting; to reflect on actions).

A paucity of opportunities to ‘impress’:

  • Unsteadiness, poor spatial awareness (poor performance in PE);
  • Difficulties with co-ordination and fine motor control (poor handwriting);
  • Working memory problems (difficulty organising work; remembering instructions; contributing, unprompted, to class discussions).

Every single human being is born with a desire to ‘act on the world’. This urge encourages exploration of the physical and social environments. Through a process of trial and improvement, children can learn to maximise the positive feedback they get from their efforts to, for example, manipulate objects and establish supportive peer relationships. They learn to think ‘I can...’. When there are few opportunities for such positive feedback, it may be difficult to establish a sense of self-esteem. Such circumstances are familiar to everyone in relation to ‘down-sizing’ in employment. The feeling of not being in charge of one’s own destiny, and being unable to ‘impress’ others, can be as devastating for children as for adults.

The Teacher's Point of View

(The term ‘teacher’, here, applies to teachers, therapists, classroom assistants, carers and all other responsible adults).

Some of the following problems may be more evident in children who were pre-term babies and have shunts. Difficulties in maintaining concentration may be apparent irrespective of the general ability level of the student. Misleading interpretations are indicated in brackets:

  • Distractibility and short concentration span (needs to be ‘stood over’);
  • Apparent inattention to instructions (needs a ‘personal invitation’ to follow a class instruction);
  • Difficulty with peer relationships;
  • ‘Over-familiar’ (lack of differentiation in manner of addressing different people);
  • Very talkative, but reluctant to respond to a direct request for explanations/ descriptions (‘patchy’ answers focusing on isolated, unconnected details);
  • A disorganised approach to work, untidy writing;
  • Reluctance to engage in ‘difficult’ work without help, lack of initiative, easily frustrated;
  • Impulsiveness (shouting out an answer before ‘thinking it through’) and restlessness (‘fidgety’);

Multiple Perspectives

Although it has been indicated that the ‘problem’ is often due to a lack of understanding, this does not mean that ‘blame’ should be portioned out to parents, or teachers. ‘Blame’ is not a useful concept. Everyone concerned needs to be ‘open’ enough to admit that more could be learned about why children (and adults), with and without hydrocephalus, behave the way they do.

It is important to investigate whether or not the observed behaviour could be the result of any of the ‘physical condition’ listed above. The consequences of overlooking any of these problems could be very serious.

Once this has been clarified, and ‘physical’ explanations ruled out, alternative approaches can then be investigated. It is likely that more than one intervention will need to be implemented at the same time. For example, although a child may be very badly behaved at home, but not at school (or vice versa), everyone needs to understand that there is a problem to be tackled and agree on specific approaches. Good home-school partnerships will ensure that information relating to possible medical problems is shared and understood, and that the ‘strategies’ to be used to solve behavioural problems are consistent. No strategy will ‘work’ unless the child is also involved in the ‘problem-solving’.

It is important to make a point of observing and noting the outcomes of these approaches and modify them as necessary after discussions. If a child has a classroom assistant (Learning Support Assistant), it is useful to consider both the assistant’s and the teacher’s observations.

Skills and Motivation

Behaviour management can sometimes be interpreted very narrowly as ‘crisis management’. This short-term view fails to recognise the skills children need before they can begin to respond in an appropriate way. If they can begin to think ‘I can…’ and become aware of the skills and knowledge they are developing (social, physical, and academic), they may be more likely to find the energy and commitment to focus on self-improvement.

Developing Co-Ordination and Perception

The limitations re, for example, fine motor skills, should be understood and, if remedial interventions are not effective, alternative ways of presenting work should be considered. Multilink activities provide the opportunity to develop important concepts about spatial relationships, and to establish the concept of ‘pattern’ (see ‘Hydrocephalus and Mathematics’). In turn, these abilities and understandings can boost self-esteem. (For some children, there has also been a ‘knock-on’ effect on handwriting/colouring -in.) Ideas about time are more advanced than spatial concepts and will take longer to develop. Many children begin to feel more proud of themselves when they are encouraged to take on more practical tasks at home, e.g. making a cup of tea, cleaning etc.

Developing the Working Memory System

To begin with, they may need short ‘relaxing’ tasks interspersed with tasks that require high concentration. ‘Working memory’ problems can have an effect on concentration; self-inhibition (as opposed to impulsivity); organisation; creativity (taking the initiative, problem solving); and flexible thinking (a readiness to adapt to change). Children can be helped to learn the memory and thinking skills that others seem to develop ‘naturally’. It is important that they learn ‘self-inhibition’ (‘holding themselves back’). With young children this can begin with learning to ‘wait’ for very short periods and then being praised. Older children also need to learn to ‘stop and think’ before they act. It is the awareness of deliberately ‘stop to think’ that is important.

Until the ‘listening’ memory improves, all instructions should be as brief as possible; should be worded positively; and should be unambiguous. Avoid the word ‘don’t’ as the extra processing time required may mean the most important part of the instruction is ignored. The children can learn to repeat instructions given to them and, in this way, learn to link the instruction with the action to be performed.

Oral information can also be backed up with written/pictorial reminders and. When the children are older, they can learn to remind themselves in this way. Long tasks can be broken up into ‘mini’ tasks that can be listed as a timetable, so that they know what to do next when one task is finished.

Developing Communications Skills

The majority of children learn behaviours and thinking strategies by ‘being with’ other people. For children with hydrocephalus, this tacit knowledge often needs to be made explicit. Practice in responding to a request to recall, organise, and communicate personal memories can help. It is important to remember to link up the visual and oral modes by ensuring that the children can ‘see’ what they have said. Symbols are important for them, as is sentence structure.

Class discussions will be difficult for many, but they can be helped to learn how to ‘rehearse’ information (see above). Later, they can learn to ‘whisper’ instructions, and texts, to themselves before repeating or reading the same information aloud. While they are learning this skill, they will still need visual (written or pictorial) reminders of spoken information (checklists, diaries etc).

Because many are unused to expressing their own views and feelings, they need plenty of opportunities to learn how to do this. ‘Circle Time’ provides one such opportunity. Some also have difficulty with non-verbal communication. There may be difficulties in ‘reading’ the body language of others and reacting appropriately. Role play, and dramatisation of poems and stories can help to develop a range of vocal and facial expressions, and gestures. (For many, the number of different social roles they have learned is very limited, and they tend not to ‘switch’ between these roles as easily as other children).