Is my child lazy...Or is it 'Output Failure'?Noted pediatrician offers a new kind of diagnosis

By Renee Cho April 21, 2003

Your child is lounging the entire length of the sofa, eyes glued to a seemingly mindless TV program. The weekend homework assignment hasn’t even been started, and he had promised to begin cleaning up his room. How lazy can a kid get? Add a new catch-phrase to the 21st-century dictionary — output failure. Your child may be suffering from this affliction, rather than the old standby: laziness, according to a leading child developmental expert. In fact, Dr. Mel Levine goes so far as to say there is no such thing as laziness. “While we may all have lazy moments, no one is a lazy person,” says Dr. Levine, professor of pediatrics at the University of North Carolina Medical School, director of its Clinical Center for the Study of Development and Learning, and author of The Myth of Laziness and the best-selling A Mind At A Time. His belief is that everyone is born with the desire to be productive and to feel effective. But some people lose momentum along the way, and parents and teachers often interpret this loss of momentum in children as laziness or not living up to their potential. These individuals, he says, may in fact be suffering from breakdowns in certain areas of their brain wiring that hinder productiveness — the problem he calls ‘output failure’. Output failure is a result, not a cause, and can take these forms of neurodevelopmental dysfunction: • Ineffective motor output, which can affect coordination and writing. • Insufficient memory, involving short-term, working and long-term memory. • Weak production controls which affect self-control and impulsiveness. • Insatiability and/or social distractibility characterized by thrill seeking and a preoccupation with stimulation and fun. • Low mental energy that affects alertness and the ability to concentrate. • Disorganization involving managing materials, time, and priorities. • Language dysfunction, which manifests itself in difficulty with expression and elaboration. • Impoverished ideation, which impairs creativity, critical thinking, problem solving and brainstorming. While output failure affects both adults and children, adults can be fortunate if they are able to find work that suits their strengths and weaknesses. Children, however, are expected to be competent in everything: reading, writing, math, speaking, spelling, art, music, gym, socialization, etc. But “each of us is endowed with a highly complex, inborn circuitry — creating innumerable branching pathways of options and obstacles…we all live with minds wired to excel in one area and crash in another,” writes Dr. Levine. Many children with output failure seem to be competent students at first, as neurodevelopmental dysfunctions can often go undetected for years (Dr. Levine is not addressing the problems of children with delayed cognitive functioning or emotional and behavioral problems, but those with learning problems). It is in middle school, when the demand for higher academic output increases, that students with output failure become less and less successful. To diagnose the condition, Dr. Levine conducts interviews with the child, parents, and teachers, and performs thorough neurological and physical examinations, thereby identifying the location of the breakdown in the child. Once he ascertains the areas of weakness, he talks to the child and parents about the child’s strengths and weaknesses in a process he calls “demystification” — helping the child understand how his particular dysfunctions affect his productivity. Demystification is optimistic and empowering, Dr. Levine stresses, because it focuses on the child’s strengths and offers him specific ways to deal with his weaknesses. He then suggests accommodations to be used at home and school by the child, parents, and teachers to help the child get around his weaknesses. For example, for a child with graphomotor dysfunction — difficulty writing due to motor weakness — Dr. Levine suggests using a computer for writing assignments, or printing rather than writing in script at school. Interventions are also proposed to help remediate the area of breakdown; in the case of graphomotor weakness, the child might work with an occupational therapist to drill basic letter formation. Some children will grow out of their weaknesses, but others won’t. Dr. Levine advises, “Parents should not wait if their child is struggling, because the social climate could damage the child in the meantime.” Being labeled “lazy” or “dumb” can become a self-fulfilling prophecy. If children are not ambitious, it’s often due to a fear of failure, Dr. Levine notes. And as he writes in A Mind at a Time: “Repeated failure inflicts penetrating wounds in a child’s psyche,” and may affect a child’s motivation, moods, self-esteem and behavior. Janine Bempechat, senior research associate at the Center for the Study of Human Development at Brown University and the author of Getting Our Kids Back on Track: Educating Children for the Future, agrees that lack of academic self-esteem can affect a child’s motivation. She cites research showing that when kids begin school, most of them love it. “In first and second grade, in fourth grade and at the beginning of high school, when kids become aware of social comparison in the classroom and get tested, we see dips in motivation. This is when kids start to develop a system of beliefs about themselves, what it takes to do well in school, and why they are doing well or poorly,” says Bempechat. What Parents Can Do As children progress through school, parents should pay attention to their ability to master skills, acquire facts, deepen understanding, approach tasks systematically, cope with the rate and amount of demands, and accomplish output. Parents should watch children for signs of output failure — such as difficulty with writing, difficulty doing school projects and making presentations, and difficulty completing homework. If a child is struggling and parents suspect there is a problem, Dr. Levine advises, “Parents must read up and educate themselves. Too often, parents allow evaluations to be done as fishing expeditions. They simply accept whatever the evaluation says. I want parents to go into an evaluation with a description of their child’s breakdown and an analysis of his weaknesses. And ideally, children should be evaluated without being labeled because if you are labeled, you spend your whole life feeling deviant. Labels don’t take into consideration your strengths.” Once parents understand where a child’s breakdowns occur, they can work with the accommodations and interventions necessary to restore the child’s confidence and strengthen his output. Dr. Levine acknowledges that a child’s learning problems do not all stem from hard wiring of the brain. Environmental and inborn influences can have a tremendous impact on how a child learns. Either affluence or poverty can affect a child’s ability to learn. Children under stress who cannot deal with it effectively often have problems with productivity. The intellectual climate of a child’s life — such as having parents and siblings who are good role models, attending a school with high expectations, and having a home life where parents teach children how to work — all influence a child’s productivity. “Kids deprived of structured work experience at home may not acquire productive habits and the self-discipline needed for effective academic output,” Dr. Levine asserts. The over-stimulation and immediate gratification of television and computer games can hinder a child’s constructive output. Plus, there are innate character traits that affect an individual’s output, such as ambition, optimism, initiative, adaptability and resiliency. Dr. Levine advises parents to strengthen and cultivate children’s output in the following ways: • Provide productive role models. Kids need to see their parents involved in serious work at home and at work. • Take an interest in your child’s schoolwork. Show curiosity about your child’s schoolwork and discuss it with him. • Reinforce and praise output. • Reward productivity, not grades. Children should receive recognition for putting in the study time, not for the results. • Provide work incentives. Being able to earn special privileges for hard work helps kids feel empowered. • Undertake collaborative projects. Parents and children working on projects together enhances family relationships. • Design and maintain a well-organized work space for your child. • Set up and enforce consistent work times. Kids need to set aside a certain amount of time for mental workouts, just as they would for physical fitness. Chores should be non-negotiable. • Limit TV viewing and other passive, hedonistic, or over-stimulating activities. • Help with prioritizing and multitasking. • Foster more than one mode of output. The arts and sports, for example, require mental effort, planning, delayed gratification, organization and self-discipline. • Serve as a sympathetic and nonjudgmental consultant without doing the work for your child. • Start early in life, ideally when the oldest child in the family reaches first grade.

What Schools Can Do Teachers are in the best position to evaluate children and identify breakdowns because they observe children over the school year in many different situations. For this reason, Dr. Levine founded the Schools Attuned program in 1987 to educate educators about different learning styles, neurodevelopmental functions, and how teachers can help children who experience breakdowns in learning. Andrea Rousso, who attended the Schools Attuned program at the Bank Street East Coast Regional Training Center, is a facilitator for the program and a special education teacher as part of a collaborative team for inclusion kindergarten at P.S. 321 in Park Slope, Brooklyn. “When a child is struggling,” she says, “we brainstorm, using the Schools Attuned format. We look at the child’s strengths and try different strategies (accommodations) to help.” For example, there are children in Rousso’s classroom who have trouble with writing. She changed the seating arrangement to create a group of six, including three special needs children, who sit together at a table. This group never starts writing until they verbalize what they’re going to write because these children need to feel and hear the words first. Other types of accommodations might involve setting multiplication facts to a rhythm to facilitate memorization, or using color to help kids identify the main idea. Some educators disagree with Dr. Levine’s approach. One Norwalk, Conn., teacher, who reviewed The Myth of Laziness on Amazon.com, criticized the book for focusing on “how teachers and parents should change their standards to accommodate students, not on the work the students themselves need to do to adapt to the educational system…These children need to be in some sort of special education program, working one-on-one with someone who is trained in this area; and the onus needs to be on the student to learn to adapt to the discipline of the classroom, not on the teacher to relax the standards of the program (which will, of course, also adversely impact the education of the other students in the class).” Bempechat also feels that making too many accommodations for individual students is inadvisable because “everyone knows who’s getting the hard and easy work. It stigmatizes kids and communicates a lack of confidence in them.” She believes children should be allowed to grapple with mistakes, frustration and failure. In her research, she has found that when children are given the messages that nothing comes easily, that everything takes effort and that the effort will be worthwhile, they do better in school. There’s an unspoken expectation that Schools Attuned-trained teachers will use good judgment to strike a balance between accommodating a student who’s struggling, and letting him off the hook, says Rousso. “You’re not lowering expectations, but reducing stress for the child with the understanding that you will deal with the writing, say, another time.” In A Mind at A Time, Dr. Levine advocates the “payback system” in which a student takes on additional work to compensate for an accommodation. A teacher might give a child an extra week to finish her term paper because of her writing problems, but ask her to repay the accommodation by creating a poster utilizing her artistic ability. Accommodations are often designed to tap a child’s strengths so that she identifies herself in a positive way. Susan Hurley, a Schools Attuned-trained kindergarten teacher at Rippowam Cisqua School in Bedford, and a Schools Attuned teacher of pre-K through seventh grade teachers at Bank Street, has dealt with some teachers who felt overwhelmed when first introduced to Schools Attuned. One young teacher in her second year at a public school asked Hurley: “I have 43 kids in the classroom. Johnny in front is a behavior problem and the third kid on the left is having trouble with his work! What am I supposed to do?” Hurley suggested she look at the situation from the perspective of the child struggling with his work. The young teacher examined his output and came up with an accommodation for him: she wrote her schedule on the board and also on post-its for the children who needed it. She found that it helped not only the child having trouble, but the whole class. Says Hurley, “I advise young teachers to do what they can. Sometimes a mini-demystification is enough to keep the kids moving in the right direction.” Although Schools Attuned-trained teachers are taught to focus on the one child who is having problems, all of the teachers we interviewed reported that when they made an accommodation for one child, other children in the class were helped by it. Kathryn Perry, a Spanish teacher for grades six through nine at Rippowam Cisqua, says,“Since I don’t want to stigmatize one child, I introduce the accommodation to the whole class, then follow up with the troubled child.” The program also involves teaching children and their parents how learning works. Lisa Bianco, principal of the East Village Community School in Manhattan for pre-K to sixth grade, where 80 percent of the teachers have had Schools Attuned training, reports that almost every teacher discusses the concepts of memory and attention with the children, even in kindergarten. The school also conducts conferences and workshops with parents to help them understand how their children learn, and gives them strategies to use at home which parents very much appreciate. “We talk to the students about paying attention and about what their problems are, and have conversations about learning styles,” says Roberta Valentine, a first and second grade teacher at the East Village Community School. “When children become aware of what they need to do to learn, they are empowered to ask for help. They also become more accepting of other children’s thinking styles. And they understand that ‘Just because I can’t read as fast as Johnny, doesn’t mean I’m not OK, but that I need more time.’” Through the training, teachers become sensitized to their own learning styles and the strategies they are not employing because of their natural tendencies. Perry observes, “Once you become aware of your own strengths and weaknesses, you can offer the students multiple strategies which help them learn what works best for them.” For instance, when Perry assigns vocabulary, she offers the children four different ways of studying the words and lets them pick the one that’s most effective for them. Cathy Greenwood, a seventh and eighth grade English teacher at Rippowam Cisqua, and president of the Westchester Council of English Educators, is looking forward to taking the Schools Attuned program herself, but she acknowledges that “some public school teachers criticize Schools Attuned because they are already being asked to do so much and kids’ issues have become much more complex. Often teachers have 20-25 kids in their classroom and must coordinate their lessons with or without aides for the special needs kids.” In this era of drastic budget cuts, is Schools Attuned a luxury that overburdened schools simply cannot afford? Dr. Levine believes that training teachers in the Schools Attuned program actually saves schools money. “Educated teachers refer fewer kids for testing or to Special Ed and have less behavior problems in class,” Dr. Levine says. “Because there is less humiliation for kids, there is less acting out. And more teachers seem to remain in the teaching profession because it becomes more interesting once you truly understand the learning process.” Most of the teachers we spoke to believe that good teachers are always looking for better ways to help their students. “Schools Attuned is a finer breakdown of problems based on behavior you see and because it’s more precise, it’s more helpful for teachers,” Perry notes. “It’s a lens through which to look at kids’ behavior so you can play to their strengths and give them hope. It gives kids a reason to keep struggling.”

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“Laziness is in the mind of the accuser….When you say someone is lazy, you admit that you don’t understand him.” Dr. Levine concludes, “What appear to be dysfunctions during childhood may transform themselves into assets as individuals mature. If we are able to preserve their self-esteem, their optimism about the future and their motivation, children with output failure can grow up to become tremendously productive people.”

Resources: • The Myth of Laziness by Mel Levine, M.D. (Simon and Schuster)

• A Mind At A Time by Mel Levine, M.D. (Simon and Schuster)

• Getting Our Kids Back on Track: Educating Children for the Future by Janine Bempechat (Jossey-Bass)

• All Kinds of Minds, a non-profit institute founded by Dr. Mel Levine that develops products and programs to help parents, teachers, clinicians and children deal with differences in learning; www.allkindsofminds.org

Children Can’t Always Listen As many as one in five children may have an auditory processing problem, making listening and learning almost impossible

By Anthony Ebersole

“OK, class, before we begin today’s review of chapter nine in your science book for tomorrow’s test, please take out your math homework and put it on top of your desk for me to pick up; then we’ll get started.” David takes out his science book and just stares into space. What’s the problem? Wasn’t he listening to the teacher’s directions? Distracted? Poor attention? Hearing loss? There might be another explanation. Perhaps David is able to hear the sound of the teacher’s voice, but has a problem processing or understanding what was said — particularly when the language used is complex, spoken rapidly, or is lengthy, and when there are a lot of visual or noisy distractions in the room. This inability to fully understand spoken language in the absence of a normal hearing loss is called a central auditory processing problem. Research indicates that up to 20 percent of school age children have some form of auditory processing disorder (APD). This means they can hear, but their brains may not be able to effectively process sounds. Undiagnosed, APD in children can frustrate parents and teachers for years, since only a trained audiologist can detect the disorder. Children (and adults) afflicted with APD often demonstrate a reduced ability to read, spell, comprehend and communicate with others. To them, spoken words may become jumbled, often making any communication or understanding impossible. Left untreated, these difficulties can lead not only to academic failures, but to increased anxiety in social settings, the inability to make and keep friends, and a damaged sense of self. While APD is treatable, it is often a disorder without any surefire cure. The earlier it is detected in children the better, and there are a variety of strategies to help overcome listening and processing difficulties. In the classroom and at home, interventions can help students with APD learn and achieve. Success depends not only on early detection, but also on a consistent team effort by the child, his parents and his teachers.

“What?” With children, a tip-off that APD is present is his or her tendency to ignore a speaker when engrossed in something, or constantly replying, “Huh?” or “What?” whenever spoken to. This stems from their hearing not only the sound of a voice, but also all kinds of other background noise, and being unable to discriminate between all the sounds. These children are usually extra sensitive to loud noise, have a tendency to confuse similar sounding words, or get confused if several directions are given in one sentence. The origins of the disorder can be traced to any number of factors, including frequent ear infections as a young child, under stimulation during a child’s early years, dietary and environmental issues, allergies, even family history.

A child should be tested for APD if they display any number of symptoms, including misunderstanding directions, delays in responding to instructions or questions, or problems understanding in the presence of background noise. APD children often have poor expressive or receptive language skills, and can lag behind in spelling, reading, and other academic problems. Socially, these children also have difficulty forming or maintaining friendships, because they lack the processing skills that allow them to pick up non-verbal social cues, like humor, sarcasm or subtleties of speech. “Many children with APD become masters at hiding their disorder,” writes Teri James Bellis, Ph.D., in her book When the Brain Can’t Hear, Unraveling the Mystery of Auditory Processing Disorder. While they may actively try to participate early on in classroom or other activities, Dr. Bellis says these sensitive children often become guarded when they are repeatedly ignored, even ridiculed, because their responses are slow or seem to lack understanding of a topic. “After years of (feeling outcast or ignored), some (APD) children simply withdraw from communication altogether…But this is merely a mask that allows them to protect their vulnerable, hidden inner selves and to retain some semblance of power over the daily situations in which they feel powerless,” Dr. Bellis writes. Since APD is not commonly recognized or understood by parents or teachers, a child can go years before a proper diagnosis is made, and only then by a trained audiologist able to go beyond a routine hearing test to examine how a child’s central nervous system is functioning.

Getting the Right Diagnosis Even though a child may have passed a school-screening program, only an audiologist — one who is familiar with APD — can rule out all degrees of peripheral hearing loss and check out the integrity of the auditory system. While children with this disorder often show good hearing results on routine screening tests, at the core of their difficulty is an inability to integrate information when it gets to the brain. “Integration is basically synthesizing information in terms of how the two sides of the brain work together, so that you can take in more and more stuff,” according to Jeanane Ferre, Ph.D., an audiologist who specializes in APD. “Your output skills reflect how well you can organize, sequence it and get it out again. Any type of breakdown in any of these areas is going to cause a processing problem,” Dr. Ferre says. Auditory processing in children affects their ability to solve problems, to reason things through. The breakdown can begin when sounds (words) aren’t getting through properly, so they don’t hear a lot of the information needed to solve problems in the first place. These children can be inflexible. That’s because in their attempts to overcome their difficulties in understanding sounds, they cling to a narrow, black-and-white view of the world. They aren’t able to see the subtleties, the gray areas in words or relationships, like irony or sarcasm. They interpret things literally. Because of this, they often have difficulty thinking logically, or seeing the consequences of their actions. In other words, they can’t see the trees for the forest. They need help not only in seeing the big picture, but all the steps and parts that go to make up that picture. APD children can seem younger and less mature than other kids their age. In their ability to synthesize information, they actually are younger, and have to be thought of as such. They can be very sensitive to criticism, often hearing anger in adult voices when none is intended.

Strategies for Learning and Teaching with APD Once a qualified audiologist makes a determination of APD, a number of strategies can help improve processing. They include various therapy programs, managing the listening and teaching environments, and learning more active listening techniques. Some children can catch up through this remediation and can grow out of the problem. Still others will have processing difficulties throughout their lives. The degree of success can depend on the extent of the disorder and types of interventions.

—In the classroom. The learning environment needs to be modified to help the child with APD. These changes should include paying special attention to classroom acoustics to reduce reverberation or distractions, and preferential seating to maximize benefits from a teacher’s auditory and visual cues. An open, unstructured teaching environment should be avoided.

—Teaching modifications. There are numerous improvements that can be made in teaching APD children. According to Dr. Dorothy A. Kelly, an audiologist who specializes in teaching the hearing impaired, they should include: • Organization – these include regular routines and schedules that increase predictability and decrease listening and memory demands. • Repetitions/Restatements – when a direction is not understood or not completed, wait a little while, then restate it in a different way. If the direction is still unclear, repeat the direction, slowly, a bit louder. Some children have slower processing time. • Visual Aids – these can reinforce auditory information. • Eye contact – it always helps to say the child’s name before speaking to him or her, and maintaining eye contact, which helps speech reading and attention. • Pre-teaching new material – it is often helpful for someone (a parent, an aide) to go over new vocabulary or critical concepts before they are delivered to the rest of the class. These can be presented in writing, so the student is familiar with the words and ideas that will be presented.

—Strategies for the child/student. Children with APD can learn to be better listeners, but it takes work and patience. According to Dr. Kelly, these involve: • Requesting clarification – whenever words seem unclear, the child should be encouraged to ask the teacher for additional information or to restate what she just said. • Take accurate notes – to listen for key words, summarize in bulleted form, restate the lecture aloud using notes. • Follow directions accurately – a student should try to be aware of “what” he or she is doing throughout a task. • Proofread – this is a way to check written work, and can include listening to how the voice changes as words are read aloud.

There are a number of therapies available for people with APD, including audiotapes, music lessons, exercises that force the two halves of the brain to work together, and computer-based therapy programs. These should be employed only after a thorough diagnosis by a qualified audiologist and should be directed toward the specific type of APD in a child or adult.

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