Williams Syndrome (WS) is a rare condition, occurring in approximately 1 in 20,000 live births. As a result, most people will not have encountered a child with WS before, and they will understandably know little, if anything, about the characteristics and difficulties associated with the condition. Of course every individual is different, and not everyone with WS will show all of the characteristics and difficulties described below. Some of this information is based on research undertaken over the last decade, which demonstrates that WS is associated with a number of distinctive behavioural and psychological features, which differentiate children with this condition from others with learning difficulties. It is hoped that this information and the advice and suggestions that follow will be of benefit to the families of children with WS.

The following topics are aimed at trying to answer some of your initial questions:
Description of the Syndrome
Abilities of Children with Williams Syndrome
Behaviour of Children with Williams Syndrome
Feeding and Eating Difficulties
Sleeping Difficulties
Toilet Training
Dressing
Social Relationships
Suggestions for Dealing with the WS Child's Over-Friendliness
Anxiety
Preoccupations, Obsessions and Stereotyped Behaviours
Temper Tantrums and Aggressive Behaviours
Hypersensitivity to Sounds
Coping with Hyperacusis
Speech and Language Skills
Concentration Difficulties and Over-Activeness
Improving the Child's Concentration Span
School Related Concerns
Implications for Siblings

Description of the Syndrome

Williams Syndrome (WS) is a genetically determined, intellectually disabling condition. Most affected children develop severe feeding difficulties in the first year of life, including vomiting, constipation and refusal to feed; they may be irritable, cry excessively and do not thrive well. Some of the children are found, on testing, to have raised levels of calcium in the blood (infantile hypocalcaemia); they will be put on a low-calcium and vitamin D-restricted diet by their doctor and the feeding difficulties then improve, either rapidly or, in some cases, more gradually. Many of the children also have a distinctive facial appearance (the "elfin" face), renal and cardiac problems (a heart murmur, narrowing of the walls of the main blood vessels carrying blood from the heart), which may be severe or quite mild. Other children, while having the typical facial appearance and heart problems, do not have high calcium, and so are not put on low-calcium diets.

Individuals with WS may also have dental abnormalities, back and joint problems, raised blood pressure and a delayed rate of growth, including low stature and a slight build. The average adult height is 5ft for females and 5ft 6ins for males. Missing material (a micro deletion) on chromosome 7 has been identified in affected individuals, resulting in disruption to the elastin gene. Elastin is the structural protein in our body that gives elasticity to our tissues and organs. It is found predominantly in the walls of the arteries, in the lungs, intestines and skin; and reduced or abnormal elastin may explain some of the physical and medical characteristics, as well as the distinctive facial features associated with WS.

Most cases occur sporadically, and the risk to parents of having another child with WS is no higher than the original risk. Brothers and sisters of WS individuals, too, are not at any increased risk of having children with WS. However, people with WS themselves have a 50% chance of transmitting the condition to their children.

Children with WS tend to be delayed in their development and show a range of learning difficulties which, in different children, can vary from mild to severe development disability. In addition, they show a distinctive pattern of abilities and particular behavioural and personality characteristics which are common to most individuals with this syndrome, and which set them apart from other children with learning disabilities.
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Abilities of Children with Williams Syndrome

• Mild to severe learning difficulties
• Relatively good verbal abilities
• Fluent and articulate speech by school age, often with incessant chatter
• Marked gross and fine motor problems
• Marked visual-spatial difficulties

The children tend to be very outgoing, sociable and affectionate, and by school age most develop fluent and articulate spoken language. They love talking and interacting with adults, and are helpful and eager to please. Many chatter incessantly, but at a superficial level, and often in a formal, adult-like way with frequent use of stereotyped phrases and clichés. Taking turns and keeping to the point in conversation may be especially difficult for them. In many cases their understanding of speech is not as good as their expression, so the level of spoken language and highly developed sociability may give the impression that the child is more able than she actually is. In contrast to their relatively good speech, many of the children have visual-spatial problems and difficulties with gross and fine motor co-ordination. So they may be slower than usual in learning to sit and to walk, and they may find tasks like riding a bicycle, doing up buttons, cutting with scissors and holding a pencil particularly difficult to master. They tend to have poor posture, an awkward gait and limitations of joint movements. Because of their motor and perceptual problems they may also be fearful of heights and of negotiating stairs and uneven surfaces such as grass, gravel or sand.

Many of the children are overactive and find it difficult to sit still and concentrate on particular tasks for any length of time. On the other hand, they can become fascinated and preoccupied by particular objects or topics and spend a great deal of time absorbed with these. While many are very friendly (and even over-friendly) to adults and seek out adult company, they may have difficulty making and keeping friends of their own age, often managing somehow to antagonize their peers.
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Behaviour of Children with Williams Syndrome

• Overactive
• Limited concentration span
• Sociable & outgoing
• Overfriendly to adults
• Excessively anxious
• Preoccupied with objects / topics
• Hypersensitive to sounds
• Fearful of heights / uneven surfaces

Children with WS are often described as having anxious personalities and worrying excessively about themselves and others. Sleeping and toileting problems are fairly common. Many are also hypersensitive to a variety of noises, such as loud bangs, clapping or laughter, and they may become tense and fearful when hearing or anticipating these sounds.

Of course every child is different, and not all children with WS will show all of these characteristics to the same extent. However, the research undertaken over the last few years with children and adults with WS indicates that these difficulties are common to many of them, and that unless parents tackle them early on they may well persist into adulthood. We would therefore encourage parents and teachers to address these difficulties as early as possible in the child's life. In the following sections we describe these difficulties in greater detail and suggest ways in which you can guide your child in each area. The methods and approaches we will describe are well tried and have been used successfully to cope with the difficulties of a wide variety of children. They can be adapted for use with any individual child.
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Feeding and Eating Difficulties

Feeding difficulties, including vomiting and refusal to feed, usually appear in the first months or year of life and are one of the earliest symptoms of the condition. If a blood test shows the child to have a high level of calcium, he may be put on a low-calcium and Vitamin-D restricted diet, and a low-calcium milk preparation. With time, the feeding difficulties will lessen and disappear.

In some cases, problems with swallowing and chewing persist and you may find it difficult to feed your child with anything other than a soft food diet. And a child who only takes smooth foods will never learn to chew! In this case you could try to introduce first very small and then larger lumps into the smooth, liquidized food, or gradually to make the food thicker. Then introduce a few small pieces of minced meat etc. into the soft food, and move on to easily chewed foods like fish fingers and rissoles. You may want to enlist professional help from a psychologist or speech therapist (through your Pediatrician or local Child Development or Health Care Centre) to introduce a feeding training program, with emphasis on developing sucking, swallowing and chewing skills.

Once the child's blood calcium has stabilized over a period of time, the Pediatrician will advise you about taking your child off the low-calcium diet. For many of the children feeding will now no longer be a problem. However, some children continue to be fussy eaters and may refuse to eat all but a very limited range of foods even once they are off their diets. Such idiosyncratic diets can cause difficulties, for example when the child starts school and is expected to eat set school meals. Since at this stage there is no medical reason for a limited diet, your child should be encouraged to try and eat a wider range of foods. One approach you could use is to insist, at mealtimes, that the child try just one spoonful of a food he normally will not eat, and then immediately praise him and reward him with his favourite food, and perhaps also with a favourite toy. Such an approach fits in with our knowledge of the principles of rewarding desirable behaviours. By immediately following a desirable behaviour with a reward, you make it more likely that this behaviour will occur again. Gradually, you should require the child to eat larger amounts of the non-preferred foods before giving him preferred foods and other rewards. Sooner or later most children actually begin to enjoy eating these other foods, and forget their earlier aversion to them.

A few children develop a habit of vomiting at mealtimes if they are made to eat foods they do not like, or perhaps as a means of gaining attention from parents, or when they are anxious or under pressure. If it is confirmed that there is no physical reason for the vomiting, it is advisable for parents to be firm and to withdraw sympathy and attention at times when the child vomits (and perhaps to insist on the child cleaning the mess himself if he is able to), but to praise the child and reward him with toys or with foods he likes if he does not vomit at mealtimes or at other times during the day. Another approach is to take the pressure off mealtimes and leave the child to eat as much or as little as he wants, on the theory that he will eat if he is hungry. This approach will obviously only be effective if the child is denied sweets, biscuits and snacks between meals. Some children dribble, and they will need regular reminders from adults to close their mouth and swallow. Again, a reward system may serve as an added incentive, with the child being rewarded if he can spend increasing periods of time without dribbling.
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Sleeping Difficulties

Some children with WS have problems settling down to sleep, or they may wake in the night and cry or go to their parents' bed. These problems are by no means unique to WS, and as with other children, they can become severe and prolonged and parents could find themselves spending several hours each night comforting their child or taking her into their own bed. Dealing with these difficulties requires a firm and consistent approach. If your child takes a long time to fall asleep and continually calls out to you or insists on your presence before falling asleep, try and set up a fixed bedtime routine.

Praising your child for desired behaviour and giving her detailed feedback about her behaviour is important. If she is old enough to understand, you could introduce a star chart and stick a paper star or sticker onto the chart each morning as a reward if she settled without problems the previous night. In this way, both you and your child will have a record of the progress that is being made over time.

If your child wakes during the night and cries or calls out to you, again insist that she goes back to sleep, once you have made sure that she is all right. Ignore any further calls. If she comes into your room, firmly take her back to her bed and leave the room as quickly as possible.

When coping with sleeping difficulties, it is important to be firm and consistent and not to give in to your child's demands. This is not always easy to do! Some of the approaches described above are easier to use with children who already have language. With younger children and infants, other methods may be needed. If the sleeping problems persist, you may want to approach your health visitor, GP or Pediatrician for advice.
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Toilet Training

Wetting and soiling can often persist in the pre-school years and into the school years; or they may appear as new problems, and may be exacerbated by anxiety or excitement. With a well worked out program most children can become toilet trained well before they go to school, or helped to become clean or dry again if they have regressed.

Most children become toilet trained through a combination of imitation, parental pleasure and displeasure, and luck. But if a child is not making progress in toilet training in the usual way, then perhaps by age 3, 4 or 5, parents might decide to try a more systematic approach to toilet training. Try to be persistent in whatever method you try.

If your child wets the bed at night, you could in the first instance introduce a star chart, whereby you reward him with a star and lots of praise if he has not wet the bed the previous night. This approach can be very effective, particularly if combined with a program of lifting the child to the toilet several hours after he has fallen asleep. If he can remain dry, you can gradually bring the time of lifting him forward until it coincides with his bedtime. No approach will work immediately, and it may well take several weeks or months for such a strategy to start taking effect. Related behaviours that may need to be taught include dressing and undressing, the ability to wipe clean afterwards, flushing the toilet and washing one's hands. You may find it helpful to seek advice from books, Pediatrician or Child Psychologist on the most appropriate method to use with your child in toilet training.
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Dressing

The tasks of dressing and undressing require muscle co-ordination and planning, and this is something children with WS may find difficult to master. The child may need help with putting on clothes, doing up buttons and shoelaces etc.

Learning to dress can be practiced at other times of the day, and not just during the fraught morning period when time is of the essence. It is helpful to break down tasks like dressing into smaller steps and teach the child one step at a time. Make practice books or old clothes on teddy bears/dolls and get your child to practice on these. Similarly, tying shoelaces could first be practiced on loose shoes. Giving the child verbal cues is also helpful. As an example, when teaching her to do up shoelaces, she can be helped to talk herself through the routine, for example by saying out loud "cross the laces over" "pull one through" "pull tight" as the child performs each step. In this way she learns the words and can then prompt herself in the task. A lot of modern footwear and clothing use Velcro as perfectly satisfactory substitutes for shoelaces, buttons and zips. Such items are much easier for children to put on and take off, and help to maximize independence.
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Social Relationships

Some children with WS find it difficult to make friends of their own age and show no interest in playing and interacting with their peers. As they become young adults their difficulties in establishing and maintaining friendships with others of their own age may become even more apparent, and may be a source of frustration to them and to their families. On the other hand, they love the company of adults, are affectionate and eager to please, and will often seek out adults to engage in conversation. At the same time, they often lack understanding of the underlying, "unwritten" rules governing social interactions and fail to recognize the social constraints that are apparent to others. Thus, they may approach strangers in an over-friendly and over-familiar manner and will often tag along with them. Understandably, this can be a major worry for parents, who fear that the child is too trusting and could be taken advantage of if he is not watched and supervised all the time.

Adult friends and relations do not always interact appropriately with children with WS, and they may on occasion "over-indulge" or "baby" them. It is important to try and educate adult friends and relatives to behave appropriately with your child, but also to show some tolerance and patience for any unpredictable behaviour.

Helping children with WS to make and maintain friendships with people of their own age is a complex issue. Particularly as the children move into adolescence, they may be reluctant to socialize with handicapped people, but they may also be unable to make friends with "normal" adolescents who may have little patience with them. If your child is young, you could help by inviting children from school to your house and initiating and supervising games for them to play. These could include board games, ball games and make-believe play with dolls, cars etc. Parents and school staff can work on teaching the children social skills, including turn taking and sharing. Many parents also find that their children integrate very successfully into organized and supervised children's activity groups such as Scouts or Guides, which often appeal greatly to their gregarious and extrovert natures.

You may need to be actively involved in organizing your child's leisure time even when he is older, since the initiative will not necessarily come from him. Many parents find that if they do not actively organize outings and activities for their older children, they will be satisfied to stay at home and watch television or listen to music. Information about local social and sports clubs for children and adults with a range of handicaps and learning difficulties may be available from your child's school, or from the local Child Development Centre or Social Services Department, or from a health visitor. These clubs often arrange supervised outings, sporting and other social activities where the person with WS can meet others on a regular basis.

It is important to stress that while some people with WS have difficulties in establishing relationships with peers, others do not. On the contrary, with their friendly and extrovert natures and also their sensitivity and concern for others, many children and adults with WS are popular and well-liked, and establish warm friendships with people outside their immediate families.
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Suggestions for Dealing with the WS Child's Over-Friendliness

It may seem unfair to put limits on the child's friendly overtures to adults, but if this way of interacting with strangers is encouraged, it could lead to serious problems at a later date. By looking ahead and anticipating future needs, many crises can be avoided.

1. When the child meets someone he knows, or when he is introduced to a new person, he should be taught how to greet the person in an appropriate way and discouraged from hugging or kissing the person.
2. Social situations can be rehearsed with the child at school and at home. For example, you could pretend to be an adult friend and allow the child to practice greeting you. Model appropriate greetings for the child and instruct him to imitate you. Praise him for appropriate behaviour.
3. Children can be taught simple rules, such as not to stand too close to others and not to stare; video and role play techniques can be useful here.
4. Parents and teachers should start as early as possible to discourage the child from approaching people he does not know. Whenever he does approach a stranger, parents should indicate their displeasure and firmly reprimand him.
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Children with WS are often described as being over-anxious and easily upset by criticism and frustration. They may worry excessively about the health and well-being of their families, themselves and even strangers, as well as about unfamiliar situations and all kinds of imagined disasters. This concern and sensitivity for the needs of others can be an endearing aspect of their personality which makes people warm to them. But it may also mean that the child with WS frequently demands attention and seeks reassurance from the people around her. It is advisable for parents and other adults to strike a balance between comforting and reassuring the child in such circumstances but not making too much fuss of her, since this may well encourage and exacerbate her feelings of upset and worry. You may find that you are spending a great deal of time comforting your child, but with no decrease in her level of expressed anxiety. If this is the case, you might decide to adopt the following strategy:

• Put a fixed time limit on the time you spend comforting the child. For example, you might agree to spend one or two minutes reassuring her if she expresses anxiety.
• Then move on to another topic of conversation or activity.
• In this way the adult acknowledges the child's anxiety and provides comfort and reassurance, but also circumscribes it within time limits so that it does not become just another way of gaining unlimited adult attention.

Because of their sensitivity, people with WS may be very susceptible to stress and to the demands of others, and may find it very difficult to cope in environments that are excessively demanding. If you feel that your child is becoming more nervous or anxious than usual, then it will be important to examine the home and school environments to ensure that the demands being placed on the child are not excessive. In general, children with WS do best with a predictable schedule and a set routine, and benefit from preparation before changes in activities or in routine. Stress and anticipatory anxiety can often be reduced by spending a brief period ahead of time preparing the child for a change or for a difficult task or event, enumerating the difficulties to be faced and talking through possible outcomes.
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Preoccupations, Obsessions and Stereotyped Behaviours

Children and adolescents with WS often display intense fascinations and preoccupations with certain objects (such as insects, cars or electrical gadgets), particular topics (disasters and violence on the news, illness, future events such as birthdays and holidays etc.) or certain people (a particular member of the school staff, a television star or neighbour). They may spend a great deal of time absorbed with these topics and talk about them repetitively. It is best if you can nip such obsessions in the bud before they get a real hold; so if you suspect that a particular behaviour is becoming obsessive, try to divert attention elsewhere, and introduce new activities and interests for the child. If the preoccupations are already well established try to circumscribe them to keep them within acceptable bounds. For example, where a child is very preoccupied with a certain toy, or becomes attached exclusively to one other child and always wants to stay close to him, the school staff might decide to allow him to play with the child/object in question for a fixed time (say 10 minutes every day or two) but only if he controls his preoccupation in between these times. If unable to do this he would forfeit some of his "special time" with the child/object. The aim is to bring the preoccupation under control and gradually to reduce the amount of time spent in this way. Alternatively, time spent with the object or person the child is preoccupied by could be used as a reward for desired behaviour in other areas. For example, the child might be awarded stars on a star chart for completing arithmetic assignments, for concentrating in class, for finishing his dinner etc. And once he has earned a pre-agreed number of stars he can be rewarded with an opportunity to play with his favourite friend or toy. The obsessional interest or behaviour could also be channeled into useful activity, for example practicing pencil control by drawing pictures or writing stories about a favourite topic.

Some individuals with WS display stereotyped behaviours such as rocking or hand flapping. These behaviours, which may also be displayed by other people with learning difficulties, may be particularly prominent when the individual is anxious or agitated, when he is bored, or alternatively when he is absorbed in a particular task or trying to concentrate on something. In some cases rocking may actually aid concentration. However, in general it is advisable to make the child aware of his rocking or hand lapping as soon as it begins, and to ask him to stop. He will usually need frequent reminders to start with, although with time a brief nudge or pre-agreed word will usually suffice. It is often helpful to combine this approach with a reward system whereby the child is systematically rewarded if he can spend increasing periods of time without rocking. Encouraging the child to change his sitting position or the type of chair he usually sits in (when watching television, for example) may also be effective.
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Temper Tantrums and Aggressive Behaviours

Children with WS are mostly even-tempered and co-operative. But like other children they may have severe temper tantrums when they are frustrated, when they cannot make their needs or wants understood when they want attention or cannot get their own way. Tantrums and aggressive behaviour towards others can occur in both young and older children. And, as any parent knows, they are by no means confined to children with learning difficulties or handicaps!

You should observe the child carefully when she has a tantrum and try to identify the situations and events that trigger the tantrums. For example, if you find that fear of particular events or loud noises or provocation by another person triggers a tantrum, then you could try and anticipate these and divert the child's attention onto something else before the tantrum develops. You could also teach the child more appropriate ways of communicating with others to indicate her needs and wants, which would make it unnecessary for her to throw a tantrum. When faced with tantrums or other unacceptable behaviours you and other family members might agree to ignore the child and turn away from her for a short period. As soon as she stops misbehaving you can attend to her again. Ignoring can be an effective way of managing most difficult behaviours, except where the child is being destructive or is likely to hurt herself or someone else. In such cases an effective approach is to remove the child, for example by putting her in the hall or bedroom, and to make it clear that she cannot rejoin you and the rest of the family until she has calmed down. It is important for the adult to try and remain calm and to adopt exactly the same approach every time the child has a tantrum, since an inconsistent approach will only confuse her. As soon as she is quiet, go and praise her for having calmed down and allow her to rejoin the family. At first there might be a temporary increase in the disruptive behaviour. But if you insist that the child remains in her room and ignore her until she is quiet, she will soon come to understand that the tantrums do not enable her to get her own way, and their frequency and severity will decrease.

The same approach can be used to bring other undesirable behaviours, such as hitting other children, biting, and breaking things, under control. Moodiness can be a feature of the emotional liability of some children with WS, and it can become particularly prominent in adolescence. It may be characterized by sullenness, muttering under one's breath or by overt defiance. Here too, if distracting the individual is not immediately effective, it may be advisable to make it clear to her that moody behaviour is unacceptable and that she will be expected to go out into the corridor or to another room until she has regained her good spirits and is ready to cooperate. In this way the adult withdraws attention from the child when she is moody and uncooperative, but rewards her with praise and attention when she is more cooperative. Again, it is important to stress that moodiness is not an invariable feature of the syndrome, and many WS individuals are by nature just the opposite - friendly, caring, helpful, and eager to please.
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Hypersensitivity to Sounds

About 90% of children with WS are hypersensitive to particular sounds that would not cause discomfort in most people. These can include sudden loud noises like thunder, objects falling or balloons bursting, hand clapping, electrical noises like vacuum cleaners, drills and electric shavers, loud music, and in some cases even people's voices or laughter. This phenomenon is termed "hyperacusis". The noises may be very distressing to the children, who will typically put their hands over their ears and cry, or try to avoid the sounds, for example by leaving the room or turning off the television or radio. Noisy and rowdy environments may be particularly upsetting. In some cases the hyperacusis becomes less of a problem in the child's teens or in adulthood, but in other cases it continues to cause difficulties.

The reason for this sensitivity to noise is not yet known, but it is likely to be related to the fact that individuals with WS have lower thresholds for sounds than do other people. It is possible that the noises may be physically painful to the ears, or they may simply startle the child.

Some people recommend the use of ear plugs to block out noise. Since ear plugs are likely to block out important sounds (like speech) as well as distressing sounds, great care should be taken in their use. If you do decide to let your child use ear plugs, they should only be used for a brief time where a particular noise is causing the child distress. And don't forget to take the ear plugs out immediately thereafter! Also try getting them just to cover their ears with their hands.
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Coping with Hyperacusis

The cause of hypersensitivity to noise is not fully understood, but there are certain things that can be done to make it less distressing:

1. Reassurance and a clear and simple explanation about the source of the noise often helps.
2. Whenever possible provide a warning just before predictable noises (e.g. before fire drills or before switching on the food processor).
3. The reactions will often diminish if the child is able to exercise some control over the sounds that cause discomfort. For example, encourage him to use the vacuum cleaner, or to help with household chores by turning on the washing machine or food mixer.
4. The child may be reassured if he knows that he can leave the room for a few minutes at any point, if he is exposed to a distressing noise.
5. Repeated gentle exposure to the sound may help the child to get used to it. For example, tape record one or more distressing sounds and encourage him to play back the tape, quietly at first, then gradually increasing the volume.
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Speech and Language Skills

In early childhood, children with WS may be very slow to develop speech. At this stage, verbal stimulation is vital. Incorporate language into play, talk to your child while you are dressing, washing and feeding her, and encourage her to respond to you with babble and vocalizations. In addition, you might find it valuable to spend 5 to 10 minutes each day working with your child on building up her vocabulary.

To teach word comprehension, you could start by placing 2 or 3 objects in front of the child and say "Give me the ball/cup". Praise the child if she is correct and allow her to play with the object for a short while. If the child does not respond correctly, prompt her to pick out the right object. Again, you can progress to teaching her to identify other objects, and then to respond to a range of commands (e.g. sit, stand, jump, wave) with the appropriate actions. Once she can reliably follow simple commands, you can introduce more complex instructions that are of help in daily living. These might include instructions such as "Fetch your coat" and "Go to the toilet". Each stage of the training procedure should follow the same pattern, with physical guidance and prompting, and also praise and other rewards being used to encourage motivation. When showing your child how to play with toys that interest her, you should use simple language to accompany the play, and then encourage her to take her turn. As she takes a turn imitating your play, it is likely that she will also try to imitate the language spoken.

Children with WS benefit from speech and language therapy at all stages of their development, and the therapist should also work closely with parents and provide suggestions on activities you can carry out at home in order to expand the child's language comprehension, spoken language, oral motor abilities and speech production.
By school age, most children with WS will have developed fluent, articulate speech with sophisticated, wide ranging vocabularies and complex and grammatically correct sentences, which are quite out of keeping with their general level of learning difficulty. They may use long words and unusual phrases which they have heard other people use and remembered, and they may chatter to anyone they meet, if given the chance. But often their speech is inappropriate and repetitive. They will persevere on certain favourite topics of conversation and talk about these again and again, much to the irritation of family and friends.

Many use chatter and incessant questions to initiate and maintain social contact with other people, and they are adept at using their superior verbal skills to get attention. Often favourite topics are simply areas the child is confident discussing, and is relying on in order to take part in the conversation. It is important to encourage the child to talk to people she meets, but on the other hand you will want to discourage her from chattering too much in company and from asking incessant and irrelevant questions.

Some children and older individuals with WS echo or repeat phrases and sentences spoken by the person they are interacting with, often with little understanding of what the person is saying. If the echoing is caused by poor comprehension, be sure to simplify your speech. However, if the child's echoing is simply a habit he has developed, then ignoring it and distracting the child by moving on to another topic can be a useful method of discouraging such meaningless utterances.

Understanding of language is in many cases more limited than the child's expressive language might indicate. If your child responds to your comments and questions inappropriately or irrelevantly, this may be because she does not fully understand you. You may need to simplify your conversation and to make sure that your child understands what you and other people are saying.

If you are worried about her language development or communication you can ask for her progress to be reviewed by a speech and language therapist, either through the school or through your child's Pediatrician, or local Health Care System.
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Concentration Difficulties and Over Activeness

Poor concentration, distractibility, restlessness and over activeness are highly characteristic of children with WS. Where the children are also hypersensitive to noise, they may be particularly distracted by incidental and irrelevant sounds at times when they are required to concentrate, for example in the classroom, or when they are being given instructions or listening to a story. Clear and deliberate instructions to the child will help him to understand what is expected, and regular prompting and reminders will help him stay on the task and remember what he has to do.

Where the child is fascinated or obsessed by particular topics or objects, then books or games geared to these can also be used to encourage concentration, at least initially. Alternatively, you could use something the child is obsessed with (e.g. a car or machine) as a reward he can play with, but only after he has first spent a set period of time engaged in more structured work. So you might, for example, make an agreement with your child that after he has spent 5 minutes in a structured activity he can engage in his favourite preoccupation/obsession for 2 minutes. This may be playing with a favourite toy, watching the builder working next door, or chatting to you. This 2 minute break would then be followed by a further 5 minute period of structured work, and so on. It is also helpful to break down tasks into short, simple steps with cues - such as pictures or words - to indicate clearly what needs to be completed at each stage.

In adolescents and adults with WS, overactivity is no longer a prominent feature, but a limited attention span may continue to be a problem.

Some children benefit from learning to talk out loud to themselves, repeating an instruction or talking their way through an activity. This may be particularly useful as an aid to concentration for older children and adults. Thus you could teach the child to remind himself to keep working on the task at hand, initially by thinking aloud and later by silent instructions to himself. So, while working, he is taught to tell himself at regular intervals to "keep on working", to "concentrate and look at what I am doing" etc.

Many of the children are also impulsive and find it difficult to take turns and wait for an adult's attention. They may repeatedly interrupt adults' conversations because of their desire for attention. Again, you can reward the child if he is able to sit quietly and wait his turn, initially for a few moments, and then for longer periods of time. One parent found that on long journeys, when continual chatter and interruptions can be particularly tiring, a "sponsored silence" was extremely effective. A piece of fruit, a sweet or small coin offered for a carefully timed 10 minute spell of silence can work wonders for the frayed nerves of the whole family!

It is useful to remember, and to point out to teachers, that because children with WS may be easily distracted by what is going on around them (even more so than many other children with learning difficulties), they are likely to pay attention and work better in settings that are as quiet and free from distractions as possible. Short periods of work interspersed with frequent breaks will also be necessary. Most children need one-to-one guidance and attention from an adult in order to complete a task, at least initially. Working with the child on his own or with a few other children, in a quiet room, and for short periods of time, is likely to be the most appropriate.
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Improving the Child's Concentration Span

1. Reward the child with praise or toys for sitting still and listening, or for engaging in some constructive activity such as looking at a book or doing a puzzle, for progressively longer periods of time.
2. Initially require him to sit still and pay attention for 1 or 2 minutes, and immediately thereafter reward him with a favorite toy or activity and praise. Adult attention and conversation are likely to be particularly effective reinforcers.
3. Gradually, through a series of stages, build up to work periods of 5, 10 and then 15 minutes.
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b) Working with Teachers
Most teachers will never have taught a child with WS before, so they will know very little about the syndrome. Teachers frequently say that they find children with WS confusing and puzzling to teach because their relatively good verbal abilities, engaging personalities and sociability can result in an overestimation of their overall abilities. We have found that teachers are very keen to find out about the special needs and difficulties of children with the condition, and both they and your child will benefit the more they learn about WS. We do have a Curriculum Guide for Teachers available for parents.

c) Perceptual and Motor Difficulties
Many children with WS have particular difficulties with gross and fine motor co-ordination, with discrimination tasks, with orienting themselves and objects in space, and judging distances and directions. These children will need help and opportunities for repeated practice of tasks in these areas, both at school and at home. Activities such as swimming, horse riding and gym help to improve co-ordination and visual-spatial skills and are popular with many children with WS. Tasks such as sorting and matching objects and shapes, drawing and copying shapes and being able to trace over lines, are all important skills to master before the child can move on to the basics of reading and writing. Such tasks may be more difficult for children with WS because of their difficulties with visual perception and motor co-ordination. They will need a lot of practice in all these areas, and you may want to practice some of these exercises with your child at home before he starts school.

Because many of the children tend to have good spoken language, we find that it often helps if they can be encouraged to talk themselves through each step of an exercise while they are doing it. This can help them to focus their attention on the tasks and also provide verbal reinforcement and support for the activities.

Some parents and teachers have also found it helpful to introduce teaching materials using objects and themes that the child is especially interested in or even obsessed with, in order to motivate her to work on tasks which she may not be directly interested in. For example, if the child is fascinated by cars or machines, get her to trace over, copy and draw outlines of these. If the child loves music and singing, try and incorporate these into the tasks. Parents can do a variety of activities with their child to help her develop the fine motor skills necessary for writing, including dot-to-dot drawing, mazes, colouring books, clay and other manipulative activities which involve finger dexterity.

When the child begins to learn to write, the teacher may start by getting her to trace over and then copy the letters of the alphabet. In many cases this too will be slow and require a lot of repetition. Problems with forming the letters and spacing out words are common, but with practice progress will be made. Again, using letters and words to write sentences and stories on subjects the child is particularly interested in will aid her motivation.

Because children with WS tend to have co-ordination and motor problems, they may find it difficult to hold a pen or pencil properly, and drawing, copying and writing tend to be poorly executed. The teacher may recommend that the child use a pencil grip - a device which fits on to a pencil or crayon and helps in pencil control. It will also prevent the child from grasping the pen/pencil too low down and thereby obscuring what she has just written. If your child is unable to exert sufficient pressure on a pencil or pen, you might find that giving the child thick felt-tip pens helps to overcome this problem.

Like most children, children with WS love working on computers and can practice useful exercises on them. If they can write and spell but have difficulty with pencil control, they could use computers for free writing, thus by-passing the difficulties of writing by hand. If you have a home computer, your child's teacher or the school's educational psychologist might be able to recommend and perhaps lend you suitable computer programs for your child to work on at home.

The children's visual and motor problems may also mean that they are nervous of heights and of such activities as climbing, going down stairs, walking along a bar in the gym etc. They may also find it difficult to throw and catch a ball, cut with scissors and ride a bike. All children will improve on these tasks with time, provided that they are given reassurance, support and plenty of practice.

Physiotherapists and occupational therapists can be very helpful in all of the above areas. They can assess and provide exercises for the child in the areas of co-ordination, balance, gross and fine motor activities, and they can advise on building up skills in dressing, washing, eating with a knife and fork and writing. You may wish to ask your child's Pediatrician, GP or health visitor about whether she could benefit from occupational therapy or physiotherapy, and request a referral.

d) Reading
The abilities of children with WS vary a lot, but many do learn to read at a basic or, in some cases, at a more advanced level. As already discussed, many of the children have relatively good verbal skills, including a very good memory for sounds and good auditory sequencing skills. In view of this, approaches to reading which rely on these auditory skills are likely to be most effective. The child should first be taught the names and sounds of the letters of the alphabet. This may well be a slow process requiring a lot of repetition and patience, but once the child knows the letter sounds, he can be taught to sound out the letters in a word and blend these sounds together to form the word. This is just one of a number of approaches that can be used to teach reading.

Where children are preoccupied with particular objects or topics (e.g. trains, pop stars, and foreign places), introducing reading materials on these topics will enhance their interest and motivation to read.

e) Leaving School
The question of what will happen after the child leaves school can be a major worry for parents. Our findings indicate that most adults with WS continue to need at least some supervision and support in their daily lives. People with Williams Syndrome, like all of us, go on learning and acquiring skills after they leave school. They may go to a Post Secondary Education Unit or College, or other training scheme, for a number of years after leaving school, to continue their training in independence and self help skills such as dressing, cooking, independent travel and to learn other skills. For the longer term, Special Education Centers, Adult Training Centers or Day Centers are further options which provide work activities and recreational facilities. Parents should try to obtain information about the available options well before the child leaves school.
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Implications for Siblings

Living with a brother or sister who has WS can be rewarding and fun, but also confusing and stressful. The needs of individuals with WS can at times be overwhelming, and they often require a disproportionate amount of the family's time and attention. As a result, brothers and sisters may get less attention from parents, grandparents and other relatives, and at times they may quite understandably feel resentful or angry. Parents need to try and ensure that they give their other children as much individual time and attention as possible.

Siblings may feel embarrassed or resentful when, for example, they have to explain to their friends about their disabled brother or sister, or when having to keep an eye on him or her. At other times they may feel guilty that they themselves are not disabled. Typically they also feel a great sense of responsibility towards their brother or sister who has WS, and as they become adults they may worry about the future and who will look after their disabled sibling once their parents are no longer able to do so. Giving siblings the opportunity to talk about their feelings for their brother or sister with WS, and about their worries and anxieties, is important. Furthermore, realistic planning for the future can help alleviate many of their justifiable concerns.

Many siblings are poorly informed about WS, and as a result may harbour unnecessary worries about the possibility that they may be at risk of having a child with WS themselves, or of developing the condition later in life. It is important for parents to talk with their unaffected children about WS, and to give them information about the cause of the condition, the negligible risk of recurrence in families, and its physical and behavioural characteristics. Siblings may also find it helpful to talk with the WS child's Pediatrician, Cardiologist or Clinical Geneticist. Siblings have as much need for information as do parents and accurate information will serve to allay many of their worries and fears about the condition.
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