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
Suggestions for Dealing with the WS Child's Over-Friendliness
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
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.
Abilities of Children with Williams Syndrome
- Mild to severe learning difficulties
- Relatively good verbal abilities
- Fluent and articulate speech by school age, often with
- 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.
Behaviour of Children with Williams
- 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
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.
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.
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
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.
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.
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.
- 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.
- 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
- 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.
- 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.
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
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
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.
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
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
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.
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:
- Reassurance and a clear and simple explanation about
the source of the noise often helps.
- Whenever possible provide a warning just before predictable
noises (e.g. before fire drills or before switching on the food processor).
- 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.
- 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
- 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.
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
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
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
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.
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
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
Improving the Child's Concentration Span
- 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
- 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.
- Gradually, through a series of stages, build up to work
periods of 5, 10 and then 15 minutes.
a) Type of Schooling
Children with WS have an unusual pattern of abilities, often with relatively
good spoken language but poorer perceptual and motor skills and concentration
difficulties. As a result, they have special educational needs that are
different from those of other children, and it can be quite difficult to
find a school that will be exactly suited to their particular learning needs.
Their verbal skills may suggest a higher level of ability, but if they are
placed in an inclusive school or in a school for children with Moderate
Learning Difficulties, they may be unable to cope because of their lower
abilities in non-verbal areas and their limited concentration. There is
no one type of school that is ideally suited to the needs of the child with
WS. Education Authorities differ greatly in the way they allocate resources
to children with special needs; finding the most appropriate school will
depend on the individual child's level of ability and profile of strengths
and weaknesses, and also on the provisions in the particular schools that
are available locally.
Some children start off in an inclusive school and cope very well there
at the primary level, though typically with additional educational support
being provided for them. They may get help from a support teacher or assistant
for some part of each school day or for a few hours per week, for example
in math, reading and writing. But for other lessons and at playtime, the
children are with their ordinary classes. At the secondary level, some of
these children move to special schools or units where they can benefit from
more individualized teaching and learn at a slower and less pressurized
pace. A few children continue in inclusive at the secondary level, for example
attending a remedial class for some lessons and the ordinary class for other
lessons. This gives them the opportunity of integrating with their peers
on the playground and in certain lessons.
Inclusive schooling may not be appropriate for all or even the majority
of children with WS. Many of the children need the slower pace and more
individualized attention that are currently provided in special schools
and units. Each child's needs will be different. In a study we undertook
in the late 1980s we found that:
• 30% attended schools for children with Severe Learning Difficulties
• 30% attended schools for children with Moderate Learning Difficulties
• 30% attended schools for children with mixed handicaps
• 10% were in inclusive schools (with support)
With the greater emphasis that is now being placed on integration and inclusion,
we are seeing increasing numbers of children with learning difficulties,
and thus also more children with WS, being educated in inclusive schools,
with varying amounts of additional support. We believe that for inclusion
to work effectively for children with WS, classroom settings which offer
a great deal of flexibility and substantial support will be necessary. Typically
this will require:
• extra adults in the classroom
• small classes
• intensive involvement of specialist teachers
• learning support assistants
• carefully structured and graded work plans
• teamwork between classroom teacher, assistant, specialist teachers
and speech and occupational therapists
Under the 1993 Education Act Local Education Authorities have duties to
identify, assess and provide appropriate education for all children with
special needs from the age of 2 to the end of compulsory schooling at 16
- and up to 19 if the student wants to remain in school. You, as parents,
have the right to ask the Education Authority to initiate a Formal Assessment
of your child's Special Educational Needs from the age of 2 or at any point
in his school career, in order to ensure that his special educational needs
will be identified and met. Alternatively, your child's school may feel
that he has special educational needs and they may ask the Educational Authority
for an Assessment of these needs to be undertaken. Where professionals working
in the Health Service feel that a child may have special educational needs
they must inform the parents and, after discussion with the parents, the
local Education Authority.
Once the Assessment is underway, your child will be assessed by an educational
psychologist to determine his level of ability and specific needs, and reports
will also be obtained from the school (head and teachers), school doctor
or pediatrician, and any other professional who is working with your child
(e.g. speech therapists, physiotherapist, occupational therapist, clinical
psychologist). You should be sent copies of these reports. Many WS children
have very good verbal and social skills and extremely good memorizing abilities.
They may love talking to and interacting with others and respond very well
in settings which provide them with a great deal of verbal and social stimulation.
Since most professionals will know very little at all about the special
abilities, difficulties and needs of children with WS. You will have a chance
to visit schools that you will want to consider for your child, and you
have the right to express a preference for a particular school which you
feel would be most suitable. You will want to try and make sure that the
type of school being considered for your child can cater for his special
needs but can also nurture and stimulate his special skills and talents.
Once the information has been gathered from the professionals working with
your child and from yourselves, the Local Education Authority will recommend
how and where the child's special educational needs should be met. The abilities
and needs of children with WS are so complex that in our opinion most will
need the protection of a Statement of their Special Educational Needs. This
is a legally binding document drawn up by the Education Authority, which
describes the child's special needs and specifies what provision the child
should have to support him in his learning. However, the Education Authority
may decide that the child's needs can be met without a Statement being issued.
If you disagree with the Education Authority's decision not to issue a Statement,
or with the proposed content of the Statement, and cannot come to an agreement
even after further discussion with the Authority, you can appeal against
the recommendations to the independent Special Educational Needs Tribunal.
Once a Statement has been made, it must be reviewed annually. Furthermore,
the first Annual Review after your child's fourteenth birthday must introduce
a Transition Plan which will help in planning for his transition to adult
life and continuing education.
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.
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.
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.