Sunday, January 22, 2012

10 year old with multiple diagnoses

I have just been assigned as a case manager for a ten year old girl
that is showing signs of anger overload. She has been diagnosed with
everything from ADHD, Bi-Polar, ODD, Conduct Disorder and has been on
a variety of medications. She has had three psychiatric
hospitalizations in the past year. She was severely neglected and
physically abused prior to age three. Sexual abuse is suspected, but
was not confirmed. Her mother used marijuana, alcohol, and possibly
methamphetamines while she was pregnant. She has lived with relatives
since age three. She has been in therapy for most of that time and
been on a variety of medications. Her current meds are Tenex, Vyvanse,
Abilify, and Celexa. She rages at school and at home. Her triggers are
almost any situation that she is not in control of, any change, or any
thing she encounters that she doesn't know how to do. She rages
without prejudice and has harmed school personnel and family. Rewards
and consequences do not work. After a tantrum, sometimes she is
remorseful and sometimes not. She is on a behavior plan with the
school, but rages when she does not score perfectly on that. Teachers
have stated that sometimes she goes so quickly to anger that they are
unable to see it coming. Other times they try to diffuse her or talk
to her. She has no ability to calm herself once she starts getting
angry. She has no fear of going back to the hospital or of any
consequences. I have been gathering information for an assessment and
trying to work with the family and school on strategies to help her
learn to recognize her triggers and to develop skills to keep from
harming others and from getting into trouble. Most techniques that I
have read about encourage distraction, which would work sometimes at
home, but not always practical in school, especially in the middle of
class. The school has had to clear the classroom around her when they
could not get her to go to the school safe room. The school has had to
restrain her and they usually results in staff being kicked, hit, bit,
etc. I read that the children with anger overload show an increase in
chemicals in the brains such as epinephrine, dopamine, etc. Is this
due to the rages causing this to surge as it would with anyone or do
they have higher levels to begin with and this makes those levels more
likely to rise higher than an average person? The school and family
are looking for answers and I would like to be able to point them in
the right direction. I would like to figure out if the medications are
helping or making things worse and what direction therapy needs to go.

Hi, This is a very tough situation.  The strategies which I recommend on my blog are intended for children who do not have other serious diagnoses and who have not been abused.  Also, it is worrisome that the mother used drugs and alcohol while pregnant.  That and the abuse could have seriously affected her and caused changes in her brain.  One interesting book about the effects of abuse is by Dr. Bruce Perry called "The Boy who was Raised as a Dog."  You might also want to read about fetal alcohol spectrum disorder.  When mothers drink a lot during pregnancy, especially during the first trimester, there can be profound effects on brain development.  One possible result can be behavioral problems, such as emotional outbursts, impulsivity and social problems beginning at a young age.

So what do you do?  All of the strategies you describe make some sense.  I agree that distraction would be high on the list, as would be anticipating triggering situations and trying to change the situation before she erupts.  The key to distraction is to change the emotional set; any words, funny sayings, or the first lines of a favorite melody could distract her.  However, you cannot always anticipate what will set a child off, as you write, and she may not respond to distraction at times.  Once she has a meltdown, there is not much you can do, but not to talk with her then and to restrain her like you are doing when she is hurting someone or herself. 

I know of one case where the parents use a PRN (as needed) benzodiazepine that can be administered under the tongue so that it is absorbed quickly when the child is beginning an outburst.  I am a psychologist and not a medical doctor, and you could have a child psychiatrist review the meds if you want.

It sounds like everyone is trying hard and providing as much structure as possible.  I would keep working on a chill space, and have her practice going there when she is calm.  Make it a "cool" place for her to go to, where she can lie on a mat or hold a comfortable blanket or stuffed animal.  You want it to be a chill zone, not a punishment.  Ideally you would have a different space when she is in total overload and when you have to take her there by force.

I use other strategies like developing self-observation skills, teaching children to re-evaluate situations, and teaching children how to compromise. But all these are way down the road for this child.  It is not a bad idea to begin to go over triggers with her and to use a simple labeling system for her level of anger, like red hot for anger overload, orange hot for mid level anger, and blue hot for lower levels of anger.  You would start by going over the labels and triggers for incidents after she has calmed down.  After a number of weeks, if she is working with you after the incidents, you can gradually use the colors as a cue when she is heating up and suggest when her anger is at lower levels she use the chill space.  Use a lot of praise if she tries the chill space. Once she is in complete overload she is unlikely to want to try anything you suggest.

In answer to your question, research does show effects in the prefrontal cortex among other areas of the brain when there has been fetal alcohol syndrome or profound abuse.  The prefrontal cortex is where a lot of the executive functions are based--like planning and organizing our responses to stimuli.  This helps explain why it is so hard for your 10 year old. The brain can change in response to medications and therapy, but it will be slow.   All the best, David Gottlieb, Ph.D.

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