Saturday, February 2, 2013

7 year old whose biological mother smoked crack cocaine

I have just discovered your 2002 piece on Anger Overload. This is our turning-seven daughter!  Wow!  She was tox positive at birth, so probably does have a few neurological bees in her bonnet.  Turning the tv on and saying "hey, your show is on," shifts her behavior very quickly, but its been hard to heft our tv around (just kidding), and people keep saying it's reinforcing.  I think of this anger as the survival fight or flight response turned up to 11..  Old brain overpowering new brain.

The inability for her to be calmed, or to be rational, we call "brain-lock."  My concern is tantrums begetting tantrums; the more tantrums she has, the "shorter" the neural pathway becomes getting to rage when "threatened."  I would like to use use a non-permanent course of anti-depressants which might enable her to learn self-soothing, and maybe (?) slow her response time to perceived threat.  She has been evaluated, head-shrunk, stickered, timed-out, restrained, charted, etc. etc. etc.; meanwhile, her self-esteem gets lower and lower....

Are there any practitioners in North Carolina who treat kids with this profile or train their parents?
Thanks for any help,

P.S. Her memory and IQ are over the moon, possible ADD, possible ODD (but she does have the sweet and caring disposition your article mentions), anxiety, depression, and sensory processing disorder.  She gets monthly OT for SPD. She was removed from her birth-mother at 5 days ( full-term, 5 pounds 12 oz), and has been with us since, and adopted at 20 months.  Birth mother and father chain smoked, used crack cocaine, and presumably other recreational/street substances.  Her happy, quiet, calm began to change at about 3 years.

Hi, I would recommend an evaluation at the Duke child psychiatry department.  Duke has a good child mental health team and they could do a multi-disciplinary evaluation and make treatment recommendations. They would also know some good practitioners in your area.  Given that there are probably some neurological issues, possibly related to her biological mother's drug use, I like that you have had her to psychological and occupational therapists.  It is possible that anti-depressant medication and/or ADHD medication may help, but I would get a work-up first from a psychiatrist and/or neurologist who specializes in children.  Changes may be gradual if your daughter's biological mother used crack cocaine on a regular basis during pregnancy.  Children who have been affected by drug and alcohol use in utero can still learn over time to develop better self-control but it will take more repetition and more time (over a period of months and years).  Your goal would be to reduce the frequency and severity of outbursts, but there still may be some outbursts when her brain gets overheated. 

In terms of psychological approaches, I like that you are using distraction techniques.  I would recommend you try to determine as many of her triggers as you can, and pick a couple to start with, and develop routines to alter the chain of events.  I describe this process in more detail in my book, but essentially you would arrange routines to avoid as many triggers as you can.  For example, if a trigger is getting ready for bed, you would arrange the routine so that getting ready for bed happens earlier in the evening and is followed by something your daughter likes to do, such as to play a game with you. 

You would also use behavior modification techniques but the reinforcements would need to be fairly immediate and you would probably have to vary them in order to continue to hold your daughter's interest.  Rewards and consequences do not work well when children are in the midst of a tantrum, though, so when your daughter is in overload, I would recommend not talking with her, unless she is harming herself or someone else, in which case you would have to intervene.  Once the tantrum is over, you can either talk about something else that has nothing to do with the tantrum, or sometimes later in the evening you would review what you think triggered her and what she can do instead next time she is frustrated.  Try to pick an alternative that your daughter would be likely to do.  If she uses physical releases, pick something she can do physically that is not harmful, and gradually try to move her in the direction of using words to express her anger (in the beginning she does not have to use polite words!). 

In my book, I also describe cognitive behavioral approaches, such as having cues (one example is to use colors to cue your daughter that she is beginning to heat up), teaching calming techniques, and teaching children to consider alternative points of view.  These latter ideas work better once a child's anger is not too extreme, and once a child realizes she has an anger problem.  If she is not ready to look at her anger yet, then you would stick with the techniques that I describe in the first part of my book, techniques that do not require her direct participation--like when parents re-arrange the sequence of events to avoid triggers or to re-arrange the sequence so that something she likes to do comes last. 

You sound like you are already on the path, and you have good ideas.  I would not worry too much though that her current tantrums will shorten her neural pathway and lead to more tantrums.  As the frontal cortex develops over time, children are better able to learn self-control techniques.  In fact the cortex keeps developing even past adolescence.  Continue your efforts to help her brain development along, and get a multi-disciplinary evaluation when you can.  All the best, Dr. Dave Gottlieb

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