Tuesday, February 26, 2013

Sensory overload and anger overload in 5 year old

I am writing in regards to my 5 year, 10 month old daughter.  I am a pediatric speech pathologist and have worked on a multidisciplinary team with pediatric occupational therapists for 14 years.  I have always described my daughter as "spirited"!  Very active, risk taker (climbing things at a very early age, no fear, etc).  She screamed for about 18 hrs/day and slept very little the first 6 months of her life, which I wrote off to severe reflux (which she was medicated for), but now looking back, I feel like she has never been able to regulate her body on her own.  We had to swaddle her extremely tightly, rock her, shush her, bounce on a ball, etc to even begin to calm her and most times that didn't even work, but she has ALWAYS needed help calming down when she gets amped up....what I would call in therapy terms "dysregulated" or "sensory overload".  This is when she displays the exact symptoms of what you are describing as Anger Overload and your article describes her perfectly.  When she is "regulated" and in a good space, she is kind, compliant, sweet, caring, creative.  She can attend to tasks--even non-preferred tasks if she is not on overload.

She does not kick, bite, hit or get violent during her meltdowns  (although she did go through a pretty bad biting stage in her two's even though her language was excellent).....she just cries, screams, holds her head and will yell things like "You just don't understand...my body just can't think" or "My body is just so angry right now I can't stand it".

We learned a long time ago that talking to her in that moment does not work, that she will only "hear" us when she is calm, but even though she is bright....it doesn't deter the behavior from continuing to happen.
I have tried everything I know to do from a regulatory standpoint.......exercise breaks, breathing balls/techniques, picture schedules to make routines easier (even though she is ahead in communication skills), making a frustration jar with glitter to shake, giving her heavy input/tight squeezes.  She ABSOLUTELY cannot access her frontal lobe functions when she is in this state.  Is this what you mean by anger overload?  Does it mimic regulatory dysfunction?  If not....how would you separate the two?

My other question is.....besides behavioral strategies, is something like this ever treated with medication?  and if so, would it be and ADHD med? SSRI? something else?

I really appreciate your help.  I have used all the tricks in my bag and am at my wits end, because I can't stop her blow ups.  I have tried tracking data to find her antecedents, and can control them maybe 1/10 of the time.  Luckily, they are only happening with us (parents) and not at play dates or at kindergarten...yet.

Hi, It sounds like one precipitant for your child is sensory overload.  I find that some children with extreme reactions to frustration (i.e. anger overload) also have sensory overload and some do not.  Some children only get dysregulated when angry, whereas other children have difficulty with sensory overload in general.  Regarding your description of your child's free spirited nature, I have found that many of the children with anger overload are also free spirited or headstrong, but not all.  In an earlier book I wrote (called "Your child is defiant: Why is nothing working?") I have a chapter on strong willed children who also have anger overload.  When anger overload occurs along with a strong willed personality, or along with sensory overload, then you will need to use a number of strategies, and it will take more time to help (probably over the next year or two you will see improvement, as opposed to just months).

I like a lot of what you are doing for sensory overload.  I would recommend some additional strategies specifically designed to help with anger.  You are right to wait until she calms down before you talk with her.  One really good sign is that she can verbalize at times that she is so angry.  The goal over time is to help her recognize early warning signs, because it is more likely that she will be able to calm herself the earlier she realizes she is getting frustrated.  In order for this to happen, in the beginning you will be the one to try to pick up the early signs and precipitants.  After an outburst, you want to record what the sequence of events were leading up to the blow-up.  The more you do this, the more you will see patterns.  You will not be able to anticipate many of the outbursts, but hopefully you will be able to some of the time.  

In my book on anger overload, I describe how to use "emotional distraction" and calming strategies in the early stages.  Many of the calming strategies overlap with what you are already doing, like the using the ball or blanket to help her soothe.  As for what I call  "emotional distraction," this works by re-directing the child to something that makes them laugh, or feel happy, or stop and think, such that they forget about their frustration for a few moments.  

In the second half of my book I describe strategies to teach to your child.  The one I would begin soon with you child is introducing a color labeling system for the levels of her anger--blue hot might be for low anger, orange hot for medium anger, and red hot for extreme anger.  See if she can eventually use these words.  You would tie the blue and orange labels to certain calming activities, and reward her for trying them, whether they work or not.  Sometimes your child will still move on to the red stage.  But if she tries, she is on the right track, so I would think about short term rewards for later that day.

The other approach is to plan events to avoid certain frustrating situations.  For example, if you have determined that stopping a video game often leads to an outburst, you might limit video games to days where there is more time.  If you cannot avoid a trigger, then you plan ahead and predict for your child that she will need to shift gears at a certain time of the day, and then you give her another warning five or ten minutes before the change will occur.  I also describe in the book ways to lower your child's expectations (if her high expectations are a trigger for anger overload).  

Your question about medication is a good one.  I will answer from my experience seeing children as a psychologist, but I do not prescribe, and I would recommend you check with a pediatric psychiatrist.  My experience is that ADHD medication does not help unless the child also displays symptoms of that disorder.  There are some reports in the research literature that SSRIs help some adults with severe anger problems.  With children, I have seen them help sometime when the child also shows frequent signs of irritability (even when not in overload).  Some children are prescribed mood stabilizers or the atypicals, but these can have significant side effects, so they tend to be a last resort.

I think that some day we will be able to do imaging studies of the brain that will show that in many of these children there is immature development of the pathways between the amygdala and frontal cortex, or immature development in the frontal cortex.  The ventromedial frontal cortex has been found to be different in adults with anger problems.  But there is a lot of growth in the frontal cortex throughout childhood and early adulthood,  and many children improve with repeated practice of the kinds of exercises I have outlined.  As you know in your work, the brains of children are quite malleable, and there will be a lot of development during the primary grades for your daughter, so keep trying different strategies and see what works best for her.  Progress may be slow for a while and then you may see a jump in self-control.  It is like the strategies click in, maybe because at the same time there is a leap in brain development.  All the best, Dr. David Gottlieb

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