Wednesday, June 26, 2013

19 yr old with intellectual disability has violent outbursts

I ran across your blog while trying to understand and help my son who has major anger issues.  He is 19 years old and has always had an aggressive nature when he gets mad.  He has an intellectual disability (42 IQ) and attends a school for special children.  He tends to have most of his rages with his father or myself.  Aggression is by far what we are the most concerned about.  He is currently taking Risperdal (1mg 3x daily), Trileptal (600 mg 2xdaily), Intuniv (3 mg daily) and Strattera (40 mg daily). When he has his rages he completely changes! You can tell that he has no idea what he is doing and seems to have no memory of the events once they are over.  He has been prescribed olanzapine (20 mg) for emergency use but it really doesn't seem to help him much.  When he rages he throws any item that he can, he hits, kicks, screams and spits.  He has broken many pieces of furniture, household belongings, put holes in the walls and left many, many marks on both my husband and I.  He is 5'10" and weighs approx. 170 lbs so you can imagine the strength that he has.  Sometimes when he is coming down from the rages he talks about people being hurt or about ghosts.

We would appreciate any advice that you can give us.

Hi, Given your son's size and the severity of his outbursts, it must be frightening when he loses control.  It sounds like the psychiatrist is trying a number of medications to reduce his agitation.  Honestly, at some point you may need to apply to the state you live in for additional services.  Your son may be eligible for in home care and/or a residential group home, given the severity of his outbursts along with his intellectual disability.  Especially if your son's anger endangers your safety or his own, then I would recommend you speak with the psychiatrist about how to apply for more help in your state.

Regarding behavioral strategies you can try now, I would recommend you first observe what are some of his triggers at home:  what are some of the situations that cause him to become frustrated?  Are there patterns?  Can you re-arrange some of these situations to avoid some of the triggers?  Another rule of thumb is to make sure that what your son wants to do at home comes after what you want him to do.  In other words, if your son sometimes balks at doing something, arrange things so that something he looks forward to comes after he does the thing he does not like to do.  There will be a natural incentive for him to cooperate then.  Also, maybe you can work with him (work together) on a particularly "unpleasant" task (a task that he does not like to do)  so that it does not take too long.  Maybe then your son will not get frustrated as often. (This is assuming that some tasks are a trigger for his outbursts.  If not the case, then ignore the last suggestion!)

Try to arrange the schedule at home so that there are routines and few surprises.  The more activities occur in a regular sequence each day the better.  Also, make sure your instructions or comments are stated in a way your son will understand.  Maybe make up a schedule you can post on the refrigerator each day with concrete symbols (pictures or words that are recognizable to your son) so that he can see what is planned.  

When there are outbursts, do not speak with him during these times, and make sure you are safe. You want to give him attention then when he calms down.  Sometimes we unwittingly reinforce negative behaviors because we give our children a lot of attention while we are trying to calm them down.  This usually backfires, because children will act in ways to get more attention.

I explain more about these and other ideas for parents in the first half of my parents' manual.  It can take several months to see significant changes.  In your son's case, you may need outside help, especially if his rages are dangerous.  Also, it may be useful to get someone to come in and interact with your son at home so that you can take a break some days.  You might want to ask your son's doctor how to access additional help in your state.   All the best, Dr. Dave Gottlieb

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