Tuesday, May 9, 2017

12 yr old in residential setting

Hi Dr Dave I wondered if there was any research to prove that positive parenting strategies were more effective in the long term than restraining?

My daughter is 12 with a diagnosis of autistic spectrum disorder (ASD) with Anxiety, ADHD, and she was also recently been diagnosed with the new DMDD (Disruptive mood disregulation disorder) as she spends so much time 'bubbling' with no clear understanding herself of why she feels on edge. She is fully verbal and high functioning but loses all logic once she gets too wound up.

She was hospitalized at age 9 for 9 months because she was simmering nearly all day and erupting 1-2 times a day lasting approx 2 hours - regularly hurting herself, others and causing breakages, smashing holes in the wall etc.

We now have her in a good specialist school where she is residential Mon-Fri and is getting Anger Management therapy and OT. I am learning lots.

I have been using de-escalation / positive re-enforcement with calm empathetic techniques for the last 2 years (not sure if there is a 'formal' name for these strategies and her therapist is confident we are on the right track.

But a few weeks ago she had a couple of mammoth meltdowns at the boarding part of school and was restrained.

There seems to be some discrepancy between the boarding staff, school staff and therapeutic staff about the best strategies during crises. Boarding  have stated that her place there is in jeopardy. This has thrown me as it has opened the door for doubting relatives.

I am wondering if there is any research to back up strategies to help me feel confident we are on the right path.

We are in danger of her being sectioned. She is like Jekyll and Hyde tho, in that when sensory issues and anxiety are reduced she can seem very logical. She is actually above average intelligence - but her emotional age is several years below.

I hope you can help. She appears to be quite a 'unique case' with many experts being stumped when confronted by her over whelming rage. 

Hi, A good research study in the field of anger and aggression in children has been conducted by a professor at Yale University.  His name is Denis Sukhodolsky.  He advocates cognitive behavioral strategies, many of which I advocate as well in my parenting manuals.  In my view restraint should be a last resort to be used if a child is physically harming herself or others.  I prefer to ignore screaming and tantrums if they are not destructive. The more you talk with a child in overload, usually the longer overload continues.  However,in a community setting, it can be disconcerting to other children if a child is screaming, and then it is up to staff to think through whether they can isolate the child (will she move to her room?), or whether they can remove the other children from that space.

Early detection of her triggers is ideal, because then a child is more rational.  I outline in my parents' manuals and the children''s workbook, how to record triggers and how to look for patterns.  That allows for early intervention. Then empathy and/or distraction and/or using catch phrases will help more often. (The latter is part of teaching a child to keep perspective.)   I'm wondering what specifically set her off recently since you mentioned she was having fewer tantrums until recently. Is she worried about losing her space in the residence?  Structure and stability are important for a child with severe overload issues. If she has some awareness that her position in the residence may change, she may be more anxious and prone to outbursts. 

Given her mood and anxiety issues, and the ADHD diagnosis, I wonder if medicine has helped.  Sometimes if the other symptoms lessen, there is less anger overload, and/or the anger will respond to empathy, or distraction, or to cognitive interventions to help keep one's perspective.  For the latter, see the later sections of my parent's manuals or children's workbooks. 

Best to you and your daughter, Dr. Dave Gottlieb

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