Friday, March 21, 2008

When is a tantrum not a tantrum?


Jennifer stomped into my office, hair askew and wet socks flapping around her toes. "I hate my shoes and I don't care about the seven day rule!"

Jennifer is 9 years old and has severe regulatory difficulties - a psychologist has provided the label of ADHD. She has accompanying motor incoordination, complicated by her generic lack of persistent attention to much of anything other than the Winx Club. As a result she has a hard time learning in school and socializing appropriately with her peers. She has been coming to see me privately for a few months now because she has been discharged from the school program - I am still not sure I understand why. That's another post, I suppose.


She has made some good progress with improving her posture, learning to control her body to maintain a sitting position for a longer period of time, and in maintaining persistent attention during non-preferred activities. She has made less progress with her actual handwriting and emotional stability. There is still work to be done.

This was all rather obvious as she flew past the front door of my office, assumed a fetal position in the waiting room chair, stuck her fingers in her mouth, and screamed. "I thought that natural consequences of walking through the wet and snowy parking lot in socks would be a good idea for her," her mother quipped. I think that the parent's intention was good but it was kind of like a minor league player swinging at a major league fastball.

Jennifer doesn't have any overt tactile defensiveness, corroborated by the fact that she is able to walk across a cold wet gravelly parking lot in her stocking feet. She also doesn't have any other real signs of tactile defensiveness with regard to touching different textures, or eating a variety of textured foods. The primary source of her being upset was at the prospect of having to wear her new sneakers. The previous week I told her about the '7 day rule' which was a rule ordered by the Shoe Authority stating that no child was allowed to complain about how new shoes felt until they have tried wearing them for seven days.

"I never heard of that rule!" Jennifer said with a worried tone in her voice. "You have to tell me about more rules, because I don't want to go around breaking rules." Jennifer likes order and structure - probably because her world is so often out of control to her - so this was a good strategy.

Unfortunately it failed - the parent sheepishly admitted not being able to follow through with the behavioral plan we provided. So now one week later I had a screaming and tantruming nine year old in my waiting room. Mom brought along a dry pair of socks, so I was able to help Jennifer calm down, put on the dry socks, and put on the shoes. She complained, a little, but then was distracted by the activities we were participating in. Sometimes you can use short attention span and distractibility to your advantage, I guess.

I recently read an article that reported on a study that children who have disabilities have 'different' tantrums than typically developing children. The article reported that children who have disabilities have a more difficult time calming themselves, are more likely to be self injurious or injurious to others, and that the tantrums tend to last longer. This is interesting, but I think it is important that we move past behavioral observations because behavioral observations alone don't explain if a tantrum is behavioral or if it is complicated by a lack of neurodevelopmental maturity.

I am more interested in neurophysiologic measures during tantrums, whether it is EEG or PET scan, or some other measure that would be practical to use within the context of an actual tantrum. Does the BRAIN function differently during a tantrum for children who have known neurodevelopmental delays?

I wish I knew, because I am not sure how much of Jennifer's problem is neurodevelopmental and how much is simply learned and behavioral. I am certain that it is probably both but I would like to be able to tease the issue apart a little more.

After the session was over, Jennifer quietly walked into the waiting room but upon seeing her parent the tantrum fully resumed. Once it started, it was not stoppable; she was as much a victim of it as her parent was. For a long time I watched the parent ineffectively attempt to verbally mediate the situation and as I watched I understood how large the problem was. Jennifer was developmentally delayed, she lacked appropriate self regulation, and the tired parent couldn't muster forth an appropriate strategy to solve the problem. Its an awkward time being a therapist - I would always want to defer to the parent's authority and control but at some point it is clear that the parent is not able to exercise authority and control.

Sensory preferences lead to behavioral patterns that are then reinforced or extinguished by the responses that the provided by the environment. We are not yet able to measure actual improvement in sensory processing but we are able to measure improvement in behavioral outcomes. These realities should guide our interventions and we should avoid the temptation to apply prescriptive sensory stimulation solutions.

And sometimes, our primary point of intervention really has to be the parent and not the child.