Wednesday, April 13, 2011

Jay, a Case Study

 I had such a remarkable turnaround this week with a little boy that I started seeing last month that I thought I would share it with interested readers.

A few weeks ago I wrote about a little boy who habitually entered the clinic and proceeded to zoom around from room to room.  No one and nothing could stop him.  When his parents rebuked him, loudly and sharply, he didn't appear to hear it.  If he was physically restrained from running into the back of the office area to check out the treatment rooms, as soon as he was released, he was off again.  The only way to get his attention was to physically hold him down and force him to make eye contact while speaking loudly and sternly.

My take on his behavior was that he was so sensory defensive, he was unconsciously  searching for predators.  His reptilian brain {the most primitive, reactive part} was constantly warning him that danger was afoot, and so he was driven to go on a reconnaissance mission every time he entered a new environment.  The grip of that inner force was so strong that nothing could penetrate.

I got a phone call from his speech therapist a week or so after I started seeing Jay, who wanted to know if I could help her manage his behavior better.  He was unable to sit still or cooperate with her in any meaningful way.   During his therapy sessions, he threw himself on the floor, crawled under furniture, tried to run out of the room, picked up anything he could find and hurled it, broke things, screamed, cried, kicked, and hit.  Aside from his sensory issues, it was obvious from the way he behaved with his speech therapist, with me, and at school, that he considered obeying grownups to be completely optional.

I commented that I had never experienced such disorganized behavior from any child who did not also have a diagnosis on the autistic spectrum, and the speech therapist agreed.  This child, however, was clearly not autistic in the least.

 I identified some sensory issues and some environmental issues that needed to be addressed before he could be expected to behave in an organized way.  He was quite clearly tactile and auditory defensive.  His balance wasn't very good.  He had not spent much time crawling, which is essential for developing a strong, sturdy, neurologically integrated body.  It was apparent, just looking at him, that his eyes didn't work together well, so perhaps he was seeing double, which is certainly anxiety provoking, especially in a busy classroom or on a Manhattan street.  His nose was chronically stuffy and he wheezed, which meant that his breathing was shallow and inefficient.

Environmental issues were a big part of his problem.  His diet consisted of mostly of chicken nuggets and french fries, washed down with soda.  He did not spend any time outside other than to get from place to place.  There were also issues at home about things like anger management, setting appropriate, consistent limits, and having a regular bedtime.

I suggested to the speech therapist that she start his sessions with therapeutic brushing  {there was an OT onsite who could teach her the protocol}  have him play with blow toys, incorporate movement whenever possible, and to give him lots of heavy input into his joints, like jumping on a trampoline, or putting him on the floor and rolling a big therapy ball over his body.  I told her to set the bar really low for a while and not expect too much in terms of the difficulty of the tasks she set out for him.  Children often act out when they are overwhelmed and don't know how to do what is expected of them.  This is particularly true, I find, for children who are wrapped up in their defensive responses.  They don't have enough cognitive energy available for much else.

 I also encouraged her to have a zero tolerance policy for unwanted behavior.  She had begun to just ignore the behaviors she didn't want, but I have found that with a child who does not respond to adult authority, calm, firm, consistent redirection, in combination with physically containing him to prevent him from running off, is more effective.  A child like Jay, who feels so unsafe and whose behavior is so out of control, has to know that the grownups are in charge.   He can then begin to let down his guard and depend on the grownups to protect him.  {My analyst colleague would add that he will know that the grownups are strong enough to prevent him from doing anything too terrible.}

I taught his parents the therapeutic brushing program, explained that he would behave better if they did it, and crossed my fingers that they would carry through at home.  I sent a brush to his school so that his SEIT, {a special education teacher who works with an at risk child one on one in the classroom} could brush him.   I told his father that his behavior would improve considerably if he were given regular time outside, especially at a playground with swings and a slide, and his father promised that he would make sure it would happen every day.

In my therapy sessions, I worked on integrating postural reflexes and improving his balance and core stability.  We did lots and lots of breathing work, using whistles and blow toys.  It was not easy.  The first couple of weeks were quite exhausting as he challenged my authority again and again, had many tantrums, and had to be restrained from climbing under furniture or running out of the room.  One day he came in so restless and unable to focus that after brushing him, I took him into the hallway and told him that we were going to run a race.  That worked wonders.  We ran and ran and ran, and he kept begging for more.   When he was finally tired enough to agree to change activities, we got lots of things done.  He gave me a big hug when it was time to go.

The next time he came to see me, he started to wander back into the office area.  I said, "Hey, Jay, you're not allowed back there," in a normal tone of voice.  He stopped and came right out.

What made it possible for him to finally hear me?

I believe it was a combination of things.  The brushing reduced his tactile defensiveness enough so that he wasn't wrapped up in his internal fight or flight mode and could attend to what was happening outside  of his body.  The blow toys, which I sent home and encouraged his family to have  him play with, improved his ability to breathe, further reducing his anxiety.  His father had indeed made it a point to take him outside, which he reported made bed time a breeze, so Jay was well rested.  The authority figures in his life were all making sure that he behaved in a manner that met their expectations, which made him feel secure.

Later that afternoon I got an email from the speech therapist letting me know that Jay had been participating a hundred percent in their sessions and had not had a single behavioral issue for two weeks.

His SEIT reports that he is participating much better at school, his behavior is more organized, even in the noisy classroom, and his tantrums have reduced considerably.

We're still not out of the woods yet, but these small changes have made a remarkable difference in this little boy's ability to function.


Your Therapy Source Inc said...

Not sure how old your little guy is, but with children who have trouble with authoritative figures I have found the book The Explosive Child to be very helpful by Ross Greene. Obviously you used some great tools to get him to purposefully engage, just thought you might want to add this to your tool box.

Anonymous said...

Just a general comment from an avid reader... thanks for your writing. You're helping me be a better parent. Cheers.