Month: September 2017

Emotion regulation and the art of the spin

Sometimes, parenting is all about the “art of the spin.”

In every life, a little rain must fall.  For child with challenges, it can rain a lot.  How do we help our children through challenges, set-backs and frustrations?  This can be particularly challenging for children who struggle with emotion regulation. Children who cannot regulate their emotions may (over-)react to problems multiple times a day.  It takes constant practice to help them reset their heads and take things in stride.

I recently got an e-mail from a mother I know. She wrote:

I am writing to you about Abby. We had a really, really difficult first week at first grade. Abby is a bright, energetic and happy little kid. (I know this child.  Effervescent is the word that comes to mind.  She is adorable.)  Abby has Sensory Processing Disorder.  She has a sensory diet and we are diligent about keeping up with it.  There is a plan in place at school for this. Abby is great about knowing what she needs. She self manages fairly well and is pretty cooperative about doing movement, asking for noise reducing headphones, etc. Another thing about Abby is that she likes to do things perfectly (despite teaching her otherwise.) She is a BIG rule follower, particularly at school.  She loves school.

Abby started first grade this year and came home the first day saying, “First grade ROCKS!” All was well until Tuesday. At recess, Abby made a bad choice. She told a lie to a teacher about a peer whom she felt was mean to a friend. This is very out of character for Abby and something she has never done before. When the teacher figured out that Abby’s story was not adding up and asked Abby if what she said was true, Abby wet her pants on the spot (something that has NEVER happened). The fear must have surged through her body.

Because of the lie, Abby had to ‘flip a card’ which is the behavior system her school uses. Abby has NEVER had to flip a card and this is her 4th year at the school. Trying to prepare her, I have said to her periodically, “Some day you will flip a card and it will not be the end of the world. You will learn something and we will move on.”  She would always say, “Mom, don’t worry, I’m never going to flip, I LIKE to follow the rules.” To say Abby was crushed by her mistake is an understatement.  The school had to call me to take her home.

Abby was crying so hard she couldn’t breathe. She begged me not to tell anyone, including her dad. She was so embarrassed. She took her own dessert away and wrote her apology letters to her teachers. The next morning all was well until it was time to go to school and then tears, lots. She went to school crying.  To make matters worse, unbeknownst to me, her teacher decided that the movement schedule would be changed and a new aide was to do them. This aide is certainly nice enough, but knows nothing about giving a sensory break. Abby cried on and off all day and frankly looked glassed over when I picked her up. She hadn’t eaten a bit of her lunch.

I found out then about the change in the movement break plan. I was LIVID! To change a plan that a sensory kid has had in place for ages on the heels of probably the most traumatic event she’d experienced (in her eyes) without consulting the occupational therapist or with me, her mom. So Abby was a complete disaster and didn’t even have a good way to even attempt to get back on track. I respectfully asked that the plan be reinstated until we could meet formally to consider changes in her educational plan.

Despite this, Abby has cried every day at school since then. I ended up taking her home early on Friday. Her teacher was out, the sub wasn’t managing well, and Abby was crying hysterically.

We spent a day “calming down” and working hard.  Physical activity always resets her mind.  I felt like she was pretty well reorganized, so I tried to talk with her about the week.  As soon as I broached it, she started to cry uncontrollably. She doesn’t want to go out for 3rd recess anymore (which is where the card flip and pants wetting happened) She just kept saying “I don’t need 3 recesses anymore.” She does not want to go to school anymore.

Abby has always been a little anxious and I always wondered if it was just part of her SPD or if it was something more. At this moment, I am thinking it’s something more and don’t know what to do. My child is a mess. Can you guide me? Thank you so much.

Building Emotion Regulation with a little spin

So I answered:

Wow, poor kid.  But there are things we can do. Sometimes the sensory regulation issue has an emotion regulation issue.  You tried to prep her for the inevitable, but she was pretty sure it would never happen.  Now the emotion that surged up is too high to regulate.

Certainly, getting caught in a mistake AND wetting yourself would be traumatizing for a child who loved school and was sure she would never have to “flip a card.”  And in the first week!

My thoughts are for some scripting around the reality . .  .  . and a little spin.

Sometimes you have to put a new spin on her perceptions.

The next time you bring it up, start with, “I am so thankful this happened.”  (huh!)  “No one gets through life without making a mistake and most of us make lots of them, it is good to get some practice with them.  I am so glad it was a 1st grade mistake and not a teenager mistake.  Those are bigger and harder to fix.  This one was easy.  You apologized and it is done. You handled it very maturely.”

Keep a matter-of-fact tone for yourself

As upset as Abby is, if you match Abby for gravity of the situation, she may think it really is as serious as she is making it out to be. Model that this was a small mistake.  They happen every day.

The two spins are:

  • I am glad it happened – For a child who has made a (in her eyes, terrible and unforgiveable) mistake, how can anyone be GLAD it happened?  But as we all know, mistakes will happen and we need practice with picking ourselves up, dusting ourselves off, and moving on.  Spin it as something as important as good grades (because it is).
  • You handled it very maturely – Well, there was that wetting accident and multiple bouts of hysterical crying, but there was also an apology in writing.  That was the mature thing for a six-year-old to do in the midst of being a very upset little girl.  Not many of us think to make amends when that upset.

(Just to note, this spin does not downplay the feelings, the spin is to give additional perspective to the event.   The additional perspective will hopefully help reset the feelings.)

And Use YOUR Mistakes!

The Queen (my daughter) was very intense with her emotions and was pretty famous/infamous at school for her breakdowns after any perceived mistakes.  One thing that helped her was hearing about the mistakes I had made.  “Do you want to hear the 5 mistakes I have made today alone?”  The answer was always a breathless, “YES!”  I also covered the WORST mistakes I ever made (keep to your G-rated ones if you go there with smaller children).  The Queen particularly likes the story of the time I called my mother stupid IN FRONT OF HER FRIENDS. My mother was not amused and let me know it.  My horror and embarrassment were immediate and epic.  The Queen was re-assured that I had survived my own feelings.  I had to tell that story every time she made a mistake for several years.  It got old, but it worked for her.  “Tell me about the time you called your mother stupid.”  Since I had survived that, she could survive whatever mistake she had made. (By the way, my mother, as the Queen knows, is a wonderful person who did not deserve my 12-year-old impulsive flippancy in front of her friends).

Plan for the Next Mistake

After mistakes are shared, parents can also discuss the inevitability of the next mistakes. “What do you think your next mistake will be?”  “I wonder what my next mistake will be?”  “I have got some guesses already.”  We all have stuff in our day that can go south on us due to lack of planning, putting too much on the plate, or just getting tired and irritable.  Include our funny mistakes.  Our mistakes are easy to come by.  Then we discuss solutions, but often, it is just moving on.

Other Supports

Abby seems to have really tipped herself over with this.  I told her mother to consider providing more support if possible for a little bit:

  • Joining her for part of 3rd recess by adding some mommy time in the day with a little volunteer time if possible.
  • I recommended Lilly’s Purple Plastic Purse by Kevin Henkes.  It is a similar story of a big mistake made by a little person, complete with notes of apology as well.
  • For supplements, Epsom Salt baths which helps us absorb magnesium might be of some benefit. Magnesium is calming and is depleted in times of stress.  There is also Rescue Remedy, a Bach flower remedy, which is to calm stress reactions.  These strategies may help a little. Being a psychologist, I typically recommend that parents run any supplements past their pediatrician.

Taking Support to the Next Level

I told Abby’s mom if things did not settle in the next few days, check in with the school social worker or psychologist for strategies.  If that does not help, some short-term counseling might be needed.  A good child therapist can help build emotion regulation skills.

Epilogue

A few days later, I heard from Abby’s mom.  “Hi! I just wanted to give you a quick update. I tried almost everything you recommended and she has been tear free for two days. Will continue the coping strategies. Great to have my happy girl back! Thank you so, so much.”

I glad it was good advice, but I am sure time helped a little too. However, with an intense (albeit adorable) child, there will be years of practice off and on down the road.

Putting a good spin on something is just one strategy, but an important one, when building emotion regulation.  The right “spin” on things can help her move forward more quickly.

Your Child’s Diagnosis-or Not

I don’t diagnose.  I mean . .  . I CAN diagnose, but I often don’t.  I am a developmental neuropsychologist and I do reassure parents that I can diagnose any possible learning disability.  But frankly, it’s not the point of my evaluation.  I don’t see my evaluations as diagnostic evaluations, but as comprehensive developmental evaluations with a good dash of neuropsychology.

What’s the difference?

Many evaluations in my field are diagnostic evaluations.  The goal of the evaluation is to converge on a diagnosis (or several) from the Diagnostic and Statistical Manual of Mental Disorders-5th Edition (the DSM-5 for short).  This is the manual psychiatrists and psychologists use to make mental health diagnoses, including developmental and learning disabilities.  It is bible-sized, about as dense, and a little dry.

The DSM gets updated every decade or so.  Some diagnoses are removed, some are added, some are refined and made clearer (some are made muddier).  Our understanding of mental health, cognitive issues, developmental problems and learning challenges continues to evolve at a bumpy, uneven pace.   The DSM tries to keep up.

And this is one reason why I do not focus my evaluation on a DSM diagnosis.  I like the DSM. I own it.  I pull it off the shelf regularly.  I will make a formal diagnosis from the DSM-5 when it is necessary and/or when it is helpful.  (It is necessary for college and, sometimes, other school accommodations.  It is necessary for insurance submissions. It is necessary to enter certain treatment programs.)  And sometimes it is helpful. Sometimes the child is a perfect fit for the diagnosis (or diagnoses) and the treatment protocol.  Giving the diagnosis will help everyone support the child through well-studied and accepted protocols.

But frankly, there are just not that many diagnoses to choose from.  Developmental and learning disorders are categorized as Neurodevelopmental Disorders.  You get six basic choices – Intellectual Disability, Communication Disorders, Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder, Specific Learning Disability, and Motor Disorders. There are more specific subcategories within these labels. There is also a category that is basically “Other” in case nothing else fits.

A child (or teen) can also be diagnosed with a mood disorder (depression, bipolar disorder), anxiety disorder, oppositional defiant disorder, attachment disorder or other more typically “mental health” disorder, but these are in other sections of the DSM.  I typically roam around in the Neurodevelopmental section with occasional forays to the other areas.

But, you ask, why do I resist making a diagnosis?

Here are a few of my problems with simply converging on a diagnosis:

  1. There is the use of the words “Disorder” and “Disability.”  Some of the challenges I see are not a great fit for certain classrooms, but do I consider this a “disorder.”  Maybe it is just a type of normal. For example, we love (and often envy) highly energetic adults, but we are not as thrilled with highly energetic children.  However what may be a drawback now, may be an asset later.  I discuss this with parents and we make a decision to either make a diagnosis (because it does fit well enough and would be useful in some way) or describe the child’s strengths and weaknesses (or both).  The recommendations will likely be the same either way because those are based on lots of other data collected, not just the diagnosis.
  2. There are only 6 general categories. Sometimes I think we are too narrowly defining our range of possibilities for the billions of people (and their styles) on this earth.  Even using more than one category may not fully describe the child I evaluated.  In addition, I really want to paint a picture of this child, not converge on diagnoses.
  3. Not all of my preferred options are in there. Sensory Processing Disorder (or atypical sensory processing) being a good example. That diagnosis was proposed (strongly) for inclusion in the DSM-5, but it did not make the cut.  Sometimes, sensory issues are a leading contributor to attention problems in the child I evaluated.  So if a diagnosis is necessary, I have to make an AD/HD diagnosis (or Oppositional Defiant Disorder or Intermittent Explosive Disorder or something that fits) with an added explanation of the factors causing the problems.  Sometimes I don’t make the DSM diagnosis and focus on what I think it actually going on.  I feel like the diagnosis will actually be misleading.
  4. The diagnosis might become a label. If you lead with the diagnosis – Autism, Attention Deficit Disorder, Intellectual Disability – people may only see the label, not the child.  They may form a mental bias based on the label and not expect a child to be able to learn or change because they do not see a certain skill as within the scope of that label.
  5. The DSM diagnoses still do not connect brain to body very well. It tries to and does discuss various medical factors that may contribute to some diagnoses.  But sometimes there is a diagnosis, such as Oppositional Defiant Disorder, that totally fails to take into account sensory or other physiological factors that take a part in the presentation.

I have reviewed several evaluations lately that collected a lot of information and converged neatly onto a diagnosis.  The diagnosis was justified by the outward presentation of the child and the scores obtained on tests.  In fact, it was the only diagnosis in the DSM-5 that would have fit.  But the diagnosis was not helpful.  The diagnosis did not drive treatment in a way that supported the child.  It was necessary to dig under that diagnosis and find the contributing factors that led to that diagnosis.  Treating or supporting those factors were helpful to the child.

So yes, I can make a diagnosis and I will when it is needed.  But I will also continue to see evaluations as an art, as well as a science.  I want my work to be more than industry standards.  I want to paint a helpful picture.  I want to try to get to the bottom of things.

And that is why we wrote Child Decoded.