This is an e-mail from a mother of one of my clients, an 11 year-old boy prone to frequent explosive tantrums. This e-mail is from a period early in therapy. When I received this e-mail, we had only had three or four sessions by that point, and we were still at the stage of explaining a developmentally supportive treatment framework and therapeutically supportive responding.
_________________________________________
Jared’s behavior has been escalating like mad. Please refer to the email from this teacher below.
Jared’s psychiatrist, Dr. Johnson recently switched Jared from Daytrana to Straterra and then at the next appointment he added Prozac. Jared’s behavior has escalated and deteriorated since then. He is volatile, aggressive and extremely hyperactive, almost to the point of complete out of control screaming and impulsivity. He has become very hostile and angry. Clearly this medicine combination is not working, much to my disappointment. While the Daytrana suppressed his appetite, which was not desirable, and it was not a 24-hour solution, his overall behavior was slightly more controlled.
I am really worried about these outbursts and his emotional fragility and I am wanting to take him off these medications and move to something different.
Dr. Childress, this, obviously, will be key point to talk about during our next session as I am having a very difficult time managing and working with and controlling his impulsivity and would love your guidance.
_________________________________________
Here is the e-mail from Jared’s teacher:
_________________________________________
Jared had a tough day today. He upset several children by calling them names (stupid, dumb and some other foul language) and ultimately was involved in a physical altercation with another boy who punched Jared in the privates. Both boys were sent to the principal’s office for counseling and a consequence. Jared was assigned "community service" at lunch for Friday (today), Monday, and Tuesday. Wanted to let you know. We hope Jared will make better choices and use kind words to others here at school. Thank you as always for your support.
_________________________________________
Here is my response from a developmental psychotherapeutic framework:
_________________________________________
Behavior is a symptom, the brain is the cause.
My question is why Jared acted the way he did in the classroom. Far too often we simple focus on behavior suppression without understanding how and why the behavior emerges (i.e., the cause). If we don’t understand the cause then we can't address the cause, and we will find ourselves forever chasing symptom suppression without effective resolution. If, however, we understand the cause then we can treat and resolve the underlying cause of Jared’s behavioral symptoms, and so eliminate them.
It appears as if his emotions become inflamed, and he then acts on the pain of the inflammation.
In its early state (infancy), the emotional system is explosive-expressive, what's called "catastrophic emotion." At this early stage of development, emotions are simply expressively discharged (this sounds like what Jared is doing).
In infancy, when we respond to the child's catastrophic explosive-expressive emotional discharges "as-if" the emotional discharge has communicative value, the young infant-child gradually begins to recognize that someone is listening, that his or her emotional expressions have socially communicative value.
At that point in development, the emotional system undergoes a transformation from "catastrophic emotion" to "emotional signaling" in which the infant-child begins to use emotions within the communication systems.
When emotions are brought within communication networks (as opposed to remaining "catastrophic" explosive-expressive discharges), then a set of additional brain networks runs from the communication systems BACK to the emotional networks and inhibits the intensity of the emotional networks. The intensity of the emotional experience becomes less (thereby allowing the child to bring emotions into the communication systems rather than just expressing them in explosive discharges - it's a cyclical process of communication of emotions inhibiting the intensity of emotional experience - and the inhibition of intensity allowing increased communication of emotions).
It sounds like Jared's emotional systems remain in a primitive state of catastrophic explosive-expressive discharge rather than being used within communication-relationship networks. So he doesn't have the inhibitory networks available to reduce the intensity of his emotional experience. When he feels angry, or sad, or anxious, the feelings probably feel similar to rage, despair, and terror, which overwhelm his ability to remain emotionally-behaviorally regulated. His brain then goes into a chaotic disharmonious state expressed behaviorally as calling people bad names, getting into fights, etc.
His teacher indicates that she believes this is a "choice" he makes. It's not. Choice is a product of the executive function system, a different more advanced brain system having to do with planning, foresight, and reasoning. At more sophisticated levels of development, the executive function system can also act to inhibit emotional experience, but not when the emotional system is in a primitive, catastrophic, explosive-expressive level of development.
When his emotional system dysregulates, Jared doesn't have access to the higher-order thought processes, brain systems, and behavioral self-regulation available from the executive function system (an activated emotional system can actually inhibit the executive function system – executive function and emotion actually cross-inhibit each other). Jared doesn't have a choice, his emotions are simply discharged expressively and explosively, and his behavioral expressions similarly reflect an impulsive discharge of motivation.
He acts impulsively, he flails about in a rageful tantrum, he’s non-responsive to reason or dialogue, he doesn’t consider consequences or other people’s needs, because his brain’s organization is being overwhelmed by a poorly developed emotion-regulation system that remains in a primitive explosive-expressive organizational state of catastrophic emotion.
That's the way his brain, his emotional system, works at this point.
Trying to activate higher-order thinking (executive function), more regulated emotional states (consideration for other’s needs), or simple behavior suppression approaches (punishment to activate dominance-submission networks) are all likely to fail.
He won’t have a sufficiently strong executive function system to challenge a primitive emotional system until the full executive function system comes on-line at young adulthood (and sometimes not even by that point – consider explosive-expressive tantruming adults).
He can’t access the sensitivity of a regulated emotional system necessary to be sensitive to the emotional experience of others --- the “volume” is too high on his own emotional state to “hear” the emotional needs of others, and his own explosive-expressive motivational press overwhelms his ability to suppress his motivations and adopt the motivational needs of others.
He can’t access the sensitivity of a regulated emotional system necessary to be sensitive to the emotional experience of others --- the “volume” is too high on his own emotional state to “hear” the emotional needs of others, and his own explosive-expressive motivational press overwhelms his ability to suppress his motivations and adopt the motivational needs of others.
And simple behavior suppression techniques of punishment to activate dominance-submission networks can work, but it will require a brutal level of punishment in order to achieve sufficient activation of dominance-submission networks to overcome this high a level of emotional activation, and in today’s society and culture we’re simply not comfortable brutalizing children to that extent.
The inherent failure of these approaches is why you feel so frustrated. Nothing works. What works for other kids (who have a more maturely developed emotional system), doesn’t work for Jared. The emotional systems of his brain are immaturely developed relative to other children his age. He has tantrums (explosive-expressive emotional-behavioral discharges) that are developmentally more appropriate for a 2 or 3 year old child, or even an infant, rather than an 11 year-old child. His emotional system is immaturely developed. The brain is the cause, behavior is a symptom.
We need to help his emotional system mature. So how do we do this?
We first need to bring his emotions into the communication-relationship systems. As we’re able to accomplish this over time, we’ll activate inhibitory networks that will lessen the intensity of his internal experience of the emotions. He’ll go from rage to annoyance, from despair to sadness, from terror to anxiety.
We do this by responding "as-if" his emotional discharges have communicative value, prompting the transformation of his emotional system from a state of “catastrophic emotions” to “emotional signaling. “ As we respond more frequently as-if his emotions are communications, he will gradually come to recognize that we're trying to understand (i.e., we bring him our "intent-to-understand” his inner experience from his perspective) and he will begin trying to make increasingly elaborated efforts at communication.
Currently, we’re likely doing exactly the opposite. We likely define his emotional discharges as “problem behaviors” and we try to motivate a suppression of these annoying-problematic emotional-behavioral displays. Our intent is an “intent-to-change” his outward expressions rather than an "intent-to-understand" his inner experience. Facilitating communication emerges from our intent-to-understand (children won’t communicate if we’re not listening, or at least making a sincere effort at listening, to their experience from their point of view). If we’re just listening in order to tell them that they shouldn’t feel or act that way, that they need to change their experience, then they won’t make the effort to communicate with us, so their emotional system remains in a primitive explosive-expressive state.
As we continually respond “as-if” his emotional expressions have communicative value, he will gradually bring his emotions increasingly into the communication-relationship systems. Inhibitory networks will reduce the intensity of his experience of his emotions, further allowing him to increasingly use his emotions in a socially communicative, socially organized way. This represents the social maturational process of the emotional-communication-relationship networks. It does take some degree of time, we’re building brain networks, not simply suppressing current behavioral expressions.
Developmentally, this process occurs primarily between the ages of 2-3, with further advances between the ages of 3-7 years old. So Jared is a behind in the maturation of the integrated system of emotions-communcation-relationship. But once we get him back on track we should be able to catch him up substantially. These brain systems want to mature if we give them the right interpersonal context.
The maturation of Jared’s emotional-communication-relationship integration occurs at the "point-of-therapeutic-opportunity," right when he's having the emotional experience. Talking about it later, once he's calmed down, won't do it. Right when he's having the emotional experience, that's when we need to approach with an intent-to-understand his inner experience from his perspective (bringing our "eyes-of-the-other" to his inner experience), thereby supporting his ability to bring emotions into communication-relationship systems.
Jared's meltdowns are not "problem behaviors," they're "points of therapeutic opportunity."
I wish he'd have those meltdowns in my office. As a psychologist, I want to be at the point of therapeutic opportunity, right at the point when his brain is beginning to move into a chaotic, disorganized state. Just as he begins to enter a disorganized state, that’s when helping him regain an organized-communicative state will build all of the brain networks used in the process, including the social networks of using us as a helpful resource for helping him achieve emotional-behavioral regulation when he's in distress. Unfortunately, children tend to remain well-behaved and well-regulated in my office. You and his teacher are the ones who are at the point of therapeutic opportunity, which is why it's important for you to understand how to respond in a therapeutically supportive way.
With the brain, we build what we use. As we continually use these pathways, they will become stronger, more sensitive, and more efficient, so that, by the time he's 35 years old, he'll be able to ask nicely for things... :-)
It will take time, but hopefully not that long. I would hope for visibly significant progress in a matter of months, with "mostly resolution" in 18 months (the issue is, what is "mostly resolution" - kids are designed by nature to be annoying, it's what they do... so we can't parent-out all of their annoying, but we can move from non-social emotional tantrums and explosive-expressive discharges to socially organized communication of differences in a bi-directional respectful way).
So, what does anger communicate:
"you hurt me - so I hurt you."
Anger is the "I hurt you" side of that communication. What we need to listen for, and listen to, is the front half of the communication, the "I'm feeling hurt" part. So, the question becomes, what was Jared feeling hurt about in the classroom that provoked the angry discharges?
Interestingly, anger also contains a third level that is typically hidden and so is often unaddressed. The hurt comes from a frustrated desire to love and be loved. So the actual complete communicative message of anger is “l love you (you are important to me, you make me happy, I want to be with you) – you hurt me – so I hurt you.” As we shift the communication from the back half of “…so I hurt you” to the front have of “I’m hurting” we may want to expand our own and the child’s understanding a bit more to include the deeper communication, that the reason the child is hurting is because he or she loves us and wants our love and approval.
In responding therapeutically, I care less about Jared’s behavior in the classroom than I do about his inner emotional experience. This communicates that I care more about Jared as a person (who he is) rather than as an object (what he does).
When we care only about the child's behavior (stop being so rude, annoying, disrespectful, disobedient, etc.), this communicates that we care more about the external of what the child does (you're an object), rather than about who the child is as a person; i.e., the inner experience of the child. Being treated like an object provokes pain and psychological loneliness, being treated like a person feels good, provokes understanding and relaxation, and promotes social bonding and mutual respect.
Do I approve of his classroom and social behavior? No, of course not. And we'll communicate this in due course of the complex communication exchange. But my first concern is about Jared as a person. The intensity of his anger is communicating the intensity of his pain.
We need to respond first to his pain and help him stop suffering. Then we can prune his angry-hostile expression of pain with a small dose of our own anger-rejection, or by inducing suffering in him (i.e., punishment) because he induced suffering in us (through his mean, hostile, rude, disobedient, whatever kind of explosive-expressive discharge of anger, rather than communicating with us... because, if he communicates with us then we're listening... children won't communicate if we don't listen).
Inducing suffering in Jared (i.e., punishment) is not because he did something "wrong," punishment is a social communication of relationship. He annoyed us, so we annoy him. He makes us suffer, so we make him suffer. Simple. It's personal.
My diagnosis of Jared's issues, however, is not that he is experiencing too little suffering. So, in general, I'd tend to shy away from inducing more suffering. A little suffering can go a long way, so I'd tend to use it gently and sparingly. I'd use it, because he's annoying. But I'd use it sparingly and in the context of an active "intent-to-understand" of his inner experience from his perspective... then, I'd give him a dose of suffering in a social communication exchange of "but, little fella, much as I can understand what you're going through, you annoyed me rather than communicating with me, so I'm now going to annoy you with some form of punishment... so, in the future, please stop being so annoying and communicate with me instead. If you communicate, I'll do my best to help you... because I love you and your joy is my joy, and your suffering is my suffering.”
Punishment (inducing suffering) can take any form you want. Removing good things he enjoys (e.g., no play date, no TV, etc.,), social isolation/rejection (e.g., time outs, room restrictions, grounding, etc.), anger (e.g., the withdrawal of love-approval and inflicting social rejection), physical pain (not recommended) and a variety of other forms such as extra chores, lecturing (what I call the "intention infliction of excessive boredom"), etc.
But since all punishments, at their core, involve inflicting suffering on another human being, all punishments will have negative side effects. One of the primary side-effects of punishing children is that it requires that we make someone whom we love suffer. This means that we have to shut off our psychological connection with the child, the connection in which our child’s joy is our joy and our child’s suffering is our suffering. We have to harden our compassion for our child’s suffering. So punishment, by its very nature, brutalizes both the recipient and the perpetrator.
When we have inflicted suffering (through anger or punishment), it is important to ultimately repair the relationship with warmth, affection, and understanding, and re-establish our bond of connection (your joy is my joy; your suffering is my suffering).
One other complicating factor in all of this, is that we're pouring various brain chemicals (medications) into Jared’s brain that will affect the operation of brain systems. So, it can be hard to differentiate the effects of the normal operation of brain systems from a response to medication effect.
We'll talk more about all of this when we meet.
Craig Childress
