11/13/2012. Meltdowns Lecture 2: Story of Johnny. Description of Johnny. Johnny s Personal History

Transcription

1 Meltdowns Lecture 2: Story of Johnny How to help children overcome aggression and behavioral problems through the story of a 4 year-old boy Description of Johnny Johnny is a 4 year-old boy who could engage in a continuous flow of back and forth interactions and be focused, attentive and take initiative during pretend play. Johnny would become disregulated and start tantrums banging, making noise, causing physical pain to himself if ignored or not given what he wanted. He would also show aggression towards his younger sister, parents and himself. Johnny s Personal History Finicky and fussy baby with a lot of colic Sensitive to loud noises and certain kinds of touch Slightly delayed in his motor milestones More tantrums at home than at preschool could be engaged with other children Very defiant picked on his sister and did not do what he was told to do 1

2 Advice and Labels that Didn t Work Johnny s parents had been given many different labels ADHD, bipolar disorder, cognitive disorder, oppositional defiant disorder, etc. They had also been told to ignore his aggression so as not to reinforce it. Johnny s parents had been encouraged to try a behavioral approach to reward positive behaviors and punish negative behaviors. They were also told that Johnny needed the Tough Love Approach give time-outs and use louder voices. They tried this approach with no success. They were variously told to ignore or restrain Johnny if he was acting up in order to punish his bad behavior. Principle 1 Understand the home situation and the context within which the problems are occurring. First, understand Johnny and the way his mind and nervous system work. Perform a thorough investigation of family function. Understand the reasons behind the overwhelmed, anxious, worried and angry parents. Understanding Johnny His Profile Johnny was easily overloaded and sensitive to sensations. At times he could be sensory craving, and would become aggressive when overloaded. He experienced minor delays in auditory processing and language. There were also some coordination issues and motor delays. He faced processing challenges and could not see the big picture. 2

3 Principle 2 Create an environment where the child s overall development is supported and facilitated. D mobilize the developmental process and help the child climb the ladder. I focus on the individual differences and how the child s nervous system works. R help to develop relationships and warm interactions. Creating Nurturing Interactions Introduce Floortime following Johnny s lead Recommended 2-4 twenty minute sessions per day with Mom and Dad This will help Johnny become more imaginative and have more complex exchanges of ideas. Limit alone time and screen time (both TV and computer), and engage in more interactive time. Have reality conversations Play the Thinking About Tomorrow game Johnny can: learn to read non-verbal signals. learn to answer why questions. enhance his language development and his ability to be a causal thinker. learn to describe his feelings and anticipate different situations. Using the Thinking About Tomorrow Game Have the child picture tomorrow and the things that they do and do not like to do. Have the child rate each activity on a scale from 1 to 10, one being the worst and ten being the best, most pleasurable for them (i.e.: 1 is awful homework, and 10 is coloring or playing on the computer). Encourage the child to visualize the events, as if they were TV shows. When you help the child weight their interest in different activities, they are investing the events of tomorrow with emotional meaning. This helps the child remember and sequence events. It also helps the child make a conscious decision. Asking the child whether they will do a particular activity or not turns passive avoidance into active decisionmaking. 3

4 Principle 3 Counterbalance the child s emotions with the parent s emotions. If Johnny was getting irritable and out of control, his parents should be extra soothing and calming. Johnny worked with an occupational therapist to find that firm pressure on his back or arm helped calm him down. These methods allowed Johnny to learn how to regulate and gain self-control. Each child will have their own way of calming down. Helping the Child Become Calm and Regulated Each child will have their own way of calming down, and it is important to determine how the child will react to different methods when they are angry or aggressive. Some children may become more irritable to a soothing voice, and may need to be calmed in another way, such as pacing around the room, being given personal space, etc. Take note of what calms the child, and use these methods to preempt a meltdown. Principle 4 The Agnes Principle Do not remove the child from the situation, remove the situation from the child. If you take the situation away from the child, the child will not be labeled as bad or negative, and can instead focus on the root of the problem and calming down. This reinforces the general philosophy that all children are good children. This builds healthy foundations for a child learning to set limits and cope. The child will learn to regulate external behaviors and internal feelings as well. Interacting and helping calm Johnny down, instead of putting him in a room where he is isolated, will help him learn to read and respond to his emotional and social cues. 4

5 Suggestions for Strengthening Motor and Sensory Functioning Suggestions to help Johnny become better modulated and develop more confidence in his body: Have a helper and peer do exercises to improve coordination; this could eventually be turned into a sports activity. Introduce big picture thinking exercises. Play modulation games to help him learn to modulate his activity level and his sensations. Sensory Modulation Recommendations* Gradually expose the child to sensations they are overreactive to, with the child being in charge, and always in the context of soothing, regulating interactions. For example, the child can direct you to use a softer or louder voice, or to tickle lightly or more firmly. Have the child take a greater role in directing the games, and use techniques like swinging, jumping, hugging and massage games. Play lots of games involving speed, intensity and direction. Have the child run fast, then slow, then super slow. *For more recommendations about sensory modulation and motor planning and sequencing, please see the last few slides of this presentation. Big Picture Thinking Keep challenging the child toward higher levels of abstraction by shifting back and forth between details and the big picture. Periodically ask how all the things the child has been talking about fit together, to help them see the forest for the trees. Help the child practice visualizing what they hear or read in order to identify the big picture, along with all the details. Work on different visual characteristics, using the functional / emotional levels to organize the approach. What are the characters or objects in the scene? How do they look? What are their shapes and colors? What are they doing, and how are they interacting? What problems are being solved? Use these sorts of questions to get to higher levels of development. Eventually you can get to the point where you are asking higher levels of functional / emotional questions from the material: Why is the author saying what they are saying? Do this both in pretend play and in everyday conversation. 5

6 What to do when Johnny crosses the line? Institute a sanction that is meaningful to the child: Johnny would lose access to a toy or TV for half a day. Do constructive things around the house that can have nurturing qualities: Johnny would become Mom and Dad s helper. Before instituting punishments, try to prevent the situation. It s important to learn to read and anticipate the child s meltdowns. Highlights of the Program Remove the situation from the child. Learn to read the child before they get out of control. Change the family pattern to have positive interactive time. Build basic competencies so that language and thinking will improve. The ability to read and respond to emotional signals will also improve, as well as the child s ability to think creatively. Motor Interventions Increase motor planning and sequencing through more complex obstacle courses and sports activities. Increase balance, coordination and left / right integration with balance beams, rocking boats, rapid change of direction or speed, or standing on one leg with eyes closed. Other activities to consider are: playing air cushion games, using the trampoline, and throwing and catching while standing on one leg Gradually create more and more complex balance games, obstacle courses, and sport activities. These activities focus on sequencing, agility, crossing the midline, using both sides of the body, and changing speed and rhythm. 6

7 Motor Interventions: The Evolution Game Encourage coordination, balance, and left / right coordination with the Evolution Game. Use this game as a warm-up, or to work on developmental levels not fully mastered. Progress to the level of the game where challenges occur, and then provide extra practice for the level just before that level. The levels include the following type of activities: Wiggling and rolling worms Slithering snakes Creeping alligators or turtles Crawling dogs, cats or rabbits (of increasing speed) Walking chimps Walking person Running person Jumping, hopping, skipping person Recap This case study and Lecture review the basic Floortime principles as applied to meltdowns and disruptive behaviors. The other case studies draw on them and illustrate how the DIR/Floortime methodology can be successfully applied to all ages, genders and situations. When the principles arise again, we will summarize them. If needed, please revisit this case study and the accompanying handouts, or Lecture 1, for a fuller description. 7