This blog is my place to vent and share resources with other parents of children of trauma. I try to be open and honest about my feelings in order to help others know they are not alone. Therapeutic parenting of adopted teenagers with RAD and other severe mental illnesses and issues (plus "neurotypical" teens) , is not easy, and there are time when I say what I feel... at the moment. We're all human!

Sunday, January 17, 2016

My Child Is Raging

Recently, a trauma mama asked, what do I do when the rages of an older (10+) child become violent? What about keeping the other children in the home safe?

You said, "he won't make the choice to stop." Just to let you know, that's probably not a choice he is capable of making at this time. Once our kids slip in to "Fight/ Flight/ Freeze" mode, the thinking part of their brain literally stops working. They react instinctually.

Fight/ Flight/ Freeze - A child who is dysregulated and/or in fight/ flight/ freeze mode is “thinking” with the reptilian part of the brain (survival!). Their behavior is a purely instinctual response to what the brain believes is a life or death situation. The rational part of the brain just isn't online. Their eyes frequently glaze over, they are out of control, and it is like the child isn't "home." Afterwards they do not remember what happened just before or during an episode. Holding a child responsible for what happens when in a true fight/ flight/ freeze is pointless- it’s better to just move on after it's over and try to figure out what triggered it so you can avoid it in the future.

Rage versus Meltdown A “meltdown” is different from being in Fight mode which usually looks more like a rage. During a meltdown, the child has some control over how far things go. It is still possible to "reach" the child and de-escalate the situation and calm him/her down.

Our bodies' nervous system is very basic - it doesn't know the difference between say, excitement and anxiety. Medications, calming techniques, and maturity can help the body stay calm and keep from sending "AiieeeAiieeeAiiee" signals to the brain stem. Bear tends to go into "Fight mode" when he's upset, worried, anxious, afraid... Whereas Kitty tends toward "flight" or "freeze" and she dissociates (distracts herself).

WHY IS THIS HAPPENING?!
Every kid is different and so many things could be causing the rages and meltdowns. Knowing why our child is acting the way they do, can help us decide how to address it.



DOCUMENT, DOCUMENT, DOCUMENT -

Documentation helps protect us, get services for our children, and refreshes my memories of past issues so I can see progress and make sure chronic issues get addressed correctly. It can help you get a higher level of care (like RTC) or if you need proof that you're not a child abuser (most people with kids like ours will get accused of child abuse at least once), or even just so you don't have to repeat a treatment technique that didn't work.

When dealing with police, CPS, getting your child services and treatment, trying to get people to understand and believe what you're going through... it's amazing what they'll believe when it's in writing, versus hearing it from the parent - even if you're super calm and logical about it. For this reason, I always carry a one page summary of my child's current meds and diagnoses.

One of the main things to remember about documentation is to do it as SOON as possible after an incident. Adrenaline and time really alter memories quickly.

Our children are especially prone to false allegations for many reasons -

  • an actual distortion of the events in their mind - their perception is off when they describes events that led up to a meltdown. My daughter will say "Daddy was yelling at me," when all he said was, "Who left the butter out?" in a totally normal voice
  • they get events mixed up with things that happened in the past - remembered abuse by a female caregiver gets projected on to the new female caregiver
  • they don't remember anything when they're in "fight/ flight/ freeze mode"
  • it's a defense mechanism to reject you before you reject them (deep down our kids believe they are unlovable and unworthy) so to give themselves the feeling of control of the situation they push you away
  • ...

To protect all involved, I recommend writing an "Incident Report" and keeping it in a log, sending it in an e-mail to the child's therapist or whomever might keep track of the info, and/ or on the child's timeline:

Antecedent - what was going on before the behavior or possible/probable triggers.

De-escalation - what we said/ did to try to prevent the event (if we had time) - calming techniques used

Behavior/ Event - with as much detail as possible
Intervention - what we we did during and immediately after the event - how we tried to calm the child, confrontation, redirection, distraction, sitting with them, time-ins, holding, rocking..,

Follow-up - how you processed what happened with the child. Injuries, damage, repairs needed/ made (emotionally and physically)... What consequences were given (if any). Agencies contacted. Reports filed.

Contact Log:
Especially when dealing with bureaucracy (like insurance or school!), try to keep as much communication as possible in writing (e-mails, notes). If the person insists on phone calls and face to face meetings, take detailed notes and IMMEDIATELY type up a transcript afterwards with as MUCH detail as possible. Include names, titles, agencies and affiliations, DATES and TIMES! When you need documentation you can use these transcripts and they are MUCH more admissible then saying, "Well Ms. So and So said he was doing this a few weeks ago." Once again, people believe what they see in writing.



PROTECTING YOUR CHILD AND FAMILY

Our kids were big when they came to us, and our biokids were younger and smaller, so we had the same concerns about protecting the other children (and ourselves).

We put in place a lot of regrettably necessary rules, like:

  • No physical touches between siblings - this included hugs, tickling, wrestling...
  • If you're teasing someone and they say, "Stop." then you HAVE to stop.
  • You cannot be in the same room with your siblings without an adult present. This might mean that if I had to go to the bathroom, then they needed to be in their room. If I was cooking in the kitchen then they needed to hang out with me (I tried to make Shadowing seem like a reward).
  • When needed, we had the same rules for the pets.
  • If a sibling is raging, STAY OUT OF IT! The other kids would sometimes accidentally/ deliberately make things worse.
At first, I focused on the squeaky wheel and left the other kids mostly to their own devices (except to tell them to stay out of it, because my trauma sibs liked to "poke the bear" with the sibling already raging).

We came up with a basic plan.


  1. Handling the raging sibling is the parent's job. Not yours. 
  2. If a sibling is raging, you are not allowed to engage with the sibling. At all. For any reason. Even if they started it. Just leave the room. Now.
  3. If you don't feel safe, you can go to your room or the parent's bedroom. You can watch a movie (and play it a little louder than normal). This is an exception to normal rules about media watching.
  4. When the raging sibling is not present, you can talk to mom or dad about how this makes you feel. You will not get in trouble if you talk about how unfair this is, how mad this makes you, how jealous you are about the raging child getting more of mom and dad's attention, how you feel about your sibling... 
  5. This type of conversation is ok to have with mom and dad any time, but is not appropriate to have with others (except maybe a trusted adult), especially not with friends or siblings (raging or otherwise). Yes, we know you want to vent to your friends, but that is unfair to the friends (that's a big burden) and often they know your siblings so your feelings will get back to them and damage your relationship.
  6. We planned special parent and child "dates" and activities. Where the healthy child(ren) got a chance to celebrate being a kid or other accomplishments, without having to deal with the drama. We saw the raging child being in the hospital or RTC as respite and planned fun outings around it.
  7. At one point, I gave small candy treats to all the other kids after a child's rage. Sort of a reward for having to deal with it. Unfortunately food is a HUGE trigger for the kids that rage, so this made things worse.
    {Then Bear found and ate all the candy, and that was the last time we messed with it.} 
  8. One of the most needed parts of this plan was an engaged, rested caregiver, because I couldn't be there for the other kids if I was completely drained. So self-care was important too. 


DE-ESCALATE THE SITUATION
Most important thing we did is to try to de-escalate before things got to the point they were out of control -

Prevention -
Establish Structure, Support, Routine and Boundaries - as essential as child-proofing your home.
Recognizing Triggers
Handling Child Stress

Calming/ De-escalation Techniques
Co-regulating emotional levels - matching emotional arousal


DURING A RAGE

Many of our kids have such a small window of tolerance that there's not time to de-escalate the situation. All of the sudden you're in the middle of a full out rage. So what do you do?

Once they hit fight/ flight/ freeze level, which for our kids can be 0 to 60 in 10 seconds, it feels like there is so little we can do. Calming techniques won't work in the middle of the storm. They are for before (if you can) and afterward. You can do physical restraints to protect yourself and others if you need to, but they are a last resort.


  1. Stay calm. (I know. This is the hardest one for me. I am super triggered by conflict and violence.) Use those calming techniques on yourself. If there is another adult present, switch out, and give yourself some time to get yourself under control. Being in this situation can trigger your own fight/ flight/ freeze mode or trigger Secondary PTSD
  2. Keep everyone safe - We've been known to send the other kids to another room (scary as all get out to them, but we've had them lock themselves in our bedroom to watch a movie on our TV). If one of your kids hurts another, YOU are legally liable for failure to protect. It's important to keep the other kids safe. Note: Often the other kids accidentally/ deliberately made things worse, so removing them from the situation was best.
    Self-Defense - If you've done everything you can to de-escalate the child and they become aggressive and attack you, here's a video of some self-defense moves. Better examples.
    Practice these self-defense moves (with someone other than your child) so they become instinctual.
  3. Do not engage or interact. I sooo wanted to argue and point out how irrational the child is being and threaten them with consequences... anything so they'll stop. I had to keep reminding myself that there is no one home right now - the thinking part of their brain is offline.
    **Threats, Consequences and Punishments - any attempt to use these during a rage will have NO EFFECT - long-term consequences don't exist when your brain is off line.
    **Prisoner of War - When dealing with PTSD, the inside of our kids' heads is like living in a war zone all the time. No punishment would work on severely traumatized kids that is worse than what they've already been through.
  4. Avoid direct eye contact. Eye contact is often hard for our kids anyway, and can feel like a challenge which can escalate the situation.
  5. Speak softly.  If I speak at all, I try to keep a calm, monotone, soothing voice.
  6. Deep breathing. Slow, deep, even, LOUD, breaths. (Maybe not as loud as Darth Vader, but close). Your child will begin to unconsciously mimic you, helping them calm down. Bonus, it helps you stay calm too. 
  7. Stay present - (feelings of abandonment make things worse), but distant. We usually used the 4 Foot Rule (also known as line of sight supervision). My child usually said they wanted me to leave, but I would quietly repeat in a monotone, that I needed to be there to keep him/ her safe.
    4 Foot Rule - My daughter knows this is what we do, so I think that sometimes she initiates it deliberately to feel safer. The "4 Foot Rule" means an adult must be within (approximately) 4 feet of the child at all times (usually just means line of sight not 4 feet exactly). If I know she can't hurt herself (like if she's holding the door shut then she can't hurt herself without moving away from the door), I might sit outside the door.
    A more ongoing (rather than crisis mode like the 4 Foot Rule) line of sight technique that we use is Shadowing – Have the child stay close to you and follow what you do or you stay close to them.  It is not a punishment- it’s an opportunity to help the child regulate safely.  To get compliance, it can even be presented to the child as a reward.  “You can be my special helper and help me pass out snack.”
  8. Call the police. If you cannot keep yourself, your family or your child safe then you need the police. It's different in every state and even county, but where we live, we ask for a "mental health deputy." This is a police officer who is trained in assessing people with mental illness to see if they need psychiatric hospitalization (suicidal, homicidal, or psychotic) rather than juvenile detention or jail.  I have to have a regular officer come out first and then they'll call the MHD. One time when my child had punched me in the face, they called for a psych hospital with an available bed and transported my child (who had finally calmed down) and I to the nearest psychiatric facility with an opening (2 hours away). They might take you to the nearest emergency room instead.

    It may be a good idea to contact the police before there is an emergency  (don't call 911), to give them a "heads up." Explain your situation and ask for their advice on what you should request next time. It will probably make that emergency call go smoother, because they know a little about you and your situation - they're less likely to get the "scared straight," "just smack the crap out of him," you're a "bad parent," "boys will be boys"... kind of stuff that cops who don't "get it" might do/ say.
    Current Meds and Diagnoses summary. If people understand your child has a mental illness or trauma disorder, they are more likely to help you get the psychiatric care your child needs and less likely to threaten the child (scared straight methods don't work on our kids!) or take the child to juvie.
  9. Psych hospitalization - it's tough, but if your child is suicidal, homicidal, or psychotic - your child may need hospitalization. Ways to get there: take your child to the nearest ER (if you can safely transport), call the psych hospitals on your own asking about a bed, crisis counselor can make recommendations and even call ahead for you, call the cops and ask for transport...
  10. Physical Holds/ Restraints - We only used this as a last resort to protect our self or another family member, or to protect the child from hurting him/herself. Because this can be dangerous (children have been known to suffocate and die from improper restraints), I don't believe proper restraints are even being taught anymore. We used the standing basket hold or sitting basket hold, and were always very conscious of the child's breathing.

    There don't seem to be any good examples on the internet. So I'm giving you an example of the Wrong Way to use a holding restraint (the child's arms should be crossed at the waist rather than across the chest which can restrict breathing, hold arms above the wrist joints to prevent strain, if a child is kicking and struggling then I have put one leg over the child's legs, make sure to tuck your head to one side - preferably behind the child's shoulder - to prevent the child from throwing their head back and breaking your nose).

    The sitting basket hold worked best for us. As the child calmed, I was able to loosen the hold, until it became more of a comforting hug. We often stayed like this after the child was completely calm and we could process what happened.  When the children first came to us, I believe our children often needed physical comfort, but were unable to express it or accept it because of their attachment issues, so they initiated events that would lead to this hold.



Management:


Self-care - Dealing with conflict is not in my nature. I hate it. I avoid it. It is so DRAINING to me. Self care is ESSENTIAL to being and staying in a good place emotionally. I need it to stay calm, cool and collected.

Self-care is a Necessity!  PLEASE, PLEASE take care of yourself and keep your tank full!




CALLING IN REINFORCEMENTS

For a child who still cannot get himself under control, I would:

  1. Make a safety plan with your child's therapist/ treatment team. Look at worst case scenarios, make a decision about how to handle each of them. Reassure your child this is to keep the child and all the family safe. Mine were convinced that this was a precursor to being kicked out again (it always had been). Words were not totally convincing, but that combined with the fact that we ALWAYS took them back helped a lot. 
  2. Have a serious talk with your psychiatrist about a PRN medication for calming the child - if there's a possibility the child will take it. Mine were pretty med compliant. Hopefully, you've been working with your psychiatrist on medications already. Definitely keep the pdoc posted on all changes and behaviors.
    I found that it's a fine line with meds. Sometimes whatever triggered my child just overwhelms the meds. That's why I like to have a PRN, something they can take when the meds aren't enough, but don't need all the time. I have to admit, we never really found a good PRN. My kids needed massive doses of everything to even function on a daily basis.
    Finding the right combination of meds is what finally stopped the rounds of hospitalizations for us. Once their brain was calmer and under control, their window of tolerance was bigger and they could handle things without becoming violent as a first option.
  3. Have a crisis counselor on speed dial (our local MHMR equivalent had one - 24/7 availability and they would come to us to do an assessment).
  4. Get the police involved. It may be a good idea to contact the police before there is an emergency  (don't call 911), to give them a "heads up." Explain your situation and ask for their advice on what you should request next time. It will probably make that emergency call go smoother, because they know a little about you and your situation - they're less likely to get the "scared straight," "just smack the crap out of him," you're a "bad parent," "boys will be boys"... kind of stuff that cops who don't "get it" might do/ say.  
  5. Residential Treatment - this is why you document, document, document. If your child cannot be in your home safely then they may need to go to residential treatment. This could be for a few weeks to find the right med combination. It could be a few months to try to learn some coping strategies (like DBT). It could be for years for a child who is not actually capable of living in a family environment safely. 


THE RAGE IS OVER. NOW WHAT?

Probably with your help, your child is able to regulate his/ her emotions again. Your child's brain is coming back online.

Emotional Release
Like most physical activities, after a rage a person's emotional
defenses are lowered. We made more therapeutic progress in the 20 minutes after a rage, then we would in weeks of therapy.

This is the best time to emotionally reconnect and start the healing process with your child. 

Start mending your relationship, and reassuring your child that you still love them and are not going to abandon them or let this push you away. This is NOT the time to start talking about consequences. 

Before Bear went to residential treatment and got on his current medications, he exploded on about a monthly basis. All emotions were stuffed inside and converted into angry lava. You could see it seething and bubbling inside him. When he lost control the volcano exploded in an angry outburst. Afterward, for about 10-30 minutes he would exhibit true emotions - he usually cried and talked about his feelings of abandonment, fear, anxiety and anger (accessing the emotions he kept stuffed inside).

Much as I hated Bear's rages, I felt his healing progress slowed dramatically after medicating his bipolar disorder stopped the rages.

Now Bear has his anger under control, but he still stuffs his feelings inside instead of processing them. Now they go in what appears to be a huge box inside him. When Bear had an outburst, that box got opened and examined and maybe processed a little. Now that he has no more outbursts, the box stays closed, the emotions untouched and buried deeper and deeper.
Bear is making progress academically and socially. He does talk about things and has even cried, but it tends to be current stuff. He is getting more mature, and can control his emotions- which is a good thing don't get me wrong! But I can't believe that not dealing with all the bad stuff that I know is festering in that box is a good thing. I can't believe that him not dealing with most of his feelings is a good thing.
Before, he wasn't able to learn anything because his life was in constant chaos - and now he is advancing academically and socially. He will never be off medication completely, but I wonder if it's time to start lowering his doses so that he can access his "box" and deal with his emotions. Or should we give him more time to be successful in all the areas that had been falling by the wayside while the rages kept his life in chaos?
Update: Looking back, I'm glad that Bear got treatment for the rages. When he did decide to go off his medication at 18, he had much more self-control, learned in those years when his life wasn't out of control with rages. I don't know if he would have been able to access and process his emotions anyway.


CONSEQUENCES

Don't be surprised if your child cannot remember what happened immediately before, during, or after a rage. Ask someone what happened during a traumatic event (like a car crash), and most times they cannot tell you. I'm sure someone could explain the scientific reasons (adrenaline rush, thinking part of the brain gives way to the instinctual, dissociation is a protective measure...), all I know is I've seen my child with tears stains on his/her face and still dripping with sweat, "flip a switch" and have no idea why I'm upset, and no memory of the events that occurred mere minutes before.

Discipline versus Behavior issues
Discipline problems (noncompliance, misbehavior) occur when the caregivers have not structured the child's environment for success, or when parents are inconsistent (expectations or consequences), non-responsive, or inaccessible. When adults adjust their behaviors and attitudes, often children with discipline problems can be brought under control in as few as 3 to 7 days.

Behavior problems on the other hand lie within the child. These are persistent behaviors that do not disappear even with the best parenting (although good parenting can help to control the behaviors). These can include impulsivity, inattentiveness, and other behaviors like ADHD, FAD and immature behaviors associated with missing capacities in object relations.

YOU CANNOT EXPECT PUNISHMENT OR DISCIPLINE

TO "FIX" BEHAVIOR PROBLEMS!



So how do you give consequences to a child who doesn't know what you're talking about and has little to no control over his/ her rages?

FOCUS ON PREVENTION NOT CONSEQUENCES. I finally realized that the need for consequences and punishment for my child was my problem. I knew they weren't having any effect on my child except to damage our relationship (if you're being punished for something you don't even remember doing then it must be happening because your parent is mad at you/ rejecting you... because you're unloveable and unworthy of love).  

  •  Structure, support, routines, and boundaries.
  • Make your child's world smaller so they feel safe (this feeling of safety has nothing to do with physical safety. It is a leftover defense mechanism, a life or death feeling. It is not rational - it cannot be changed with persuasion or logic. A child who feels unsafe is a scared child. A scared child will act out (or act in) to try to feel safe again.)
  • Discover your child's triggers. 
  • Empathy. The premise of the Beyond Consequences books is that there are only two primary emotions, love and fear.  For example, when a traumatized child shows anger it is because he or she is scared. It helps me to remember that during a meltdown, my child feels like a cornered or injured animal and is lashing out to protect himself. He is a scared little boy. This helps me be empathetic, which makes it easier for me to be therapeutic.

For when there just has to be some consequences. 
Maybe so the other kids won't see this child "getting away with" something and decide to start emulating it. Here's a couple of things we've tried: 

The FAIR Club - When a child is old enough to understand abstract concepts emotionally and intellectually, we use the FAIR Club. If a child is not being RRHAFTBALL (pronounced "raft ball") or is complaining that life is not fair, then they go in the FAIR Club, which is designed to provide boundaries and additional support while the child practices and gains (or regains) the ability to be RRHAFTBALL.  This involves removing a lot of the distractions and drains of life (like electronics, phone, friends, even where to sit) and adds ways of dealing with stress (earlier bedtime, spending time with parents who can role model, only going places as a family).  
To demonstrate they are ready to get out of the FAIR Club the child must be RRHAFTBALL and complete their writing assignment and extra chore.  Assignments and consequences are based on the child’s developmental age, Logical Consequences and Restitution.   

The Trust Jar - This is a visual, concrete way to explain trust to a child.  The trust jar is a very visibly placed large vase filled with cotton balls, lima beans, anything not intrinsically appealing.   The vase should be mostly full, so if the child is 6 and the jar was less than half full, the child would get the life of a 3 yr old....constant supervision, no friends houses, or paints, or scissors etc... If the jar is near full the child has full rights to everything a 6 yr old can do....playdoh access, bike riding, friends’ houses, big kid books etc...

Things that don't work:
  • Sticker charts 
  • Reward or Point Systems
  • Level Charts
  • Spanking or other physical punishments (or threats) - In the middle of a rage, their brain is turned off so they don't understand it. After a rage, punishing a child for a behavior problem won't be effective at all, because by definition a behavior problem is out of their control.
  • "Scared Straight" type methods - don't work for the same reason punishments don't work - this is out of the child's control. Many children don't understand long-term cause and effect so in their mind, this will never happen, plus, they often cannot "learn from their mistakes." Prisoner of war mentality - there is nothing you can do that is worse than what has already happened to them.

2 comments:

Ginger Newingham said...

Thank you for this thorough answer. My oldest is 9, and has just been hospitalized for the third time. This time, it was due to his first rage episode. It's so important to have these tools in my back pocket for the next one.

I've been writing about my son's journey some as well: www.ourmomentsdefined.com

marythemom said...

I hope it helps. Hospitalizations can be so hard.

I enjoyed reading your blog. Thanks for sharing.