“Picture yourself calm and relaxed. Suddenly, a stereo blasts in your ears, and you are punched in the arm. This would be frightening, painful and overwhelming. For someone with sensory processing problems, such auditory hypersensitivity might occur in a noisy classroom or hallway. Such touch hypersensitivity might occur with the routine jostling in a school corridor, or the accidental touching by a peer. In other words, every day life becomes overwhelming.”
Jason (not his real name) was a 9-yo boy referred to our tertiary care clinic for lifelong explosive rages. Due to his frequent, daily rages, he had been removed from a regular classroom. Teachers and caregivers reported that “everything” was a trigger.
Past mental health resources included psychiatrists, psychologists, child and youth care workers, special education teachers, and even an occupational therapist in the school focusing on motor interventions.
Prior diagnoses included bipolar disorder, ADHD, oppositional defiant disorder and non-verbal learning disability; he certainly had features in his history that could be seen as supporting each diagnosis. Previous psychopharmacologic treatment for bipolar, ADHD and oppositional defiant disorder had been unsuccessful, and had included mood stabilizers, psychostimulants, as well as both typical and atypical anti-psychotic medication. Psychotherapy and counseling had been tried, with past interventions including anger management, and even ‘explosive child’ approaches based on Ross Greene’s Collaborative Problem-Solving model QUOTE “(Greene, 2001
)” (Greene, 2001
Precipitants for his rages were “everything” and included:
Triggers such as sound and touch. Sound triggers included normal noisy situations, as seen on the school bus, playground, gymnasium or lunchroom. He’d often yell at peers, “Stop yelling at me!” even when peers were talking at a normal volume. Touch triggers included any accidental touching by others, which would lead to violence at his perceived attackers.
Any changes in routine, such as a change in order of his classes. His attempts to control situations led him to be seen as domineering and manipulative.
He had “good days” and “bad days” where he was able to cope (e.g. with background noise) on some days yet not on others, leading caregivers to believe that he “chose” to be intolerant on the bad days.
Since many of his triggers seemed to be sensory-related, he was referred to an occupational therapist with training in sensory processing approaches. The assessment, using standardized testing as well as clinical observations, revealed severe problems with sensory processing. Standardized testing included the sensory profile (Dunn, 1999
) which provides a “standard method for professionals to measure a child’s sensory processing abilities and to profile the effect of sensory profile on functional performance in the daily life of a child.”
From a sensory processing viewpoint, it was felt that his problems with rages were due to his being under continual sensory overload. As a consequence of this overload, his nervous system perceived that he was in a constant state of danger, thus responding with ‘fight’ (rages, tantrums) or ‘fight’ (withdrawal, shutting down).
It became clear that his inflexibility and oppositionality reflected his body’s inability to self-modulate (or regulate), and was in fact an attempt to keep things as predictable as possible. When routine changes, so do all the stimuli that a person has to deal with, and thus change can be overwhelming.
It also became clear that his inconsistent responses with “good days” and “bad days” was not intentional misbehavior, but rather the consequence of his neurological condition. Caregivers had a hard time understanding why a given trigger might have triggered him one day but not the next, so it was helpful for them to learn that it was more the accumulation of sensory input that exceeded his threshold, with the final trigger being “straw that broke the camel’s back”.
Over six treatment visits with an occupational therapist, interventions to help reduce his sensory overload and help his nervous system modulate sensory input were implemented.
The overall hierarchy of strategies was:
- Ongoing assessment: following the initial assessment of his sensory profile, he had ongoing assessment of his reactions to environments and stimuli as sensory reactions can change over time.
- Education/awareness: teaching about sensory concepts as well as helping the child/caregivers become more aware of their own sensory needs.
- Coping strategies, which involves obtaining ‘occupational .t’ by a combination of:
- Changing the environment so that it could meet his sensory needs (e.g. increase in some areas, decrease in others)
- Changing the individual (e.g. teaching him techniques to modulate his responses, i.e. ‘modulation techniques’, and implementing a sensory diet, which is “a planned and scheduled activity program designed to meet a child’s specific sensory needs.” (Yack, Aquilla, & Sutto, 2003)
Specific strategies included:
- Strategies that would give him control over the amount of sensory input he had to deal with, thereby decreasing his stress and keeping him calmer throughout the day, which included:
- Giving regular breaks for him to seek out the relative quiet of a resource room or bathroom
- Allowing the use of earplugs
- Allowing the use of headphones with relaxing, masking music or sounds
- Flexibility about letting him avoid loud situations such as school buses, gymnasiums and school cafeterias
Within weeks of initiating various interventions with teachers and caregivers, Jason was calmer, more alert and focused, and therefore better able to learn and to deal with stress. He returned to a regular classroom, and finished his school year with excellent grades, and was even given an award for being the ‘most improved’ student. The following year he entered a gifted program, and currently, at 2-years post discharge from our consultation clinic, he continues to do well. According to Jason and his mother, the pivotal turning point was reducing his sensory overload, so that he could actually benefit from counseling and therapy.