Number 54 • January 2015



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Case example


Before starting at a new residential school, Sarah, age 14 and diagnosed with CHARGE syndrome, had been excluded from school for two years as a consequence of her difficult behavior. Some of Sarah’s issues were:

• Regular emotional outbursts

• Unable to tolerate being with her peers and being very easily annoyed or upset

• Inappropriate attempts to initiate interactions

• Saying hurtful and inappropriate things to others

Being very angry with herself, with a negative self-image and self-esteem

• Lack of awareness of her own emotions – Sarah had an analytical understanding but was not able to link this information to what she herself was feeling

• Unable to negotiate or tolerate when things did not go her way

• Difficulty coping with the unexpected

• Difficulty controlling her own behavior and impulsivity (saying “I just want someone to make me stop.”)


A full team of practitioners were involved in developing a program to support Sarah, which was regularly monitored and strategies developed or adapted in response. Some strategies developed to support Sarah in this area were:

• Providing Sarah with her own space, with a gradual reintroduction to being in the room with her peers.

• Ensuring a consistent routine, with any changes kept to a minimum and every effort undertaken to prepare Sarah for changes.

• A highly individualized curriculum, using Sarah’s strengths and interests to build her confidence and self-esteem.

• Modeling and discussing how Sarah might respond in different social situations. For example, in preparation for attending a local youth club, staff discussed with Sarah what was likely to happen; how to respond if someone said hello; how to initiate a conversation; how to move away if the situation became too much. A picture-board sequence was used to provide a concrete visual cue.
• Sarah struggled during role play, and so plastic characters were used. Social scenes were enacted, exploring different ways a person might respond in each situation. This was also used to re-enact situations that Sarah had found difficult, exploring what might have been a more positive way of managing the situation.

• Weekly yoga was introduced to help Sarah develop and regulate her physiological state more effectively. ‘Deep belly breathing’ became a useful strategy for Sarah to use independently to help her calm.

• Pet therapy provided Sarah with the opportunity to enjoy caring for and nurturing Darcy the dog.

• Discussing Sarah’s own emotional state. Initially she found this extremely difficult, and staff who knew her well, labeled her emotional states for her (e.g. “I think you are feeling a bit frustrated,” etc.). A break though came when Sarah was in conversation about a forthcoming trip and suddenly said: “I’m feeling something”. Unable to label what she felt, the supporting adult explained she was probably feeling a bit excited and also anxious.


Now 18, it has taken time but Sarah has made huge progress. She is a much happier young lady who is fully included in her class and making real friendships. She is much more socially aware and able to socially engage, sharing a joke and coping with gentle teasing. Sarah is more in touch with her own emotional state and is better able to regulate her emotions and behavior. Very importantly, Sarah is now able to talk about how she is feeling which has proved to be vital as she has undergone a period of ill-health requiring hospitalization and surgery. Overall she has grown in confidence and is looking forward to moving on to college in the near future.


References


Barrett, L. F., Gross, J., Christensen, T. C. & Benvenuto, M. (2001). Knowing what you’re feeling and knowing what to do about it: Mapping the relation between emotion differentiation and emotion regulation. Cognition and Emotion, 15:6, 713-724.

Cicchetti, D. (1994). Emotion regulation: Influences of attachment relationships. In N. A. Fox (Ed.). The development of emotion regulation: Biological and behavioral considerations (pp. 228–249). Monographs of the Society for Research in Child Development, 59, (2–3, Serial No. 240).

DeGangi, G. (2000). Pediatric disorder of regulation in affect and behavior: A therapist’s guide to assessment and treatment. San Diego: Academic Press.

Eisenberg, N., Guthrie, I. K., Fabes, R. A., Shepard, S., Losoya, S., Murphy, B. C., Jones, S., Poulin, R. & Reiser, M. (2000). Prediction of elementary school children’s externalizing problem behaviors from attentional and behavioral regulation and negative emotionality. Child Development, 71, 1367–1382.

Gioia, G. A., Isquith, P. K., Guy, S. C. & Kenworthy, L. (2000). Behavior Rating of Executive Function. Lutz, FL: Psychological Assessment Resources.

Gross, J. J. (1998). Antecedent- and response-focused emotion regulation: Divergent consequences for experience, expression, and physiology. Journal of Personality and Social Psychology, 74(1), 224-237.


Gross, J. J. & Thompson, R. A. (2007). Emotion regulation: conceptual foundations. In J. J. Gross (Ed.). Handbook of emotion regulation. New York: Guilford Press.

Hänsel, A. & von Känel, R. (2008). The ventro-medial prefrontal cortex: a major link between the autonomic nervous system, regulation of emotion, and stress reactivity? BioPsychoSocial Medicine 2, 21.

Hartshorne,T. S., Nicholas, J., Grialou, T. L. & Russ, J. M. (2007). Executive function in CHARGE Syndrome. Child Neuropsychology, 13, 333-344.

Koole, S. L. (2009). The psychology of emotion regulation: An integrative review. Cognition & Emotion, 23, 4-41.

Lamm, C. & Lewis, M. D. (2010). Developmental changes in the neurophysiological correlates of self-regulation in high– and low-emotion conditions. Developmental Neuropsychology, 35, 156-176.

Saarikallio, S. (2011). Music as emotional self-regulation throughout adulthood. Psychology of Music, 39, 307-327.

Wyman, P. A., Cross, L., Brown, C .L., Yu, Q., Yu, X. & Eberly, S. (2010). Intervention to strengthen emotional self-regulation in children with emerging mental health problems: Proximal impact on school behavior. Journal of Abnormal Child Psychology, 38, 707-720.


1 Doctoral student Central Michigan University (kenne1bs@cmich.edu)
2 Doctoral student Central Michigan University (ramir1ma@cmich.edu)
3 Department of Psychology, Central Michigan University (harts1ts@cmich.edu)
4 Children’s Specialist Services, Sense, UK (gail.deuce@sense.org.uk)
5 Regional Resource Centre for Deafblind/Haukland University Hospital, Bergen, Norway (jude.nicholas@statped.no)

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