Rage in medical situations

[PGTlatte]

Right before his 3rd bday, our younger son had his appendix rupture.  This led to emergency surgery, and an extremely traumatic hospital stay.  His bowel did not start working again so he had to have an NG tube for a week - that goes in your nose, down your throat, and basically made him constantly gag for the entire time it was in - he was miserable.  He also had a lot of blood draws.  All of this was necessary to save his life.  I did get the hospital to use EMLA cream to make the blood draws less painful, but there was little else I could do to make the whole ordeal less of a nightmare for a very scared and sick little child.  While he was in the hospital, he "found his rage"...and it is fierce.

Now, he is five.  He has extreme reactions to any medical situation.  Especially anything involving his mouth or nose.  He was not able to complete a dental cleaning until six months ago without absolutely losing it at the start. The dental practice has been very compassionate and not done anything that isn't immediately necessary and has very gently brought him around to willingly cooperating.  But sometimes in medical situations, something has to be done and it has to be whether the child will cooperate or not.  We all have a really bad case of the flu here, and I took both of them to the ped today.  They both needed a breathing treatment. Really needed it.   Because this involved something approaching his mouth and nose, he flipped out.  We did it with me sitting on the floor with him in my lap.  He was raging and screaming and calling me names the entire time, and trying to kick me.  He was also attempting to call our doctor names and kick her.  Obviously this isn't acceptable and is something I have to figure out how to change.  But knowing the emotional background that started this behavior, I don't think I can just respond to the behavior without also trying to help him with the feelings behind it...for him it is really terror, not just him being difficult.   He is also still very angry about his hospital experience.  He has asked "why did you let them do that to me" about it and still remembers it vividly.  Today at the doctor's office,  I told him I needed him to stop calling me names but that if he wanted to talk about his feelings, that was fine...what he said was "I am so scared of that thing, why did you do that to me ?"  It is really like a flashback and he reverts to being 2 again. 

We need to use the nebulizer every four hours.  Right now he is sitting watching his brother use it, and he's wailing and saying "I'm so scared !  I'm so scared !"  Somehow we have to get him through this week.  And longer term,  I need to find a way to help him deal with his rage and terror about his hospital experience, so he doesn't keep reverting to it when a medical situation scares him.  I can't have him calling doctors and nurses names and kicking them, esp at age 5 and beyond....and more than that, I don't want him to keep experiencing so much trauma.  How do I help him with this ?  Hypnosis ?  EFT ?  I don't know EFT, but I'm willing to learn. Do I need the help of a child psychologist ?  I feel so bad for him. 

[Chamomile Girl]

Oh, your poor baby! It doesn't sound like this is a discipline situation, but that you need ideas to help him cope. Is there any way that some of this stuff can be done at home (like using a nebulizer at home for example). Do you think he would feel safer at home? Is there any other ways to make him feel safe?

Holding him down and forcing him to do stuff like that is not a good idea...Work with him to see what he will do willingly.

ETA: OK, since you posted more of the situation my response is not that helpful. I will reiterate though that I don't think he is just being difficult, but he is legitimately scared.

[PGTlatte]

We are doing it at home now, every four hours.  I would love to never have to force anything, but it's really necessary to do it no matter what, or he could end up with pneumonia.  Lung problems can become very serious very quickly if they are not addressed; to borrow a phrase, "it's a matter of life and breath", so I won't make it optional.   I will sit with him and be as comforting as possible.  Overall I would like to help him learn to relax, and deal with just the situation of the present moment - and not be dealing with the trauma of the hospital over and over again..does that make sense ?   I would like to help him disconnect from that past trauma.  Do I need professional help to do that ?  Also the discipline part of it - I know it's more coping that is necessary here than discipline, but the name calling and hitting and kicking can't continue.  I want to deal with those compassionately, realizing they are connected to a past trauma that he is flashing back to, but ultimately sometimes medical stuff can't be optional, and this isn't behavior most medical practices will be willing to accept from a kid who is 5 or older, so I need a way to change the behavior too. 

[its_betty]

I feel for both your son and you--that's a hard situation.

My gut reaction is that it would be a good idea for your son to see a therapist of some sort to help him sort out his fears and feelings (and to give you some ideas for helping him). It would be better for him to figure out how to deal with medical situations in a way that doesn't terrify him now. In a few years, he'll be bigger and could be a danger to himself and others if he lashes out when someone is trying to give him needed medical treatment.

I imagine the doctor would be able to give you a referral to someone who could be helpful.

[Squrrl]

That sounds absolutely terrible for both of you.  I agree that it might be worthwhile to seek a professional with the right sort of expertise--this is a serious problem, you're right.  Possibly some play therapy would be helpful also?  Like, give him back his power by being the patient and making him the doctor?  All my sympathy and best wishes!

[sublimeliving]

This sounds like PTSD. I think with such trauma involved, and his vivid memories, I would seek a counselor ASAP. Poor little guy; I'm so sorry he has to go through this.

[PGTlatte]

Thank you.  I am looking up therapists that treat PTSD and children.  I am using the Psychology Today find a therapist tool.  I found someone I will call tomorrow.  I'm not sure how else to look for someone.  We won't be able to make an appointment until we are over this flu (it is really bad) but I want to start the process.  I do think this is PTSD and I don't want it to be a problem for years and years.  His feelings are intense and so angry and sad and afraid, and he needs a way to deal with them. 

[seren]

Poor guy! My son has a similar response. He had some pretty invasive procedures and surgeries this past summer, plus numerous blood draws. It would take three of us to hold him down kicking and screaming to do it, but they were important. I second getting therapy. We didn't and we should have. It's now progressed to acting this way other times, he goes into these rages and kicks and hits dh and I and threatens the other kids. He NEVER did this before. We're starting therapy tomorrow if the weather isn't bad.

[carfreemama]

I'm glad you're getting therapy! I had two really traumatic accidents when I was a kid; one when I was 7 months old and had third-degree thermal burns and the other having most of my top teeth broken and surgically removed (without general anaesthetic) after falling downa a flight of stairs.

One incident I remember VERY strongly was after having skin grafts. I was worried about stitches and I was told there were none, that the grafts were just laid on top of my old scars. Well, a week later the doctors came in to "remove my stitches." I felt SO betrayed. There were hundreds of them. I remember screaming "stop it!" over and over again. Finally, after over an hour, they gave in and agreed to come back the next day. That was so important, to have some control. But years later, I was having some very minor revisional surgery and I was at the doctor's to have the stitches out. I was in full-on panic and no one seemed to understand. The docs were exasperated, until one resident said "she's having a panic attack." I was so grateful to him, just for acknowledging that I wasn't being deliberately difficult...

I'm not sure why I'm telling you this, except that I did and do suffer PTSD from these experiences and many other medically-invasive procedures. I remember them as violations; but they are so rarely acknowledged as such, because they are considered to be done FOR you, rather than TO you. You're right, most health professionals have a very low tolerance for "acting out," especially among older children. I get that kids can't hit and swear at docs, but to them it is completely different than an adult giving consent to painful procedures. From my own experiences, the two most important things are NEVER lie to a child about the extent/nature of a procedure and get all the facts; and to try and stay with your child as much as possible for any medical procedure. Docs say things to kids when their parents aren't around.

As for therapy, I think just the fact that you are hearing him is going to pretty much mean he will be okay. I would never discipline for inappropriate behaviour in these circumstances. I actually think hypnosis is a really great idea. But I think any kind of counseling would have made a huge difference to me. Kids are resilient and I actually think this kind of trauma can be successfully treated, it's just that it too often isn't. Your son is lucky you get it.

[One_Girl]

If you like your pediatrician then I think you should ask her to refer you to a good play therapist.  I think it is very important to make sure your son's doctor knows why he is acting out.  Doing dramatic play and modeling with stuffed animals what needs to happen while you tell the stuffed animals why it needs to happen may help.  It helped turn my dd away from a fear of needles that was so bad she would cry when we got to the parking lot at the doctor's office.  It may also be something that he just gradually will have to learn to tolerate though and that is probably going to be a long road.  I detest needles and exams because of some very traumatic events but have learned to put up with them when it is important for me to.  I am even working on visualization so I can start giving blood regularly also but that is a hard process and I am able to identify the need and the fact that it really isn't a scary or horribly painful experience in reality, I can't imagine how much harder it would be for a child who doesn't see a need for the treatment and sees only the scary.

[chfriend]

The play therapist seems so important. In the meantime, can your doctor have any medical recommendations for the anxiety?

[Llyra]

Has your ped been understanding? The reason I'm asking is that this could be something it takes him awhile to move past, even with the therapy. I think therapy is a terrific idea, BTW. But even so, it's going to be a process. If the ped has not been maximally understanding, I think that as part of my plan, I'd be shopping around for a new ped.

My DD2 was hospitalized last winter for an antibiotic resistant pneumonia, in the middle of a blizzard when half the hospital staff had been stranded in the building for twelve hours, and everybody's tension and anxiety was running WAY high. She then developed a tertiary lung infection, a c.diff. infection in her gut, and a systemic yeast infection. It was horrible for her. She went through nothing that wasn't completely necessary, but it was still terribly traumatic for her. (She was a few weeks short of three years old at that point.)

Anyway, for the whole year since then, every time DD is confronted with anything medical, she deals with a LOT of anxiety. Not like you're describing-- nothing like that-- but still a lot of fear. Our ped has been marvelous about it, and I credit her with the fact the DD has shown as much resilience as she has. A good pediatrician should be doing everything possible to give the child as much control as possible, and should show a maximum of patience and understanding.

[Vancouver Mommy]

My dd experienced a significant trauma at that age (related to an airplane trip, not a medical procedure) that left her with some extreme phobias related to any form of transportation. Even walking down a small hill in the stroller made her hysterical. She didn't go in the car for the better part of a year. We used a play therapist for several months and it was wonderful. Luckily we found somebody who would come to our house, as we didn't go anywhere beyond the 20 block radius of home. No matter how we tried to help her with her anxiety, we couldn't have done what the therapist was able to do. I highly recommend play therapy for your son.

[PGTlatte]

Thank you all, very much.  He's accepting the nebulizer now - after watching his brother, and me, and DH all take a turn with it, he decided he's not afraid of it.  I have set up an appointment with a therapist for next week (hopefully our flu is gone by then).  The practice treats children, including for trauma, and uses EMDR as well as other methods.  I will ask specifically about play therapy.  I just looked up the therapist's name and it says she is a registered play therapist with the Association 4 Play Therapy.  So I think we are on the right track.  Thank you !!!!!

[porcelina]

Wow, my mom is a psychotherapist and is trained in dealing with trauma. She bought me the book How to Trauma Proof your Child. The bottom line message is that after a bump or something, you go through, step by step and describe what happened. In the case of what your child has been through, it will take more work. I think the recommended approach is to do role-playing of the situation. Maybe you can be him at first, and he can be the doctors, to re-enact what happened when he was 3. Then he can be the patient. Describe what is happening, and how he feels at each step of the way. Do it over and over again, so that he can work through the trauma. The idea is that he can eventually take control of the situation. Perhaps if it involves name-calling for a few of the iterations, that's okay. Let him get it out. Then, after he seems to exhaust that, encourage him to express himself differently. Encourage him to use words to describe his emotions. He should have these words as you have been describing them for him through the role-playing.

Unfortunately, this is happening at the same time your son actually HAS to use the nebulizer. Maybe you can try the same thing -- do some pretend nebulizing first, over and over again, and then the real thing. I know how hard this must be for you. It is awful to have to force something, and it is exhausting to think of creative ways not to force it. I wish you the best!

Also unfortunately, child psychotherapists also vary a great deal. Ask them if they have experience and training in trauma. Ask them to be specific. If they don't seem to have any real training, move on to the next one (calling). Don't waste your time and money seeing someone who is not specifically trained. Maybe check out the book I mentioned!

Good luck!

ETA: just noticed you already found someone that sounds trained! Good for you and good luck again!

[heartmama]

We have been there with ds who had 3 open heart surgeries, the last one at age 4. We literally drove halfway across the country when he was 7 to see a dentist who specialized in gentle dentistry because he COULD NOT (not would not, but really truly could not) calm himself down enough to lay in a typical dentist chair.

With PTSD there is a huge TRUST issue. Ds actually did cooperate with this woman we drove so far to see, because she spent an hour or two just talking to him, making friends, letting him play with the equipment, showing him how it worked, etc. Once he trusted her, he was a model child, and cooperated perfectly. But it took extreme patience and understanding for a dentist to get him to that point.

PTSD is NOT a discipline situation at all. You can't discipline a kid to behave if they are having PTSD flashbacks (and i know you know this, I am saying it to benefit others). You son certainly shows signs of PTSD and therapy is a great way to address it. The great thing about PTSD is that it really can be improved by therapy and often remarkably so!

Ds was helped a great deal by Traumatic Incident Reduction (TIR) at age 9--there is an interesting study somewhere online comparing the results of EMDR and TIR and TIR was found to be more effective (but I think both are fine!). You can visit www.tir.org to see if there is a TIR therapist in your area who works with children. However if you have found a therapist you like then by all means stick with her.

I would also recommend you keep in mind that future medical procedures can be made less stressful with medication, and you can ask your son's doctor about this. There is no shame in a child taking a one time dose of an anti-anxiety med or a dose of a mild sedative if it helps to avoid triggering panic or flashbacks. You have to ask the doctor for this though, they won't offer it otherwise.

[PGTlatte]

Thank you all so much for your support.  I feel validated that this is a real issue, and not just poor behavior and some excuse that's just in my head.  He has an appointment for next week.  I'm also glad because once he found his rage in the hospital, it became part of his personality and it shows up in other situations too, not just medical.  Anytime he is confused and frustrated, or feeling insecure, rage is his response.  I know it started in the hospital.  That experience changed him.  I want to help him with this. 

For now, he is accepting the nebulizer and not afraid of it.  I am hoping the therapy can help him cope with future situations, because they are bound to happen.

[hopefulfaith]

I just want to give you a hug through the internet.

You are a great mom and your son is blessed to have you.  I'm so glad that you are helping him deal with this so lovingly and so gently.

Hugs to you.  :)

[chiefmir]

you are doing SUCH an awesome job!

It sounds like your DS does much better with the nebulizer now that he's had time to observe, think about it, and process... that is very different than a semi-emergent treatment in the doctor's office.  As he continues to work through these issues in therapy, knowing this about him could help you prepare him (to the best of your ability) in non-emergencies.  So, if he has a doctor's appointment, maybe double check with the doctor a week ahead of time for well visits to find out exactly what the visit will entail.  Any shots? any blood draws? prepare your DS for the blood pressure cuff, the ear phones for the hearing test, etc.  Ask to minimize any type of examination procedure that actually isn't needed at a given visit.  My DH is a pediatrician and he has jokingly told me that more than half the time he spends so long listening to a child's heart and looking into their ears (for an unrelated visit- like a rash or a wart) because otherwise he sometimes feels like parents don't think he's "done anything" at the visit.  I'm sure you've done this, but also give your DS as much warning and control as possible- even in situations where you haven't had much chance to prepare him... like letting him decide which arm he gets a shot in-- whether he sits or stands for it, etc.  Some simple strategies for reducing anxiety (and often also pain to the extent that anxiety can make this feel worse) may also help-- deep breathing, self-talk (I don't like this, but I need it... It will be over in one minute...), distraction (watching TV during a procedure/treatment, chewing gum, "blowing out the birthday candles" when getting a shot, etc.)  Also, if something is particularly scary to him, maybe there is an acceptable alternative that would scare him less and make him feel more in control.  Although he is now accepting the nebulizer, I was thinking of, in particular, asking if he could use an inhaler and spacer for his q-4 hour treatments... I know that we were able to teach our daughter to accept this at 14 months- she can now do it herself at 5 years... and it takes 30 seconds and delivers the same amount of meds as a neb if done correctly.  Another probably-irrelevant example... my DD is terrified of eye drops, but she is for some reason, less upset by eye-ointment- who knows why...

It sounds like  you are being so sensitive and thoughtful about both your DS's feelings/experiences and the need to help him feel better so he can behave differently in those stressful situations.  I'm sure you've already done this-- but have you ever directly addressed what happened when he was younger, from your point of view?  Said something about how you wish SO much that you could have protected him from all the things in the hospital that scared him and hurt him... but that he was SO sick that you didn't have any choice either... we had a somewhat related (though much less significant) situation with my DD, and she (a year later) still says things like, "you WISHED you could give me a choice about taking that medicine, but you couldn't because I was very sick and needed the medicine to be healthy again- no matter  how you or I felt about it..."

many hugs to you guys!