Children and adolescents may experience a range of feelings following a brain injury or during therapy sessions. Sometimes these feelings can be difficult for them to manage and may impact on a child’s rehabilitation and progress. Some children experience pervasive feelings across settings or activities, such as feeling depressed or irritated, while others may only experience intense feelings in response to a task (e.g. feeling anxious about walking and risk of falls). At times, children with a brain injury may have sudden, intense changes in their feelings, much like “flipping a switch”. They might be suddenly excitable, angry, or inappropriately happy/ tearful.
The way children show their feelings differs based on, their age and developmental stage, cultural norms and background, personality, and the situation they experience the feelings in. Sometimes behaviour that appears to be naughty or defiant may be a cue that the child is experiencing intense feelings about a task or situation. For instance, behaviours such as, task refusal, argumentativeness, avoidance or disengagement from therapy may be due to underlying anxiety, low mood, or poor self-esteem. If left unidentified these feelings can have a significant impact on a child’s progress and engagement in therapy.
How to help support emotional regulation in session
There are many things therapists can do to help support a child’s emotional regulation in session.
- Try to prevent emotional dysregulation before concerns arise. For instance, check in with the family or other therapists. Sometimes emotional upsets are predictable (e.g. when the child is fatigued, or on certain tasks) and alter your session plan to take this into account.
- Being mindful of what a behaviour may be signalling (e.g. is the child worried? Do they think they will fail?), and work with the child and their family to prevent distress. For instance, does the child need more information? Is the task “too big” (i.e. doing a relatively easier task first and building up to the challenging task)? Are they overstimulated?
- Try to avoid accidentally reinforcing behaviours such as task avoidance (e.g. allowing a child to not try a task because they are worried). Instead, break the task into smaller more manageable steps and gradually build up the complexity and the child’s confidence with reinforcement for their effort.
- Where possible, tune in and recognise the child’s feelings (e.g. “I can see you are feeling sad that you can’t ride the bike by yourself”) and work with the child/ family to problem-solve a solution (e.g. “maybe we could try bike riding together”).
- Provide the child with plenty of encouragement and reinforcement for their effort and success. This can be nonverbal (e.g. high five’s, thumbs up), verbal (“great job!”), or a visual chart (e.g. a rewards chart).
When should I refer a child on, and who should I refer them to?
It might be necessary to refer a child on for further emotional support. Some signs this may be necessary include:
- emotional upset that is pervasive across settings
- distress that is impacting on a child’s function at home, school, or in therapy
- distress that is impacting on a child’s relationships or well-being
- when there is risk of harm
- when requested by the child or family.
Families may be able to access additional funding support for therapy via their NDIS plan or by visiting their GP. Local psychologists can be found by visiting the Australian Psychological Society’s website, social workers via the Australian Association of Social Workers website, or occupational therapists via the Occupational Therapy Australia website.
Emotional regulation and mental health
Children and adolescents may experience a range of feelings following a brain injury or during therapy sessions. These feelings may be in relation to their accident/ illness, in response to changes in their function, or in response to the impact of their condition on their family and friends. Some children may also be worried about their future or ongoing medical needs.
Mental health concerns are more common among children and adolescents with a brain injury, with these children often experiencing a range of emotional and mental health concerns. Most children with brain injuries can develop skills in better understanding their feelings and managing their feelings. However, additional support and time as well as different approaches may be needed.
Recommended treatment approaches for those treating children with emotional dysregulation
Among children without a brain injury, approaches such as cognitive behaviour therapy, mindfulness, acceptance and commitment therapy, and play therapy are generally well accepted as evidence-based approaches for supporting emotional regulation. Unfortunately, there is limited research around using similar approaches for children with a brain injury. The little research that has been conducted however appears promising.
Considerations for intervention
While traditional approaches to managing feelings in children/adolescents may be an effective treatment approach, adaptations do need to be made. It will also be important to develop an understanding of the child’s brain injury and treatment, as well as the impact these may have on their emotional regulation (e.g. is a medication worsening mood, is the child impulsive and acting on feeling before thinking through ideas to manage them?). Some key considerations include:
- It will be important to consider the child’s developmental age (not just their chronological age) when implementing therapy, providing education, and teaching strategies.
- Children may need ideas and strategies that are:
- explained in simple, familiar terms with concrete examples
- information paired with visual aids, such as diagrams or videos
- information presented slower, extra time to respond, and in smaller chunks (so you may need many more sessions)
- repetition of key points
- plenty of practice of key strategies
- frequent, regular review of skills and knowledge
- consistent in terms of recommendations and approaches given by all caregivers.
- Allow breaks and opportunities to rest, particularly if fatigue is a concern.
- Allow opportunities for movement breaks.
- Support the child in planning and preparing for homework activities. They may need prompts and reminders.
- Consider ways to help the child remember information (e.g. taking photos, using a story board, etc)
- Consider the child’s ability to understand information – you may need to work with the speech therapist to help support the child’s communication in session.
Unfortunately, “talking therapies” (e.g. CBT) are not appropriate for all children with a brain injury, particularly those that have significant challenges with thinking or communication skills. It may be necessary to use approaches such as understanding and preventing emotional upsets, working closely with caregivers, and more behavioural/ physical approaches (e.g. sensory toys).
If you are unsure how best to support a child it can be helpful to consult with the child’s treating specialist and their other allied health caregivers.
Queensland Paediatric Rehabilitation Service
Queensland Children’s Hospital
Level 6, 501 Stanley Street, South Brisbane 4101
t: 07 3068 2950
t: 07 3068 1111 (general enquiries)
f: 07 3068 3909