Blind Rage

Contributed by Dr Janice Forster

Dr Janice Forster, Pittsburgh Partnership

PWS is known for hyperphagia and temper outbursts.  Researchers have discovered that temper tantrums precede the typical food related behaviors in early childhood.  For all children, including those who have PWS,  tantrums occur when the reward centers of the brain begin to mature.  The reward center enables all children to learn from experience and to form expectations about things that happen in their world.  When a child wants something and does not get it, a tantrum occurs.  Or, when something occurs that is different from what the child is expecting, a tantrum occurs.  Among children who have PWS, this tantrum behavior differs from typical children in 2 important ways:

• It is more intense
• The biochemical braking system to stop the tantrum is broken *

Each tantrum is unique to the child, but in PWS it is usually very quick in onset and may appear to occur out of the blue.  If one looks carefully at the antecedents of the situation from the perspective of the child, often the etiology can be determined.  Once a tantrum begins, there is nothing that can be done to stop it, other than to keep everyone and everything in the environment safe.  The tantrum will run its course.  After the tantrum is over, some children will be exhausted and require a nap.  Other children will get back on track fairly quickly and resume their daily activities; they may or may not acknowledge  their behavior. 

The cortex of the brain not only governs reward, but it is responsible for thinking and reasoning behavior.  Another part of the brain is involved in behaviors such as tantrums and shut downs.  The amygdala directs brain mechanisms associated with survival (fight, flight or freeze); it is responsible for emotional expression, aggression, and impulsivity.  For this reason, the cortex has been referred to as the ‘baby sitter’ of the amygdala.  Although neural connections to the reward center of the cortex begin around age 2, the thinking and reasoning behavior is slower to mature in typical children and takes even longer to develop in children with PWS.  Using the analogy of a computer, when a child has a full blown tantrum, their thinking and reasoning ability in the cortex goes “off-line”.  This is why children with PWS appear to be in a ‘blind rage” during the tantrum; they are literally behaving in survival mode, acting without thinking.  In PWS it takes a while for the brain to “reboot.”  After they recover, they may act as if nothing has happened (brain reboot), and they may or may not remember what has occurred. 

A tantrum is a learning experience for the caregiver.  The keys to successful behavioral management are    determining what the trigger is, redesigning the daily plan to avoid it, and developing coping strategies to deal more effectively with it. 

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[1] GABA (gamma-aminobutyric acid) is the major inhibitory neurotransmitter in the brain; it regulates muscle tone and provides the braking mechanism for behavior, allowing a person to “stop and think” before acting.  GABA receptors are reduced in PWS, resulting in decreased GABA action in the brain that may also contribute to epilepsy, anxiety disorders and depression. 

Behaviour in PWS - where? What? Why?

by Linda Thornton

In .52 of a second, Google furnished me with a choice of 158,000 articles on behaviour in Prader-Willi syndrome.  It is overwhelming and if I were a new parent, I would not know where to start.  In fact, I probably would yell at Google, close the page and burst into tears.  There are scholarly articles, there are profiles of behaviours, advice on managing behaviours of pre-schoolers, toddlers, pre-teens, teens, adult and so on.  After 20 pages of Google and in amongst all the PWS articles,  suddenly I find a page on growing marijuana and by this stage, I’m thinking “what a good idea!”

Personally, I think that finding a PWS Association either online or in reality, is the best possible thing to do.  To be able to talk to someone face to face, or on the phone, or even just an email, will result in a calmer, easier-to-understand answer than trying to assimilate information from 158,000 different articles.  That’s just frightening.

The best possible thing you can learn about behaviour and PWS is that children and adults are all different.  They are people first, and just happen to have Prader-Willi syndrome.  Knowing your child, what motivates them, what they love and who they love, what scares them, what makes them anxious, and so on, is the first step towards understanding behaviour.  When you stop and think about it, everything we do, from getting up in the morning to going to bed at night, invokes behaviour of some kind or another.  Our behaviour sends messages to others in many different ways – no matter whether we have a disability or not.  It’s how we interact.  

I’ve watched the behaviour of my 32-year-old over the years and can read her like a book.  But I can also do this with my other children as well, the only difference is that my 32-year-old has more pages in her book.  That’s life.  Whether her behaviour is challenging, whether she’s testing whatever system that’s been put in place, or whether it's her every-day behaviour, for me the most interesting thing is how she interacts with other people.  I used to worry that she would ‘snap’ if someone said or did the wrong thing – and by this I mean a stranger, not someone she is familiar with because the more familiar she is with someone, the more likely she is to let loose! 

The other day, for example, I listened to her on the phone to her bank.  She was polite, very clear in her request to transfer funds and knew exactly what she was talking about.  She quickly and efficiently changed one automatic payment into another.  No problem at all.

I’ve heard her ring and make a doctor’s appointment; phone the library and request a particular book; she manages a visit to the Vet with her cat perfectly well and asks all the right questions and makes sure she knows the answers.  In an emergency (her concept of one) she will get herself down to the Emergency Department at the local hospital (with a staff person) and wait until she can be seen.  She knows when she is ill (see previous blog on gastroenteritis).  By being able to do these things she avoids becoming anxious, frustrated, and angry.  It has become so clear to me over the years that by first teaching her about making good choices, she is able to do so much more for herself.

Sometimes, in the middle of a catastrophic outburst I tend to forget everything I’ve just said above and feel as though I’m clinging to the life-raft for all I’m worth.  Just getting through to the other side of the meltdown is all I’m hoping for at this stage!  I hate it when these happen because I know how terrible it is both for her, and for the person she is focussed on.

I began to wonder what sort of chemical imbalance might be in place when these meltdowns got under way.  So I asked Tony Holland about this and about his research with vagus nerve stimulation.  He responded,

"Our work on vagus nerve stimulation suggested that people with PWS essentially have a a low threshold for such outbursts and also impaired emotional control - in other words people with PWS are easily triggered and once it starts such an outburst more easily builds up and leads to loss of control when compared to people without PWS. This appears to be improved by vagus nerve stimulation. The vagus nerve is part of the autonomic nervous system of the body that manages our response to threat - what we think vagus nerve stimulation is doing is normalising that response. The other rather different issue we are beginning to look at are two chemical (neurotransmitter) systems in the brain - GABA and glutamate - the former is inhibitory and the latter, excitatory. It may be that an imbalance of these two systems is important - a new study we are starting uses brain imaging to explore this hypothesis"

So, although I know that there is much behavioural research going on with Oxytocin* (Google: 1.10 seconds, 115,000 articles) and the Vagus nerve stimulation** (Google:  .72 of a second, 60,600 articles), I can’t help but think that deep down it pays to really understand your child and what makes them tick.  You may be surprised.

 (If you would like help with behaviour issues and would like to talk to our specialists about this, please email us)

*Maithé Tauber Oxytocin research

**Tony Holland Vagus Nerve Stimulation