Wednesday, November 15, 2017

7 yr old throws things in anger at school

I have a 7 year old son who is having problems at school.  He did fine in kindergarten, but started 1st grade and explodes in anger on several occasions.  He gets angry if children are looking at him, he gets angry if he can't be the first person in line, he gets angry when he is told to stop talking.  Recently he got so angry that he crumbled up his work at school and threw his math book in the trash.  He also swung at his principal.  This led me to remove him from the school.  It was a private school.  He is now in another private school.  A couple of days ago he got angry because he wanted a certain eraser and the teacher told him someone else was using it.  He threw the eraser at the child, threw a pen at the teacher and ran out of the school into the street.  He tells the teacher that they can't tell him what to do and only his mommy can tell him what to do.

      I returned from a deployment a year ago in the military.  I was gone for about a year.  After a year, I came back for my son and he spent the duration of my deployment with me.  This is when the behavior started in school.

      He does not display this type of behavior at home or with my alternative babysitters. If he does get angry at home, it is only for a second and he changes his behavior.   He is a straight A student in school.  This new school is more challenging for him.  However, I feel that it is only a matter of time before this school dismisses him.  Any help would be appreciated.


Hi, I have a few thoughts.  One is I would consider convening a meeting with his teacher, and include your son. You could then say in front of your son that the teacher is the boss in the classroom and that it is important that everyone listen to her.  The teacher could send home a daily sheet with smiley faces if your son followed directions and if your son was respectful to others. Then you could praise your child for showing respect and self-control.  In a sense, what you would be doing is making the teacher an "extension" of yourself.  Since your child respects you, maybe this would help him learn to respect the teacher.

The theme of many of the triggers for your son's outbursts have to do with not getting what he wants or expects at school.  It is a tough developmental task for many young children to accept that they are just one of many students, and they cannot have everything they want.  At home, it is different.  Your son may be the only child, or one of a few children, so his needs are more front and center at home.  I would suggest telling nightly stories (you can make them up or ask the local librarian for suggestions for appropriate books for young children) about going to school and following directions, and how happy that makes Mommy.  Or draw pictures together at home about what to do when you don't get to be first in line, or don't get to use the eraser you want.  Stories and pictures are a good way to transmit behavioral expectations to young children.

The last thought I have is whether underlying your son's behavior is his need to be "first" because he missed being the center of your attention for a year, and in a sense wants to make up for lost time.  This can happen despite everything you have done to attend to your son. This is only speculation, but if your son does not make progress in self-control at school with the behavioral suggestions above (or with the additional suggestions in my parenting book on anger overload), then I would consider psychotherapy to examine possible underlying separation issues.

Best, Dr. Dave Gottlieb  

Friday, October 27, 2017

8 yr old's outbursts in school

Dr. Dave,

My grandson is 8, and struggling behaviorally at school. This past year he was put on ADHD medication, which does make him quieter. But his real problem is still there. He is having uncontrollable angry outbursts: throwing chairs, kicking, hitting, yelling at the adult in his way. Honestly, a description would be Dr. Jekyll and Mr. Hyde. He has the biggest heart and other than the outbursts, he is a smart, behaving 8 year old boy.   After his outbursts he is very remorseful, and beating himself up for it, accepting the punishment.  He will come to our  house and say I was bad at school I can't watch TV or play video games. Makes my heart break for him. I think the true problem is anger overload. 


Hi,

First, what I would recommend is that the teachers keep a list of all the precipitants over a two week period.  What is your grandson doing right before he gets angry?  What are some of the triggers, and is there a theme to the triggers?  Themes could be:  when he feels ignored, when he feels criticized, when he can't do what he wants.   Then the teachers can try to anticipate what will cause him to get angry, and try to change your grandson's expectations in advance.  For example, if he feels criticized, the teachers could explain that every child needs help sometimes, or explain that no one gets it all right, or that it is okay to make mistakes.  They would choose ones of these phrases or another short explanation that they think would resonate with your grandson, and then begin with that phrase before they comment or correct his work in the future.  

You could also work with your grandson at home by going over the teacher's explanation with him, and maybe draw a picture together of one situation where the explanation would apply.  I call this explanation a "mantra."  The idea is to go over the mantra briefly each day before school to help your grandson deal with what he perceives as criticism.

Other strategies are described in my parents' manuals and children's workbook.  If the teachers can't head off an outburst, then they may need to restrain him if he is about to hurt someone.  While it is usually best to ignore a child in the middle of a tantrum, and praise him when he is calm or when he uses a self-control strategy, if someone is likely to be kicked or hit, then the staff would need to protect themselves and the other children as best they could.  

Children with ADHD are often impulsive.  They can react quickly without thinking in advance.  The doctor could monitor the medicine and adjust it somewhat if the outbursts do not decrease.  Sometimes that can help a child to think first, and use a strategy rather than explode.

Best, Dr.Dave Gottlieb



Tuesday, August 8, 2017

BUDDE: an acronym for controlling anger overload

In my clinical work, I have started using an acronym to help clients remember some of the strategies from the parent's manual and from the children's workbook.  Each letter in BUDDE stands for an important part of how you can develop self control.  Work on the strategies below while you are calm, so you develop a plan.  Remember the plan will not work all the time, but the more you practice it, the more you will be able to have self control.

The B stands for the brain.  First it is important to understand that anger emanates from the brain, and that one's brain can change with repeated practice.

The U stands for understanding one's triggers.  Be sure to think about what was going on before you got enraged.  Try to identify two or three different triggers.  My anger overload workbook gives suggestions to help you come up with your triggers.

The first D stands for deep breaths.  When you notice a trigger happening, or notice yourself getting frustrated or angry, before you say anything try to take slow deep breaths for one minute. This releases calming chemicals in your brain.

The next D is for distraction.  This is another tool you want to develop.  What helps you get your mind off your triggers?  Is it music, playing a video game, talking with someone, or something else?  Try to focus hard on something.

The last E is critical.  It stands for alternative explanations.  What you want to do here is think about why somebody said or did something that got you mad.  What was their motivation?  Try to look at things from their perspective, and  you will realize that they did not want to bother you, nor get in your way.  If you can, think of how to compromise next time with whomever got you mad.

For a more complete review of these ideas and more, see my parent's manual, and children and teen's workbook, and/or read other posts on this blog.

Dave Gottlieb, Ph.D.

Tuesday, June 20, 2017

9 yr old has meltdowns at bedtime

Hi,

Stumbled over your report and blog a few weeks back and a lot of things fell into place regarding our now 9 year old daughter. We're now trying to work through some of your suggestions. 

Thinking there may be a dietary trigger in that the last few meltdowns have followed chocolate or very sweet puddings at restaurants. Could this be a trigger?

One other question. Tonight's meltdown came after a lovely day when we told her it was bedtime. She instantly switched off to us and became increasingly agitated. Despite trying to explain and to reason with her she focused on any negativity. Left alone she has calmed and gone to bed. However she shares a room with a younger sister - something she wanted to do - and has scared her to the point we had to remove the younger sister to our room in order to resettle her. This is not ideal. So, any bedtime meltdown tips please?

Grateful for any help.


Hi, bedtime can trigger a meltdown because a child may not want to stop whatever she is doing that is fun.  Generally, if some fun activity follows a boring activity, then a child is more likely to do the boring activity.  But nothing fun follows bedtime, except maybe for the parents, who get a breather when their children are asleep!  What I recommend is doing something the child enjoys after she gets in bed, like a story or a card game.  If this engages your child, she will be more likely to get into bed.  Pick a relatively calm activity so that your child is more likely to wind down.  

Rewards do not usually work well because a child isn't concerned with a reward that will come tomorrow when she would rather do something with you tonight!  

What happens if you successfully get your child into bed with a fun activity, but when the activity is over, she does not want to stay in bed and sleep?  That's a tough one.  You could do another more calming activity, such as have your child lie down and read her a story in dim light.  The other option, if she continues not to drop off to sleep, is to try a later bedtime when she is more likely to be exhausted.  

Once you have determined it is time to leave, do not talk a lot or spend much time in her room.  If she has a meltdown, you do not want to "reward" it by giving her a lot of attention. Usually these meltdowns tail off after a week or so, when the child sees that you will not spend more time with her. 

As for sugar, there is controversy in the literature about its effects.  More doctors feel that hunger (or a lack of sugar and other nutrients) is more likely to trigger irritability than an excess of sweets.  However, chocolate does contain caffeine, so if your child is sensitive to caffeine, that could delay sleepiness.

Best, Dr. Dave Gottlieb

Wednesday, June 7, 2017

PANDAS, an autoimmune disorder

Dear Dr. Gottlieb,

At age 4 or 5, my once happy child started having more angry outbursts and oppositional behaviors along with anxiety. Since the initial episodes were fairly low in intensity and frequency and were easily mitigated with humor or social-emotional strategies, I didn't think much of it and chalked it up to growing older and being faced with increased frustrations. 

But that all changed this winter, when he morphed into a very angry and anxious child. The smallest frustration caused huge angry and aggressive outbursts. Separation became a problem. Any strategies previously learned were useless in the moment and did not seen to stick for long. I was at a complete loss and motherly instinct told me there was something seriously wrong that was not externally based. 

After lots of research, I had him checked for strep due to behavioral symptoms. He was positive and to my shock and relief after a few days of antibiotics, I was seeing my old articulate and happy son returning. He was diagnosed by 2 doctors (pediatrician and neurologist) with PANDAS and with longer term antibiotics, we are continuing to see our son's emotional health returning. 

I am writing to you because, as a psychologist myself, I had the tendency to believe all behavior is trigger-based (because if we look hard enough we can always find some connection, right?), but it is not necessarily so. I am glad I considered medical issues and did not continue to search for external causes, which would only have shortchanged my child.

While of course not all children with anger issues have this disease, I think it is important to rule possible medical causes (e.g., PANDAS) in or out first, especially when coexisting symptoms, such as separation or the anxieties are seen and a child has changed significantly. Of course trauma must be ruled out as well. That being said, your strategies are well-thought out and help countless people. Continue your great work, but please alert parents to this very real disease that, if caught early, can be fully treated with antibiotics (in conjunction with CBT, if indicated. I am attaching a link to a brand new documenary on PANDAS, which as both a psychologist and parent has opened my eyes to the possible medical side of behavioral issues and has enriched my repertoire when helping families. In fact, this knowledge has already been useful for me in assisting parents in recognizing and treating early emotional signs of strep.


 Thank you for reading. I would love your feedback.


Hi, In my clinical work of 30 years, I have had one case of PANDAS; I am not an expert on the disease.  Research results on the prevalence of PANDAS varies but a study referenced by the National Institute of Health found 1 case of PANDAS per 3,000 throat cultures positive for strep.   PANDAS is an acronym for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Children who develop a strep infection occasionally develop severe behavioral symptoms. Usually there will be a tic disorder (sudden involuntary motor movements or repetitive sounds or words) and/or obsessive-compulsive symptoms (OCD).  Basically the strep infection causes an abnormal autoimmune response that includes these behavioral symptoms.  The behaviors can last for months, but these children often respond well to antibiotics and cognitive behavioral treatment. Sometimes other medications are used depending on which behavioral symptoms are prominent.  (For example, serotonin reuptake inhibitors can be used for OCD symptoms.) Problems can recur especially if the child develops strep again.  

There can be other symptoms like anxiety and temper outbursts, but in my experience and from what I've read about the disorder, anxiety and anger are not in themselves definitive characteristics of PANDAS.  Tics and OCD symptoms following a strep infection are currently seen as key symptoms.  Research is ongoing, and we will know more in coming years.  

If there is a sudden increase in behavioral symptoms, and your child may have had strep recently, it is wise to get a medical evaluation from your child's pediatrician or family doctor. For more information on PANDAS, the National Institute of Health has an informative website: https://rarediseases.info.nih.gov/diseases/7312/pandas.

For most children with anger overload issues, there is a different biological pathway that makes children susceptible to anger overload.   As I write in my parent's manual, the prefrontal cortex of the brain and amygdala are structures most likely implicated, and the most effective strategies I have included in my parent's manuals and children's workbook. Cognitive behavioral strategies can help children develop better self-control. 

Best, Dr. Dave Gottlieb 

Tuesday, May 23, 2017

Using the anger overload workbook

My son is 9.  He has many diagnoses over the years, from autism to bipolar to anxiety.  Anxiety is the one that has stuck and we have since found out he is gifted.  The problems with anger started when he was 3.  He had a flip switch and would rage for hours, run away from us, destroy daycare classrooms, etc.  He has gotten better over the years.  His IEP and behavior plan were removed this year due to his progress.  He has also gone off of his Risperdal and is tapering off and almost off of Trileptal.  However, starting at the beginning of May - his anger came back at school.  His triggers are during recess mostly (90%) and related to people not playing by the rules as he deems them.  For example, four square.  He knows all the rules because he has researched them and gets mad if others do not play that way.  He has hit, kicked, shoved.  The school  year ends in a few days and summer camp starts.  Summer camp is outside and has many of the games which have been his triggers this month.

I am thinking of having him complete the kids' workbook.  Any other thoughts to help?  Much thanks in advance!


Hi, in the beginning of the anger overload workbook, I ask children to keep track of their anger:  who did you get angry with, what did they say or do, and what did you say or do. Then I have children fill out worksheets that help them see patterns.  In your child's case, one pattern is when the rules are broken during playground games.  

Then the workbook explains strategies to deal with anger.  One chapter looks at how to prevent anger from starting, and another section of the workbook looks at what to do for early signs of anger, and then there is a section for the high anger stage.  Later I discuss more advanced techniques, like how to deal with different points of view and how to compromise.

For your son, he could prevent anger on the playground by playing a different, non-competitive game, but he probably would not like that idea.  So then I would work with him on mantras that would help him look at the game differently.  For example, one mantra could be "other kids won't always follow the rules, and I can't change that" or "some kids will make up their own rules, and if I want to keep being allowed to play with them, I have to play by their rules sometimes, even if I am right."  You would want your son to come up with a version that he thinks would help him remember how to deal with the kids during four square.  Then you want to practice it with him each night, or each morning before school. Remind him to repeat it during the game if he is starting to get aggravated.  

The next section of the workbook deals with low levels of anger.  We teach children how to be aware of body signals that they are getting frustrated. We also explain various coping strategies: a) physical activities, b) "chill" activities, c) reaching out to others, d) sensory activities, or e) mindfulness.  We explain how a child can implement these various techniques.  Some are more adaptable to a school environment.  Basically we want your child to have a toolbox of strategies, so that he can pick what he wants in a given situation. Then we recommend giving him a lot of praise for trying a strategy, whether it always works or not.  

If his anger gets to the overload phase, finding a "go to" place to calm down is important.  

As your child gets more reflective about what is happening, there are advanced techniques that we recommend toward the end of the workbook.
.  

Best, Dr. Dave Gottlieb

Tuesday, May 9, 2017

12 yr old in residential setting

Hi Dr Dave I wondered if there was any research to prove that positive parenting strategies were more effective in the long term than restraining?

My daughter is 12 with a diagnosis of autistic spectrum disorder (ASD) with Anxiety, ADHD, and she was also recently been diagnosed with the new DMDD (Disruptive mood disregulation disorder) as she spends so much time 'bubbling' with no clear understanding herself of why she feels on edge. She is fully verbal and high functioning but loses all logic once she gets too wound up.

She was hospitalized at age 9 for 9 months because she was simmering nearly all day and erupting 1-2 times a day lasting approx 2 hours - regularly hurting herself, others and causing breakages, smashing holes in the wall etc.

We now have her in a good specialist school where she is residential Mon-Fri and is getting Anger Management therapy and OT. I am learning lots.

I have been using de-escalation / positive re-enforcement with calm empathetic techniques for the last 2 years (not sure if there is a 'formal' name for these strategies and her therapist is confident we are on the right track.

But a few weeks ago she had a couple of mammoth meltdowns at the boarding part of school and was restrained.

There seems to be some discrepancy between the boarding staff, school staff and therapeutic staff about the best strategies during crises. Boarding  have stated that her place there is in jeopardy. This has thrown me as it has opened the door for doubting relatives.

I am wondering if there is any research to back up strategies to help me feel confident we are on the right path.

We are in danger of her being sectioned. She is like Jekyll and Hyde tho, in that when sensory issues and anxiety are reduced she can seem very logical. She is actually above average intelligence - but her emotional age is several years below.

I hope you can help. She appears to be quite a 'unique case' with many experts being stumped when confronted by her over whelming rage. 


Hi, A good research study in the field of anger and aggression in children has been conducted by a professor at Yale University.  His name is Denis Sukhodolsky.  He advocates cognitive behavioral strategies, many of which I advocate as well in my parenting manuals.  In my view restraint should be a last resort to be used if a child is physically harming herself or others.  I prefer to ignore screaming and tantrums if they are not destructive. The more you talk with a child in overload, usually the longer overload continues.  However,in a community setting, it can be disconcerting to other children if a child is screaming, and then it is up to staff to think through whether they can isolate the child (will she move to her room?), or whether they can remove the other children from that space.

Early detection of her triggers is ideal, because then a child is more rational.  I outline in my parents' manuals and the children''s workbook, how to record triggers and how to look for patterns.  That allows for early intervention. Then empathy and/or distraction and/or using catch phrases will help more often. (The latter is part of teaching a child to keep perspective.)   I'm wondering what specifically set her off recently since you mentioned she was having fewer tantrums until recently. Is she worried about losing her space in the residence?  Structure and stability are important for a child with severe overload issues. If she has some awareness that her position in the residence may change, she may be more anxious and prone to outbursts. 

Given her mood and anxiety issues, and the ADHD diagnosis, I wonder if medicine has helped.  Sometimes if the other symptoms lessen, there is less anger overload, and/or the anger will respond to empathy, or distraction, or to cognitive interventions to help keep one's perspective.  For the latter, see the later sections of my parent's manuals or children's workbooks. 

Best to you and your daughter, Dr. Dave Gottlieb