Monday, February 12, 2018

4 yr old tantrums going to preschool

My son is four and was late at learning how to walk and talk. He’s always had anger issues and even as a baby would scream and scream and we never knew why. Now his behavior matches your description of a child who has anger overload; he’s good when he’s not experiencing that. So my first question is, what resources do you recommend for those of us who have a child this young, and secondly, how do I get him to go to preschool. He starts regular school in August, so I am worried that if I don’t teach him to go to school now then he won’t then. He says he loves school but he has stayed at home his whole life up until now and is used to staying at home and playing games all day. Now he has to go to school and every morning it takes twenty minutes to get him from the car to the school; he kicks and screams as loud as you can possibly imagine. He tries to run away; he does everything he can to not go. I’ve given in to not taking him a couple of times but now I realize I need to stick to him going but it’s really hard and I feel guilty for giving the teachers a kid who is screaming and kicking like that.

Hi, Two of my books are written for parents to use for children of all ages:  "Anger Overload in Children:  A Parent's Manual" and the supplement: "Anger Overload in Children:  Additional Strategies for Teachers and Parents."  Two strategies that might be useful for your son are 1) changing the expectations and 2) altering the sequence.  Children who have a close bond with their parents often show separation anxiety when it is time to get ready for school.  For some children this takes the form of crying and for others there are angry tantrums.  How can you change expectations or the sequence in this case?  One expectation a child has is that if he screams loud enough, the parent will hear his distress and take him home.  After all, most parents pick up their child when he cries at home, so in a child's mind, why not scream now on the way to school? Thus, one thing to do is to leave immediately when the teacher meets you and your child.  Tantrums will last longer if your child expects he may be able to go home with you, and generally decrease in intensity once the parent is out of earshot and the child can no  longer expect to be taken home.  

Another rule of thumb is don't give in to the tantrum and stay longer, as the child has succeeded in delaying the separation from you and will continue screaming.  After a few weeks, tantrums usually lessen, as the child comes to expect you will leave despite his screams.  For some children this can take more than a few weeks, and others less time.

One way to change the sequence is to have someone else get your child ready in the morning and drive your child to school:  your spouse, or a grandparent, or a parent of another child going to the preschool.  Children will scream longer when leaving the parent to whom they are most attached.  Having a different adult come get him ready for school or come to pick him up will lessen the tantrums.  One possible scenario to disrupt the sequence is for you to stay in bed and pretend to be sleeping or pretend to be sick, and have another adult get your child ready for school.

Once a tantrum is in full gear, it is hard to stop.  This is when I recommend trying emotional distraction. In the case of leaving home for school, it can be difficult to change a child's emotional state, but if you can get your child to laugh, or to participate in singing a favorite song, or to play a favorite game in the car, it will lessen the tantrum. 

When your child is in full tantrum mode, do your best to ignore it.  Try not to talk with your child while he is screaming, as generally, the more attention you give, the longer it will last.  If your child settles down, talk with him then.  Don't feel guilty, it is okay for your child to react to separations.  And it is okay for you to ignore them.  Separation anxiety is quite common for preschool and kindergarten, and sometimes for early grades in elementary school.

Best, Dr. Dave Gottlieb


Wednesday, January 17, 2018

Medication question

I have an 8 year old that I think is experiencing anger overload based on your descriptions. He does not exhibit any symptoms that would indicate he also has ADHD.  If that is an isolated diagnosis, is there a particular medication route that you recommend in additional to cognitive and behavioral therapy?


Hi, There is no medication specifically for anger overload.  If there are other problems that are contributing to the anger overload, then sometimes medication can be helpful.  For example, if a child has ADHD or if a child exhibited signs of bipolar disorder, the medication for those problems might lessen the eruptions of anger.  Or if a child is highly anxious or depressed, there are medications that are sometimes helpful.    

If you want to read more about what else could contribute to anger overload, I explain about dual diagnoses and possible medications in my other books. One book is called: Your Child is Defiant:  Why is Nothing Working?  The website that reviews this book is yourdefiantchild.com.  You can also order the book from this site.

My earlier book is about dual diagnoses for ADHD.  It is called Why is My Child's ADHD Not Better Yet?  Recognizing the Undiagnosed Secondary Conditions That May Be Affecting Your Child's Treatment.  I wrote that book with two other authors, a psychiatrist and a learning disability specialist.  It is available on Amazon.

Take care, David Gottlieb, Ph.D.

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