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


Tuesday, March 21, 2017

Therapy recommended for self harm behaviors

Hello Dr. Dave,

My 9-year-old daughter suffers from anger overload and her episodes have gotten more frequent and pretty scary. My husband  and I are wondering if we should follow the course you recommend in your book on our own, or seek professional help. Some background…

We can trace E’s angry outbursts back to when she was a newborn and would get so mad when we would put her in her carseat that she would hold her breath and turn purple. As a toddler, she was more volatile than my older daughter, but we figured her behavior was in the range of normal for her age. Between the ages of 5 and 7, she had several over-the-top reactions to seemingly small disappointments or when she would not get her way. The summer after she turned 7, things got worse. Practically every day, something would set her off and she would scream at the top of her lungs, cry, say nasty things to her parents and sister, and throw stuff around. Once she pulled out a clump of hair and once she banged her head on the floor, before realizing it wasn’t a great idea. In desperation, I searched the Internet and came across your book, “Anger Overload in Children: A Parents’ Manual”. I ordered it and quickly read through the introduction. Your description of anger overload fit E to a tee. Before i could get farther into the book, the summer ended, school started, and the horrible episodes disappeared. I filed the book away, hopeful that we didn’t need it after all.

During the winter of 2nd grade, E had a struggle with anxiety, and we ended up seeing a LCPC, who helped us identify the problem, label it, and taught E some basic skills to deal with it. E has not had to deal with anxiety interfering with her life since then.

E continued to have infrequent anger episodes, though few stand out in my mind, as I reflect back on that time. Fast forward to February 2017. E is now 9-1/2. Without warning, she began to have more frequent and more intense episodes. The triggers are different - once she was struggling with homework, another time she received a piece of modestly disappointing news. The reactions are often fierce. She screams, cries, throws hurtful words at her family, and is modestly destructive. Of most concern, she has hurt herself by pulling out her hair and hitting herself in the head. She says that she wants to kill herself or wishes we would kill her. After the episode passes, E acknowledges that she does not want to hurt herself and is generally a sweet, happy kid.

We went back to the therapist she had seen for anxiety, but I realized that the therapist was not equipped for this type of problem and it was no longer a good fit. I also met with a psychologist, who E is supposed to see for the first time later this week. However, the psychologist didn’t seem to have any experience with behavior like this and I am a little concerned that she will take the wrong path. E does not want to see anyone.

In the midst of all this, I remembered your book and once again read through the introduction. I am certain that anger overload is descriptive of E’s condition. I am unsure, though, if we should handle this on our own, following the recommendations of the book, or if we should be working with a professional, given the threats of self harm. 



Hi, Yes, given the self harm behaviors, I would recommend you consult with a mental health professional who works with children and their parents.  Many of the strategies in my parent's manual may be helpful and woven into the course of therapy.  Continue to record what some of your daughter's triggers are.  That will help you and the therapist anticipate some of her outbursts and devise the best strategies to help.  

In reading your e-mail, I wonder if your daughter expects too much of herself.  You wrote that she experiences anger overload when she struggles with homework or gets modestly disappointing news.  I would recommend cuing her before she starts homework that some of it will be hard, and that it's good she does not know some answers.  If homework were too easy, she would not be learning anything new.  You could shorten this into a catchy mantra that your daughter helps to create.  An example would be "mistakes are good. It means I'm learning new stuff."  Or "everyone makes mistakes."  This would be practiced daily, until it gets internalized (i.e. until your daughter can deal better with disappointments, like homework difficulties).

Beyond the mantra, the parent's manual has other strategies to help her with self control. In addition, therapy can help identify further the source of her upsets, and help your daughter feel better about herself.  Therapy helps with underlying issues as well as helps a child develop self control strategies.  

Best, Dr. Dave Gottlieb

Tuesday, March 7, 2017

5 yr old trashes the classroom

Dear Dr Dave

I came across your article on anger overload after desperately in tears reviewing the internet. It is the first time I have actually read something that sounds like what my just turned 5 year old has!

We are waiting for proper Assessments to be carried out at the moment but first discussion with Pediatrics & we were asked to complete Conners 3 & the social communication checklist. Neither myself or or the teachers at my sons school think he has ADHD or Autism. He is a very intelligent little boy & is extremely loving especially to animals & younger children & his no problem with attention. They have witnessed his sweetness & had great conversations with him over lunch.

From an early age he has what we call a flip switch, where he just  loses his temper. It's usually linked to frustration, what he thinks is unfairness or just not getting his own way.
Sometimes we can distract him out of it, normally with something that requires thinking & sometimes we can't. Outbursts at home are limited probably as we have learned to control them or just tackle major stuff but at nursery (where the changes began in preschool room lashing out at adults) & now school it is has been a real problem.

First two weeks at school he struggled to settle (separating from me) but then after this, he had great first term & even got certificates & awards for his good work. The teachers have said he is ahead with his work. It all changed in 3rd week in December last year. None of us know why.

He has taken to lashing out at the teachers & walls mainly, shouting, hitting, kicking in an anger episode. He also sometimes runs off when he gets cross down the corridor. The outbursts are short in time & never normally over 30 minutes.

He was taken in from the playground one day in January due to fighting with two other boys & he wouldn't calm down. He deemed this to be unfair & he then trashed the classroom. Throwing things off pegs, pen pots, books etc, kicking teachers & hurting them. The teachers called me to collect my son. This happened again later that week & the whole classroom was trashed. I was devastated & he was then excluded & then put on a reduced timetable since the end of January. This is when we reached out to our GP.

Outbursts have reduced in intensity & he has not wrecked classroom since (he didn't like mummy crying & being upset) but ED psychologist linked to school has suggested a few things like 1:1 supervision & to give him choices out of two options & they now use now & next cards to prepare him. This strategy has seemed to back fire. This last week he has started to refuse more & more direction at school & the anger outbursts (hitting staff) have returned almost daily. One day he was great until he was asked to use soap to wash his hands & he got angry & lashed out. I asked him later, & he said they don't usually have soap available in the toilets to use & so he has to usually use just water.

He is not allowed playtime with the other children as the staff are worried that another child may get hurt in his outbursts. It is difficult for us to understand as we have play dates, go to parties etc & if he ever gets cross we are able to manage it but this is rarely.  We suppose we are in a fun setting, we are there & can intervene & he knows this.

We have tried reinforcing how he should behave at school, no hitting, kicking & reading books together on how he should act & rule following. Even sticker charts don't seem to be working.

Have you ever come across anger overload happening more often in a controlled setting? And refusal of direction? Do you have any advice as how I can help the school?
We are not sure if there is anything underlying linked to school that is increasing the anger episodes there.

After reading your parent guide I am planning to start recording occasions at home. I was going to ask school to do this too?

Any advice you can give I would really appreciate it.

Hi, You have done a good job of trying different techniques and worked well with the school. It must be so frustrating that your son's outbursts at school increased in December.  Do you have any idea whether something changed in your son's life at home or school at that time? 

I try to get clues about the triggers from what is happening when a child gets angry.  As I read through your email, I was making notes of some of your son's triggers: separation when you drop him off, when there was a dispute on the playground with two other boys, and when he was asked to use soap to wash his hands (when he was used to only washing with water).  Transition times seem to be a trigger sometimes, and unexpected changes seem to be another trigger.  Keep trying to make a list of triggers and then see if you and the teachers can anticipate a stressful situation for your child and intervene before the overload phase.  It will be difficult to anticipate all things that will trigger his anger, but if you can anticipate some, and work out a strategy ahead of time with the school, it may reduce the frequency of outbursts.  I outline how to use emotional distraction and relaxation strategies in my parents' manuals.  The second manual has a section specifically on applying the strategies to anger in school.  Also in the second manual, I explain how to develop jingles or mantras that you would practice with your child ahead of time.

I like the ideas of the school psychologist: offering a choice of two options sometimes helps head strong children.  But if a strategy stops working, then the school may need to try something else. I find that mantras, early emotional distraction, and relaxation "stations" (a place separate from the other children with relaxing objects) are often helpful.  In answer to your question, structure usually helps, but not always with children who are head strong. 

If you try again to use positive reinforcement, keep the chart brief--one or two items--and have a daily, exciting reward.  Sometimes it helps to teach your child how to "go with the flow."  The teacher could use a hand signal when she wants your son to "go with the flow." Then if he does that once or twice a day, he earns a fun activity at home or school. Keep in mind that it is sometimes trial and error to find what rewards motivate a child.

I would continue with the evaluation by your child's doctor to see what else may be contributing to the outbursts.  The frequency and intensity suggest that psychotherapy is a good idea.

Best to you, Dr. Dave Gottlieb