Monday, January 16, 2012

9 year old with intense periods of anger overload

Dear Dr Dave,

I have just been reading your blog on Anger Overload. 

My son will be 9 in March and has extreme anger outbursts that include direct violence towards myself and my husband that are currently lasting for up to 3 hours each time, and are presently at least 4 days of the week.  

We have two children, an 10 year old daughter and our son. We have three small pets and we/he has never been exposed to domestic violence, drugs or alcohol addiction, so there is no learned behavior.

The symptoms for Anger Overload appear to match my son. Triggers can be as basic as being told he cannot play on the wii, to as minor as getting three words wrong during spelling practice.  
He is however very intelligent, in the top sets at school for maths and English. He enjoys school and is a well liked member of class, not overly surrounded by true friends but he has a couple of close friends. 

He is very strategic and plays chess and war games to a high level, but on and off for 4 - 5 years we have had sporadic outbursts of anger from my son, we can go weeks even months without any outbursts, yet they are currently escalating to approximately 4 times a week and are including violence and behavior which is starting to endanger himself (violently shaking the balustrade/banister trying to rip it out of the wall/floor). Pushing us backwards at the top of the stairs, kicking, biting, punching, being rude, plus many more. His stance is more often very tense, arms crossed and an intense look of hatred on his face.  When he is not having an episode he is a loving caring thoughtful child.

He doesn't however, allow anyone else other than us to witness his behavior, he does not exhibit any anger at school or cubs or with friends and in fact everyone else thinks our son is a very placid, quiet child - but he gets very defensive if we talk about it to others,  and when we discuss behaviors with him he claims he can't remember the outburst occurring. What he never has is any remorse or guilt after the outbursts.

We attended brief intervention when he was about 5 years old where we had three discussions with a social worker, but; because he doesn't allow any other people to witness the behavior we were fobbed off and told there was nothing wrong with him. We have now started to discreetly video his outbursts in an attempt to be believed.

Last night we ended up attending out local Accident/Emergency unit at the local childrens hospital and they have admitted him until Monday when we can see someone from the Childrens Mental Health Team.  However, tonight reading your blog makes me think he could have anger overload.

I think if he does have Anger Overload, then we have been dealing with the problem all wrong,  he presently has some toys confiscated as a punishment and is banned from the computer or wii for a number of days after major episodes, we have also been trying to talk it through with him mid-event!  I think your Parents Manual would be a wonderful tool for us to try and would be very interested in getting hold of a copy.

Any guidance would be gladly received.

Dear parent of 9 year old,
I can see how difficult and upsetting the anger episodes are for all of you.   While your son is in the hospital, the staff will rule out any other diagnosis, such as bipolar disorder or other mood disorder.  Does your son act impulsively for his own pleasure with total disregard for what other people are doing? Does he get revved up, or driven, when he wants to do something?  If there are frequent signs of these behaviors in addition to anger overload, I would recommend consulting with the doctors about pediatric bipolar disorder.  It is unlikely, but you would want to rule it out, as then a particular medication protocol might be indicated.

I would be glad to make my manual available to you as soon as it is ready.  One suggestion I would have for now is to talk about a "chill" place in the house where your son or anyone else could go when they are upset.  It would not be a punishment, and would have interesting activities there to help distract him and help him calm down.  Your son will likely refuse to go there when he is extremely angry, as he is not thinking rationally at those times.  The emotional side of his brain has flooded his prefrontal cortex, which is the executive area of the brain.  However, if you can sometimes catch him before he totally rages, he may be willing to try the chill place.

You would be better off not talking with your son while he is in an anger episode, as he will not listen to reason and may escalate in response to your comments.  Try to tune him out and get busy in the house.  However, if your son physically harms someone or breaks something of value, then you will need to restrain him.  Can someone hold him on the floor or bear hug him until he is calmer, if he is hurting someone?  It may turn out that going to the hospital will help you in the future, because your son may be able to hold off from hurting someone if he knows this will involve another trip to the hospital.  Though children have limited reasoning capacity during an episode, they often can re-direct their anger (express it loudly but non-violently) if they know what behavior will trigger returning to the hospital.

My manual will describe ways to change the sequence in the house to limit future outbursts and will prescribe a method to teach your child how to look at trigger situations differently.  To start, you will want to chart anger overload situations for a couple of weeks, noting what is said and done, and what happened right before your son got angry.  You will look for some themes, and this will help you then work with your son while he is calm to think differently about the triggers.  This will become clear in the manual.   In the meantime, hopefully the hospital staff will help you get started.  

By the way it is a good sign that your son shows self-control in school and in public.  He will likely be able to learn self-control at home eventually too. 

I hope this note is helpful,  Dr. David Gottlieb

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