Thursday, May 31, 2012

4 year old angry in school

Dear Dr. Dave,

My just-four year old exhibits precisely the types of behaviors you discuss in your manual, and in interviews.  He does not appear to exhibit any symptoms of ADHD or ADD-- he has a good attention span and can remain focused for quite a while when engaged.  However, he is prone to intense anger reactions to minimal disappointment-- generally connected to perceived embarrassment (even gentle suggestions sometimes set him off, and one can see clearly he feels humiliated, as though he is being roundly criticized) or simply feeling awkward and uncomfortable.  While he used to engage in tantrums at home, that behavior has mostly stopped.  However, his outbursts have intensified at school and in music class, where I think he sometimes feels awkward and uncomfortable, and where he often lashes out and hits and kicks other kids and even his teachers.  The result has been nothing short of devastating. He used to have play dates with the other kids every day, and was delighted. Now, they are beginning to shy away from him because he hits... and sometimes he is too worked up at the end of the day to play, anyway. 

We have consulted with his preschool's therapist and recently engaged a private therapist ..... but I am afraid our new therapist just doesn't "get" him.  She is an older woman, and was not successful in engaging him in talk-- and didn't really "play" with him. She put toys on the floor but didn't use them to get him talking-- she asked questions and didn't seem to know what to do when he didn't feel like answering. But he's only 4!   As it turned out, he was in a very happy, silly mood during his session, and so he mostly giggled and rolled around on the couch.  The next day, he had another bad anger incident at school. 

I feel at a loss.  I don't want to jump ship and leave this therapist quickly, but I am also out of my mind with worry and just want to know that we will get help.  How can a therapist help us if and when she doesn't get to witness one of his angry outbursts?  How do I know when to move on to someone else?  Also-- he is so young.  Is it too much to hope that this is a stage that he will grow out of?

Is it ok to respond later on the blog, I will not use any names, Dr Gottlieb

Yes, please do! I am a big fan of the blog and follow your responses to other families very carefully. I'd be delighted if you would respond on the blogs so others can benefit.

You can actually feel free to use my "name," if you wish, as it is a pen name (I am a writer) and would not identify me or my son.

I want you to know that I deeply and truly appreciate you identifying "Anger Overload."  I have read at least ten parenting books and hundreds of articles on "difficult" children and none hit the nail on the head.  They all suggested the child was looking for attention and enforcement of rules and boundaries, which honestly is not the case with my son, whose issues seem tied up at least in part with shyness and discomfort with his peers....  I am so grateful to finally see a professional "get it."  Thank you.

Hi, I'm glad the blog has been helpful.  I'd suggest talking with the therapist alone after she has met with your child a couple of times and asking her what her plan is.  Also, ask if she thinks it would help to consult with the school and with you periodically.  For young children with anger issues, I find it helpful to meet with the family and consult with the school about strategies.  Coaching the adults in your child's life can have a great impact because you and the teachers see your child every day while therapy sessions are often just once a week.  However, your child's therapist may prefer a play therapy approach;  talk with her about the goals (reducing angry outbursts) and how she will try to reach the goals.  Maybe she wants him to get comfortable in the first session and maybe she will engage him more in the future.  

Children often act on their best behavior, especially when they are new to therapy.  So your child may not display his angry behavior in therapy.  However, if the therapist knows what it is like (from your report) and has a hypothesis as to the cause and a plan to help, then therapy can still proceed.  One approach could be to help your child with his feeling that he is being criticized (which occurs before some of his outbursts as you noted).  If the therapist uses individual play therapy, maybe she will be able to get at that issue in the play and then talk about how to deal with hurt or embarrassed feelings during the play.

I usually try to develop a rapport with a child and talk in simple terms about what happened in music class, for example, particularly if the outburst were recent.  I review briefly what the teacher said and how the child felt.  Often I empathize with the child's feelings at this point.  Sometimes I would wonder out loud what else the child could do when he gets mad.  With older children I might try to help the child see what the teacher might have been thinking.  Another option is for the parents to calmly and non-critically review what happened with their child after school (if the school has sent a note home about the incident) and show empathy for the child's feelings, or the teacher can notify the school social worker who can then talk with the child when he is calm about what he thought about the incident in class and what he could do next time.  These discussions need to be within a day or so of the incident so that your child remembers how he felt.  One goal might be to help your child understand that he is not being criticized.  

It can be hard to have this kind of discussion with a four year old, though, and so it would be important to also plan a strategy with the teachers.  If the child is feeling criticized or embarrassed, the teacher could preface her comments to your son with something like "you are doing a good job" before making a suggestion to him.  The purpose would be to head off his feeling of being criticized.  Once you have enough data to know what is triggering your child's anger, you can often come up with a way to prevent (or limit the frequency) of the outbursts. In my manual I explain how to chart the interaction preceding the outburst and make more suggestions about how to intervene. 

In answer to your other question, it is possible your child will outgrow this, but I would recommend working on it because it is already causing problems for him with his peer group.  Your son's brain will be maturing a lot over the next few years, and his self-control will likely improve as his frontal cortex develops.  The exercises in my manual are intended to help that process along.

One last thought:  What did you do at home to reduce the outbursts?  Can the same strategy be applied in a classroom setting?  Maybe talk with the teacher about what worked at home.  All the best, Dr. Dave Gottlieb

Thursday, May 24, 2012

Rage of 4 year old adopted child

Dear Dr. Dave,

I  am a single parent of a child adopted internationally.  My 4 1/2 year old was adopted two years ago, and she lived in an orphanage from birth until just after her 2nd birthday.  By all accounts, she was a favorite in the orphanage and received very good care as far as orphanages go.  Using attachment parenting and following principles described in "Attaching in Adoption," we have a very loving relationship, and my daughter is well attached.   Previously, she had tantrums with me, but I was able to use behavior modification to the point where tantrums and/or rages are very rare at home or with me.  However, last year, she began having rages at school, and we worked with a play therapist for about six months to resolve the issues.  Since then, she has had periods of regression to tantrums and progressions towards behavior modification, and we have checked in with the play therapist several times.  In the Fall, her daycare began disciplining her in an unhealthy manner that caused a serious regression.  While working through that, I moved her to a Montessori which both she and I love.  Recently, the school reported some issues with rages that seem to often be rooted in jealousy over her favorite classmate playing with another child.  She also says, "I don't have any friends" or "nobody wants to play with me."  I again consulted the play therapist, who has provided some suggestions for helping her identify her emotions or concerns and to work through them.  When I shared the information with the school, they advised that the rages are becoming more intense and frequent.  The rages are sometimes fueled by the attention of classmates, although she is removed from the class when she starts.  The school describes her rages as "almost manic...her eyes change, and she doesn't seem to hear what we say.  She continues until she is either too exhausted to continue or until she starts to cry and is ready for comfort." Initially, they will put her in time out, but she refuses to sit in the chair. They will put her in a room and try to ignore her, but she will scream and/or hit a door or furniture.  If they get her to stop hitting the furniture, she will lick it, put her mouth on it, or drool by it.  If the teacher takes her into her lap to hold/protect her, she will spit or try to hit her.  She takes her shoes off when she's enraged, but she has now started to take her pants off instead.  She does NOT do any of this at home; it is situational to her daycare.  However, I do not doubt their description, as I have previously witnessed the behavior when she was younger and eliminated it at home via behavior modification techniques that schools seem unable to duplicate.

When she is not enraged, my daughter is extremely sweet and loving, which is also what the school indicates.  She gives and receives hugs from her teachers and classmates, and she is able to empathize with them.  In addition, she is very intelligent, enjoys working on schoolwork and artwork, can focus for long periods of time and has an excellent memory.  She wants to make good choices, but she says that sometimes it is just too hard to do that.  The school says that it is like two separate people when she's happy and when she is angry.  She recognizes when she's made a poor choice, but she shuts down or becomes angry when I try to discuss the details with her.  She knows the behavior is wrong, but she is unable to control it in the moment.  Her play therapist diagnosed her with adjustment disorders with emotional and behavioral elements.  The school says that they would like to help work through her problems but that realistically they are not set up to do so, are not able to identify the triggers prior to the rage with a classroom of kids, and have to be fair to the other kids and parents.  Her teachers are afraid to upset her, so they seem to appease her with alternative treats vs. setting a firm boundary.  For example, she wanted to be line leader.  Instead of saying, "it is not your turn right now;" they made her "gate keeper" to open the playground gate instead.  They normally do not have a gate keeper; it was created to keep her from being too upset.  The constant appeasement eventually leads to a relatively small issue sending her into a rage, but the teachers feel that they are heading off a rage.

 I am brokenhearted for my daughter because she loves her school, as do I.  It has been very good for her in a lot of ways, and changing schools again seems very detrimental.  However, her current school will not let her stay there without some very rapid changes and with limited adjustment from them.  Of course, I will be contacting her play therapist again and will also obtain your manual.  Here are my questions:  1.) Is there any type of daycare/school for kids like this?   I need childcare for my daughter and do not want to constantly move her from school to school or have her seen as a problem child.  2.) Are there any techniques that see rapid change?  3.) Should I be open to medication for her or resist it?  Advantages/disadvantages? 

I need some immediate help for the daycare situation.  However, I also do not want my daughter to go through the educational system with the same issues.  I worry that this is a never ending cycle.  
Thank you for your help.

Hi, It sounds very frustrating that the current day care program is not willing to work with you on solutions, since you have made progress before with behavior modification principles at home.  You might contact the special education coordinator at your local school district to see if they know of a day care program that would be willing to work with you.  Also, would your school district be willing to consult with the day care director and offer  advice?  Many school districts offer early childhood programs to help head off problems before children enter kindergarten.
Your second question about what to do quickly would be to try to adapt what you did successfully at home.  What behavior modification strategies worked before and how could they be adapted for the day care?  Maybe your therapist could help you put together some ideas for the day care, if they are willing to listen.  I would hold off on medication because your child is so young and because she has responded to behavioral interventions before.  Many of the medications that would help with agitation have potentially significant side effects and I do not believe they are FDA approved for very young children.  It is not unusual for children adopted past infancy to have regressions at times.  It seems overall you have made great progress with your child and you are to be commended.  

More specifically, I would try to identify the triggers; you have started to do that, for example you mention jealousy.  The earlier you can identify anger situations and re-direct your child the better.  It will be hard for one teacher in a large class to do this though.  There would need to be an aide who can help.  Also more frequent, brief rewards for self control may help.  You indicate your child wants attention.  Would she try to have self-control (you would need to be specific with her about what entails "self control") if she could get a hug, or earn a fun activity with an aide or with a friend?
In the manual I also explain strategies that involve labeling levels of anger and using catch phrases with children.  But these strategies take time to work (sometimes months).  They would not be a quick fix, but still worth considering as you get her ready for elementary school.  

All the best, Dr. Dave Gottlieb

Wednesday, May 23, 2012

Interview with Dr. Gottlieb in the Chicago Tribune newspaper

Here is the interview in today's newspaper about dealing with anger overload:

Managing Your Child’s Meltdowns: 
It’s Best Not To Intervene in the midst of anger overload

By Bonnie Miller Rubin, Chicago Tribune reporter
May 23, 2012
Kids are kids, which means they get angry — and don't always choose the right time or place to lose it. So, how best to maneuver around a meltdown? We turned to David Gottlieb, a Harvard-trained clinical psychologist, who has worked with children and families in the Chicago area since 1985. He is the author of the just-published "Anger Overload in Children: A Parent's Manual," a follow-up to last year's "Your Child is Defiant: Why is Nothing Working?"
He also has a parenting blog,, and as a father of three, plenty of on-the-job training.

Q. What is "anger overload," and how do parents know when it's a problem in their child?
A. "Anger overload" is an intense rage reaction to some frustration, and the level of anger is out of proportion. Usually this is because the child misperceives or exaggerates the significance of a disappointment. For example, if a parent says their child cannot play video games today or have a friend over to play, any child might be disappointed, but the child with anger overload goes into a rage that can last minutes or hours. ... The child does not keep the disappointment in perspective. This child might feel if he can't have the friend over today, then the friend will stop liking him.

Q. Can you describe it?
A. Anger overload is a problem when a child "loses it" and screams hateful things or throws things. ... We all can get quite angry once in a while, but this child has outbursts frequently that can last for minutes or even hours. If the child does not learn to contain his rage, this problem can get in the way later in life.

Q. What's the appropriate reaction when your child is going to have a meltdown?
A. Parents can intervene in the early stages or after the fury has subsided. During the overload phase, it is best to say or do nothing, unless someone is getting physically hurt. ... Your child is not thinking rationally. If you recognize a pattern for when your child is more likely to lose it, you can intervene early by lowering your child's expectations. ... So, if your child loses it when it's time to turn off video games on school nights, one possible solution is to not play video games after dinner.
You can't always predict the triggers, but if you see your child starting to show signs of anger overload, try an "emotional distraction"... saying or doing something that he'll find engrossing. ... If you know your child loves a certain game or activity, you can start the game ... or try a calming activity. For some, it's music on their iPod, for others, a bike ride or yoga.

Q. It seems that more children are defiant these days. Is this accurate?
A. Honestly, I haven't noticed a change in the last 30 years of practice. When I work with defiant children and get a family history, it's not unusual to hear a story about a parent, grandparent or relative who gave his parents a hard time ... or left home in anger.

Q. Is this learned behavior or an organic issue?
A. Some children are more prone to angry outbursts, and there is increasing evidence of underlying biological factors. The prefrontal cortex is believed to be the main "control center" of the brain, while the amygdala is generally thought of as where angry feelings originate. One prominent theory: The prefrontal cortex is immature in some children and is not able to regulate the emotions in the amygdala. Recent studies in adults suggest that low levels of certain neurotransmitters — chemicals in the brain — are associated with people who exhibit extremely angry or violent behavior. Research is ongoing, and we do not have a medicine that is an anger "antidote." However, with repeated practice, most children can develop better coping skills. ... With practice, the brain changes.

Q. Should parents use consequences if a child swears or strikes out during anger overload?
A. The issue of consequences is an interesting one. During an outburst, it's not wise to talk about consequences because it will cause most children to escalate. However, it is sometimes helpful to talk about a brief consequence after everyone has calmed down — especially if certain family rules are broken. So you are not punishing the outburst per se, just a behavior, such as swearing or throwing things. Some children learn from consequences ... however, many children will continue to say the meanest things they can think of to "strike out." If a child says, "I hate you. You are the worst parent ever," I tell them that children do not mean what they say at that time. Don't pay attention to the words. If you can ignore your child, that is in itself a consequence. When he calms down, then you start listening and talking with him.

Q. Can certain foods, allergies or diet trigger angry behavior?
A. There are not large-scale studies that I am aware of showing that allergies or diet trigger tantrums. Some parents notice that their children have more outbursts during allergy season, and this makes sense, because if children are struggling with allergies, they are often more irritable.

Q. What has proven to be the most effective technique in dealing with anger overload? Is it the same if kids have some kind of disability?
A. I give parents an "arsenal" to work with ... different strategies for different stages of anger and different ages. For children with a disability — say, like fetal alcohol spectrum disorders — timeouts or any suggestion — even well-meaning — usually exacerbates the rage during the overload phase. These children have structural brain damage, so suggestions before and after outbursts will have more modest effects.

Tuesday, May 15, 2012

10 year old with anger overload

Hi Dr. Dave!  I have a 10-year old son who fits your description of anger overload.  Is this something my husband and I can work on him at home with or can this only be fixed via a therapist?  Is it fixable? 

Yes, if the behavior is exhibited at home, my parent's manual on anger overload, available on Amazon, will be useful.  It does not change things overnight of course, and will involve work for you and your husband for a month or so, and then include your son over several months.  There are instructions and worksheets you fill out together.   A therapist and the school social worker can also help; the latter is especially useful if the behavior happens at school.  Therapists can coach you and also rule out other causes.  You will see in my manual that I explain in the beginning what "anger overload" is and what it is not.  You can also read some of the other blog posts to get ideas on strategies.  All the best, Dr. Dave Gottlieb

Thursday, May 10, 2012

Follow-up to 13 year old with ADHD and anger

The parent in the previous post wrote some examples of what precipitates her son's outbursts but asked that the specific content of the examples be confidential.  What follows are my thoughts about her son's situation:

It sounds like the precipitants are when your son is rough housing, speaks impulsively what his on his mind instead of censoring what might get him in trouble, and when he is goofing around instead of staying focused on his work in school.  I see a lot of these behaviors in kids with ADHD or who tend to be somewhat impulsive.  They are not "bad" kids, just somewhat quick to act without always thinking ahead of the potential consequences.  You want to help your son learn to think ahead more often.  This will take time and patient practice on everyone's part.  See what the professionals you are working with recommend, but one approach would be to go over these situations (after everyone is calm) every time they happen:   help your son see what happens in each of the three kinds of situations, and help him think about whether he is willing to risk the reprimands.  Then help him see the reprimands in a more neutral way.  I give some worksheets in my parent's manual about anger overload 1) to help with self-observation, and 2) with understanding other points of view and 3) with using catch phrases to help children "catch" themselves before going too far.   Sounds like yo have a good team.  All the best, Dr. Gottlieb

Wednesday, May 9, 2012

13 year's angry outbusts in school

I came across your blog yesterday after being called in to our son's school to face angry and upset teachers - again.

After "fighting" for years against the ADHD label and putting our son on medication, our 13-year-old has now been on Ritalin and then Concerta for three years. It has helped with his concentration. However, recently he has been having anger outbursts and his school has run out of patience with him. He seems to react whenever he feels "picked on" although he is actually being reprimanded for bad behaviour and disrespect. It's as though he cannot actually stop with his verbal backchat and he has shouted out at his teachers on several occasions. In hindsight he has reacted to this "picked on" feeling throughout school and has had to change schools because of it. Is this feeling of being picked on possibly related to something we are not seeing? At the moment his teachers feel it is purely bad behaviour and our concern is that he will face suspension and expulsion from school. I hope you can help.

Many thanks and kind regards.

Hi, Sometimes kids with ADHD feel "picked on" because they are often impulsive and distracted, so that adults have to remind them to use appropriate language and to concentrate on their work.  What starts the reprimands at school?  You say he was disrespectful--did that start after he was told to do something (focus or not talk so much) because of the ADHD, or was he being disciplined for something else?  It sounds like when reprimanded he has trouble keeping his reaction to himself.  Could the teachers cue him without a critical tone if he is just off task, and would he then get back to work, or would he still react angrily?  

Once he is angry, will he take a time out to slow down  or can teachers re-direct him and give any consequence (if he used inappropriate language) later on when he is calmer and may be able to accept a consequence.   

I'm not sure if I got the sequence right (what starts the interaction with the teacher?), so the first step is to chart the sequence: what is said by each party.  Look for patterns and try to change the sequence in one way or the other.  I talk about this (changing the sequence)  in more detail in my parent's manual on anger overload.  The idea is to intervene early before the stage of anger overload.  But you have to know what the early signs of anger are, which is sometimes difficult to pick up on if the child hits the overload phase in a matter of seconds.

Other suggestions include working with your son at night or (at school with the social worker or counselor) to look at the pattern and help him later that day (the day of an outburst while it is still fresh in his mind but after he has calmed down) to see what the other person was thinking (your child feels picked on, but you explain maybe the teacher is just reacting to certain words or behaviors and if he could change these somewhat the teacher may not give him severe consequences.  You try to help him see what the teacher is responding to and how he could avoid severe consequences.) The idea is to help him not feel picked on, but to see that adults may look at his behavior differently than he does.  Then he can be encouraged to think of alternatives he could use in the future if he is upset.  This process would take place over several months to help him see the patterns and the alternatives.  Eventually he will then likely understand better other points of view and begin to use alternative words before he says the wrong things.  Another suggestion I make in my parent's manual is to use catch phrases at the time he feels angry to help him remember to think it over. 

If he is in the overload phase (extreme anger lasting several minutes to an hour or more) he will not be thinking rationally so this is not the time to discuss his behavior.  It would be best to remove your child from the room and have him sit somewhere quietly until he calms down.  

Please refer to other posts in the blog or to my book for other suggestions.  Hope this helps, Dr. Gottlieb

Monday, May 7, 2012

14 yr old with depression and anger overload

Dear Dr. Gottlieb,
  I want to thank you for your article "Anger Overload in Children:  Diagnostic and Treatment Issues".  My husband and I agree that our 14 year old son fits this description.  He was diagnosed with depression in Nov 2011 and is on Prozac, which not only helped with the depression but also helped with these severe anger moments (lasting approx 1 hour).  He now only experiences these anger reactions approx 2-3 times a month.  However, even though we are down to 2-3 a month, when he does have them, they are just terrible.  When he gets angry, he completely looses control and nothing can stop his anger.  We let him know there are consequences for these behaviors (we take away all electronic such as I-pod, computer and TV for 24 hours), but that just seems to get him more angry.  It's like he is a different person and it appears that he cannot control himself. Fortunately, he does not hurt himself or anyone else, but he does throw things and kick things (but has not broken anything).
 We read in your article that counseling can help.   If you have any other advise for us, we would sure appreciate it as well.
Thank you so much.

Hi, I would suggest not mentioning any consequences during an outburst because, like you have observed, most children escalate further.  When someone is in the overload phase he is not thinking rationally and most anything you say will be met with anger.  You can use consequences later or the next day if he violates a house rule like swearing or physically acting out.  In other words you would target any behaviors which were in violation of house rules and not target your son's anger per se.  Anger overload is tough to control so I do not generally recommend consequences for the anger itself.

In my parent's manual I offer a number of strategies that you can use before and after overload. The "before" strategies include emotional distraction, changing the sequence, and calming strategies, if you can catch the anger early enough.  If not, the "after" strategies include labeling the level of anger, teaching your child about other points of view, catch phrases, and teaching compromise techniques.  These strategies will help if practiced regularly after outbursts.  The idea is to make self-control an important issue and enlist your child's participation by non-judgmentally working on the anger episodes together.  All the best, Dr. Gottlieb