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

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