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

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