Friday, June 29, 2012

4 year old with anger overload

I just came across your article after searching for what is wrong with my son.
He struggles with what I describe as Jekyll and Hyde anger fits. Anything can trigger them even when he's well rested and well fed. Besides that he's normally a bright sweet child.

There isn't a lot I could find on the Internet about this and was wondering who I should be taking him to to see if this is what he has and to help treat him?

Also wondering which of your books you recommend we start reading first.
Thank you so much for writing about this in the first place and helping us pick the right track to get started. The more I read and poke around about it the more it fits so well to his behavior.

Hi, My parent's manual for anger overload in children would be a good book for you to read first.  It is available at the publisher's site: or on Amazon.  My book on defiance in children would be useful if you want to explore other possible diagnoses that can occur when a child is exhibiting angry and disobedient behavior.   Sometimes there are other underlying conditions that need to be treated in addition to anger overload.  However, I would start with the most direct approach, which is to work on your son's blow-ups by trying some of the methods in the anger overload manual.

For 4 year old children, I would focus on the first half of the manual.  Here I give strategies that use the parents as the "agent of change."  In other words, you employ strategies that do not require your son's direct participation or consent.  The second half of the manual outlines cognitive behavioral strategies that parents work on with their child.  Most of these work better with school age children and teens.  The one strategy in this second section that I would recommend trying with your child is labeling out loud the levels of your child's anger.  I suggest child friendly terms to help make your son aware of when he is starting to get wound up.   The idea is to help him realize what is happening so that eventually he can participate with you in calming activities.  However, this labeling process takes time and is not where I would recommend you start.

The strategies that put you in charge of the change process are going to be key for a young child.  There are three main stages and I describe strategies for each stage.  First is prevention.  Here I show you how to lower your child's expectations and change the sequence to avoid anger overload.  Next I explain what to do in the early anger phase:  how to use emotional distraction and calming strategies.  Then I explain what to do, and what not to do, when your child is in the height of the anger overload phase.  Also, I explain how you and your husband can be role models by labeling your efforts out loud to control your own anger.  You can also use praise and consequences but these generally do not work well when a child is in the full anger overload phase. 

You can also read more about these strategies in the earlier entries in my blog. 

Regarding your question about who to take him to, I would recommend a psychologist or social worker who works with young children and their parents.  The strategies that are most effective for young children involve you, the parents, as the agent of change, so you want a therapist who coaches parents in addition to evaluating your child. 

All the best, Dr. Dave Gottlieb

Thursday, June 14, 2012

7 year old with ADHD has outbursts with stimulant medication

Hi, My seven year old son was diagnosed with ADHD this past January.  He immediately started on stimulant medication prescribed by our pediatrician.  His first prescription was for 10mg of Focalin.  This really disrupted his sleep, so we switched to Concerta.  He did well on 18mg of Concerta, but he felt like it wasn't enough to get him through the school day so it was increased to 28mg.  This again started to interrupt his sleep, so we switched to 20mg of Adderall.

His anger overload issues began shortly after starting the Adderall.  He began having severe manic temper tantrums at bedtime.  Shouting, hitting - extremely inconsolable and very angry.  We stopped the Adderall and went back to 18mg of Concerta.  This seemed to help a bit, but did not stop the manic tantrums.  We stopped all stimulant medication for a bit, and changed to Intuniv.  He currently takes 2mg of Intuniv at around 7:30pm each evening.  While these tantrums no longer occur every night, he still has them on occasion (maybe 2 or 3 times a week).  They seem to be triggered when he doesn't get exactly what he wants at bedtime.  While we try to be accommodating, we can not always give him exactly what he demands.

He is now under the care of a new Psychiatrist, and we have switched to a new therapist who was highly recommended for Cognitive Behavioral Therapy.  I should note that while on the stimulants, his behavior and the quality of his classwork at school was greatly improved.
Could his anger overload/tantrums have been triggered by the stimulant medication?  Would you recommend a low dose of SSRI with the Intuniv?  We are very concerned about going back to a stimulant, as he never really experienced manic tantrums like these before taking them.

Any insight would be greatly appreciated!

Hi, I will try to answer your question the best I can, but as a clinical psychologist (with a Ph.D.) I specialize in psychotherapy.  In most states psychologists are not licensed to prescribe medications.  However I have worked with a lot of children on medication and have written a book on treatment of ADHD.  Stimulant medication usually helps with ADHD symptoms but stimulants occasionally increase the frequency of emotional outbursts.  Intuniv is a completely different kind of medicine, and should not cause anger overload.  In my experience it does not work as well as stimulants for ADHD, but when stimulants have significant side effects, it is an alternative that may help some with ADHD symptoms. 

If your son did not have angry outbursts before you started stimulants, hopefully over the next few weeks, the anger outbursts will get less and less (now that he is off stimulants).  If not, I would suggest some of the recommendations in my anger manual to break the cycle.  See if you can re-arrange the sequence at bedtime so that if there is something he wants at bedtime, it is the last thing that you do after he is all ready, or if the preferred activity is not possible at bedtime, offer a favorite story or quick card game if he stays calm.

In the manual, I outline cognitive behavioral strategies you can implement with your son.  You can work on it with your therapist as well.  I suggest labeling levels of anger and developing calming strategies that you can tie to lower levels of anger.  I also explain how to teach your child to consider other points of view.  At the moment, maybe he feels you are being unfair when he does not get what he wants.  The idea is to talk after the anger subsides about how you were thinking and help him see that there is more than one way to look at what you did (i.e. you are not trying to be unfair).  

About SSRIs, they sometimes help with emotional outbursts and sometimes they do not.  They are most often prescribed for depression or anxiety.  There is some recent research that low levels of serotonin in the brain (serotonin a neurotransmitter that SSRIs facilitate) are associated with adults who have angry outbursts; however, this has not been studied with children to my knowledge.  If your child has anxiety issues, and these occur around the time of his outbursts, then SSRIs are more likely to help.   I am a psychologist, not a psychaitrist (who prescribes medication), so please consult with your psychiatrist.   All the best, Dr. Dave Gottlieb

Tuesday, June 12, 2012

How to handle spitting by 5 year old

Thank you for your post, Dr. Gottlieb. It has been difficult as of late when he keeps spitting over and over, but does not appear fully angry. It is hard to know what to do to pull him out of this. (This is a follow-up question by the parent of the previous post.)

Hi,  First try to keep a record for a week of what is going on before the spitting starts.  Is there a pattern:  type of situation (such as meal time), theme (such as not getting to do what he wants), time of day, the person who is on the receiving end.  Then think about whether it is possible to re-arrange the sequence to avoid spitting, or whether it is possible to use distraction before it gets to the point where spitting occurs. 

You can also consider behavior modification strategies, which work better if your child is not in complete anger overload.  If in complete overload, the child would not be thinking rationally at the moment and would be less likely to respond to incentives or consequences. However, if you catch the sequence before this point and you target spitting (but not the anger per se), you may be able to reduce the frequency of spitting.  What you would do is this:  when everyone is calm give the example of spitting compared to some other examples such as yelling "I don't want to."  Then mention a short term incentive, for example, playing with a certain toy (whatever toy you pick becomes off limits unless he earns it) for an hour, if there is no spitting for a whole day (or you could make the goal no spitting for some part of a day if he currently spits more than once a day).  He would earn the reward time if he yells "I don't want to" (or any words other than spitting).  You are not expecting him to stop getting angry, just stop spitting.  You do not mention the reward while he is angry but wait until everyone is calm before announcing that he earned the reward.  (Say nothing if he did not earn it.) If you use a short term consequence, do not mention it until everyone is calm.  Now a word of warning:  behavior modification strategies do not always work with anger overload because the child sometimes wants to get back at you in whatever way he knows is most noxious to you.  But some children will try to cut back on a behavior if they care a lot about the incentive or consequence.  All the best, Dr. Dave Gottlieb

Monday, June 11, 2012

5 year old with developmental delays and anger overload

My 5.5 year old son is developmentally delayed closer to age 3, including language. He also has  ADHD. He is always easily distracted, impulsive, and has short attention span. He also seeks adult attention, both positive and negative. He is a child that has a difficult time with transitions, but has not been found to be on the spectrum thus far. He has a divorced family, so transitions can be very hard, especially for sleep. He has never been a good sleeper. He is usually very sweet and loving, but whenever he gets congested from a cold (and he gets recurrent sinus infections, in the past with recurrent febrile seizures) or seasonal allergies....transitions and asking him to do something or stop something he doesn't want to...he suddenly starts throwing, spitting, hitting, etc over and over....telling us he is doing this but as if he cannot stop. If we ignore during these heightened times, these behaviors escalate. He has had a good preschool year overall, with these behaviors appearing whenever congested, along with heightened sensory seeking, less able to calm asleep, and potty regression to diapers. This May he slid back hard with these behaviors at the start of pollen in all home and school settings. He has missed a couple weeks of school and ot, pt, and speech services because of this. He started 10mg of Ritalin LA on Friday and so far, though meltdowns are shorter, they are still appearing. I am very concerned. I also know that his father has an up and down explosive personality. Any thoughts/tips?
P.S. Also, I meant to mention that he does not always appear angry during these moments and will sometimes giggle like it is a game, especially at school.

With developmental delays, sinus infections, and sensory integration issues, it is good you have a team of professionals helping.  With development and with control of his sinus infections and allergies, you will likely see an improvement in your son's ability to deal with frustration.  In the short term, what I would suggest are trying to adjust the sequence of activities when possible to limit the number of difficult transitions, as well as developing a "go to" soothing place in the house for when your son is getting frustrated.  The tough part is going to be to try to catch his frustration early, before he is totally out of control.  The OT may be able to help you develop a soothing place in the house--maybe with a mat, blankets, soft object to hold, soothing music and possibly soothing smells.  You would go with your son to this place and help him soothe, because ignoring does not work well if a child is frustrated and has significant developmental delays.  You would practice for a few weeks when your son is not upset, and make this space in your house a calming and enjoyable space.

At the same time you would try to anticipate your son's frustrations and re-arrange the schedule where possible to have something fun follow something difficult.  Also, if your son cannot stop an activity, you may have to hold off and only allow this activity when there is plenty of time (on weekends for example).  Sometimes advance notice of a transition helps, or sometimes it helps to let your son know something fun that is going to begin in a short while, but sometimes the transition is still difficult.  Brainstorm with your professionals what cues might help, or if it is best to avoid certain fun activities when there is limited time.  You may have to alter your expectations about transitions, i.e. expect it will be difficult and schedule fewer transitions.

In my anger manual I also describe a process in which the parent verbally labels a child's level of anger in a calm and non-critical way--you may need to wait until his language skills are at a kindergarten or first grade level.  At some point when your son's language skills allow, you may be able to help him recognize his moods; if he can recognize a change in his mood, he will be ready to be a more active participant in using calming techniques, techniques that are best employed when he is just starting to get angry.  In the meantime, you and other adults will need to "catch" the frustration and re-direct your child to a soothing place or to another activity.

Your last comment about the giggling suggests there are times he is not in full anger overload.  That is a good sign because the above strategies will work better if he is not in full overload.  You might also want to use humor (or silly comments) to engage him and thereby distract him when he is having trouble with a transition in school or at home.  All the best, Dr. Dave Gottlieb

Sunday, June 3, 2012

6 year old lashes out on school playground

Hi, I have a 6 year old he has started lashing out at kids in school in the playground.  When you ask him what happened he says he can't remember: he says his body shakes like he has no control.  He is normally a lovely little boy but when he turns it can be quite bad.   I took him docs when he was younger about tantrums but doc said if it not effecting school then don't worry.  But now it is; he does not like anything changing either.  He starts to panic.

Hi, I would suggest you mention something to his teacher and see if any adult can observe the playground activities in order to get a better "read" on what might be precipitating your son's outbursts. What happens right before he loses it?  Also, your observation that he does not like anything changing makes me wonder if your son might have some Asperger's qualities, but I cannot diagnose this online.  Maybe it is not Asperger's but some social awkwardness or anxiety.  You could consult with a mental health professional in your area.  Children with Asperger's syndrome like routines, are resistant to change, and have trouble with the nuances of social interactions, especially with peers.  Does your son get upset when the activity changes on the playground or someone changes the rules?  Or maybe your son is upset because he misunderstands something being said on the playground.  What I'm thinking is that maybe he is having trouble adjusting to the "demands" of the peer group on the playground--rules and activities can shift rapidly when six year old children are playing outside.   Activities on the playground are less structured than in the classroom, and maybe this makes it more frustrating for your son.  

In any case, you would want to look more closely at the precipitants of your son's anger and see if some adult can re-direct the interaction before your son lashes out.  Maybe your son can play with some other children who are easier for him to get along with.  Maybe also you and the teachers can help him learn to walk away when he feels himself beginning to get upset.  However, most young children have trouble recognizing the early stages of anger, and he would need an adult who is out on the playground to help point out when things are starting to go off track,  i.e. when it looks like he is getting frustrated.   Over time, your child may be able to recognize early stages of anger himself.  In my book, I explain how to help children recognize early signs of anger.  One approach is to begin to use simple labels for different stages of anger both at home and in school.  

All the best, Dr. Dave Gottlieb