Monday, September 17, 2012

14 year old with history of angry outbursts

Hi Dr. G., Today is the first I've ever heard of "anger overload", but I think this describes by 14 year old daughter.  But like most disorders, it's hard to to know if this really is the correct diagnosis.

My daughter is 14. She is a straight A student and always has been.  I can't say that all school work comes easy to hear, but she's willing to spend the hours needed to do well.  A classic overachiever.  She does not exhibit angry behaviors at school (that we know of) and respects authority figures.  She has friends and engages in extra-curricular activities.  She would appear to be a typical teenager.  She is a middle child; her brothers are 14 and 8.

As long as I can remember, she has had severe outbursts of anger.  It was and still is primarily directed at my wife or my sons.  Something that would seem so minor to someone else can set her off and she become verbally abusive.  Some of the things that she says are so horrible that I refuse to believe she actually means what she says.  When she was very young her outburst would result in prolonged screaming session.  Any attempt to speak to her (or console) her made it worse.  

As time went, the anger outbursts become shorter in length but no less traumatic for the family.  Early on we tried to use consequences for this behavior but it didn't change anything.  As much as she disliked the consequences, the anger remained.  We brought her to a nutritionist because we thought her diet was possibly triggering the anger. I still do. It seemed to help some but the anger continued.  As a family, we just learned to tolerate this behavior because we needed to get through the day and care for her brothers (and ourselves).  She refused therapy for a long time but currently we are seeing a social worker therapist to get help.  Unfortunately, I don't think she fully understands what we are trying to describe.

I've been a high school teach for over 20 years and have been in countless IEP's and 504 meetings.  I've heard about and dealt with children with many types of disorders.  I honestly believe that she cannot control her anger.  My wife has not always agreed with me on this point.  I think she can learn to deal with anger better but the anger will still be there.  I'd like to think that somehow we can find a way to make all the anger go away as this has taken a toll on our family.  This is something we deal with every single day.

Here are some other bit is information:

She has never really showed any empathy toward others.  She will NEVER admit she is wrong or apologize.  She's only said "I'm sorry" a few times in her life that I know of and even then there may have been an ulterior motive (facing consequences).  Outbursts last 10-15 minutes with the strength of a hurricane.  She retreats to her room for an hour or so and comes back down as if nothing has happened.  My wife, sons and I are still emotionally drained from the experience but she's completely fine.  As if nothing happened.  While in therapy she has admitted that she has a problem and doesn't want to continue being angry.

This may sound like she's a terrible girl but aside from the anger issues, she can be as normal and sweet as any girl.  She's very intelligent and has lots of interests.  One on one, without her brothers around, she can be so much fun.  At times even over the top giddy.  Sometimes we actually set her off unintentionally by calling her on a comment when she was just trying to be funny.  She has a  dry sense of humor.

Here is what I constantly struggle with in terms of consequences.  Is it fair to continually punish her for something that she can't control?  She has always had this anger.  I do feel that she can and should try to control this anger better so I try to distinguish between the two.  It is impossible to have a discussion with her about these issues (even when she's calm), she will not engage.  I have found that emailing or texting her is the only way we can communicate about the subject.  Never face to face.  I could go on and on but I hope this is enough to give you an idea of what we are dealing with.

Thank you.
Yes, what you describe fits with anger overload.  Anger overload is a term I began writing about ten years ago.  Other clinicians have written about children who have angry outbursts, and the next psychiatric diagnostic manual  will have a diagnosis called "disruptive mood dysregulation disorder" (or DMDD), which is similar to anger overload, but for DMDD there is negative mood even when the child or teen is not in the overload phase.  I have seen many children who have anger overload, but do not otherwise show signs of irritable or negative mood; that's why I prefer the term anger overload.   In the psychological research literature, there is discussion of children and adults who have recurring bouts of extreme anger, and there is more and more evidence that there is an area of the prefrontal cortex that seems to be involved.  These individuals have difficulty regulating anger.  However, with maturation and with practice, children can improve.  That is what my anger overload manual is about.  I offer strategies parents can use to help their children develop better self control.  The outbursts will be less frequent and less extreme.  

It is a good sign that your daughter agreed to therapy and wants to have better control.  If she is motivated to work on it, the second half of my book describes strategies parents can work on together with their children.  
Consequences do not work on a consistent basis for anger overload.  It is as if the brain is overheated, and the person is not thinking entirely rationally at that point.  This is why I tell parents not to take what their children say seriously when they are in overload.  It is also why I recommend ways for parents to catch their children's anger early, when possible, and suggest ways to change their children's expectations (it is often some kind of disappointment that precedes the angry outbursts) or change the sequence of events that sometimes lead up to an outburst.

Consequences sometimes help after everyone has calmed down if you are trying to stop one specific kind of behavior during the overload phase.  In other words, consequences do not generally work to stop anger, but if your child says a particular word, or throws things, you can target one of these extreme behaviors, and if the consequence is meaningful to your child, she may try to avoid it by stopping herself from saying the words you want to extinguish.  But sometimes this backfires, and the child says the "dreaded" words even more so.  Thus, the more useful approach is to teach your child strategies that will help her control herself before she reaches the overload phase.  Check out other blog entries or my book for other ways to limit anger overload.  All the best, Dr. Gottlieb

Monday, September 10, 2012

Making a Diagnosis: Hyperactivity, Oppositional, or Anger Overload

Dr. G,
I just happened across your blog while researching my son's behavior. You have described him almost to a tee. He has been diagnosed as hyperactive and also as oppositional defiant. Although he has showed some behavior relating to those disorders I have never felt like they were spot on. My question is:  How would I go about getting a proper diagnosis? (I am positive he has anger overload) and How do I help my son?
Thank You! I feel you are an answer to my prayers.

Hi,   A diagnosis can be made by a medical doctor (M.D.) or a doctor of psychology (Ph.D. or PsyD. degree) or a licensed clinical social worker (LCSW).  You would want to see someone in your area who has experience with children who have anger issues.  You could ask who your school or family doctor recommends, or check with your state's psychological association.  My book on defiance in children explains to parents the characteristics of the diagnoses you mention (oppositional defiant disorder, hyperactivity, and anger overload) and gives suggestions for what to do for each diagnosis.  My book on anger overload focuses on that issue and has a step-by-step guide for parents.  Ultimately if you are trying to decide on a diagnosis and there are several possibilities, it would be wise to check with a clinician who has experience seeing children with these diagnoses, so he or she can help you decide what is going on and what to do.

It is possible your child has aspects of two or more diagnoses.  It is not unusual to have a couple of things going on.  Furthermore, in the real world, people do not always fall perfectly into one diagnosis or another.  Your child could have some aspects of oppositional defiant disorder for example and not meet full criteria for this diagnosis.  To fully meet the diagnosis of oppositional disorder, the a child's argumentativeness with authority figures needs to be frequent and persistent over time (6 months or more), and must affect the child's performance in school, or social situations.  In other words, the child is oppositional  even in situations where it hurts his performance in something where he ordinarily does well:  in school, or in a sport, or in some other extracurricular activity, or affects his social standing with people outside the family.   If a child just argues frequently with his parents in the home, but not with other authority figures, there are some oppositional features but the child would not meet criteria for oppositional defiant disorder.

For more information on this or other diagnoses, read my book "Your child is defiant:  Why is nothing working?"  My book will help you think about what is going on and have suggestions for you.  But you can't really make a diagnosis yourself; it's best to check with a professional in your area to decide among the diagnoses you are considering.  Take care, Dr. Dave Gottlieb

Friday, September 7, 2012

4 year old has daily tantrums with people he knows

I found your site tonight while Googling for the thousandth time about the issues we’ve had with our son for the past few years.  I’m surprised I haven’t found it before, but better late than never.

We have just turned 4-year-old boy/girl twins and have had no real issues with our daughter over the last few years outside of what I consider normal 2/3/4 year old minor tantrums and defiance…testing limits and such.  But our son started having severe tantrums really early…somewhere around 10 or 11 months if I remember correctly.  It has just gone downhill since then.  We did work with a counselor (MSW,LCSW) who came to our home for a couple of months, but told us we really didn’t have an issue.  She told us to put him in timeout and simply wait for him to calm down, but we’ve been trying that for two years now with no improvement.  The problem is that until he is comfortable around someone, he actually behaves quite well.  It is the same each new year at preschool.  He’s great at the beginning of the year and then as he gets more comfortable the anger issues start rearing their heads.  He is a very smart, sensitive, loving kid half of the time, but the next minute he is mean and hurtful and screaming and kicking.  I’ve wondered if he was bipolar since it does run in my family, but I’ve called child psychiatrists who say he’s too young to be seen!!  He has multiple bad tantrums a day usually and even more shorter angry outbursts.  Once he “loses it” there is no talking to him, no calming him down, and he doesn’t know how to calm himself either.  And afterwards, we cannot talk about the behavior that sent him to timeout or the transgression at all, or it send him right back over the edge. 

I’m lost on what to do.  I am going to buy your book on defiance and also the one on anger overload, because they both seemed to hit a few nails on the head, but in the meantime, does this sound like something your book will help with?

He also has some mild sensory issues, but we’ve been working with an Occupational Therapist on those.  I was hoping it would help his behavior, but it has not significantly.

Thanks in advance for your response!

Hi, My book on defiance looks at various causes of defiant behavior in children.  The book helps parents identify the cause and then suggests strategies for each cause.  My book on anger overload is a parent's manual focusing on children who have severe meltdowns--tantrums that can last for minutes or hours--but who otherwise behave well.  The anger overload manual outlines specific strategies for you to try.  For four year olds, I recommend parents focus on the first half of the book:  the first two sections are "what is anger overload?"  and "parents as the agent of change."  The defiance book discusses anger overload but also other behavioral and personality issues.  There is a section on bipolar disorder in children, which you may find helpful, for example.  Yes, doctors do not usually diagnose and treat bipolar disorder in four year olds, because the brains of these children are still developing, and the children may develop better self control in the years to come.  Also the medications for bipolar disorder can have significant side effects, and most are not approved yet for young children.

     In the anger overload manual, I encourage parents to first observe the patterns, and if there are some situations that are more likely to trigger outbursts, I explain how to approach your child before he has an outburst.  You can change the sequence of events, lower your child's expectations in advance, use "emotional" distraction (I explain in the book that the distraction technique must grab your child emotionally in order for it to work.), or sometimes calming techniques can help.  Once your child is in overload, he is not thinking rationally and it is usually better not to say or do anything at that time, unless someone is being hurt.  Sometimes consequences can help later in the day when he is calmer, particularly if he uses some words that are not acceptable in your house, or if he broke something.  The consequence is not for anger overload per se, but for certain behaviors that you want to try to extinguish.  I explain more about these topics in the book.

     The last part of the anger overload book "teaching your child new skills" works better with older children--preteens and teens--however some young children benefit from using labels for the level of their anger.  The idea of the labels is to help children begin to be aware they are angry before they lose it.  Then they can be guided to use a calming technique before they explode.  Sometimes a fun activity works better than a relaxation technique to help a child calm down, but neither usually works well once a child is already in overload.  So you can see that the key is early intervention, when possible.   Otherwise you wait out the storm and try to not respond to mean or hurtful comments a child typically makes during overload.

All the best, Dr. Dave Gottlieb