Monday, October 22, 2012

8 year old with separation anxiety and anger overload

Dr. Gottlieb,
  About eighteen months ago my daughter, who was then 7 years old, was in her second semester of the second grade. In late February of that year, with no warning, woke up saying she was not going to school. This behavior lasted two months. She resisted, then panicked, and then would outright resist in a panicking anxiety attack. She would run from us around the house trying to escape going to school. Once at school her mother and I, along with the Principal and school counselor would have to pulled her dragging and screaming into the Principal's office. There she would immediately calm down, yet was still in resistance of going. After two to three hours she would then agree to go to class. During this time we were helped as much as possible by the school counselor. My daughter would come up with any excuse not to go, which may be she was sick (when she wasn't) to "they" will be mean to her, which would later be anyone from the teacher, which before this time absolutely worshipped, to the principal, to the fourth grade kids, to her best friend, to whomever she could think of. It usually would come back to wanting to be with her mother, who at the time had been substituting at school. During this time my wife quit substituting at her grade school to try to lessen the temptation of her wanting to leave class "because she was about to throw up" and then would always find her way to my wife's class. In the afternoons she would get home and begin worrying about going to school the next day. At night she was prone to getting mad quickly and have horrible tantrums. Her pediatrician ran blood work on her but found nothing she felt was any causing factor....
Luck for us during this time her resistance to school came to a stop. Between the teachers, counselor, principal, and my wife and I, we never could figure out what the problem was. But she continued to have the anger issues, which was something that she had been doing off and on for quite awhile before the school anxiety issue came up. She would glare at you straight in the eye when she didn't get her way or something made her mad and yell at you like a drill sergeant. She would use phrases like "you are crazy lady", "I wished I lived with someone else", "I hate it here", "don't you look at me like that". Time outs and all the punishments suggested did little if any good. We had literally at times spent up to two hours trying to get her to stay in a time out. These occurrences were not all the time, but would occur about once or twice a week....
Although the school anxiety has subsided, her anger is off the charts, even with the medicine. If she wants to do something that you cannot make happen, she goes into anger mode. Again she will stand there and verbally assault you and argue like an adult. She tries to twist anything and everything around to make it our fault. (Once we planned to camp in the yard one weekend night but storms moved in and it rained all evening. Her response was "you promised!!!! This wouldn't have happened if you had set the tent up this morning!!!!". We have tried (and still making the attempt) not to argue and just walk off, but even then she will follow you and keep hammering at you until we finally feel we have no choice but to send her to her room or ground her. At the time, she shows no remorse, and does not care what you take away. When she calms down she returns to being in a great mood.
During all this time, when she is not in school anxiety or anger mode, she is a happy, energetic child, always on the move. In school she does great (she got into the Gifted and Talented Program this year) and the teachers, counselor and principal all say she is a fantastic, well behaved student in class. And although she had resisted the teachers about going to class, they said she was never hateful or disrespectful, just matter of fact.
She is now getting to the point when she "overloads" she is showing aggression to her mother, reaching out and trying to squeeze or claw her arms. She does this with no one else, and does not show any aggression in school. Her counselor keeps wanting us to try the "speak softly and use 1-2-3 Magic..." When we do this, all she does is mock us by screaming "1-2-3-4-5 blah blah blah".
After reading your articles today I want to ask you, from what I have described, is this "anger overload"?
Hi, It sounds like you have been through a lot.  The level and duration of anger fit with the criteria for anger overload.  The separation anxiety is separate from anger overload, but it is interesting that in both cases, once the emotion (anxiety or anger) starts, it often escalates and is difficult for her to control.  You were on the right track when you kept taking her to school despite the anxiety and when you had your wife stop working nearby.  Those decisions probably helped her eventually to see that she could handle school without having to stay home and without having to go to her mother's classroom.  One other possible diagnosis for children who have intense emotional reactions (that your doctors may have ruled out already) is pediatric bipolar disorder.  For this diagnosis there are frequent fluctuations in mood.  Does your daughter also have periods of excess energy, agitation, irritability, or risk taking behaviors even when she is not in the anger overload phase? 

In my manual I describe how to re-arrange the sequence and lower children's expectations in order to try to head off anger overload.  For example, if she is excited about an upcoming event (like the camp out), you would caution her ahead of time that you might not be able to have it, that it depended on the weather,  that it was a possibility only.  In addition if there are certain times when she is more likely to explode, can you change the situation around to avoid the precipitant?  For example, some children get angry when they have to get off a video game and go to bed.  Then you would either not allow video games on school nights, or stop the video games much earlier in the evening.  Admittedly you cannot frequently predict when a child will explode with anger, but you try to keep a record of her explosions and head off what you can in the future.

In the second half of the manual, I explain ways to teach your child about anger overload and how to develop self control.  You would do this while she is calm later in the evenings.  You help her learn about different levels of anger, about ways to develop self soothing, about using catch phrases  to "catch" the anger early, and about how to see things from other people's point of view.  You also teach her about compromise.  
You are right to not talk with her while she is exploding.  However, if she harmed your wife, I would have significant consequence for the following 24 hours .  I would tell her ahead of time what it would be and not discuss it during overload.  But when everyone was calm again, I would be sure to impose the consequence.  You would not be punishing her for anger overload, but for the particular behavior of hurting someone.  
Best, Dr. Dave Gottlieb

Tuesday, October 9, 2012

Out of home placement for child with severe symptoms?

Dear Dr. Dave:
Today after school we are meeting with our daughter's psychiatrist and psychologist to discuss placing our 12 year old daughter out of our home.
When I read your article on Anger Overload, it gave me hope because it so describes my daughter. She has no diagnosis; I am advised I do not want one and must treat the symptoms, as treatment would be the same regardless.
Her anger is always just under the surface and once triggered (which I cannot always predict) lasts until some violent climax. She used to hurt her two-year younger brother but now focuses mainly on me.
She loves using the worst language and insults to engage. She takes pot shots at me and even comes up behind me and hurts me.
I can't figure out why she is so angry except she tells me that I've never loved her and that I only love her brother, which is ridiculous.
I would like to work on this at home with behavior modification.
Can you suggest anything please?
Thank you.

Hi, My book on anger overload explains when to use behavior modification (ignoring, other consequences, and incentives), and the manual also outlines strategies to teach your daughter about her anger triggers and how to control her angry responses.  The first part of the book is about what you can do as the parent, and the second half describes a program you work on in conjunction with your daughter.  The second half of the book works best with children who are 8 years old or older, but some younger children can participate in the exercises in the second half of the manual with assistance from their parents.  

It is important to try not to say much of anything when she is in the overload phase.  Your daughter is not rational at that time, and anything she says is meant to get your goat, but is not what she really feels.  You can use consequences later, if you want, for language you forbid in your house (wait till everyone is calm), but do not say or do much while she is screaming or insulting you.  If she tries to harm you than you will need to restrain her or call for someone to help you do that.

I wish more clinicians recognized anger overload as a serious problem, rather than lump these children into the diagnoses of oppositional defiant disorder or bipolar disorder (a mood disorder).  There is much evidence in the psychological literature on brain function that some people have intense angry reactions, without necessarily having an underlying mood disorder.  The current thinking is that the prefrontal cortex is not fully developed, and behavioral strategies can help children learn better self control.   There is also research going on about "SSRIs" and "atypical antipsychotic" medications to see if they can help children with anger problems. 

Do you or your daughter's doctors have further ideas about her triggers?  You wrote that she feels you love her brother better.  Does she say this when she is calm too?  Is she sensitive about other people not caring about her too?  How long how this been going on, and did something happen when this started?   Does she let you do some activity just with her, and does she feel better then, or still feel rejected?  Is she depressed?  I know these are a lot of questions to consider, but I'd recommend going over these with your daughter's doctors if you haven't already.

Placing your child out of the home is a tough decision, and I would try to get more help for your daughter first if you have not already done so:  more intensive outpatient treatment (such as day treatment program), or aides in the home (for children with serious behavior problems many states have funding for help in the home though it is sometimes hard to qualify).   It sounds like you have two professionals helping you, and they know your situation better than I, so see what they recommend when you see them later today.

All the best, David Gottlieb, Ph.D.

Tuesday, October 2, 2012

9 year old with angry outbursts at home

I was excited to find your article about anger overload.  My 9 year old son has issues controlling his anger at times.  I don't think that he fits the description of oppositional defiance disorder and the like, but I know that something is wrong.
He's normally a sweet boy and he is extremely smart.  He is in his school's gifted program.  He has never had an issue at school.  Most of his outbursts occur at home, although he has had a couple during soccer games when he felt he was wronged (which was very embarrassing). Usually, his outbursts involve his older brother.  Big brother knows which buttons to push and this is something that we have been working on, too.  Summer was a trying time, since the boys were together all day, every day.  Things have been better since school has started up again.

His outbursts usually involve a lot of yelling, slamming doors, throwing or kicking things.  During the incident, he has no concept of reason and has no remorse.  That changes once he has completely calmed down. We have asked him about his behavior when he is calm.  He tells us that he can't control himself when he is angry.  I have also asked him why this doesn't happen at school.  He said that no one bothers him at school.

Unfortunately, once when he got angry with his brother, he tried to throw a large toy at him.  Instead he accidentally hit his cousin in the head, resulting in stitches.  Yesterday during an argument over a game, he threw a large rock at his brother.  I told him to stop and during the short time while I was making my way to where the boys were, he picked up another large rock and threw it.  Luckily, no one was hurt.  I worry that he may hurt someone again or have an outburst when he is away from me (at a friend's or relative's house.)   

We try to prevent his anger outbursts by intervening when we see he is getting upset and making sure he gets enough sleep.  He is definately more prone to them when he is sleep deprived.  However, life is life and I can't control all of the circumstance.  He needs to be able to cope on his own.

My main concern is two fold.  First, how do I know when he needs professional help and second, what techniques should I be using to help him?  I am looking forward to getting your book and I appreciate any insight you can provide.
Hi, What you describe is consistent with anger overload.  These children feel an intense surge of anger that is difficult for them to control.  One step that you have taken already is to try to intervene early in the sequence when your child is beginning to get upset; what I would recommend you do next is to try to prevent a blow-up from even starting.  See if you can identify some of your son's triggers as early as possible and try to re-arrange situations to avoid these triggers, when possible.   You mention that he often gets angry with his older brother.  See if you can identify the themes for some of these situations:  does the anger erupt in competitive activities, or when he is teased?  If the latter, what activity is going on when he is teased?  If you can identify some of the types of situations that trigger your son's rage, you can prepare him (and your older son) in advance:  "When you guys play soccer (if this were the situation, for example), remember that you are older and stronger, so I don't want you to play against each other, but rather on the same team."  You try to avoid a blow-up by identifying your younger son's trigger and preparing him (and his brother) in advance.  You repeat your advice regularly before they go out to play.

You can also teach your son other strategies that I outline in my parent's manual.  For some of the strategies, it is important first that your son recognize that he has a problem with anger, and believe that it is important to work on it.  You lay the groundwork after each incident of anger overload.  When he is calm, you review the situation, and explain that you are going to work on this together so that he can learn to be the master of his anger.  I explain in the manual that it is important for parents to be empathize with how hard this is, but also parents should point out to their child that he can learn tools to have better control, and that you, the parents, are going to help him.
In the first part of the manual, I explain strategies that parents can use without having their child agree on a plan of action.  If your son is not ready to see his angry outbursts as a problem, there are still strategies you can employ to lessen the frequency and severity of his outbursts.  
A professional can help when you are not making headway at home.  Sometimes parents are "so close" to the situation that they overlook something, or they inadvertently do something that angers their child.  One common mistake is to talk to children when they are raging.  This usually prolongs an angry episode.  You want to take action if someone is about to be hurt, but otherwise you want to wait out your child's outburst.  Whether you have to take action or not, you do not want to talk much.  The more you say, the more your child will say back.  As you point out in your comments above, children are not thinking rationally during anger overload, so they will not listen to what parents have to say at that time.
Besides helping to implement the strategies, a professional can help if there is an area of vulnerability (maybe there is a self-esteem issue) that underlies the episodes when he gets angry.  Another reason it may be hard to make headway at home is that there could be a secondary diagnosis that a professional can help identify.  So if you do not make headway in the next month or two, consider reaching out to a mental health professional in your area.  All the best, Dr. Dave Gottlieb