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.

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