Monday, December 23, 2013

Helping 6 yr old in school

Thanks for publishing this article. My 6 and 1/2 yr old son seems to be exhibiting the behaviors associated with anger overload. He has no other diagnosed medical issues, his grades are phenomenal and is a loving kid most of the time. Once he gets in this state of rage, usually over something minuscule that he takes offense at, it becomes difficult to get him out of this or redirect.  I have just started him in therapy and we will be visiting his primary care doctor after the new year. The school he attends is not helping that much. They are only focusing on punishment and tracking despite my best efforts to work with them.  I need redirect and coping advise. I realize that every kid is different, but would like to try something so that alternative placements will not be put on the table.  What is urgent is appropriate responses and preventive measures for teachers and other staff during school hours. Happy holidays sir. 

Hi, My parent's manual has suggestions for home that can be adapted for school.  The first step is to observe the situations when he loses control.  Can the teachers keep track of them, and then look for some patterns.  Does the anger overload occur when he is frustrated or disappointed with certain assignments, tests, grades, comments from a peer or teacher, or some other precipitant?  There will not necessarily be a pattern for every instance of anger, but try to find some types of situations when he is more likely to get angry.  

The next step is key.  Can the teachers anticipate or catch early signs of frustration?  It is difficult to do because anger overload can occur so quickly and with little warning.  But if you have identified certain situations when the child is more likely to get frustrated, your radar can be up when theses situations occur again.  If you can catch anger in the early stages, it is easier to prevent overload.  If your son gets frustrated by certain grades, for example, then the teacher could try to lower your child's expectations ahead of time, let him know he is supposed to get some wrong because he is just learning.  Another option is to change the sequence.  If the grade is going to disappoint him, hold off on the grade until a fun activity is about to begin, or leave the grade off the paper altogether.  A fun activity, like gym or recess, can be distracting and help change your son's emotional state before anger gets too difficult for him to handle.

A related suggestion would be to have in place some distracting activity, such as helping the teacher with something, running an errand, or going to a place in the school where he could calm down.  Some schools have an OT room with a mat or exercise ball, where a child can go to relax if he is beginning to get stressed.  It is not a punishment, and should be a place the child is familiar with and has enjoyed.  The distraction needs to be engrossing--it doesn't have to be fun but needs to be something the child is really interested in doing.

Once a child is in anger overload, the teacher would engage as little as possible.  The goal is to provide a setting where the child will not disturb others and not get a lot of staff attention.  This place could be inside or outside the classroom and would not be the same place as the OT room, or the activity that is used for distraction.  If the child is loud and bothering others, there would need to be an aide to escort him out of the room.

There are other strategies I describe in the manual that aim to reach children how to recognize their emotional state and how to develop self-soothing strategies.  These strategies would be taught when your son is calm, and could be worked on with the school social worker or psychologist in conjunction with the teachers.  For example, some young children can learn to use verbal labels for different degrees of anger or frustration.  The second half of my manual outlines six different skills to teach children to help them better manage their anger.  The difference is that these strategies involve teaching the child skills over time, and the first set of strategies I mentioned in the above paragraphs are directed by the adults and do not require the child to anticipate or understand his reactions. I would recommend starting with the adult directed strategies because these can be implemented more quickly.

All the best, Dr. Dave Gottlieb

Sunday, December 1, 2013

9 yr old: Anger Overload or Explosive Disorder?

We have a nine year old boy who struggles with anger. He's always been a challenging child, requiring more consistency, consequences (both positive and negative), and supervision than his older two siblings. Until second grade, he did not act up in school. Now, however, he's had a number of incidents where he's become so angry that he's hit a classmate. Often it is because of perceived "fairness" - a foul at recess.  We've tested him for ADHD and he shows impulsivity but doesn't fit that diagnosis completely. We did start him on ADHD medications in the fall (Concerta/Intuniv) and that seemed to work for a couple of months, in conjunction with therapy.

We've had some good success, but not enough - this week, he completely lost his temper at school, tried to hit the classmate and then tried to run away from the teacher and refused to listen. Therapy alone isn't enough. Do you know of another class of medication which we should consider? And would you consider "Anger overload", as you describe it in one of your articles, a classification of intermittent anger disorder as described in the DSM V?

Hi, Anger overload is an intense reaction to frustration that can sometimes be physical, but often is verbal.  By contrast, to be diagnosed with intermittent explosive disorder, there must be physical violence:  there are serious physical assaults and often destruction of property, which you usually do not see with anger overload.  Anger overload is more common in children in my experience.   

Children with ADHD can have a) hyperactive and impulsive behaviors, or b) distractability, or c) both.  So your son may meet criteria for the hyperactive-impulsive type. 

You mention the issue of "fairness" as a concern of your son.  I have seen this issue for other children with anger overload.  What I would recommend is "priming" your son before he goes to school.  Explain that children often "foul" at recess and it is not called because there is no referee.  If he wants to play a competitive game at recess, this will happen often.  Is it worth it to him to play?  What are his alternatives?  Try to discuss these issues when he is calm in the mornings, or if there is not time then, try to do it at bedtime.  Empathize that there is unfairness when fouls are not called, but explain that it probably will keep happening.

Another strategy is to talk with him about how people can have different points of view.  There is a section in my parent's manual that explains a way to do this.  As a last resort, I would consider talking with the school about taking away the privilege of playing a competitive game at recess for a day or two and then try again.  If there are repeated problems, then see if the school can have an adult nearby to intervene early.  Once your child gets real upset, it would not be advisable to talk with him until he calms down.  If possible, there could be a space away from the action where he can settle himself.

As for medications, there are anti-agitation medications, but they can make children tired and/or gain weight, among other possible side effects.  Sometimes low doses can help with minimal side effects.  However, some of these medications are not FDA approved for pre-teens.  Talk it over with your child's psychiatrist or medical doctor to see if he or she thinks another medication is indicated.

All the best, Dr. Dave Gottlieb

Saturday, November 16, 2013

7 yr old explodes over minor frustrations

My wife and I have been "under siege" by our nearly 7-year-old daughter (Simone) for a few months now (off and on).  Besides one incident where she hit a boy on the bus and made him cry, she gets along fine and school (has a lot of friends, seems really happy when she's picked up, no serious discipline problems at school besides that one hitting incident).  In public, she's also self-controlled and generally level-headed -- but she regularly ignores all other adults (never says hi or answers questions, even close family friends).
The real problems are always in the home. First of all, my wife and I have a very close and loving relationship.  We seldom argue and are a "united force" when it comes to privileges, discipline, etc.  We also have a 2 and 1/2 year old son. For the past couple of months, nearly each day for the past couple of weeks, Simone has had intense, sometimes violent reactions to things like (1) not being able to watch a TV show; (2) dinner time (in general -- she regularly claims that the food is "yucky" and then demands something else, often chanting it over and over again; (3) being asked to clean her room or pick up her belongings, (4) even extremely minor things like having difficultly pulling off her tights when changing into her PJs.

She doesn't seem to have a filter.  She "turns it up to 11" for everything -- whether she falls and gets a scrape or can't find the perfect pair of socks to wear for school.  She also FREAKS OUT if we try to show our son a "Curious George" video and she's doing something else ("I want to watch it!!! Don't start it yet!!!" ... then she may start sobbing loudly and uncontrollably).  And in general, she often tries to sabotage things when we're trying to have fun as a family.

She digs in deep and opposes us regularly (not always) for minor requests and instructions.  She has an amazing vocabulary and performs at a high level in school -- but it's really, really difficult to engage her in conversation.  I can usually sense when the "dark cloud" is about to descend over her. She'll get a really cross look on her face, with a frown, and seems intent on being miserable and making people around her miserable.  Even if we provide a decent solution, she makes sure it doesn't solve her problem.  

She often punches and kicks when she gets a surge of angry energy, often while frothing at the mouth and sobbing loudly.  

It's not fair to our youngest, especially when we have to stop a fun family activity in order to deal with Simone's outbursts, while my wife and I are feeling particularly shell-shocked by it all.  I'm not an objective source, but I feel like we've been incredibly patient and calm and have tried many methods.

Again, she's well-adjusted at school and in public, and is sweet to her brother (most of the time -- all siblings squabble sometimes), but very hard on us way too often.  

I plan on purchasing your book but wondered if you could be so kind as to provide some direct feedback as well.  My psychiatrist (I've been treated for depression/anxiety) suggested she may have oppositional defiant disorder, which has a high probability of turning into sociopathy in adulthood. That freaked me out, but upon further investigation it just doesn't seem like a fit. Thank you for your time and expertise.
It sounds like your daughter has anger overload, rather than oppositional defiant disorder (ODD).  For the latter, you would expect to see argumentative or disagreeable behavior toward adults in multiple settings, e.g. school as well as home.  Your daughter gets along fine at school you wrote, so I would be reluctant to use the ODD diagnosis.  Furthermore, in my experience most ODD kids do not become sociopathic.  Sociopaths exhibit a lack of empathy for others, and you describe your daughter as kind and likable when she is not angry.
The diagnosis you might want a mental health professional to rule out is pediatric bipolar disorder.  In this disorder there are also repeated outbursts.  In addition, there would be signs of grandiose thinking, frequent mood changes, risk taking behaviors, and impulsive decision-making.  It does not sound like your daughter exhibits risk taking or impulsivity, and it is unclear whether she exhibits grandiosity (feeling she is the most important and best most all the time).  From your description, she does have mood fluctuations, but this can occur with anger overload as well.  It sounds like your daughter frequently gets highly emotionally aroused by frustration.  Like you said, she has extreme reactions to so many frustrations and disappointments, and can't seem to dial it down.  This fits with anger overload:  these children get overheated, and we think there is a biological underpinning--the frontal cortex is not able to control the arousal of the emotional parts of the brain, mostly the amygdala. 
But with development and practice, there can be improvement.  The strategies in my parents' manual are intended to help that development along.  It will take time and practice, but your daughter can learn to have better self control when angry.  Part of the manual describes strategies you and your wife would use to help avoid tantrums.  Early detection here is critical.  You enumerate a number of situations when your daughter loses it.  You would want to anticipate these and try to find ways around them.  For example, getting dressed sounds like a frustrating time.  I would recommend being present, if possible, during these times, and be ready to assist or divert her if she starts to get frustrated.  Because of her low frustration tolerance, you may need to assist with tasks that you might otherwise leave a 7 yr. old to do on her own.  The same for cleaning up her room.  Be around to help; maybe making it a joint activity will remove some of the frustration for now.
For meal times and television, I would suggest trying to have a regular schedule as much as possible, and cue her with five or ten minutes to go that the next "activity" is about to start.  Try to arrange the schedule so that something fun comes after something she does not like.  Then there are natural incentives to follow the schedule.  If she does not cooperate, try not to engage her in a discussion at that point, but make sure the next activity does not start until she completes the one before it.  Talk as little as possible if she is in the overload phase.
In the second half of the manual, I explain strategies to try to engage your child in the process of learning self-control.  A first step is to assign a neutral word to each of three levels of anger:  low, medium, and overload.  I often use colors with kids:  blue for low, orange for medium, and red for real hot.  Once you arrive at the words to use together, you or your daughter could use the colors to point out when someone in the family was getting upset, preferably at the early stages.  Once this system is in place, you would tie diversions or relaxation exercises to the lower levels of anger.  The idea is to teach your child how to self-soothe.  This is a long process, admittedly, but it is worth the time and effort.  If children learn to self-soothe, it will make it so much easier for them to deal with the frustrations of everyday life!
All the best, Dr. Dave Gottlieb

Monday, November 11, 2013

5 yr old hits and bites if does not get his way

Hello .  I am hoping you can provide me with resources or maybe some feedback regarding my son.  He is 5 years old and gets very angry ( only towards close family members and most usually me ).  If I use a tone he doesn't like, doesn't feel listened to, or if I say No to somewhat he considers a "need," he will hit me and at times say that he wants to hurt me badly .  He has bit me and thrown objects at me .  He is cautious what he throws and usually will pick up a hard object put it down and then throw a soft object . 

 He is very sensitive .  He picks up on every emotion in the home .  My husband and I can bicker and I have been dealing with some complicated grief since losing my mom abruptly almost 4 years ago .  He has lots of energy and fidgets a lot but I don't think he fits the criteria for ADHD as he is focused and sits nicely in kindergarten .  He will take his time with his school work if he cares about it .  If he doesn't he rushes through it and if corrected ( by me typically) he yells at me that i am a mean mommy or says " be quiet , don't talk to me , I hate you , I want to hurt you ".    His outburst are very short lived ( thank god ) and I usually can redirect or distract him onto something desirable .  But this is a lot of work and emotionally draining for my husband and I . 

I don't know what makes him so angry .  He is an only child . He is pretty spoiled by my husband and immediate family who often give him many tangible items .  He feels that he should get something in every store we walk into and will wheel / deal any way he can to try get this "need" met .  Generally he is a very spirited boy who loves nature and noticing the seasons changing , he is pretty creative with art or even ideas about things, and his vocabulary is exceptional .  He is very loving and affectionate .  He loves our dog and is gentle with her . He is 5 ( six in April).  He shows little interest in reading but appears to be keeping up with his peers .  If he feels he has received genuine praise for something he is very prideful .  He picks up on "bullshit" easily . 

It is beginning to make me anxious as i don't know what will tick him off .  Additionally he needs us to always engage him .  Running errands or cleaning the house makes him irritable if he can't have an active role in it.  Watering down the cleaning to his level doesn't work, he wants to do whatever the adults can do .  He has recently been doing more mischievous things he knows is wrong as if he is looking for negative attention .   I feel terrible that I can't find a strategy of parenting that resonates with him.  He is acting out for a reason .  I don't think this is biochemical . I pray it's not .
Thanks in advance for any feedback you can provide .

Hi, I can tell you are trying real hard to understand your son, and it sounds like you are still grieving the loss of your mom. You mention too that you and your husband bicker sometimes.  Do you feel you need more emotional support at this time of your life?  I wonder if your frustration with your son is aggravated by your disappointment that he is another source of stress.  Maybe if you had more support (friends, support group in the community, or therapist), you could make limits stick better with your son.  You mention that he is spoiled.  Maybe you are trying too hard to please him.   It can be hard to say no when you anticipate a child will explode!

It is good that this is only happening in the home, because it means your son does have some self control.  Then the question is how you can get him more in control at home.  One thought I have is that it is going to be important to set a firm limit about physical violence. Do not talk to him while he is having an outburst.  When he is calm, however, you could all talk briefly about how dangerous this is.  Explain a couple of alternatives: saying "I don't want to" or "I don't like that." This does not mean he will get to do what he wants, but you will at least consider it.  And explain that in the future there will be serious consequences for violence.  Think with your husband what immediate, short term consequence might be meaningful for your son, e.g. no television for the day if this is important to him.  You do not have to announce the consequence right away if he is hitting or throwing things.

But when he calms down, let him know that it was dangerous, and he needs to find something to do other than television for today, and that if he does not hit for the rest of the day, he can have television tomorrow.  This may set him off at first, but in the long run you will establish a limit about violence.

The other approach to violence in the home for a young child is to restrain him when he becomes violent.  Bear hug him and hold him until he calms down (this could take many minutes).  It is reassuring to a child to know that you will not let him hurt anyone and that you are powerful enough to keep him and everyone else safe until he calms down.  Do not talk to him a lot during this time.  But talk with him after he calms down.

You want to pick your spots when it comes to discipline.  Think whether the issue is important to the functioning of the family.  For example, if his school work is rushed or incomplete, maybe you could let the teacher handle that with him.  If he cares about pleasing his teacher, her/his comments may help motivate him, and then you do not have to be the enforcer for homework.

I like how you distract him at times.  Also, consider ways to avoid tantrums.  For example, maybe don't take him to the store for a while if this is one of the battle grounds.  Maybe one of you go shopping and the other parent stay home with your son for now.  Or clean the house while he is in school, or while one of you takes him out for a walk.  You want to cut down on the number of possible conflicts until he learns better self control.

My manual for parents on anger overload explains some of these and other strategies you could use.  If you do not see some improvement in a few months, ask your school or family doctor for a referral for a child psychologist to help you. 

All the best, Dr. Dave Gottlieb

Saturday, October 26, 2013

14 yr old breaks things, smacks mother

My husband and I have 3 daughters and we are raising 3 of my brothers children.  We are a poor but proud family that is in dire need of some serious help.  Our middle daughter, who will be turning 14 in November, has been seeing a developmental pediatrician at a local hospital. He has told us that our daughter suffers from ADD/ADHD combo, social and educational anxiety and oppositional defiance disorder.  I've tried all but 1 of the methods that he has offered and they are not helping.  Unfortunately we can't find a cognitive therapist that will accept her medical card and I honestly am at my wits end!!!  

We can't handle her any more and it is causing a lot of problems in our home.  One minute she is the sweetest most helpful person and in the blink of an eye, she's throwing things, breaking things, yelling and screaming.  My husband tries to get control of her but all it does is cause fights and things end up broken and holes in the walls. Just tonight she broke a fairy figurine that my aunt gave me and she upset her dresser, put a huge hole in her wall and she smacked me so hard on my bare chest and neck that it left a welt.  

The other kids are on edge and scared when she starts to act out and I'm ready to have a nervous breakdown. Our daughter is at her wit's end too.  She just left a few minutes ago to go to my mom's house for a few days.  My mom just texted and told me that our daughter was very upset and said that she feels like she really needs help and that she has prayed to God and asked him to help her.  She's like a yo-yo!  When she's with my mom, she says she feels she needs help, but when she is home with us, she thinks she's fine and refuses any help.  

I have thought several times about having her admitted to a major psychiatric hospital.  She has been to the ER at our local hospital and admitted at the local psychiatric unit a few times.  I don't know if putting her in a psychiatric unit would help resolve the issues or not.  I guess what I'm hoping for, is that you might know of something we might be able to do, or somewhere we might be able to take her, to help our daughter take control of her anger and help us all to be a family again.

Wow, you have been though a lot at home and have tried getting her professional help.  Yes, ongoing outpatient therapy with someone trained in dealing with anger issues is a good idea.  The psychiatric hospital you mention might help too, especially if she continues to be out of control and physically endangering family members.  One question I have is about the diagnosis.  The way you describe the intense and rapid changes in mood make me wonder if pediatric bipolar disorder has been ruled out.  There are medications especially helpful for bipolar disorder if she were to have that condition.  Maybe ask your pediatrician, or check with a psychiatrist who sees teenagers to help decide about the diagnosis.  

The fact that your daughter said recently she wants help (at least when she was with your mom) is a good sign.  You would want to talk with her at times when she is reflective and wants help, and talk about strategies she could develop to recognize and head off her angry outbursts.  The second half of my parent's manual outlines strategies you can teach your daughter.  These are cognitive behavioral strategies, which is what your doctor recommended.  The first step is to develop your child's observation skills.  I explain in the manual how to help your daughter identify when her anger is rising, and to identify some of her triggers.  Then she would try different calming strategies.  It is hard work to identify triggers and to intervene early enough to head off an outburst.  But if your daughter is motivated, it would be a good time to try some of these strategies. 

See if she will let you work together.  Explain you would be the assistant coach, who might notice triggers and help her develop calming strategies, but that she would be the head coach and could decide whether she agrees or not.  The more you can get her thinking about the triggers and alternative strategies, the more likely she will be able to slow down her impulsive outbursts.  It will not always work out because anger is a powerful emotion, and when in full force, it is hard to get the rational part of our brain to act.  But at early stages, when a trigger is just beginning, it is easier to head off anger.  So one key is early identification of situations that cause frustration or disappointment for your daughter.

If one cause of the outbursts is arguments with you or her father, then you would work on teaching your daughter about different points of view and ways to compromise.  There are sections in my manual about how to help children recognize that there are different ways of looking at things.  Often new information about other people's motives help children to see others (you and your husband) as benign and as trying to help them.  Many teens think their parents are just trying to manipulate or control them, and that perception makes their anger worse. You want your daughter to see that there are different ways of looking at things, and that you are not trying to manipulate her.  For example, parents' rules about curfew are intended to help children to stay safe and to get to sleep at a reasonable hour.  Many teens think parents are trying to prevent them from having fun with their friends.  Once teens understand there are different ways of looking at curfew, there is a chance they will react less angrily and learn to compromise.

Lastly, if your daughter can calm down at your mother's house, this might be a good place to start with a family discussion about the strategies I outline in the manual.  Your mother could be in on the discussion if your daughter is less likely to explode in her presence.  Sometimes having a neutral party present helps teens to think about things rather than react emotionally.  All the best, Dr. Dave Gottlieb 

Tuesday, October 22, 2013

What to do when there are additional problems

Hi, I wanted to let my blog readers know that you can find brief articles I have written about other parenting issues on a website for the Chicago parents' network.  So far I have written about how to handle these issues: temper tantrums (usually an expression of anger overload), potty training, divorce, and most recently shyness.  Sometimes children with anger overload have additional issues, and if any of my blog readers would find these articles useful, below is a link to the Chicago parenting website.  This link gets you to my recent article on shyness, but once you are on that website you can search the blog posts for my other articles.  To find my other articles, go to the left side of the parents' webpage and look under these blog categories: "children and divorce,"  "diapers and potty training," and "behavior and discipline."  Take care, David Gottlieb, Ph.D.

If you first click the link below, and you do not get immediately to the article, a message should appear that you then click on again.,is-your-child-shy

Thursday, September 26, 2013

Parent uses manual and 6 yr old hits in school

Dear Dr. Gottlieb,
I have a 6 year old son that seems to fit your description of a child that experiences anger overload. I've been following your advice outlined in your manual along with using strategies described by Dr. Ross Greene in The Explosive Child. Thank you for your manual. It feels like a god send as I live in a small town where it is very hard to find quality health care.

I have two main questions about what we are experiencing in the early stages of our new approach. We’ve only been trying these techniques for about 3 weeks.

(1)  While it seems like we are improving with avoiding overload altogether by detecting triggers and sensing his body language when he is getting frustrated, it now seems like he is triggered more often. His episodes are shorter and less intense, but it seems like there are more of them now. An example would be that just this week he hit a fellow student. School has never been a setting where he acts on his anger. It’s always at home or when he is with me and/or his father. He is triggering in more situations now at home too. Is this a common phenomenon that you experience with your patients as they start the techniques you prescribe?

(2)  The second question I have is concerning a broader pattern. Sometimes he seems to go for weeks without much of a struggle even in the face of his usual triggers. We often think of his triggers in terms of ultimate and proximate. He might be upset because his spelling his hard, but if he is hungry, it’s a greater challenge to control his anger during difficult homework exercises. There are times when he is fed and rested and has had play time (all ultimate triggers covered) ….but he is still excessively trigger sensitive. And then in other times, he can control his anger fairly well with the same triggers in play. In your opinion, is there is evidence to show that there are periods where hormones can affect his trigger sensitivities for weeks on end? Or is there another situation that could cause this?

My deepest appreciation!

Hi, You ask good questions.  Generally, there is not an increase in anger overload in new situations when you apply the techniques in the manual.  Do you know what was going on before he hit the student in class?  What was the trigger?  Sometimes a child struggles to contain his anger in school (and is usually able to exhibit self control), but then there is a day when he is more sensitive (tired or hungry).  When in addition on those days there is an unusually difficult situation, he may have a melt down.  For example, sometimes a child does not do well on a test or assignment, and is feeling down about it, and then the same day a fellow student is verbally provocative.  The combination of triggers is overwhelming and leads to hitting.  My guess is that this will not happen often for your child in school.   If it recurs, it would be important to try to figure out the triggers, and also apply the strategies you are using successfully at home.  You might meet with the teacher and explain what you are doing at home, and see if the teacher would apply similar techniques (or one of the other techniques in my manual--the teacher might feel a different technique might work better in her class).  Usually over time a child develops better self control and there are fewer explosions at home and school.  

I don't know the answer to your second question.  I have also observed that some children have better control some weeks, but I do not know of any research that looks at fluctuations in hormones or brain chemicals over time and their effect on anger.  There have been some studies on violent behavior in adults that show that low levels of a brain chemical called serotonin are associated with more violent behavior.  But even these studies have not looked at week to week fluctuations in serotonin.  Furthermore, the correlation between serotonin and violent behavior does not mean that low levels of the brain chemical cause violence.  It is possible that there is a third variable that causes changes in violent behavior and changes in serotonin.  It is also important to keep in mind that violence is not the same as anger overload.  There are various contributing factors to violence that have nothing to do with anger.

My guess is that there can be week to week fluctuations biologically that affect anger overload.  Also, there can be fluctuations in environmental stressors, and we don't always know our children are feeling stressed until they explode.  But that doesn't mean your child still can't develop better control even during those weeks where he is biologically vulnerable.  He may need more help with the strategies those weeks, and over time (several months) there will often be a decrease in explosions, though not necessarily a total cessation.  As your son gets older, you will be able to apply more of the strategies in the second half of the manual that will help him become more aware of his triggers and how to use strategies himself.   Usually at age six, the strategies in the first half of the manual (that involve parents directing the child) are more effective.

All the best, Dr. Dave Gottlieb

Thursday, September 19, 2013

8 year old loses it doing homework

Hello Dr. Dave,
I'm at my breaking point with my son.  I have 3 children, he is my middle 8 year old.  He's always been sensitive, easily angered, quick to cry when feelings are hurt, and quietly emotional (will run to his room to cry if his brother hurts his feelings etc.).  However, he's generally a pleasant, happy child.  When things are going his way (ie. he has a friend over for a playdate, and his siblings aren't getting involved) he is sweet, kind to others, and incredibly funny.

Lately (just started the 3rd grade) he's been frustrated by schoolwork, and I believe he bottles up that frustration until he gets home.  With me he is incredibly angry, won't do homework, and when I press forward and insist that homework needs to be completed...well that's blow up time.  I try and stay calm, but one little thing I say can set him off and he's throwing cushions off the couch, he runs and buries his head in his bed, he cries, yells at his siblings.  He never has hurt anyone, but he throws things now and he's a strong boy.  I'm afraid of this escalating, and having him cause damage to things or hurting someone during his fits.

I also am ashamed to admit that he has gotten me so worked up that even I have lost my patience and I've yelled, or tonight I turned one of his Lego bins upside down in his room because I was so completely exhausted and enraged, I lost it.  I tried so hard to talk to him, but he won't talk. He says I ruin his life, that he hates everything, and he doesn't want to go anywhere for help.  I've offered tutoring, a doctor to help us figure out a way to work together so we are both happy. Ugh! I'm so upset, if  you have any recommendations, please let me know.

Hi, It sounds so frustrating for you and for your son.  We all have trouble containing our emotions sometimes.  When your son is calm, you may mention that sometimes you get so angry too, and add what you try to do to control your anger.  You can be a role model for your son.  He may not respond to your remarks, but he may feel less frustrated knowing that he is not alone in having times of overload.

You mention that some of the blowups recently have occurred at homework time.  Did this problem begin this year in third grade?  Do you have any ideas why now homework is getting to be a struggle for your son?  You might want to talk with his teacher if you suspect that the work is difficult for him or if you think he is having difficulty concentrating.  You would want to rule out a subtle learning disability and rule out attention deficit disorder. If the teacher is unsure, then you could ask the school to do some testing to rule out learning problems.  If there is a chance that your son has a learning disability, you would want to take some pressure off doing all the homework until you and the teachers know how to help him.   If you think there is no learning problem nor attention issues, and if you think that the problem is motivational, what is your son wanting to do instead of homework?  Is there a way you can tie in completion of homework with extra time doing what he wants when he finishes?  Make sure that whatever your son loves to do comes after (and not before) the homework. 

You mention also that your son is sensitive to being hurt by his sibling and that he is emotional then.  Some children are more quick to cry than others, and crying by itself is not a problem, but if your son feels inadequate in some ways compared to his brother, you would want to try to help him with his self esteem.  Help him see that he has an area of expertise, or help him build an area of expertise (for example, sports, music, art, social service, or kindness to others) or explain that his brother has had more practice in the areas where your son feels frustrated (if this is the case).  Continue to have friends over that your son enjoys, and think about whether there is some other activity in your community where your son would like to participate (and it could become an area of pride for your son).

When your son gets angry, if you can, try to intervene before his anger is explosive.  In my parent's   manual, I explain how to do this:  by using "emotional distraction"  or calming  strategies.  In addition, you would want to lower your son's expectations (in whatever area causes him stress) when he is not angry.  It sounds like your son does not like to talk much about his anger, but you may be able to propose a new way of looking at things when he is calm, maybe later in the evening.  Keep your comments brief, since he is sensitive about his anger issues.  In the parent's manual, I explain how to do this. 

When your son is explosive, do not talk with him then.  As long as no one is being hurt or nothing valuable is being destroyed, then try to wait it out.  Usually the more you talk when a child is in overload, the more emotionally reactive a child becomes.

As far tutoring or counseling, think about what you feel is best, or consult with his teacher.  Then you make the decision, rather than ask him his opinion.  Your son may not like the idea at first, but if the person you hire can form a good rapport with your son, his resistance will decrease.  Remember he is frustrated and just wants the problem to go away.  But you know that it won't go away without something changing, so you have to do what you think best.  Hang in there!  I can tell you care a lot about what your son is going through.  Hope these comments are helpful.

All the best, Dr. Dave Gottlieb

Wednesday, September 11, 2013

6 yr old explodes when touched or if not in charge

My son is almost six, and simply cannot seem to control himself when he gets angry.  If he is pushed, or touched (even by accident) he explodes. His anger is often directed to those whom he perceives as threats in some way (his younger brother, a threat for his attention) or peers who have strong personalities (He likes to be in charge.).   He rarely will hurt or explode at someone younger than him, or girls (He actually usually plays very nicely with girls and passive boys.).

He gets easily frustrated with himself when he cannot accomplish something, and can also explode then. 

He has not had issues in school yet, and in fact his teachers have even told me that he is a rule follower, and a great listener. focus and attention do not seem to be issues either.  I have watched him in sports and activities and notice than when he is engaged, he is the paragon of good behavior, However, left to his own devices, he is not to be trusted, and I am concerned that one day he is going to really hurt someone in one of his fits of anger. 

He seems to fit many of the characteristics of children with anger overload.  He is very energetic, and loves to play on the playground and loves jumping, climbing, and physical activity. While he is often very outgoing and confident in many areas, other times he is shy, especially if he is late or does not know people.  There are many moments of kindness, and sweetness, and friendship.  However, there are also too many times where he gets angry and can't control it. 

I have tried everything. positive reinforcement seems to work best, but he will go through phases of good behavior and then revert back to a downward spiral of behavior rooted in anger. 

I just ordered your book on amazon, but was wondering if you might think other diagnoses would be appropriate rather than anger overload.  Also, I don't know if your book mentions when to seek professional help and/or medication rather than rely on do it yourself behavioral therapy.  I am willing to try one more thing, but am wondering when enough is enough.

From what you describe, it sounds like your son exhibits anger overload.  It sounds like he pays attention well in school (does not have ADHD) and is not unusually moody (not depressed or bipolar).  It does sound like he likes to be in control, which is true of many children.  In addition to the strategies I outline in my manual, you might want to talk with your son (when he is calm) about how to handle certain tough situations you have noticed.  For example, help him understand  how to respond to pushing or touching by peers.  You could recommend he look at the other child and think about whether it was an accidental touch or a more deliberate shove.  Explain how he could respond verbally to each type of situation.  Practice with him short, firm, verbal responses if he thinks he was deliberately pushed, like "Don't push me." or "stop it."  If it was an accident (and the other child wasn't looking at him but just walking by) suggest he say to himself "no harm no foul" or "he didn't do it on purpose."  Since your child responds to rewards, you and/or the teacher could set up a reward if he tells you about a situation when he held back.  

Your son may not be able to implement these ideas right away if his anger escalates quickly, because as I discuss in my book, some children are flooded so fast with emotion that it is hard for them to delay and think about what to do.  Adult observers become key then.  If an adult can intervene early and distract him, engage him, or help him soothe, he may be able to slow down without exploding some of the time.  The important point is to intervene early, if possible, before your child's anger reaches the overload phase.  Or, re-arrange situations in advance to avoid a trigger.  For example, if your child is jealous of his sibling getting your attention, cue your son when you are about to help your other child that it will be his turn (to talk with you or do something with you) in a few minutes.  You want to give him a heads up since that may help soothe him and prevent overload.  

My manual is designed so that parents can try the strategies themselves.  But it can also be used in conjunction with therapy.   Sometimes there are underlying insecurities that contribute to a child's anger overload, and a therapist can be helpful in addressing possible concerns or worries that a child might have.   In other posts to this blog, I have explained how to find professional help.   

In my experience working with children with anger overload, medication is not helpful.  Medications might help if a child is depressed, anxious, or distractable, but do not help with anger issues alone.  Anger overload does take time to work through with a child because there can be biological factors, such as immaturity of the frontal cortex of the brain.  However, the strategies I explain in the manual will help a child develop better self control.   If you do not see any changes over a few months, then I would recommend a professional consult to see what else may be affecting your child. 

All the best, Dr. Dave Gottlieb

Wednesday, August 21, 2013

8 yr old physically attacks even the police

My son is now 8 years old. He has been on medication and seen therapists since he was 2 years old. He is now in a residential treatment center. He has been on numerous medications.  His diagnosis now is adhd, conduct disorder, ptsd, disruptive behavior disorder,  severe agression mood disorder,  not otherwise specified. He had recently got a felony charge for hitting a dcf lady with a socket wrench. He has destroyed my house, he will attack anybody including the police when he is in one of his rages. He has the same issues at school. I am trying hard to get him on track. Any information you have for me would be appreciated.  I don't want to lose him to the authorities.  (His father had anger issues also, don't know his diagnosis. ..he is now deceased.)

Hi, It would be important for a mental health professional to review all the diagnoses you mention and to review your child's and family's history to try to determine what issues are most significant and where you can best intervene.   There could be a number of causes for your son's explosive outbursts, but where should you start?  A child psychologist and/or psychiatrist might be able to review everything and help you devise a plan. 

My parent's manual offers strategies for dealing with anger overload, but when there is PTSD, ADHD, or severe mood disorders, more intensive therapy and medication are often needed in addition.   When  ADHD and mood disorders are better controlled;  then a child's rage reactions will not be so explosive.  If your son is not so quick to explode, it will be more likely that the staff can re-direct him using the techniques I outline in my parent's manual.  The first half of the manual specifies what adults can do to help, and the second half outlines how to teach children to recognize their anger and to gain better self-control themselves.

When applying the techniques in my manual, it will be important for staff first to identify the types of situations that are more likely to trigger your son's rage, and to identify early signs of anger (if possible) before he explodes.  If the staff can catch it early, they may be able to use "emotional distraction" and/or relaxation strategies to divert him.  I review these techniques in my manual and in previous posts on this website.  The key is early intervention because if you can catch anger early there is a greater likelihood that emotional distraction will work.

Once your child is in full anger overload, the main thing is to insure everyone's safety.  Keep dangerous objects away from him, and the staff probably has a restraint procedure to make sure no one is seriously hurt.  Hopefully in the residential facility there is a treatment team that can get at the key causes of his outbursts and help him develop better self-control.

All the best, Dr. Dave Gottlieb

Tuesday, August 13, 2013

Does the manual deal with child abuse?

Does your book and philosophy take into consideration these children might have ( or currently) being abused (mentally physically or emotionally) and they're acting out in a result of it?

Hi, The manual does not deal specifically with abuse issues.  Sometimes children can react angrily when they have been abused.  If you suspect that this might be the case for your child, you should contact your family doctor and/or make an appointment with a mental health provider who works with abused children.  The strategies in the manual  may still help you deal with your child's anger, but the underlying abuse issues should be dealt with too, or the emotional pain of the abuse will likely continue to affect your child's behavior.  

In my earlier book, "Your child is defiant: Why is nothing working?" there is a section that explains what to do for abused children.  There are also chapters that deal with other possible causes of defiant behavior.  In the book about defiance, I explain how to figure out what is causing your child's behavior and I explain what to do for specific underlying problems.  It is not a manual with step by step instructions like my latest book, though.  I found that parents wanted a more specific manual that applies to anger overload, so that's why I wrote the manual for anger overload in children. 

Take care, Dr. Dave Gottlieb

Tuesday, July 23, 2013

8 yr old with anger and anxiety: therapy or medicine?

Dr. Gottlieb,

I came across your website while searching for a way to help my 8 yr old son.  My son is very intelligent and does very well in school.  About 7 months ago his 2nd grade teacher suggested to us he may have ADD, and suggested we talk with our pediatrician.  We all filled out surveys on my son, and the pediatrician put him on Quillivant XR - which I understand is a liquid, long acting form of Ritalin.  We started at 20mg in the morning before school.  The teacher, who we like and respect, said she noticed a difference at school even though we did not see a difference in behavior at home. The pediatrician recommended raising he dosage to 40mg per day.  We tried 40mg for a couple of days, and he really seemed out of it.  We lowered his dose to 30mg per day, and he has been taking this dose for a couple of months.

Now that he is home most of the day for summer vacation we can observe his behavior all day.  Not only do we think the medication is not helping, it may be making his behavior worse.  I believe he has above normal anxiety, like me.  I believe his angry outbursts are because of fear and anxiety and lack of self control.  Your article on anger overload describe him very well.

I have two questions.  How do we find a therapist who is familiar with your concepts of anger overload in children?  Also, is there a medication we should consider to help him with anxiety?

I appreciate your time an advice.

Hi, To find a therapist in your area who is familiar with anger problems, I would first ask your pediatrician or school social worker.  You would want a therapist who works with children and with the parents, since many of the anger overload strategies are practiced at home with the parents.   Another possibility is to check with the mental health department of a teaching hospital in your area.  Ask the mental health professional if he has worked with anger issues, and maybe show him my blog or parent's manual to see if he/she could help your son develop self control strategies.   If anxiety is a related problem, you would want the therapist to address this issue as well.  

Regarding the ADHD medication, sometimes ADHD is misdiagnosed in young children, but sometimes the medication is helpful in school, and not so much at home.  In school, the demands to sit quietly and listen are greater than in the home where children can move around and switch activities more freely.  Also, some children do better on a lower dose of medication.  You will see next school year if your son does well in school without the ADHD medication.  Furthermore if he responds to treatment for anxiety and anger overload, then he may be more focused in school.  See what happens in the year to come.

As for medication for anxiety for children, doctors will often consider a small does of an SSRI medication (serotonin reuptake inhibitor) if psychotherapy is not helping.  With an eight year old, though, I would recommend first trying psychotherapy, as medication may not be needed.  If your son can learn how to lower his anxiety, he will have tools to use his entire life.  Many SSRIs have been approved by the FDA for children, but there are possible side effects, so many doctors suggest psychotherapy first.

All the best, Dr. Dave Gottlieb

Wednesday, July 17, 2013

Do 6 year olds outgrow anger problems?

Hi Dr. Dave-

Out six-year-old has been having angry outbursts since he was about 18 months old.  He screams, cries, beats on the door, throws things, kicks and bites for up to an hour.  When he was younger, he would stop when he got too tired to go on and would fall asleep. The tantrums don't last as long anymore.  I honestly can't tell you what makes them stop.  He eventually just runs out of steam I think.

Then, after he's done, it often takes 30-40 minutes until he is really approachable.  He just seems on edge and if I can avoid frustrating him, eventually he just seems to forget.  Once it's over, he is happy, sweet, wants hugs and is almost overly happy.  Sometimes it's like he just flips.  One second he's raging, the next minute he's happy and sweet. 

It comes and goes.  When he was ages 2-4 it probably happened 3-4 times a week, up to a few times a day. Now, he won't have any tantrums for a month or two and then will have five in a week.  It seems to me like if he has low blood-sugar or is tired, he's more likely to have a tantrum.

I think he has control over it because he rarely has done it with people he doesn't trust and know well.  It has happened a handful of times at school and not until well in to the year when I think he felt safe with his teacher.  He has done it a few times with grandparents and one time with two different babysitters that he knew well and trusted.  But it almost always happens with me and sometimes with his dad.  

In general, he is a happy, fun and creative kid.  He is impulsive and reactive compared to other children and he has more energy than any kid I've seen.  He is definitely a risk-taker and talks more about all the awesome things he can/will do then actually doing them. 

We saw a behavior specialist in his pediatrician's office once and he basically told me to just be consistent and reinforce positive and negative consequences. 
I wanted to pull my hair out because I have been very consistent with him and feel like I honestly can't do any better. 

I'm exhausted from six years of parenting him.  I love him but much of my time with him is difficult.  I can't keep him entertained or engaged and I never know what is going to set him off.  It's typically when he's told no or has a fight with his 4-year-old sister over something but it's not consistent enough for me to determine why he does it. I'm a stay-at-home-mom with two other kids (ages 2.5 and 4) and it's almost impossible for me to manage it all.  He has set an example of anger and defiance and taught them many of his raging behaviors that they mimic now.  

In seasons, I've thought he has outgrown this and felt relief but it always comes back.  He seems to fit the profile of a kid with anger overload.  I also think he has symptoms of ADHD (both his dad and I have it) but he's doing well at school and his teacher says he is a "model of patience and listening" so I haven't pursued this with a doctor yet.  He is impulsive and doesn't seem to have a sense of when to stop things that are bothering other people but he seems to be able to focus well in some areas.  

Do kids with anger overload outgrow this type of behavior or do they struggle with this all their life?

Hi, There are not longitudinal studies of anger overload, to my knowledge, but my experience with children over thirty years is that most children can learn to better control their outbursts.  For some children, there remain times when they lose it as they get older.

If there are additional diagnoses, it is important to address all these issues; then the it will be easier for children to develop self control.  In your son's case, you would want to rule out "ADHD, hyperactive-impulsive type," and rule out "pediatric bipolar disorder."  At some point I would make an appointment with a psychologist or psychiatrist who specializes in childhood mental health issues in order to rule out these additional diagnoses.  The way you describe your son's energy and impulsiveness is why I recommend you make sure.

ADHD can take different forms; not all these children are inattentive.  Some show hyperactivity and impulsivity without serious attention problems.  Children with high energy and impulsivity have a harder time with self-control when they get angry.  They tend to be quick reactors when they are emotional. If they become less impulsive over time, their anger control will usually improve as well.

Pediatric bipolar disorder is more rare; some key symptoms are frequent severe mood changes, impulsivity, dangerous risk taking, frequent pleasure seeking behaviors without regard for consequences, and grandiose thinking.  It is more difficult to diagnose, and you would want a mental health professional with experience in diagnosing this disorder in children.  

For anger overload, you should focus first on the strategies in the first half of my parent's manual.  You mention above a couple of triggers: when your son is told no and when he fights with his younger sister.  One key is to try to catch his anger in early stages; this is not often possible because kids can erupt so quickly.  I describe in the manual how to use "emotional distraction" and a "calming" zone when you can catch it early.

You would also want to try to re-arrange situations so that you avoid certain triggers.  For example, if the kids fight over using the computer or the television, you would arrange a schedule to try to avoid the conflict.  Maybe there would be no television or computer some nights, or alternating days when one child gets to choose or go first.  You might also try to verbally praise both children when you see them cooperating.  I don't know what you have tried so far, but keep experimenting until you find a strategy that works.  Rewards and consequences do not usually help much with anger overload because children are not thinking rationally when they are very angry.

I also recommend using a neutral label for levels of anger to help your child begin to recognize when he is starting to get angry.  I give examples in my manual, one labeling system being colors like blue (for low level of anger) to orange (for mid range) and red (for overload phase).  The idea is to help a child recognize when they are at the blue or orange levels, because it is at this stage when they still have a chance to avoid overload.  Once they recognize early stages, you would teach them strategies to help them with self control.  I explain this in more detail in part two of my manual.  

The process takes months, and sometimes a year or more, but it is well worth the effort, because self-control is a key to success in life.  It sounds like your son already has some control because he has fewer outbursts outside the home.  That is a good sign.  With practice he will eventually be able to use strategies at home.  All the best, Dr. Dave Gottlieb

Monday, July 15, 2013

"Possessed" 4 yr old: Is it genetic?

I have a 4 year old daughter who has had many rage/anger episodes since the day she was born.  Yes, she was an angry newborn!  She has many triggers: being tired, not getting a toy/treat at the store, not wanting to share a toy with her brother, being sick, being in pain, waking up in middle of night, power struggles, etc.

Generally, she is a very happy,compassionate, active girl.  But, when a rage is triggered it can last hours.  The most mind boggling was recently she had a stomach flu. For 4 hours I held her hair, coddled her while she vomited and dry heaved.  The entire time she was soo angry at me.  Barking orders to give her water, a washcloth, blanket; etc. in a very angry manner.   Also, she frequently wakes up in the middle of night with growing pains. Again, she will be so mean to me.."Give me a heating pad, now!" or "No,  I will not take that medicine!".  She will cry, scream and growl..hours.  Like she is possessed!  Help!!

A few more thoughts on my 4 year old.  Another trigger is being restrained in a car seat.  It has gotten better recently but, from baby to 3 years old she would rage while we were driving; trying desperately to get out of her car seat. Screaming and crying the entire car ride.  Again, usually while she was tired.  We could never do night drives with her, she would scream the entire time.

We have ignored her, held and cuddled with her, took away "stars" for good behavior, put her in timeout,  told her she couldn't come out of her bedroom until she stopped screaming (that one escalates her anger big time!). 

Anger most definitely runs in my family.  I also struggle with anger.  My father, grandpa, brother, aunts,etc.  Something must be wrong with our genetic make up?

Hi, It is possible that there is a family component to your daughter's anger overload.  It can run in families; there can be genetic and environmental factors that contribute to the intensity and frequency of outbursts.  It would be best if everyone in the family worked on it, and you could mention out loud from time to time how you are trying to handle your anger--that can serve as model for your daughter.  If you talk about your anger, be very concrete about what aroused your anger and what you are doing to try to keep self-control.  You want to get across the message that many people get angry, and that the feelings are natural, but we all must try not to hurt or overwhelm other people with our anger.

Given that your daughter is only four, talking about anger will only get you so far.  What I would do is use a combination of strategies I explain in more detail in my parent's manual.  For  some situations, like the car seat or shopping for toys, I would cue your daughter a half hour so so before you leave what the plan is.  Remind her again before you walk to the car.  Sometimes knowing in advance helps children contain their anger.  You do not want to compromise on the car seat, because it is a safety issue.  Some children hate the feeling of being restrained in a seat.  Does it help to let her hold a favorite toy, or to watch a video, or listen to music in the car seat?  It sounds like your daughter is finally getting used to it, after several years!

When you can avoid a trigger, do so:  for example,  maybe sometimes avoid taking her to the store, if she gets mad when she does not get a toy.  Or, if you need to take her with you, have you tried lowering her expectations before you leave the house?   Explain ahead of time that there will be no toys today, but that she can bring something to hold if she wants.   

Exhaustion, fevers, and illnesses can make children (and adults!) irritable and more likely to have outbursts.  When a child's brain is physically exhausted or feverish, it is more likely that parts of the brain, like the frontal cortex (that is used for self-control)  will not operate at normal efficiency.  You may need to try to extend sleep time or encourage rest times.  I remember when one of my sons got a fever, he was totally out of sorts and inconsolable.  Once the fever went down, he was somewhat better.  We relied on liquid Tylenol to lower the fever.

Incentives and consequences often do not help with anger overload.  Especially when a child is already upset, there is not much that they will listen to.  Children are not really thinking rationally during an outburst, so the less said the better.  If she is sick or tired, I would try to do something soothing, like music, movies, pleasant aromas, or tactile stimuli (hugs form you or holding a teddy, blanket or pillow) if your daughter finds any of those things comforting.  You would want to establish a "soothing" or "calming" place and routine for several weeks while your daughter is already calm, before trying the routine when she is upset.  Also, this strategy is more likely to help if you catch her frustration before she explodes. 

I offer other ideas in my parent's manual.  Keep trying, because children can learn over time to develop better self-control, even when there is a familial component.   Improvement may be gradual, often over a number of months.  But it is worth it, because developing better self-control will help your daughter so much in the years to come!

All the best, Dr. Dave Gottlieb

Monday, July 8, 2013

Is the manual helpful for three year olds?

Dr. Gottlieb,
I’m thinking of getting your book about anger overload. My 3 year old has thrown epic, enraged, crazed fits since she was 1. They are becoming violent now, with her biting, scratching and kicking me, her grandmother, herself and everything in sight. She has no calming mechanism and will completely destroy a room with a quite impressive display of strength for someone who still wears 24-month clothes.

Does your book address children this young?

Is there any other advice you have? I really worry that she needs to see a professional. Yes, we have babied her (her sister is 20 months older). Yes, she is likely showing spoiled behavior when being told no. Yes, we engage in her fits when we shouldn’t. But she’s done this since before she could walk. I fear that this is more than a discipline issue.

Thanks for your help.

Hi, Some young children have a very difficult time soothing themselves and have explosive outbursts.  After reading your e-mail, some questions I have are 1) what is the frequency of her violent outbursts, 2) what are some of the triggers, 3) what have you tried so far.  In my book I explain that the first step is to carefully observe the triggers for a couple of weeks to see what patterns there might be.  Then I explain various strategies that you can employ.  The first half of my book would be useful for working with a three year old.  These strategies do not involve your child's direct participation.  If you have observed triggers for your daughter's outbursts, ask yourself if you can you sometimes alter the sequence of behaviors to avoid an outburst?  For example, if she rages when you tell her she has to stop playing and take a bath, you could re-arrange the sequence so that the bath comes earlier before she starts to play.  A related topic in my parent's manual is to lower your child's expectations.  The idea is to try to prevent an outburst when possible. 

The next section of the manual explains how to use "emotional distraction" and calming strategies.  In your case, it would be important to practice calming strategies with your daughter while she is not having an outburst.  You would try to develop a quiet and fun place in the house (some parents use a mat with blankets and pillows and wrap their child in a blanket, or have their child lie in a bunch of pillows) and put on distracting and calming music or a video.   Once your daughter is enjoying this space when she is calm, you would sometimes suggest she go there with you when she is just a little bit frustrated.

This is not likely to work however when she is already in serious overload.  Then you say as little as possible, but if she is hurting you, you would need to restrain her (possibly bear hug her) for a few minutes or more until she is no longer trying to hurt you.  It is real important then to give her more of your attention once she has calmed down, so that she sees there are definite advantages to calm behavior. 

Since it sounds like the outbursts are severe and have worsened the last two years, it would be helpful to get a consult with a mental health professional who sees young children.  You would want to rule out developmental delays, and possible co-occurring conditions like autistic spectrum disorders, attention disorders, and sensory integration issues.  A young child's brain is growing so much, but sometimes there is unevenness in development such that self-soothing is delayed.  You would want to learn why this might be happening, especially if you do not see some improvement in using the strategies in my manual over a couple of months.   I'd also recommend you read my post from June 12, 2013 that was in response to another parent of a three year old.  All the best, Dr. Dave Gottlieb

Tuesday, July 2, 2013

6 yr old: anger overload, ADHD, and sensory issues

I came across your page after a very stressful morning trying to seek answers. The majority of the time my six year old son is a sweet, kind child. He is very active and always seems to be in constant motion. He has an active imagination and attends well to preferred activities like most children do. I have always thought of him to be impulsive as he does many things without thinking of the possible consequences for his actions. I have always thought there could be the potential for an ADHD diagnosis, but being a special education teacher, I have seen many children misdiagnosed. After reading articles, he seems to fit the anger overload profile.

He does not seem to consistently respond to the typical behavioral approaches. If you give him a logical consequence, he is reactive with his episodes consisting of hitting, swearing, throwing, spitting. He pushes our buttons and does everything in his power to make the situation even more explosive. He throws tantrums typical of a toddler when he doesn't get his way and limits are set, or when his pants are fitting him right, or when his tag is itching him, or when his shoes are too tight.

Yesterday, he was having a play date with three other children and when one of them wanted to switch teams to make it fair, he flipped out pushed and kicked another child and shouted out a variety of choice words. No doubt his actions would have continued, but I felt I had to physically remove him from the situation. After coming inside, he managed to "escape" the cooling off area and go back outside to pick up a baseball bat with rage in his eyes.

This morning when he needed the tag off his pants and was throwing a fit, I told him to hold on while I put his sister in her playyard so I could get the scissors. He did not think I was moving fast enough so he called me choice words and began trying to kick me. I told him there would be a consequence if he continued and he seemed to take it as a challenge and he wanted to engage in a power struggle I wasn't willing to have. I ignored him and that led to more behaviors at first and then I employed a distraction technique. He also got into another explosive episode with my husband when he came home an hour later.

I am at a loss of what to do. Everything I try works temporarily. Nothing seems to work. My husband and I are trying to work together, but my husband tends to start off trying the "right" methods, but then my son gets the best of him and my husband becomes reactive and explosive himself. Thank you in advance for your response. I as well at times lose my cool. I am at a loss of what to do now. I thought he might grow out of his impulsivity and anger, but it only seems to be getting worse and he is getting bigger and stronger. I am not sure if I should go to a neuropsychologist and get him evaluated or what my next step should be.  I am sure if you met him you would think I was crazy because he is a charmer, but if you could be a fly on the wall you would see the battle I am up against on a daily basis.

Hi, It sounds to me like there are possibly several issues.  It is possible that you son meets criteria for anger overload, ADHD, and sensory issues.  The explosive temper (for seemingly minor provocations) is consistent with anger overload, the hyperactive and impulsive behaviors are consistent with ADHD, and his tactile sensitivity (tags, tight clothes and shoes) suggest there could be sensory issues.  It is not that unusual for there to be more than one diagnosis, and for the different issues to interact.  In other words, his "tactile defensiveness" and his impulsivity make it more likely that his explosive tantrums will be triggered.  When you work on each of the issues, you lessen the interaction, and there is more improvement than if you just work on one issue alone.  Having a neuropsychologist evaluate him is a good idea.

Yes, typical behavior modification, like rewards and consequences, often does not help with anger overload.   In my parents' manual I explain other strategies.  I like how you are using distraction and also a "cooling off" place.  For distraction to work, it must be emotionally engaging for your child.  I explain in my manual how to pick distractions that are engrossing or amusing, things that really grab your child's attention.  You are right that it is hard sometimes when children are extremely mad to get them to go to the cooling off place.  If you can intervene early in the sequence and re-direct him (to a different activity or suggest to him an alternative response for the current activity) that might work sometimes.  Early intervention is the key; I know it is hard to intervene early because these children "rev" up so quickly.  Activities that are more structured will probably work better for your son.  For a ball game, there would need to be an adult referee who could intervene early.

You want to say as little as possible when he is in extreme anger overload, except if he is hurting you (kicking you).  Then you need to make sure you are safe, by either moving away or restraining him.
Because your son has some hyperactive behaviors and is impulsive at times, he may react extremely quickly when triggered.  That's what makes the anger overload strategies take longer to work, and that is why I would recommend evaluating whether or not he meets criteria for ADHD.  For hyperactive children, you almost have to be thinking one step ahead of them (which I know is not always possible) in order to avoid triggering situations.

Since tactile sensitivity is also a main trigger, you would want to address this with a pediatric occupational therapist so that you can lessen his tactile sensitivities.  In the meantime, you would want to remove tags in advance and avoid tight clothes.

I know I have already asked a lot of you, and it will not always be possible to predict his tantrums.  But if you attack the possible ADHD and tactile issues, you will lower the number of triggers, and that will make it easier to use the anger overload strategies in my book.

All the best, Dr. Dave Gottlieb

Wednesday, June 26, 2013

19 yr old with intellectual disability has violent outbursts

I ran across your blog while trying to understand and help my son who has major anger issues.  He is 19 years old and has always had an aggressive nature when he gets mad.  He has an intellectual disability (42 IQ) and attends a school for special children.  He tends to have most of his rages with his father or myself.  Aggression is by far what we are the most concerned about.  He is currently taking Risperdal (1mg 3x daily), Trileptal (600 mg 2xdaily), Intuniv (3 mg daily) and Strattera (40 mg daily). When he has his rages he completely changes! You can tell that he has no idea what he is doing and seems to have no memory of the events once they are over.  He has been prescribed olanzapine (20 mg) for emergency use but it really doesn't seem to help him much.  When he rages he throws any item that he can, he hits, kicks, screams and spits.  He has broken many pieces of furniture, household belongings, put holes in the walls and left many, many marks on both my husband and I.  He is 5'10" and weighs approx. 170 lbs so you can imagine the strength that he has.  Sometimes when he is coming down from the rages he talks about people being hurt or about ghosts.

We would appreciate any advice that you can give us.

Hi, Given your son's size and the severity of his outbursts, it must be frightening when he loses control.  It sounds like the psychiatrist is trying a number of medications to reduce his agitation.  Honestly, at some point you may need to apply to the state you live in for additional services.  Your son may be eligible for in home care and/or a residential group home, given the severity of his outbursts along with his intellectual disability.  Especially if your son's anger endangers your safety or his own, then I would recommend you speak with the psychiatrist about how to apply for more help in your state.

Regarding behavioral strategies you can try now, I would recommend you first observe what are some of his triggers at home:  what are some of the situations that cause him to become frustrated?  Are there patterns?  Can you re-arrange some of these situations to avoid some of the triggers?  Another rule of thumb is to make sure that what your son wants to do at home comes after what you want him to do.  In other words, if your son sometimes balks at doing something, arrange things so that something he looks forward to comes after he does the thing he does not like to do.  There will be a natural incentive for him to cooperate then.  Also, maybe you can work with him (work together) on a particularly "unpleasant" task (a task that he does not like to do)  so that it does not take too long.  Maybe then your son will not get frustrated as often. (This is assuming that some tasks are a trigger for his outbursts.  If not the case, then ignore the last suggestion!)

Try to arrange the schedule at home so that there are routines and few surprises.  The more activities occur in a regular sequence each day the better.  Also, make sure your instructions or comments are stated in a way your son will understand.  Maybe make up a schedule you can post on the refrigerator each day with concrete symbols (pictures or words that are recognizable to your son) so that he can see what is planned.  

When there are outbursts, do not speak with him during these times, and make sure you are safe. You want to give him attention then when he calms down.  Sometimes we unwittingly reinforce negative behaviors because we give our children a lot of attention while we are trying to calm them down.  This usually backfires, because children will act in ways to get more attention.

I explain more about these and other ideas for parents in the first half of my parents' manual.  It can take several months to see significant changes.  In your son's case, you may need outside help, especially if his rages are dangerous.  Also, it may be useful to get someone to come in and interact with your son at home so that you can take a break some days.  You might want to ask your son's doctor how to access additional help in your state.   All the best, Dr. Dave Gottlieb