Tuesday, February 26, 2013

Sensory overload and anger overload in 5 year old

I am writing in regards to my 5 year, 10 month old daughter.  I am a pediatric speech pathologist and have worked on a multidisciplinary team with pediatric occupational therapists for 14 years.  I have always described my daughter as "spirited"!  Very active, risk taker (climbing things at a very early age, no fear, etc).  She screamed for about 18 hrs/day and slept very little the first 6 months of her life, which I wrote off to severe reflux (which she was medicated for), but now looking back, I feel like she has never been able to regulate her body on her own.  We had to swaddle her extremely tightly, rock her, shush her, bounce on a ball, etc to even begin to calm her and most times that didn't even work, but she has ALWAYS needed help calming down when she gets amped up....what I would call in therapy terms "dysregulated" or "sensory overload".  This is when she displays the exact symptoms of what you are describing as Anger Overload and your article describes her perfectly.  When she is "regulated" and in a good space, she is kind, compliant, sweet, caring, creative.  She can attend to tasks--even non-preferred tasks if she is not on overload.

She does not kick, bite, hit or get violent during her meltdowns  (although she did go through a pretty bad biting stage in her two's even though her language was excellent).....she just cries, screams, holds her head and will yell things like "You just don't understand...my body just can't think" or "My body is just so angry right now I can't stand it".

We learned a long time ago that talking to her in that moment does not work, that she will only "hear" us when she is calm, but even though she is bright....it doesn't deter the behavior from continuing to happen.
I have tried everything I know to do from a regulatory standpoint.......exercise breaks, breathing balls/techniques, picture schedules to make routines easier (even though she is ahead in communication skills), making a frustration jar with glitter to shake, giving her heavy input/tight squeezes.  She ABSOLUTELY cannot access her frontal lobe functions when she is in this state.  Is this what you mean by anger overload?  Does it mimic regulatory dysfunction?  If not....how would you separate the two?

My other question is.....besides behavioral strategies, is something like this ever treated with medication?  and if so, would it be and ADHD med? SSRI? something else?

I really appreciate your help.  I have used all the tricks in my bag and am at my wits end, because I can't stop her blow ups.  I have tried tracking data to find her antecedents, and can control them maybe 1/10 of the time.  Luckily, they are only happening with us (parents) and not at play dates or at kindergarten...yet.

Hi, It sounds like one precipitant for your child is sensory overload.  I find that some children with extreme reactions to frustration (i.e. anger overload) also have sensory overload and some do not.  Some children only get dysregulated when angry, whereas other children have difficulty with sensory overload in general.  Regarding your description of your child's free spirited nature, I have found that many of the children with anger overload are also free spirited or headstrong, but not all.  In an earlier book I wrote (called "Your child is defiant: Why is nothing working?") I have a chapter on strong willed children who also have anger overload.  When anger overload occurs along with a strong willed personality, or along with sensory overload, then you will need to use a number of strategies, and it will take more time to help (probably over the next year or two you will see improvement, as opposed to just months).

I like a lot of what you are doing for sensory overload.  I would recommend some additional strategies specifically designed to help with anger.  You are right to wait until she calms down before you talk with her.  One really good sign is that she can verbalize at times that she is so angry.  The goal over time is to help her recognize early warning signs, because it is more likely that she will be able to calm herself the earlier she realizes she is getting frustrated.  In order for this to happen, in the beginning you will be the one to try to pick up the early signs and precipitants.  After an outburst, you want to record what the sequence of events were leading up to the blow-up.  The more you do this, the more you will see patterns.  You will not be able to anticipate many of the outbursts, but hopefully you will be able to some of the time.  

In my book on anger overload, I describe how to use "emotional distraction" and calming strategies in the early stages.  Many of the calming strategies overlap with what you are already doing, like the using the ball or blanket to help her soothe.  As for what I call  "emotional distraction," this works by re-directing the child to something that makes them laugh, or feel happy, or stop and think, such that they forget about their frustration for a few moments.  

In the second half of my book I describe strategies to teach to your child.  The one I would begin soon with you child is introducing a color labeling system for the levels of her anger--blue hot might be for low anger, orange hot for medium anger, and red hot for extreme anger.  See if she can eventually use these words.  You would tie the blue and orange labels to certain calming activities, and reward her for trying them, whether they work or not.  Sometimes your child will still move on to the red stage.  But if she tries, she is on the right track, so I would think about short term rewards for later that day.

The other approach is to plan events to avoid certain frustrating situations.  For example, if you have determined that stopping a video game often leads to an outburst, you might limit video games to days where there is more time.  If you cannot avoid a trigger, then you plan ahead and predict for your child that she will need to shift gears at a certain time of the day, and then you give her another warning five or ten minutes before the change will occur.  I also describe in the book ways to lower your child's expectations (if her high expectations are a trigger for anger overload).  

Your question about medication is a good one.  I will answer from my experience seeing children as a psychologist, but I do not prescribe, and I would recommend you check with a pediatric psychiatrist.  My experience is that ADHD medication does not help unless the child also displays symptoms of that disorder.  There are some reports in the research literature that SSRIs help some adults with severe anger problems.  With children, I have seen them help sometime when the child also shows frequent signs of irritability (even when not in overload).  Some children are prescribed mood stabilizers or the atypicals, but these can have significant side effects, so they tend to be a last resort.

I think that some day we will be able to do imaging studies of the brain that will show that in many of these children there is immature development of the pathways between the amygdala and frontal cortex, or immature development in the frontal cortex.  The ventromedial frontal cortex has been found to be different in adults with anger problems.  But there is a lot of growth in the frontal cortex throughout childhood and early adulthood,  and many children improve with repeated practice of the kinds of exercises I have outlined.  As you know in your work, the brains of children are quite malleable, and there will be a lot of development during the primary grades for your daughter, so keep trying different strategies and see what works best for her.  Progress may be slow for a while and then you may see a jump in self-control.  It is like the strategies click in, maybe because at the same time there is a leap in brain development.  All the best, Dr. David Gottlieb

Monday, February 25, 2013

Finding professional help

I have a sweet and cooperative child that has had anxiety and anger bursts as long as I can remember. Reading your blog has brought an extreme amount of relief knowing that I am apparently not alone.

I am searching for a psychologist in the Houston area that possibly could help. Would you have any recommendations as I would obviously prefer to visit with one familiar with anger overload?

Hi, I am in the Chicago area and don't have a specific recommendation in Houston.  However, I would make these suggestions.  You want someone who has worked with parents and children on anger issues.  With younger children (pre-teens), it is especially important that the mental health professional meet with the parents at times (either along with the child or separately) and not just see the child.  Since many children do not yet recognize when they are getting frustrated and are likely to "blow-up" if no one intervenes, it is important that parents be ready to deal with potentially difficult situations. Parents need to have in mind several strategies to use in anger-provoking situations.  Parents can then apply a strategy and sometimes prevent blow-ups, or guide their children so that anger can be more easily controlled.   Also, I find it is real helpful if parents can review anger arousing situations with their children after everyone has calmed down, rather than wait until the next therapy session, by which time the child may have forgotten what happened.  Many of the strategies that I outline in my book involve the parents taking the lead.

So if the therapist wants to just meet with your child and not with you, ask why.  If there has been a trauma in your child's life, it might make more sense to meet primarily with your child, but if your child has experienced anger overload over the years and there is no clear precipitant, then it is unlikely your child will learn to develop better self-control without your help.

You might want to ask your child's teacher or pediatrician for suggestions of therapists in your area.  Also, you could ask if the mental health professional in your area has either heard of anger overload or of the diagnosis called  disruptive mood dysregulation disorder (or DMDD).  In the new diagnostic manual (for mental health professionals)  that is coming out in a few months, there will be a diagnosis  DMDD that is similar in many ways to anger overload.   Anger overload is a phrase I coined twelve years ago to capture the extremely angry outbursts some children (and teens) have when they are disappointed or frustrated . The main difference between anger overload and DMDD is that for anger overload the child does not necessarily exhibit irritable mood in between outbursts, whereas for DMDD, there is a continual mood issue.  But in both cases angry outbursts occur regularly.  So if the therapist is familiar with DMDD and how to treat it, the therapist should be able to help with anger overload.  I hope this is helpful, Dr. David Gottlieb

Wednesday, February 6, 2013

5 year old with anger and anxiety

Hello,  I just read an article regarding your book  Anger Overload in Children. Would definitely want to read the book. I have few question/ concerns regarding my own son who is 5 years old. He is one of the twins. He is a very emotional child ( my husband is also very emotional). He does not have many friends in school, only two of them. He is generally very good to his twin sister, but at times hits her, when she does not do as told by him. He gets upset very often, he won't listen or understand something that is not correct according to him. Does this happen with 5 yr olds?

When we go out to a  mall, my daughter and son always want to buy things, even if they have been told that we are not going to buy any toys as you have loads of them already. Any major toys will be purchased only on birthdays, though we keep buying books for them and never say no, if we come across any. Even when we go to any restaurant or any family gathering, we instruct them, especially my son, that there should be no crying, whining, screaming; whatever is troubling them should be talked out to either of the parent, and yet we have an outburst each time.

My son does not like crowds, so even any birthday parties of his friends, I always have trouble with him, he would not participate in any games, or dance, he is just sitting with me all the while.  Any attempt to make him participate would be followed by an outburst at the party, though he mentions later that he did like it at the party. He also gets up each morning crying, wanting me to be by his side when he wakes up (which becomes very difficult, as there is always a rush in the mornings).  Every attempt to make him understand fails, as he does not want to listen to what according to him is not right.

I have consulted with a Developmental Pediatrician here, and she suggested some discipline methods that, unfortunately worked for sometime and again its the same. I would highly appreciate if you can suggest what could be the reasons for such behaviour and what can be done to calm him down.
Hi, I would suggest you also consult with a child psychologist.  There could be several causes for your son's behavior, and an evaluation by a mental health professional who works with children may help you decide on the best course of action.  Here are some of my thoughts:  your son's anger may be part of an underlying anxiety disorder or social developmental disorder.  You note that he is uncomfortable in crowds, and shy at birthday parties.  He also shows some signs of separation anxiety:  he has a hard time leaving your side at the parties and also wants you by his side in the mornings when he wakes up.  What an evaluation by a mental health professional could determine is whether your son's anxiety is part of a social developmental disorder (in which case therapy would focus on social skill development) or is a sign of separation anxiety (which would call for somewhat different suggestions to deal with the anxiety).  It is hard for me to tell exactly what is going on without someone doing a more complete evaluation.  You are right to be concerned and to look into what is underlying his behavior.  Early intervention is a good idea. 
Your son's anger and frustration might be part of the social or anxiety issue, in which case it would improve as those issues are worked on, or his anger may be somewhat separate.   If it is the latter, then the strategies I recommend in my book would help.  One recommendation in my book is to re-arrange the sequence to avoid certain triggers of your son's anger.  So if going to the mall is a difficult situation for your son, I would take him less often.  With birthday parties, I would recommend you continue to take him, but I would not force him to participate.  What I recommend instead is that you sometimes get a little busy at the parties talking to the other parents.  Maybe your son will eventually model your behavior and talk to the other children.  Also, if you are busy part of the time, he may get tired of sitting there doing nothing.  However, if there is an underlying social or anxiety disorder you will have to go slow with this, and you will need to work with a psychologist on how to develop his social skills.

When he gets angry and hits his sister, I would use some behavior modification strategies, such as a short time out.  In addition, I would try to intervene early (if there is a chance to intervene when he is starting to get upset).  Sometimes children's anger escalates so fast that it is hard to catch early.  If you can catch it sometimes before there is an explosion, then use distraction, or separate the children by getting  one of them interested in a different activity.  Another strategy is to reward both of them with a small treat or a hug if they can play together without fighting for a certain period of time.  It sounds like they do cooperate much of the time, which is terrific.  All the best, Dr. David Gottlieb

Saturday, February 2, 2013

7 year old whose biological mother smoked crack cocaine

I have just discovered your 2002 piece on Anger Overload. This is our turning-seven daughter!  Wow!  She was tox positive at birth, so probably does have a few neurological bees in her bonnet.  Turning the tv on and saying "hey, your show is on," shifts her behavior very quickly, but its been hard to heft our tv around (just kidding), and people keep saying it's reinforcing.  I think of this anger as the survival fight or flight response turned up to 11..  Old brain overpowering new brain.

The inability for her to be calmed, or to be rational, we call "brain-lock."  My concern is tantrums begetting tantrums; the more tantrums she has, the "shorter" the neural pathway becomes getting to rage when "threatened."  I would like to use use a non-permanent course of anti-depressants which might enable her to learn self-soothing, and maybe (?) slow her response time to perceived threat.  She has been evaluated, head-shrunk, stickered, timed-out, restrained, charted, etc. etc. etc.; meanwhile, her self-esteem gets lower and lower....

Are there any practitioners in North Carolina who treat kids with this profile or train their parents?
Thanks for any help,

P.S. Her memory and IQ are over the moon, possible ADD, possible ODD (but she does have the sweet and caring disposition your article mentions), anxiety, depression, and sensory processing disorder.  She gets monthly OT for SPD. She was removed from her birth-mother at 5 days ( full-term, 5 pounds 12 oz), and has been with us since, and adopted at 20 months.  Birth mother and father chain smoked, used crack cocaine, and presumably other recreational/street substances.  Her happy, quiet, calm began to change at about 3 years.

Hi, I would recommend an evaluation at the Duke child psychiatry department.  Duke has a good child mental health team and they could do a multi-disciplinary evaluation and make treatment recommendations. They would also know some good practitioners in your area.  Given that there are probably some neurological issues, possibly related to her biological mother's drug use, I like that you have had her to psychological and occupational therapists.  It is possible that anti-depressant medication and/or ADHD medication may help, but I would get a work-up first from a psychiatrist and/or neurologist who specializes in children.  Changes may be gradual if your daughter's biological mother used crack cocaine on a regular basis during pregnancy.  Children who have been affected by drug and alcohol use in utero can still learn over time to develop better self-control but it will take more repetition and more time (over a period of months and years).  Your goal would be to reduce the frequency and severity of outbursts, but there still may be some outbursts when her brain gets overheated. 

In terms of psychological approaches, I like that you are using distraction techniques.  I would recommend you try to determine as many of her triggers as you can, and pick a couple to start with, and develop routines to alter the chain of events.  I describe this process in more detail in my book, but essentially you would arrange routines to avoid as many triggers as you can.  For example, if a trigger is getting ready for bed, you would arrange the routine so that getting ready for bed happens earlier in the evening and is followed by something your daughter likes to do, such as to play a game with you. 

You would also use behavior modification techniques but the reinforcements would need to be fairly immediate and you would probably have to vary them in order to continue to hold your daughter's interest.  Rewards and consequences do not work well when children are in the midst of a tantrum, though, so when your daughter is in overload, I would recommend not talking with her, unless she is harming herself or someone else, in which case you would have to intervene.  Once the tantrum is over, you can either talk about something else that has nothing to do with the tantrum, or sometimes later in the evening you would review what you think triggered her and what she can do instead next time she is frustrated.  Try to pick an alternative that your daughter would be likely to do.  If she uses physical releases, pick something she can do physically that is not harmful, and gradually try to move her in the direction of using words to express her anger (in the beginning she does not have to use polite words!). 

In my book, I also describe cognitive behavioral approaches, such as having cues (one example is to use colors to cue your daughter that she is beginning to heat up), teaching calming techniques, and teaching children to consider alternative points of view.  These latter ideas work better once a child's anger is not too extreme, and once a child realizes she has an anger problem.  If she is not ready to look at her anger yet, then you would stick with the techniques that I describe in the first part of my book, techniques that do not require her direct participation--like when parents re-arrange the sequence of events to avoid triggers or to re-arrange the sequence so that something she likes to do comes last. 

You sound like you are already on the path, and you have good ideas.  I would not worry too much though that her current tantrums will shorten her neural pathway and lead to more tantrums.  As the frontal cortex develops over time, children are better able to learn self-control techniques.  In fact the cortex keeps developing even past adolescence.  Continue your efforts to help her brain development along, and get a multi-disciplinary evaluation when you can.  All the best, Dr. Dave Gottlieb