Wednesday, April 24, 2013

3 year old with ourbursts in preschool

I have a 3 yr old son who has not been officially diagnosed, but from an article of yours I read it does describe his behavior. A few weeks ago we met with my son's preschool director and teacher, and they told us he had had a few episodes of behavior that were unexpected and uncontrollable, and they did not know how to manage him. They asked us to seek outside help, so we have an appointment with a child psychologist coming up soon. In the meantime we had to pull him out of the preschool, because he was screaming and crying every morning that he did not want to go, and then I would get calls from his teacher about bad behavior. It just became too stressful.  Since then he has been home with grandparents, and he has been really well behaved for the most part. We are now debating whether we should try another preschool or keep him home with a nanny.  At home the behavior seems like can be managed, however we feel if we put him into a preschool it will help him deal with issues now rather than when he gets to kindergarden. We are trying to find a preschool with teachers that are nuturing and can work with him. What are your thoughts, should we keep him home or try a different preschool?
Hi, You ask a good question, and I'd recommend you gather some more information and consult with your child's psychologist.  In my manual on anger overload in children, I write about the importance of recording several situations when a child gets angry, and see what some of the precipitants are.  Then you can talk with the preschool staff and with the psychologist about 1) whether these are situations that can be avoided, or 2) whether behavior modification (rewards and consequences) might help, or 3) whether your son needs some more time at home with fewer emotional and social demands for another year.  Let's look at the possibility of avoiding some stressors first:  If there is a patter of outbursts around a cerain toy for example, can the situation be structured so that the toy is only taken out at certain times, or can a timer be used to indicate when it is time to take turns?  The basic idea is to prevent outbursts by altering the situation so that your son might be less likely to get upset.  I write more about this approach in the first section of my parent's manual.
The other basic approach for three year olds is to use immediate short term rewards and consequences in order to try to motivate your child to behave differently.  The behavioral goal must be explained concretely to your child ahead of time, and must be in his behavioral repertoire (i.e. it could be one or two words or a gesture that would be something a three year old is capable of; you would not expect him to use words that an eleven year old might use).  However, once your child is in anger overload, you would not talk about rewards or consequences.  In fact, if your child is extremely angry, the teacher should say as little as possible until your child calms down. 
The third alternative is to wait if you feel the social demands are too difficult at this age, or to try a different preschool that may have a structure that is easier for your child.  Some children at age three get overheated very quickly when they have to share or switch activities, for example.  I would consult with your child's psychologist to help you decide whether waiting a year for preschool would be better.  Often there is no one right answer about when to start preschool, and if you have a good nannny, it is okay to wait a little longer to expose your child to preschool and to its social expectations.  I understand your concern that he learn how to relate to other children, and in the meantime, maybe there is a parent/child activity in your neighborhood where you and your child can interact with other young children and their parents.  Some young children do better in a child/parent group for six months to a year, before introducting them to a preschool.  All the best, Dr. Dave Gottlieb

Tuesday, April 9, 2013

8 year old with ADHD and anger overload

First of all, I want to tell you how thankful I am that I found your article on anger overload.  I had been struggling for months with these meltdowns with my son and had figured out some strategies that worked but just didn't have any answers.   I was feeling alone and quite frankly pretty hopeless when I finally came across your article.  It explained my son exactly and was a huge relief to me that I was doing some things right.  I have purchased your parent's manual and plan on implementing your strategies in finding even more success with my son.  Thank you for giving me hope.
I have a few questions for you regarding anger overload.  My 8 year-old son has ADHD and is in 2nd grade (repeating).  His pediatrician diagnosed him in May of last year and he has been taking Strattera ever since.  He was doing very well on the Strattera (combined with a daily report card), was showing improvement with his work in the classroom and at home, and seemed very happy in school.  Then in November a new special needs student entered his classroom.  This student cries, screams, and disrupts the classroom on a regular basis.  This is highly stressful on my son, from comments he has made to me.  The time period that this student entered his classroom is when I started seeing these anger overloads in my son at home.  Being that everything is consistent at home and had not changed at all during this time, I really felt this student was the underlying factor in my son's behavior. 
His meltdowns are always with me, and have never occurred at school.  Is it possible that he is holding all of these frustrations in at school and then they are triggered at home with me? Do children with this problem sometimes only exhibit this behavior at home? 
I also wanted to know if you have seen Strattera cause a higher incidence of these anger overloads in children?  Or make the anger overloads more severe?  I am just concerned because I have seen improvements in my son with the meds, but I wonder if these anger overloads are reason enough to take him off of the medication.  Honestly, I have received very poor or no advice regarding his medication and these meltdowns.
Thank you very much for your time.  I greatly appreciate any information you can share with me.

Hi,  In answer to your first question about whether children often have anger overload at home and not in school, the answer is yes.  Often this is the case.  I think these children try really hard at school to control their emotions because they do not want to be embarrassed in front of their peers and/or do not want to get a detention.  Many children let their guard down at home, or like you said, they have worked so hard at school to control themselves that they have difficulty maintaining self-control later in the day.  Also, I think children know their parents are more likely to listen to their complaints.  Parents need to be careful to not give their time and attention when their children are in overload because that usually increases the frequency of anger overload in the home.  In my book, I explain how to catch anger early (when possible) and use "emotional distraction," but when you can't catch it early, try to ignore your child during an outburst.  I know that is not easy to do!   I also explain when to talk with children about their behavior and how to encourage children to use various techniques, such as catch phrases, to help them deal with their anger.

Since you have had a good experience with Strattera for your child's ADHD symptoms, I would be hesitant to change course.  It does not sound like your son's outbursts increased when he started the Strattera, but if they did increase when you started (or increased) the medication, then I would recommend you consult with your child's doctor.  A possible side effect with Strattera is increased moodiness, but I have not seen this in children I have worked with.  Also, you should know that I am not an expert in medication; psychologists in my state cannot prescribe, so I leave it to child psychiatrists and pediatricians to handle the medications.  
From your description it sounds like your son's anger increased when the new student entered his classroom in the fall.  See if you can talk with the school staff about your observation and work with them to reduce the effect on your son.  Maybe also talk with your son from time to time when he is calm about this child and how he could try to tune him out.  In my parent's manual, I write about the importance of reviewing alternatives on a regular basis later in the day when children are calm and not busy with another activity.  You could also brainstorm with the school about ways they might help.  Would the school allow him to get up and get a drink if he needed a break?  Could he use ear plugs for a few minutes until the other child calmed down?  Could the school remove the other child more quickly if the child begins screaming?  The key is to talk with your son and with the school about what would work best in that school setting.  All the best, Dr. Dave Gottlieb

Thursday, April 4, 2013

12 year old is having fewer outbursts

        Hi, I receive some notes about children who have improved, and I wanted to share this update on the blog because it explains the various changes these parents made to help their son develop better self-control.  Notice that there are a combination of changes:  from altering a stressor (math class) to walking away during a tantrum. Also, note that there are still some outbursts, but the frequency has gone down significantly.  There are changes over time, rather than a quick fix, in most cases. (For the original description of this child's behavior, go to the Nov. 7, 2012 post on the blog.)  Here now is the update: 

Hi Dr. Gottlieb,  Although there are still occasional anger outbursts, the frequency has declined dramatically, for several reasons (I believe):

1.  We are so extremely fortunate to have a Math teacher as dedicated as our son's.  After explaining that our son was having a lot of issues stemming from his anxiety in Advance Math, she went above and beyond her duties, and had been staying after school, as well as, during lunch to help him with his homework.  She also promptly gave him an "award" for "Most Improved Student" last month to boost his morale.  Although his grade has only improved slightly, that gave him a peace of mind immensely.

2.  He is less aggressive with his sister, after we explained that he is her leader, and she looks up to him.  He really took that role as "Big Brother" seriously now.

3.  He has not had any physical episodes with me since we implemented all these changes.  There were still a few 'shouting matches," but those subsided much faster than before.

4.  My son seems to be more aware of his actions now, and it helps that I just walk away when he escalates.  That "little break" helped to calm him down and he is managing to calm himself down quicker as well.

5.  We also told our son that if he finds Adv Math too challenging, he can go back down to his own grade level next year.  That option seemed to sit very well with him as well.

I understand that not one single thing brought on these changes, but I truly believe that your suggestions set us on the right path. 

In addition, and I'm not sure if it's just coincidence, however, we have permanently eliminated all his TV programs.  It took a few months to adjust and it was tough at first.  But now, he seems a lot calmer now.  He only watched Disney and Nickelodeon channels before (so nothing violent), but even those programs seemed too stimulating for him.  He is still allowed occasional movies, but no more regular TV shows.  Perhaps there is a strong correlation between his anger outbursts and television.

I just wanted to give you an update, and also to say thank you for everything.

Wednesday, April 3, 2013

Finding a professional to work with

Hi Dr. Gottlieb:

I write to you because I read your article today and finally I could give a name to what I have been dealing with my son for the last 8 years .  I am writing from Norway and here in this country, I believe that this disorder is very little known.  My question is do you know anybody in Norway who could be treating this disorder here ? If not, is there someone else in Scandinavia that I could contact?  I believe that many kids in this country haven´t been diagnosed yet.  I really need to get this information to this country.  I believe that I am not alone and that a lot of families need information of the treatment for this disorder.

Hi, Unfortunately I do not know who to recommend in Europe.  Maybe you could print the article, or sections of my blog:, or my parent's workbook (available from Amazon:  Anger Overload in Children: A Parent's Manual) and show one of these things to a professional and see if they use similar methods.  My blog (see the Feb. 25, 2013 entry) also has one previous answer to a parent about picking a mental health professional.  Basically, I said there you want someone who works with parents and children, not just children, and someone who teaches strategies parents and children can use at home.  All the best, Dr. Gottlieb