Tuesday, May 28, 2013

Aggressive 10 year old endangers others

Hi there.  I live in Canada and apparently psychiatrists here dont believe in diagnosing bipolar or any mood disorder for that matter in children.  My 10-year-old son has been diagnosed with ADHD and ODD and is on some pretty heavy meds.  He spent one year in a residential treatment school for his highly aggressive nature in order to learn warning signs and coping, however, he returned to his community school in January of this year and it has been a disaster.  

My son does not like competition and has been suspended for assaulting children he feels are not playing fairly.  My son felt one child in his class was asking too many questions, so took scissors and cut up the kids sweatshirt.  He has threatened to kill kids in his class.  He has delivered severe upper cuts to the face of his female educational assistant, has kicked the principal, consistently swears, and has thrown large rocks at three of his teachers earning  him not only another suspension, but a call to the Police.  When the Police arrived, my son swore at them and also threw rocks at them which resulted in him being handcuffed (for shock effect), which didnt work.  He has run away from school on a number of occasions.  

He has angry and very physically aggressive outbursts almost on a daily basis and then becomes extremely exhausted and needs to sleep afterwards.  When he wakes up, he doesnt want to talk about what happened, and presents as a very calm and loving child.  Its almost as if he is possessed when he enters these episodes and then he snaps out of it.  Aside from diagnosis (which I am curious for your feedback), what therapies would you recommend?  The schools have pinpointed, for the most part, his triggers, but it has also been decided that often there is no indicator.  He has hit me, his father, his sister, his grandmother.  Thankfully, he is extremely gentle caring and compassionate with animals and is a very smart kid academically.
Any thoughts?

Hi, It sounds like your son is extremely impulsive and aggressive toward his family, teachers, and peers.  In situations where the aggressive behavior can seriously harm other people, I would recommend a residential school.  I assume the behaviors you describe have occurred since he came back home from residential treatment.  If so, it sounds like he was released too soon.  There ought to be continual supervision and a very structured environment that only a residential placement can provide.  Was there improvement while he was in that setting previously?

The change in moods sounds dramatic.  He can go from gentle and caring to extremely aggressive and dangerous toward others.  I would not rule out pediatric bipolar disorder, but I cannot make a diagnosis without being there to evaluate your son.  I describe some of the criteria for pediatric bipolar disorder in my earlier books:  "Your defiant child:  Why is nothing working?"  and "Why is my child's ADHD not better yet?"   If bipolar disorder is present, appropriate medication should be considered.

Also you would want to rule out post traumatic stress disorder (PTSD) and fetal alcohol syndrome (FAS).  The former can be caused by being exposed to violence or sexual abuse, and the latter is caused by being exposed to large amounts of alcohol in utero.   FAS children can have extremely poor self-control, and it can take years to make small gains.  For PTSD children, there is a range of functioning, depending on the abuse and on the child's make-up, but intensive therapy can often help. 

In terms of behavioral treatment for your child, adults would need to intervene as quickly as possible when he gets angry, and be prepared to use physical restraints if people's safety is threatened.  Usually ignoring outbursts is indicated, but not when someone could be seriously hurt.  If some triggers are known, adults should try to avoid them or prepare your child in advance each time a known trigger might occur.    Some other ideas are to establish distractions that are highly engaging for your child,  and to go over "catch phrases" every morning before school  like "Sometimes I'm not going to like the way other kids ask questions or play games.  No one is perfect. Turn away if I don't like something."  These possible cues are in response to the triggers you mentioned in the first paragraph of your e-mail.  These and other approaches are outlined in my workbook on anger overload.  Keep in mind that any of these behavioral approaches will not yield immediate results, especially if there is a mood disorder or other serious underlying diagnosis. 

I would also recommend having your son evaluated at a major teaching hospital mental that is known to work with severe behavior problems and is aware of the kinds of mood disorders that can occur in children.  Best, Dr. Dave Gottlieb

Friday, May 24, 2013

Can a 7th grader recognize and prevent anger overload?

Here is an update from the parent of the April 4th blog post.:

We're in a bit of a dilemma here and I was wondering if you can shed some light on our situation.

Since our son had been receiving after school tutor from his teacher, things had really turned around.  We only had one outburst in 2 weeks (a definite first for us), and that subsided in less than 5 minutes (another definite first). 

So our goal was to have our son attempt his 7th Grade Math Placement test with minimal coaching from us.  The only thing I told my son to do was to do his best.  Don't purposely bomb his test, but don't worry too much as well...just do your best.  We were hoping that he would land in the middle tier ~ Pre-Algebra class, in order to eliminate a major stressor.

Well, as Murphy's Law would have hit, his teacher advanced him to the top tier ~ Algebra I.  I know that our son is naturally competitive, so he was really super happy/excited about it, but I'm worried that the Anger Issues would come back.  I asked him how he felt, and he said that "making the cut and getting into Algebra I is super good news!"  I'm just so worried, especially when things had been improving so much lately.  He even took the initiative by approaching his teacher and asked her whether there would be after school tutoring available for 7th grade.

I spoke with my mother about this, and she suggested that I talk to his teacher and pull him down to Pre-Algebra.  However, I'm more inclined to let him try out Algebra I since he took the initiative to seek out after school tutoring...ie, I'm thinking that perhaps he is recognizing his own stressors, and trying to work around it himself (by being proactive about after school tutor next year etc). It's almost felt like we just gotten ourselves out of shark-infested waters, and now we're diving back in again. My question is, in your experience, can a child recognize and adjust/work around their own stressors?  How would you approach this?  Please advise.

Hi, Yes children can develop greater awareness of their stressors over time and learn to use strategies that help them maintain self-control.  The second half of my workbook explains how to teach children skills to manage their own anger, and over time children will be able to recognize they are getting upset and apply a strategy in order to maintain self-control.  It sounds like your son realizes that the tutoring really helped him.  Is next year's teacher willing to be available after school?  Hopefully the answer to your son's question about this was yes, and hopefully your son and next year's teacher will have as good a rapport as he had with this year's teacher.

I would suggest you also sit down with yous son when everyone is relaxed (if you have not already done so) and talk about the dilemma you feel.  You could say you want to support your son's wishes to be in the advanced class but you worry that he may get upset if he has trouble understanding some assignments, and you wonder if it would be better for him to be in the other class where there would likely be less pressure.  You could say you are not sure, and you want him to be happy and not stressed out next year.  (By the way by predicting there will be some frustrating assignments, you are helping to prevent unrealistic expectations and thereby lessen the chances for anger overload.  Often anger overload occurs when children expect something that is impossible of themselves or of others!)

Your son will probably say he can handle the more advanced class.  Then review together what he will do next year if something is difficult to understand.   What are some ways he will try to handle it?  First choice might be to ask for tutoring.  You could say that you are proud that he already asked if tutoring will be available next year!  But what will he do if he has to wait a few days to get the tutoring?  What can he do then to help himself not get too upset?  You do not want to put him on the spot to answer these questions, but rather you want to open up a discussion about what some alternatives might be to help him cope with frustration when there are difficult assignments next year.  There is no one right answer.  You just want to think through together some alternative ways to help deal with possible frustration.

I would also mention to your son that despite all our efforts to prepare for the algebra class,  if it turns out the class is too difficult, you will ask the teacher to put him in the pre-algebra class.  You can explain that you know he will be disappointed then, but your first priority is your son's well being, and that this is more important than which class he is in.  You can say you love him and do not want him to be stressed out.  Worse comes to worse he can take algebra the following year.  

If your son has difficulty next year and you have to move him to pre-algebra, he will probably be quite upset despite your discussions about that possibility.  Ultimately, as parents we make the best guess we can about what our kids are ready for.  If you feel now that he is not ready, then make that decision without having the discussion with your son that I outlined above.  Once you have the discussion, if your son feels he can handle it and if he is able to think through how he will deal with frustrating assignments, you do not then want to say no.  Remember that either way it works out, it will have been a learning experience for you and your son.  He is on the path to understanding how to control his anger, and you have done a great job of helping him on this path..

All the best, Dr. Dave Gottlieb

Thursday, May 23, 2013

Is the anger overload workbook helpful for 5 year olds?

My daughter is 4.8 years old.  She has angry outbursts at home, which are manageable. She has anger outbursts in school.  They have to send her to the office.  The teacher is at a loss as to what to do.  Once my daughter gets angry, starts calling everyone stupid, it's really hard to say anything to her.  She will kick and scream if one even tries talking to her.

I am keeping it brief, b/c it's kinda late, but is your book something that would be helpful for me to read/appropriate for addressing this behavior at this young age, or is it more geared to school aged children?

Thank you!

Hi, The first half of my book explains interventions that an adult can use to help any age child with anger overload.  For your child who is almost five years old, I would recommend this part of my book.  The book is geared toward parents, but teachers can use similar strategies.  I explain how to identify a child's triggers, how to lower a child's expectations (sometimes unrealistic expectations can lead to disappointment and angry outbursts), how to re-arrange the sequence of events to avoid anger triggers, when to use distraction and calming techniques, and when to ignore.

The second half of the book is more for school age children and teens.  It explains techniques that children can learn to develop better self control.  Some young children can recognize when they are getting angry and apply a strategy, but many young children do not have great self-observation skills yet.  I explain in this part of the book how to start with simple terms, like colors, to label levels of anger.  This is a first step to help a child to develop self-observation skills; some young children can learn to say when their anger is "red hot" (very angry) versus "blue" (milder anger).  

However, I would start with the strategies in the first half of the book because these techniques are used by the adult.  Since the parent applies these strategies, it is not necessary for the child to recognize that he/she is angry.

All the best, Dr. Dave Gottlieb 

Wednesday, May 22, 2013

Angry 3 year old whose young brother died

Good morning.  I came across your name and information when searching for help for our defiant and difficult 3-year-old daughter.  We are suspecting she struggles with the "anger overload" you have studied.  She is a preschool student and, according to her teachers, she is very well-mannered, focused, and listens to instructions.  However, at home it is a different story.  She regularly wakes up angry and gets completely angry and out of control when she is frustrated with even the smallest thing.  She will have a meltdown if she doesn't get attention when she wants it, if she wants a different cup, if she can't get her shoes on, etc.  It turns into a meltdown and takes quite a long time for her to settle back down.  We spend our entire days tiptoeing around her and trying to head off any potential "catastrophes."

My husband and I are at a complete loss.  We are also struggling with intense grief, as our infant son was mortally wounded in the care of a daycare provider just a couple of months ago.  We are unsure of how our young daughter is affected by his loss as well.  Our daughter refuses to play by herself for even a few minutes and I am worried about this going forward as she will likely be an only child now.  She thrives in the company of other children, and I am a bit concerned about her over the summer when she no longer has that connection.  I am a stay-at-home mom, but looking for a part-time job.  However, I will admit I am very cautious now about daycare providers and worry about putting her in a new place - one that I am unfamiliar with.

I guess I'm just seeking advice on what techniques might work or might not work for her.  We have met with psychologists in the past but they really just lump her problems into the "terrible twos" phase and nothing more, which isn't helping us at all.

Hi, I am sorry about the loss of your young son.  It must be so hard to deal with your grief and at the same time have to deal with the angry outbursts of your other child.  Did your daughter's meltdowns increase after her baby brother died?  Young children exhibit grief in different ways and at different times.  If you think she is in part responding to the loss, you would want to consult with a mental health professional who who has worked with children who have experienced a loss.  There are also support groups for children and parents, such as Brave Hearts.

If your child's meltdowns began earlier, before the loss, there are likely other reasons.  One possibility is that she is wanting attention, as you suggested.  Three year olds are expected to do more for themselves, but often act like they need your help because they miss being taken care of (like when they were younger).  If you think this could be happening, you would want to give her a little assistance sometimes and see if she can do part of the task herself with you watching and praising her.  In this way she is getting attention for being competent.  You would not want to react with strong disapproval when she cannot do something, or when she is complaining (like about the "wrong" cup), because then she would be getting your attention at the wrong time; keep in mind that any attention, even disapproval, can be rewarding to a child.  Try to ignore some of her complaints, or distract her with a silly comment, a song, or by talking about something that is happening later in the day.

In my workbook, I offer strategies for anger overload.  I describe how to intervene early before the anger reaches the overload phase, when possible.  I also explain when to use distraction, when to ignore, and when to use calming strategies.  If your daughter is in the overload phase, you would try to say as little as possible, and try to ignore her until she calms down.

Since she does so well with other children, I would talk with the preschool teacher or other parents, and try to get some phone numbers so that you can arrange play dates over the summer.  When she is by herself, will she do better if you are nearby and she can interact with you some of the time?  Maybe work with her on an art project or puzzle, and then say you will be back in a few minutes, and tell her you want her to show you when you get back what she did while you were in the other room.  Some young children need more "touch base" time than others.  Her need for your constant presence will probably diminish as she gets older.

Take care, Dr. Dave Gottlieb

Monday, May 20, 2013

Outbursts and sensitive to criticism in school

I came across this blog after reviewing an article you had written. My son every year since 1st grade has failed one or more subjects, but the teachers place him in the next grade because he knows the work; he simply does not apply himself and the outbursts of anger/emotional behavior impede his performance in class. I have been told that he has done better this year and has shorter cooling off periods.

With me, I do not have the issues of these outbursts at home. He can be belligerent and non responsive to adults in general including me, but I don't see the anger fits. The school wants me to test him for ADD, yet I am trying to decide if the medication would make things worse or treat the root issues. I tend to believe situational circumstances have lead to this behavior and not a chemical imbalance. He was beat by his father when he was 3 several times; after the divorce the father took off and has seen my children once in 5 years. His dad calls and that seems to be a behavior trigger. My son has had to help with his sister, we have no family, and the only grandparents he knows do not spend time with us. Sometimes I feel his belligerence towards adults has to do with him feeling no one cares, or he sometimes feels he is an adult and equal to his teachers above other students. I have tried to correct this thinking numerous times. He is hypersensitive to any and all seemingly criticisms. The teachers feel he is impulsive, wanting to do what he wants to at times; I'm just at a loss. They say he is a sweet kid, but the acting out/anger pushes him over the top. I asked if depression could manifest as anger, as bipolar does not seem to fit as he is not a risk taker at all. I don't see the mania.

I am a nurse as well as my friends, one ICU the other pediatric. I thought perhaps I am trying to avoid the inevitable,  but they have known us for several years spending a good amount of time with us and also do not see him symptomatic of ADD. He does have issues with authority, but the rage seems to be exclusively at school. They do not want him held back and negatively effect the incoming younger kids, but they say his behavior does not warrant an alternative school. He doesn't hit or kick, it would be ripping up his assignments, emotional outburst, crying (mad), everything is measured by fairness in his mind. What should I do?

Hi, I would bring him to a psychologist who works with children and families in order to have him evaluated.  There are several possible causes of his behavior.  You would want someone to determine whether he meets criteria for ADD, post traumatic stress, anger overload, and/or self esteem issues.  You mentioned that he feels no one cares and that he is sensitive to criticism.  Do the outbursts at school come after he feels criticized, or are there other triggers as well.  You would want to identify the triggers and then brainstorm with his teachers to find ways to help him cope with the triggers.  

Sometimes a kind word will help insulate a child from criticism and thereby prevent some outbursts; I often suggest parents or teachers point out as many positive behaviors as negative, so that the child does not feel only criticized.  In addition, can some of the triggers be avoided by cuing him that after he finishes something he does not like he will then have a chance to do something he likes?  Of course this will only work if there is time for him to do something he wants after he completes an assignment.  Another possibility is to earn points that he can trade in for a reward at home later in the day.

For anger overload, my workbook outlines a number of other strategies to head off anger before it escalates.  You want to intervene early in a potentially difficult situation if possible, because it is harder to head off anger once it is in the overload phase.  However, if there are self-esteem issues, post traumatic stress, or possibly ADD, you would want to address these too.  That's why getting an evaluation by a mental health professional would be a good idea.  You want to know, as best you can, what the underlying issues are so that you can address each of them.  

One last thought:  It sounds like there has been some growth in self-control, since you mention that your son cools off faster than previously.  Is there something you or the school has done to help him with self-control this year?  Check with the teachers to see what they have done in class to help him cool off.   Once you find something that helps, continue on the track if possible.

All the best, Dr.Dave Gottlieb  

Tuesday, May 14, 2013

Possible bipolar, anger overload, and ADHD in 8 yr old

Dr. Dave,

Our son struggles with what I believe may be “anger overload”. His struggles are very much like what you and your readers have described in your blog. He gets angry when he doesn’t like what he is hearing, is sometimes told what to do, another child is annoying him and he can’t ignore the other bad behavior, makes a simple mistake doing his school work, or other similar situations described in your blog. Our son is incredibly smart, fast paced, and driven when he wants to do well at things. He sleeps well at night. He is currently in an ISE program at school and has his biggest and most often outburst there. They include hitting his teacher, spitting, throwing things, and tearing things up around the classroom. He sometimes finishes with crying saying he can’t help it. He has been suspended 5 times this school year so far.

We have been to more than one psychologist, and more than one psychiatrist. Mostly due to insurance reasons or others such as one doctor needing more information from another doctor first, etc. Blood work has been done. Our most recent psychiatrist  suggests our son has a mood disorder and has just recently put him on 150mg of Trileptal and plans to go to 300mg and then combine it with an ADHD medication (unknown at this point). When we question him he is very insulted by our questions being we have come to him for help.  But our pediatrician  suggests the psychiatrist has been doing this for a while and as desperate as we are we should listen and just watch our son carefully. As you probably know this med is usually prescribed for children with epilepsy and similar disorders. So it concerned us. Medicines were always going to be the last resort for our son. It’s just not what we want for him. But the school is becoming impatient.

Our un-trained thoughts are son doesn’t have ADD or ADHD. When he wants to do something he doesn’t show signs of attention problems. He is very easy to teach when he is interested. He is an honor roll student at school most quarters (but again he is only in 2nd grade). Most of his meltdowns are at school or with his mother when I am not home. Usually for the same reasons mentioned above. He goes to a friend's for after school care and he is PERFECT there. Zero incidents.

My questions to all of this is when should we decide a medication is or is not working? Our son will be on the 150mg of Trileptal for 2 weeks this week than we go to 300mg. At what point do you say this is not working and then we have to slowly wean him off the drug and begin another? Or are we still trying drugs too soon?  We have heard many say it’s the parents that need the teaching but no one seems to really offer this in our area and I don’t think the school will continue to wait before sending our son to an Academy for troubled youth.  

I am also interested in which book you recommend for us. 


It can be difficult to differentiate between anger overload and pediatric bipolar disorder.  For bipolar disorder there are usually frequent changes in mood (often daily) with some manic episodes.  The question is what constitutes a manic episode in children.  In chapter six of my book "Your child is defiant:   Why is nothing working?" I discuss the criteria for manic episodes and also discuss the criteria for ADHD.  Bipolar children are often pleasure seeking and take risks in order to seek out exciting or stimulating events.  When their desires are blocked by adults (because their wishes are dangerous or inappropriate) these children can react with rage.  The question then becomes is the anger overload you are observing with your son a symptom of bipolar disorder or just anger overload.  Many children experience anger overload, but only a small portion exhibit bipolar symptoms.  What your doctor tries to determine is whether your child has frequent changes in mood in addition to anger overload.   Since the diagnosis of bipolar disorder in children is continuing to be re-evaluated by mental health professionals (and will be re-defined in the upcoming diagnostic manual put out by the American Psychiatric Association), different doctors use slightly different criteria for this disorder.

Your son's psychiatrist feels your son meets the criteria, and Trileptal is one of the medications doctors use to treat bipolar disorder.  I am Ph.D. clinical psychologist, not an M.D. psychiatrist, so if you are unsure if the medication is working, discuss your observations with the doctor, or if he will not discuss it with you, maybe you could get a second opinion (although I see you have been to a number of doctors already). 

Regarding your observations about ADHD, it is not uncommon for children with this diagnosis to pay good attention when they are interested in a subject or activity.  The problem occurs when they are bored or when they are emotional.  Their attention ( and sometimes impulsivity) becomes an issue then.  So the words "attention disorder" is really a poor choice of words.  The problem is really "fluctuating attention," such that the ADHD child's attention drops off significantly (much more than for the average child) when the child becomes bored.

Regarding which book would help you, I'd recommend my workbook for parents dealing with anger overload so that you can try some of the strategies with your child.  The other book that would be helpful if you want to learn more about bipolar disorder and ADHD is one of my earlier books, the one on defiance (that I mentioned at the beginning of my response above) or our book "Why is my child's ADHD not better yet?:  Recognizing the undiagnosed secondary conditions that may be affecting your child's treatment."  In the latter book there is a chapter about children who have ADHD and bipolar disorder.  You can find my books by clicking on the photo of the child on this blog or by going to an online book site like Amazon or Barnes and Noble.

Hope you see some changes soon.  It sounds like you have been though a lot of trying situations with your son.  Hang in there, Dr. Gottlieb

Thursday, May 9, 2013

8 year old with anger overload, anxiety, and ADD

Hi Dr. Gottlieb,

I was very glad to find your article as it most accurately described the problems my wife and I are having with our 8 year old son.  For the most part, our son is a very happy, very obedient child with a very bright personality. He tries hard in school, has lots of friends, engages in sports and social activities. He lives a very healthy, normal life, and has two very loving parents. He is very sensitive, however, and on certain occasions he will act out with extreme rage, sometimes lasting up to 30 minutes.  The “anger overload” is always a disproportionate response to the situations that seem to trigger it.  We notice that his rage also seems to be coupled with anxiety. Examples of triggers can be: if he is unable to adequately perform a task in school or if he does not perform well in a sports. He actually does well but seems to set high expectations for himself. His teacher has even mentioned that he is doing quite well but tends to cut himself short.  He’s very hard on himself and calls himself “stupid”, the “dumbest kid in the class” or he’ll “never be good at anything”, etc.. 

Other triggers can be questioning our love or his acceptance from others.  For example, he blames his teacher for singling him out among others, over reacts to another child’s behavior towards him, or claims his grandmother favors his cousins over him. If we try to discipline him he responds with “I’m sorry” but often over uses it as a defense mechanism.  He can also misinterpret our disciplinary tone as being “mean” or that we don’t “love” him. Early on I felt that he may be trying to manipulate the situation but over time I’ve come to realize that these thoughts and reactions are very genuine.  The “anger overload” has been occurring more frequently at 8 years of age.  He also is very embarrassed and ashamed for his behavior after he feels better and does not want to talk about. 

Background: He has been diagnosed with ADD, had private tutoring and special attention in class that has helped to overcome some learning hurdles. He has made great improvements since the 1st and 2nd grades.  As a toddler he would sometimes hit a lot when he was unable to communicate verbally his frustrations and sometimes would hit his head on the ground in a temper tantrum.

A certain episode of “anger overload” just recently caught my attention.  He said things like “help me”, “you don’t understand how I feel”, “I wish I were a different person”, “I just want to leave everyone and live alone like a hobo”.  It was quite disturbing and frightening to see.  After we put him to bed my wife was in tears and I was at a loss.  I don’t know what to do and definitely want to deal with this head on before it gets worse.  Luckily, he has not been physically harmful to himself (only breaking pencils, swinging at the air or punching inanimate objects) or to others but obviously we want to prevent anything like this from happening if it goes untreated.

Hi,  In addition to using the strategies I outline in my workbook for anger overload, there is a brief discussion in the first half of the book about dealing with a child's insecurities.  Some children with anger overload are sensitive to criticism or have high expectations of themselves.  Basically, you want to work on his underlying high expectations.  One approach would be to sit down with him when everyone is calm and explain that you are supposed to make mistakes in school because you are still learning new things.  If you got everything right you wouldn't need to go to school, you'd be the teacher!  Then before school each day, you would mention a "catch phrase" like "it's good to make mistakes, it means you are learning new things" or "Don't forget to make a mistake today, and tell me about it when you get home."  

If he tells you about a mistake later in the day, be proud of him, and remind him that means he is trying new things.  Also, you and your wife want to model how to handle mistakes.  So when you forget something, or drop something, or make a mistake at work, mention it out loud at dinner time, or whenever everyone is around, and then say out loud a catch phrase like "everyone makes mistakes."  You are trying to help your son have a different set of expectations.  It will take a number of months for these new ideas to compete with his high expectations of himself, so don't be surprised if the negative self-statements continue for a while.  Over time, there will be a shift in his thinking about himself if you continue to seed the new, more realistic expectations.  Remember do do it calmly.  If he disagrees with you, do not argue with him, let it go for that day.  With one child, we even gave him points on a chart for telling us about mistakes he made in school.  The points would earn him a reward. 

For sports, you want to remind him of an appropriate catch phrase before each game.  In my son's case, he was a fan of Frank Thomas of the White Sox, so I'd remind him that even Thomas strikes out quite a bit.  I'd also remind him that the ball is small, so you are supposed to miss it a lot, or the game would be too easy.   The catch phrases were "you're supposed to miss, or the game would be too easy," and "even Frank Thomas strikes out a lot."  Depending on your son's expectations of himself, you would work out an appropriate catch phrase.

The feelings that he has about how adults love other people more than him may require more than catch phrases.  Children who are sensitive and who have ADHD notice that they often get reprimanded more than other children.  If your son is impulsive (which some ADHD children are) or if he is distractable, the teacher or other adults may need to remind him to pay attention or to slow down.  These children need an approximately equal number of positive comments during the day to help their self esteem.  Ask the adults who work with him to try to remember to notice things your son handles well, and to make brief comments admiring him.  Explain to your son that the ADD means he may be reminded of things more often than some kids, but that's minor compared to how smart and lovable he is.  Then give him a few examples of his positive qualities.  It will take time for your son to really feel okay about himself.  You may want to consult with a psychologist in your area to work on this issue in more detail.  

The comments your son made recently about wanting to live alone like a hobo and about wishing he were another person illustrate how hurt he feels sometimes, and I can see why your hearts go out to him.  It's a good idea to make an empathic comment at these times, like "I can see how hurt you feel when..."  Hopefully, the interventions in my workbook and in this posting will help him feel less hurt.  But sometimes children with ADHD, and children who have anger issues, do become depressed.  If he regularly makes comments that indicate he feels worthless or hopeless, and/or if he loses interest in doing activities with other people, it would be important to consult with a mental health professional in your area. 

All the best, Dr. Gottlieb

Tuesday, May 7, 2013

Happy 14 year old but angry outbursts

Hello Dr. Dave,

I luckily just found your blog after days of research:  My daughter sounds JUST  like the post from Sept. 12 ….  I’m going to buy your books today !  I think she’s always had “Anger Overload”.

I am desperate to get her more help and trying to figure out where to bring her, etc (If you happened to have any recommendations in the Los Angeles area,  they would be GREATLY appreciated … ?

I have a 14 year old daughter living with angry outbursts most of her life but otherwise happy.   She sounds SO  similar to the Sept post …. On the outside she does really well; school, social, sports, friends and looks like she has it all and never acts up or get angry at school, etc – she does get quite moody with friends on occasion.  (She’s always been very spoiled materially by her father and perhaps I’ve  over-nurtured her but I say no a lot to stuff! so to speak)  By chance I’ve been a stay-at-home mom,  I also have a 16 year old son who’s just been diagnosed with ADD – he’s a good  even-tempered boy who’s always been a little “absent minded” but he’s bright, easygoing and does well in school -  They used to get along really well as kids but now basically can’t be in the same room, and this hurts her.

The family is still living under one roof  but basically they know the parents aren’t on the same page (not even the same book!).  We do need to fix the living situation and make changes soon – it so not fair to the kids and not the way I’d ever expected to live.   Their dad has always been very hot-headed and impulsive and childlike, etc (never diagnosed but difficult) , it’s not a good situation but no fighting just underlying bitterness and lack of communication.   I’m inclined to nag and be the peacekeeper – always the sensible one and I give in to things just to keep the peace )

Anyway – back to my daughter;  she can be the sweetest, caring, empathic person.  She’s very humble, being surrounded by teenage bragging etc – She is very sensitive and has been isolating herself recently .   She is seeing a therapist who I find out she’s not that comfortable/truthful  with – we are doing a DBT workshop together but that doesn’t seem to help …. I think she needs to be assessed again and don’t know where to start?

She’s a high achiever at school and stresses over the smallest thing, very conscientious and can be a teen “drama queen”  – last week she had a big speech to write – well she had just watched “Silver Lining Playbook” – she choose to write about “Bipolar Disorder”;   She then  had a lot of anger last week, and has just  told me she’s had a recurring dream about being in a mental hospital and she has  diagnosed herself as Bipolar. 

She did rage at me the other night and hit me … She has hit in the past but it’s been a very long time ….   And sadly she’s always been prone to throwing things when she’s angry …. (lack of sleep was an issue last week – something I’m generally careful with)

I’m trying to find a psychologist to have her assessed and going for a “biological” check up with the pediatrician .

I’m sure she’s depressed and therefore rages more etc …. I know she’s hurting and want to help.   I’m worried about her being misdiagnosed.   Any suggestions would be greatly appreciated.  Thank you.

Hi, I don't know specific psychologists in the L.A. area; maybe start with your pediatrician for suggestions, or a major medical center like UCLA, or check with the California Psychological Association.  Most states have psychological associations that can give you a short list of people in your area who work with  teens and families.  Then you'd want to ask the psychologist whether he/she works with anger issues, and whether he/she works with teens as well as parents.  I find in most cases it is helpful to work on strategies with parents and the teenager.  Parents and teens each may have ideas about possible anger triggers.  In addition, many of the strategies involve parents and teens working together.  The second half of my workbook on anger overload explains how to work together, for example, teaching your teen about other points of view, and how to use catch phrases to help your teen think before acting out her anger.  Most teens cannot develop these skills alone.

Individual therapy can be helpful though when there are underlying problems, such as worries about family, friends, or school.  Teens may want to address these concerns without you in the room.  So ideally the therapist is able to assess the problem in the first couple of sessions, and then work with the family and/or the teenager. 

The two diagnoses that are sometimes mistakenly used for teens who get angry are oppositional defiant disorder and bipolar disorder.  Many teens who have anger overload are not usually defiant.  They just have difficulty when they get really angry.  Further, they do not usually have a mood disorder.  For bipolar disorder there would be many other mood related symptoms besides anger overload.  By the way it is not unusual that your daughter might think she has bipolar disorder after reading about it.  Any of us may think we have a disorder when we first learn about it; we call this "medical students' disease" because when medical students are first learning about diseases they think they have them.  When they get more experience they realize they don't!

All the best, Dr. Dave Gottlieb