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

Tuesday, June 25, 2013

5 yr old's anger: Low blood sugar, psych triggers

Hello Dr. Gottlieb,
I came across your article and just bought your book (waiting for delivery) Anger Overload for Children - A Parent's Manual. 
Our daughter is 5 1/2.  The summer before kindergarten she began having angry outbursts.  She'd first make angry faces like she was about to explode, then it started more often when she did not get what she wanted - no matter how minor.  It soon became - "I hate my family - I wish I was not part of this family - and you all hate me - that's why you are mean to me".  This only happens maybe 2-3 times per month - but the minor rages are often daily. They tend to last 5-15 minutes at most.

She has a 7-year old sister who often takes advantage fully of the 18 months more experience she has and pushes her buttons. The most common anger explosion is between her and her sister and it’s not unusual for her sister to have legitimately done something mean to trigger it - but the response of course is extreme.  Sister is generally very kind with no unusual behavioral problems.
The anger also often happens on play-dates when things don't go exactly her way.
It’s escalated in the past week where she'll just explode and go on a rant of how she wants another family.
While her teacher recognizes that she has a bit of an "edge" there have been no behavioral issues noted from school or from after-school programs she participates in. 
Does this seem to fit your concept around anger overload?  Could there be a link to low blood sugar?  (most outbursts are late afternoon or early evening between meals) Should we consider therapy or a child psychologist?

Hi, Yes, your description of your daughter's outbursts sounds like anger overload:  relatively minor frustrations lead to severe outbursts.  If your daughter's blood sugar drops significantly in the late afternoons, this could be a contributing factor.  Check with your child's doctor to rule out any serious medical conditions, and also consider giving her a snack every few hours.  Re-evaluate in a couple of weeks after you start the snacks and see if they have reduced the frequency of outbursts.  

You would also want to keep track of some of her psychological triggers (i.e. conflict with her sister, frustration with play dates).  Are there others?  Then think about how you can "re-arrange the sequence" (if possible) to avoid the triggers, or "inoculate" her before a play date, or teach her to become more aware of her triggers (the strategies that develop a child's awareness usually work better with children who are a little bit older).
By "re-arranging the sequence," I mean that you try to avoid certain situations that precipitate her anger.  For example, if she and her sister get into it at a certain time, try to get one of them to be busy in a different room to avoid any potential dispute.  

By "inoculation," what I mean is to talk briefly with your daughter before a trigger occurs; for example, when she is going on a play date, remind her that sometimes her friend is going to do something to annoy her.  Try to be specific and explain what her friend has done in the past.  Keep your explanation brief, and end with a catch phrase that you can repeat before future play dates, such as "remember to go with the flow!"  At home, you can model how to go with the flow when things do not go your way.  You could say "Oh well, things happen. I'm going to chill in my room for a few minutes."  Here you are not only modelling how to handle frustration, you are introducing another technique:  taking a break somewhere by yourself for a few minutes.

I explain more about these and other strategies in my parent's manual.  In my book, I explain you should start with strategies that you can control and that do not depend on your child becoming aware of her anger issues.  The second half of the book explains how to teach children about their anger and how to deal with it.  Anger is a difficult emotion for many children; change occurs gradually over a period of months.  If you do not see any changes in the frequency of outbursts or in their intensity after trying some of the strategies for several months, I would recommend you consult with a mental health professional.  Or you may prefer to work with a child and family psychologist at the same time that you apply some of the strategies in my book.   A child and family psychologist can help you develop a plan that you can use at home.    A neutral observer may see patterns or have ideas due to his (her) experience and objectivity.  You could ask a teacher, or your friends, or your child's doctor for suggestions for a mental health practitioner in your area.  All the best, Dr. Dave Gottlieb

Wednesday, June 12, 2013

3 year old's anger "terrorizing" family

Dear Dr. Dave,
I start looking at google things about angry toddlers and I stop in your article . We have two boys 1 and 3.  The 3 year old started terrorizing the whole family few months ago. We recently moved  so we were positive that he had very hard time to adjust to a new place. But after a few weeks nothing changed, he screamed, cried, kicked without the reason. I said he terrorized us because we couldn't go downstairs without him or first, opening the door.  He always found the reason to get those angry attacks; his eyes looked empty but so angry. He was waking up at night screaming. We took him to a neurologist (they said he's perfectly fine).  Everyone was saying that this is the age.  When the trigger started we couldn't do anything, there was no stop for him.  He goes like this up to half an hour a few times a day.  Talking, begging, ignoring,  nothing helped. He worked like a switch. We went to see psychologist but my son screamed in the office for half an hour, and he asked me to ignore him (which didn't helped) and then he said it was more like a cause of nightmares. Then everything kind of  stopped for few months and now is back again.

My son is sooo angry at everyone and everything . Wrong turn in a street, there was green light not red. We can't do anything, he wants to do everything by himself even things that are to heavy for him (then he gets even more angry), like taking garbage away, doing laundry, preparing meals, opening doors, opening garage, it's like we can't do anything without his permission.  When he's getting those angry attacks the trigger is always different.  Now I can't even go grocery shopping with him because I never know when he's gonna start again . When it starts he's telling me that I'm a bad mommy, that he's not my friend .Where can we go and look for help ?? and how we can we know is that Anger Overload ?? He was never like that; he was always such a sweet,  kind, caring boy, that good one . Even that he's got those attacks he still so polite but when that look in his eyes is coming ,we always say that he is a walking ticking bomb.What can we do ?? THANK YOU.

Hi,  Do you have any ideas why he calmed down for a few months and then started getting so angry again?  What changed during those three months?  Or what happened (if anything) in the family's life when he started with his outbursts again?  If you have any clues, you might be able to try to re-institute whatever was helpful before.  Another question about what the psychologist said about the nightmares:  what did he feel was the cause of the nightmares? 

Anger overload is a term I coined to describe children's angry outbursts when they feel frustrated or disappointed.  The outbursts happen quickly and can be verbal and/or physical.  They can  last minutes or sometimes an hour or more.   Three year olds are prone to outbursts because they do not often understand their limits, or the dangers in a given situation.  They may think they can do things that they can't really handle yet.  Also, biologically, the frontal cortex (self-control area of the brain) is immature in three year olds.  The frontal cortex develops throughout childhood, and continues to develop during young adulthood too. 

The reason the psychologist probably said to ignore the tantrum in his office is that usually the more attention that is drawn to a child having a tantrum, the longer it lasts.  The key though is to try to intervene before your son's anger gets to that stage (when possible).  Your son so much wants to do "adult" chores; can you tell him you want his help when it comes time to do one of those chores (like the garbage or laundry) and find a role for him?  Ask him to help you in some way (that won't make the task more difficult for you!).  And then thank him for his help.

Other approaches are either to try to use distraction, or else avoid situations that trigger him (for example, go shopping without him--if you can go shopping when you have help at home).  If you try to distract him, whatever you say needs to be "emotionally" engaging for your child.  What I mean is that you can't just say "look at that" unless it is something your child will find interesting.  Your distracting comment can be funny, silly, or in some way appealing to your child.  Also this technique will usually not work once a child is in a full blown tantrum, so only try it if you can catch your son's anger before he explodes.  I explain more about when to use distraction (and other techniques) in my parent's manual.

I think your best bet is to find a way to have your son feel he is a "big helper."  It sounds like many of the triggers have to do with him wanting to direct things or help you do things.  So you want to find ways for him to help that are constructive.  Don't wait for him to choose what to do to help, but tell him in advance (right before you are going to do a chore) you need his help because he is a big boy and you need him to do _______.  Pick something that won't make your life more difficult.  Maybe he could hold the door for you, or push the garage button when you are ready, or the two of you could take the garbage out together, or you take the garbage bag and ask him to carry a cereal box (that you say won't fit in the bag or needs to go in the recycling bin).  Whatever you can think of that gives him a role and does not lead to a lot of frustration on his part. 

All the best, Dr. Gottlieb

Tuesday, June 4, 2013

7 year old has outbursts playing baseball

Hi Dr. Dave!
I was lost! Then I Googled anger in children and found your article. It describes my 7 year old 1st grade boy to a tee. And I felt some relief.  My husband and I have been struggling with this behavior for years. When he was 4 we had a physiologist observe him and we were told that he was a normal 4 year old boy with lots of energy.  About 6 months ago, we brought him to his pedestrian's office and talked with a mental health professional. We talked to him about angry overload and he said basically the same thing. Could outgrow it, no medication necessary. He’s not ADHD or ODD.

Our son is a bright, social boy with lots of friends and is doing well in school. Where he struggles with this is competition, games, winning and losing. We alerted his teacher and most staff to this at the beginning of the school year and to our surprise and relief we have been told that he has had none of these outbursts all year! A few minor ones that his teacher was able to work with him on.  It seems that my husband and I see the worst of it. However, sometimes weeks can go by and he doesn't have any outbursts.

We are really seeing it is on the baseball field. My husband is one of the coaches. What happens is that he gets so intense, loves the game, but is so hard on himself if he misses the ball or gets out. He sometimes gets upset when others miss the ball but mainly when he misses the ball. It seems as though he is a perfectionist? Doesn't want to do wrong? But he gets so down on himself, it's a struggle within him.  We had a game last night where he had 3 outbursts, throwing the batting helmet, kicking his glove and yelling he quits. That was the worst game this year. Typically, he throws his glove down and most people don’t see this. But last night, I think everyone saw it. The head coaches are also alerted to this and we asked them to intervene instead of my husband or I because if we intervene, it seems that it get worse. So when he yelled he quit, the coach put him and all of his equipment behind the dugout and told him to stay there until he cooled down. (We instructed the coaches to do this based on reading your article). Within minutes he cooled down and was back in the game. It usually happens where it takes him a minute to get to this place. A minute in it and a minute out of it. The good news is that he’s not in it for long. It’s so Jekyll and Hyde to watch. It is so tough on my husband and I and last night I was in tears.

When I try and talk to him about this situation when he is calm, he sometimes says he doesn't know what he's doing or saying.  There is something going on!!! And we as parents feel helpless.  Thank you for reading my email and offering your support.

Hi,  It sounds like you have identified the main trigger for your son's outbursts and have begun a good strategy to help him at the baseball field:  letting your son cool off without someone talking to him (until he is calmer).  Once a child is in overload, it is best to say as little as possible because the anger has overwhelmed his rational thinking for the time being.  Once he is calmer, he will think clearly again.  

The next step is to begin to help him understand his triggers and develop strategies he can use to head off anger overload.  In the second half of my parents' manual, I explain some techniques to help teach your son how to control his anger.  Early recognition is key.  One approach is to use catch phrases like "even major league players make errors in the field and strike out at the plate." or "you're like (name of a star he knows), he strikes out too."  Rehearse whatever catch phrase(s) you develop with your son briefly before each game, and give him a high five after the game if he made a mistake and held his cool (even if his self control is only somewhat improved at first, or even if if he only was in control sometimes when striking out or missing a ball in the field).  At some point, he will remember the catch phrase at the moment he makes a mistake and it will help him.  Improvement will likely be gradual because it is hard for him when so much emotion is occurring in his brain.  

You could also teach him calming strategies to use when he realizes he is beginning to lose it.  Maybe he can learn to walk behind the dugout when he needs to (if it is okay with the coach).  Could he repeat a funny word in his head (like "fiddlydoodoo") that might help change his mood?  Or could he learn to distract himself a little by counting how many times in the last week he struck out and how many times he didn't.  This will help if he usually doesn't strike out.  If there are more times he made contact with the ball, he could tell himself he is doing better than you (or some other adult he admires).  What you are getting at with these techniques is helping your son keep perspective, rather than focus just on the immediate strike out.  Discuss different options with your son and see what he would like to try first. 

All the best, Dr. Dave Gottlieb