Tuesday, July 23, 2013

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

Dr. Gottlieb,

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

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

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

I appreciate your time an advice.

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

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

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

All the best, Dr. Dave Gottlieb

Wednesday, July 17, 2013

Do 6 year olds outgrow anger problems?

Hi Dr. Dave-

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday, July 15, 2013

"Possessed" 4 yr old: Is it genetic?

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

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

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

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

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

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

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

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

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

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

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

All the best, Dr. Dave Gottlieb

Monday, July 8, 2013

Is the manual helpful for three year olds?

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

Does your book address children this young?

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

Thanks for your help.

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

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

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

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

Tuesday, July 2, 2013

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

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

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

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

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

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

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

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

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

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

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

All the best, Dr. Dave Gottlieb