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

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