Thursday, September 26, 2013

Parent uses manual and 6 yr old hits in school

Dear Dr. Gottlieb,
I have a 6 year old son that seems to fit your description of a child that experiences anger overload. I've been following your advice outlined in your manual along with using strategies described by Dr. Ross Greene in The Explosive Child. Thank you for your manual. It feels like a god send as I live in a small town where it is very hard to find quality health care.

I have two main questions about what we are experiencing in the early stages of our new approach. We’ve only been trying these techniques for about 3 weeks.

(1)  While it seems like we are improving with avoiding overload altogether by detecting triggers and sensing his body language when he is getting frustrated, it now seems like he is triggered more often. His episodes are shorter and less intense, but it seems like there are more of them now. An example would be that just this week he hit a fellow student. School has never been a setting where he acts on his anger. It’s always at home or when he is with me and/or his father. He is triggering in more situations now at home too. Is this a common phenomenon that you experience with your patients as they start the techniques you prescribe?

(2)  The second question I have is concerning a broader pattern. Sometimes he seems to go for weeks without much of a struggle even in the face of his usual triggers. We often think of his triggers in terms of ultimate and proximate. He might be upset because his spelling his hard, but if he is hungry, it’s a greater challenge to control his anger during difficult homework exercises. There are times when he is fed and rested and has had play time (all ultimate triggers covered) ….but he is still excessively trigger sensitive. And then in other times, he can control his anger fairly well with the same triggers in play. In your opinion, is there is evidence to show that there are periods where hormones can affect his trigger sensitivities for weeks on end? Or is there another situation that could cause this?

My deepest appreciation!

Hi, You ask good questions.  Generally, there is not an increase in anger overload in new situations when you apply the techniques in the manual.  Do you know what was going on before he hit the student in class?  What was the trigger?  Sometimes a child struggles to contain his anger in school (and is usually able to exhibit self control), but then there is a day when he is more sensitive (tired or hungry).  When in addition on those days there is an unusually difficult situation, he may have a melt down.  For example, sometimes a child does not do well on a test or assignment, and is feeling down about it, and then the same day a fellow student is verbally provocative.  The combination of triggers is overwhelming and leads to hitting.  My guess is that this will not happen often for your child in school.   If it recurs, it would be important to try to figure out the triggers, and also apply the strategies you are using successfully at home.  You might meet with the teacher and explain what you are doing at home, and see if the teacher would apply similar techniques (or one of the other techniques in my manual--the teacher might feel a different technique might work better in her class).  Usually over time a child develops better self control and there are fewer explosions at home and school.  

I don't know the answer to your second question.  I have also observed that some children have better control some weeks, but I do not know of any research that looks at fluctuations in hormones or brain chemicals over time and their effect on anger.  There have been some studies on violent behavior in adults that show that low levels of a brain chemical called serotonin are associated with more violent behavior.  But even these studies have not looked at week to week fluctuations in serotonin.  Furthermore, the correlation between serotonin and violent behavior does not mean that low levels of the brain chemical cause violence.  It is possible that there is a third variable that causes changes in violent behavior and changes in serotonin.  It is also important to keep in mind that violence is not the same as anger overload.  There are various contributing factors to violence that have nothing to do with anger.

My guess is that there can be week to week fluctuations biologically that affect anger overload.  Also, there can be fluctuations in environmental stressors, and we don't always know our children are feeling stressed until they explode.  But that doesn't mean your child still can't develop better control even during those weeks where he is biologically vulnerable.  He may need more help with the strategies those weeks, and over time (several months) there will often be a decrease in explosions, though not necessarily a total cessation.  As your son gets older, you will be able to apply more of the strategies in the second half of the manual that will help him become more aware of his triggers and how to use strategies himself.   Usually at age six, the strategies in the first half of the manual (that involve parents directing the child) are more effective.

All the best, Dr. Dave Gottlieb

Thursday, September 19, 2013

8 year old loses it doing homework

Hello Dr. Dave,
I'm at my breaking point with my son.  I have 3 children, he is my middle 8 year old.  He's always been sensitive, easily angered, quick to cry when feelings are hurt, and quietly emotional (will run to his room to cry if his brother hurts his feelings etc.).  However, he's generally a pleasant, happy child.  When things are going his way (ie. he has a friend over for a playdate, and his siblings aren't getting involved) he is sweet, kind to others, and incredibly funny.

Lately (just started the 3rd grade) he's been frustrated by schoolwork, and I believe he bottles up that frustration until he gets home.  With me he is incredibly angry, won't do homework, and when I press forward and insist that homework needs to be completed...well that's blow up time.  I try and stay calm, but one little thing I say can set him off and he's throwing cushions off the couch, he runs and buries his head in his bed, he cries, yells at his siblings.  He never has hurt anyone, but he throws things now and he's a strong boy.  I'm afraid of this escalating, and having him cause damage to things or hurting someone during his fits.

I also am ashamed to admit that he has gotten me so worked up that even I have lost my patience and I've yelled, or tonight I turned one of his Lego bins upside down in his room because I was so completely exhausted and enraged, I lost it.  I tried so hard to talk to him, but he won't talk. He says I ruin his life, that he hates everything, and he doesn't want to go anywhere for help.  I've offered tutoring, a doctor to help us figure out a way to work together so we are both happy. Ugh! I'm so upset, if  you have any recommendations, please let me know.

Hi, It sounds so frustrating for you and for your son.  We all have trouble containing our emotions sometimes.  When your son is calm, you may mention that sometimes you get so angry too, and add what you try to do to control your anger.  You can be a role model for your son.  He may not respond to your remarks, but he may feel less frustrated knowing that he is not alone in having times of overload.

You mention that some of the blowups recently have occurred at homework time.  Did this problem begin this year in third grade?  Do you have any ideas why now homework is getting to be a struggle for your son?  You might want to talk with his teacher if you suspect that the work is difficult for him or if you think he is having difficulty concentrating.  You would want to rule out a subtle learning disability and rule out attention deficit disorder. If the teacher is unsure, then you could ask the school to do some testing to rule out learning problems.  If there is a chance that your son has a learning disability, you would want to take some pressure off doing all the homework until you and the teachers know how to help him.   If you think there is no learning problem nor attention issues, and if you think that the problem is motivational, what is your son wanting to do instead of homework?  Is there a way you can tie in completion of homework with extra time doing what he wants when he finishes?  Make sure that whatever your son loves to do comes after (and not before) the homework. 

You mention also that your son is sensitive to being hurt by his sibling and that he is emotional then.  Some children are more quick to cry than others, and crying by itself is not a problem, but if your son feels inadequate in some ways compared to his brother, you would want to try to help him with his self esteem.  Help him see that he has an area of expertise, or help him build an area of expertise (for example, sports, music, art, social service, or kindness to others) or explain that his brother has had more practice in the areas where your son feels frustrated (if this is the case).  Continue to have friends over that your son enjoys, and think about whether there is some other activity in your community where your son would like to participate (and it could become an area of pride for your son).

When your son gets angry, if you can, try to intervene before his anger is explosive.  In my parent's   manual, I explain how to do this:  by using "emotional distraction"  or calming  strategies.  In addition, you would want to lower your son's expectations (in whatever area causes him stress) when he is not angry.  It sounds like your son does not like to talk much about his anger, but you may be able to propose a new way of looking at things when he is calm, maybe later in the evening.  Keep your comments brief, since he is sensitive about his anger issues.  In the parent's manual, I explain how to do this. 

When your son is explosive, do not talk with him then.  As long as no one is being hurt or nothing valuable is being destroyed, then try to wait it out.  Usually the more you talk when a child is in overload, the more emotionally reactive a child becomes.

As far tutoring or counseling, think about what you feel is best, or consult with his teacher.  Then you make the decision, rather than ask him his opinion.  Your son may not like the idea at first, but if the person you hire can form a good rapport with your son, his resistance will decrease.  Remember he is frustrated and just wants the problem to go away.  But you know that it won't go away without something changing, so you have to do what you think best.  Hang in there!  I can tell you care a lot about what your son is going through.  Hope these comments are helpful.

All the best, Dr. Dave Gottlieb

Wednesday, September 11, 2013

6 yr old explodes when touched or if not in charge

My son is almost six, and simply cannot seem to control himself when he gets angry.  If he is pushed, or touched (even by accident) he explodes. His anger is often directed to those whom he perceives as threats in some way (his younger brother, a threat for his attention) or peers who have strong personalities (He likes to be in charge.).   He rarely will hurt or explode at someone younger than him, or girls (He actually usually plays very nicely with girls and passive boys.).

He gets easily frustrated with himself when he cannot accomplish something, and can also explode then. 

He has not had issues in school yet, and in fact his teachers have even told me that he is a rule follower, and a great listener. focus and attention do not seem to be issues either.  I have watched him in sports and activities and notice than when he is engaged, he is the paragon of good behavior, However, left to his own devices, he is not to be trusted, and I am concerned that one day he is going to really hurt someone in one of his fits of anger. 

He seems to fit many of the characteristics of children with anger overload.  He is very energetic, and loves to play on the playground and loves jumping, climbing, and physical activity. While he is often very outgoing and confident in many areas, other times he is shy, especially if he is late or does not know people.  There are many moments of kindness, and sweetness, and friendship.  However, there are also too many times where he gets angry and can't control it. 

I have tried everything. positive reinforcement seems to work best, but he will go through phases of good behavior and then revert back to a downward spiral of behavior rooted in anger. 

I just ordered your book on amazon, but was wondering if you might think other diagnoses would be appropriate rather than anger overload.  Also, I don't know if your book mentions when to seek professional help and/or medication rather than rely on do it yourself behavioral therapy.  I am willing to try one more thing, but am wondering when enough is enough.

From what you describe, it sounds like your son exhibits anger overload.  It sounds like he pays attention well in school (does not have ADHD) and is not unusually moody (not depressed or bipolar).  It does sound like he likes to be in control, which is true of many children.  In addition to the strategies I outline in my manual, you might want to talk with your son (when he is calm) about how to handle certain tough situations you have noticed.  For example, help him understand  how to respond to pushing or touching by peers.  You could recommend he look at the other child and think about whether it was an accidental touch or a more deliberate shove.  Explain how he could respond verbally to each type of situation.  Practice with him short, firm, verbal responses if he thinks he was deliberately pushed, like "Don't push me." or "stop it."  If it was an accident (and the other child wasn't looking at him but just walking by) suggest he say to himself "no harm no foul" or "he didn't do it on purpose."  Since your child responds to rewards, you and/or the teacher could set up a reward if he tells you about a situation when he held back.  

Your son may not be able to implement these ideas right away if his anger escalates quickly, because as I discuss in my book, some children are flooded so fast with emotion that it is hard for them to delay and think about what to do.  Adult observers become key then.  If an adult can intervene early and distract him, engage him, or help him soothe, he may be able to slow down without exploding some of the time.  The important point is to intervene early, if possible, before your child's anger reaches the overload phase.  Or, re-arrange situations in advance to avoid a trigger.  For example, if your child is jealous of his sibling getting your attention, cue your son when you are about to help your other child that it will be his turn (to talk with you or do something with you) in a few minutes.  You want to give him a heads up since that may help soothe him and prevent overload.  

My manual is designed so that parents can try the strategies themselves.  But it can also be used in conjunction with therapy.   Sometimes there are underlying insecurities that contribute to a child's anger overload, and a therapist can be helpful in addressing possible concerns or worries that a child might have.   In other posts to this blog, I have explained how to find professional help.   

In my experience working with children with anger overload, medication is not helpful.  Medications might help if a child is depressed, anxious, or distractable, but do not help with anger issues alone.  Anger overload does take time to work through with a child because there can be biological factors, such as immaturity of the frontal cortex of the brain.  However, the strategies I explain in the manual will help a child develop better self control.   If you do not see any changes over a few months, then I would recommend a professional consult to see what else may be affecting your child. 

All the best, Dr. Dave Gottlieb