Monday, December 23, 2013

Helping 6 yr old in school

Thanks for publishing this article. My 6 and 1/2 yr old son seems to be exhibiting the behaviors associated with anger overload. He has no other diagnosed medical issues, his grades are phenomenal and is a loving kid most of the time. Once he gets in this state of rage, usually over something minuscule that he takes offense at, it becomes difficult to get him out of this or redirect.  I have just started him in therapy and we will be visiting his primary care doctor after the new year. The school he attends is not helping that much. They are only focusing on punishment and tracking despite my best efforts to work with them.  I need redirect and coping advise. I realize that every kid is different, but would like to try something so that alternative placements will not be put on the table.  What is urgent is appropriate responses and preventive measures for teachers and other staff during school hours. Happy holidays sir. 

Hi, My parent's manual has suggestions for home that can be adapted for school.  The first step is to observe the situations when he loses control.  Can the teachers keep track of them, and then look for some patterns.  Does the anger overload occur when he is frustrated or disappointed with certain assignments, tests, grades, comments from a peer or teacher, or some other precipitant?  There will not necessarily be a pattern for every instance of anger, but try to find some types of situations when he is more likely to get angry.  

The next step is key.  Can the teachers anticipate or catch early signs of frustration?  It is difficult to do because anger overload can occur so quickly and with little warning.  But if you have identified certain situations when the child is more likely to get frustrated, your radar can be up when theses situations occur again.  If you can catch anger in the early stages, it is easier to prevent overload.  If your son gets frustrated by certain grades, for example, then the teacher could try to lower your child's expectations ahead of time, let him know he is supposed to get some wrong because he is just learning.  Another option is to change the sequence.  If the grade is going to disappoint him, hold off on the grade until a fun activity is about to begin, or leave the grade off the paper altogether.  A fun activity, like gym or recess, can be distracting and help change your son's emotional state before anger gets too difficult for him to handle.

A related suggestion would be to have in place some distracting activity, such as helping the teacher with something, running an errand, or going to a place in the school where he could calm down.  Some schools have an OT room with a mat or exercise ball, where a child can go to relax if he is beginning to get stressed.  It is not a punishment, and should be a place the child is familiar with and has enjoyed.  The distraction needs to be engrossing--it doesn't have to be fun but needs to be something the child is really interested in doing.

Once a child is in anger overload, the teacher would engage as little as possible.  The goal is to provide a setting where the child will not disturb others and not get a lot of staff attention.  This place could be inside or outside the classroom and would not be the same place as the OT room, or the activity that is used for distraction.  If the child is loud and bothering others, there would need to be an aide to escort him out of the room.

There are other strategies I describe in the manual that aim to reach children how to recognize their emotional state and how to develop self-soothing strategies.  These strategies would be taught when your son is calm, and could be worked on with the school social worker or psychologist in conjunction with the teachers.  For example, some young children can learn to use verbal labels for different degrees of anger or frustration.  The second half of my manual outlines six different skills to teach children to help them better manage their anger.  The difference is that these strategies involve teaching the child skills over time, and the first set of strategies I mentioned in the above paragraphs are directed by the adults and do not require the child to anticipate or understand his reactions. I would recommend starting with the adult directed strategies because these can be implemented more quickly.

All the best, Dr. Dave Gottlieb

Sunday, December 1, 2013

9 yr old: Anger Overload or Explosive Disorder?

We have a nine year old boy who struggles with anger. He's always been a challenging child, requiring more consistency, consequences (both positive and negative), and supervision than his older two siblings. Until second grade, he did not act up in school. Now, however, he's had a number of incidents where he's become so angry that he's hit a classmate. Often it is because of perceived "fairness" - a foul at recess.  We've tested him for ADHD and he shows impulsivity but doesn't fit that diagnosis completely. We did start him on ADHD medications in the fall (Concerta/Intuniv) and that seemed to work for a couple of months, in conjunction with therapy.

We've had some good success, but not enough - this week, he completely lost his temper at school, tried to hit the classmate and then tried to run away from the teacher and refused to listen. Therapy alone isn't enough. Do you know of another class of medication which we should consider? And would you consider "Anger overload", as you describe it in one of your articles, a classification of intermittent anger disorder as described in the DSM V?

Hi, Anger overload is an intense reaction to frustration that can sometimes be physical, but often is verbal.  By contrast, to be diagnosed with intermittent explosive disorder, there must be physical violence:  there are serious physical assaults and often destruction of property, which you usually do not see with anger overload.  Anger overload is more common in children in my experience.   

Children with ADHD can have a) hyperactive and impulsive behaviors, or b) distractability, or c) both.  So your son may meet criteria for the hyperactive-impulsive type. 

You mention the issue of "fairness" as a concern of your son.  I have seen this issue for other children with anger overload.  What I would recommend is "priming" your son before he goes to school.  Explain that children often "foul" at recess and it is not called because there is no referee.  If he wants to play a competitive game at recess, this will happen often.  Is it worth it to him to play?  What are his alternatives?  Try to discuss these issues when he is calm in the mornings, or if there is not time then, try to do it at bedtime.  Empathize that there is unfairness when fouls are not called, but explain that it probably will keep happening.

Another strategy is to talk with him about how people can have different points of view.  There is a section in my parent's manual that explains a way to do this.  As a last resort, I would consider talking with the school about taking away the privilege of playing a competitive game at recess for a day or two and then try again.  If there are repeated problems, then see if the school can have an adult nearby to intervene early.  Once your child gets real upset, it would not be advisable to talk with him until he calms down.  If possible, there could be a space away from the action where he can settle himself.

As for medications, there are anti-agitation medications, but they can make children tired and/or gain weight, among other possible side effects.  Sometimes low doses can help with minimal side effects.  However, some of these medications are not FDA approved for pre-teens.  Talk it over with your child's psychiatrist or medical doctor to see if he or she thinks another medication is indicated.

All the best, Dr. Dave Gottlieb