Tuesday, January 28, 2014

12 yr. old threatens teacher

I have a son that is exactly as you describe and he is now being expelled from school due to one of his rages (he’s 12 and on an IEP).  The school has recommended a more therapeutic placement for him but I am afraid it’s just going to make matters work.

Also, my child struggles at SCHOOL much more than at home (which seems like the opposite to the parents described on your blog).  My wife and I have worked to provide structure for our son and we are able to recognize when he may be getting triggered and get on top of them.  One thing we know is that food is critical to his success and we help him to maintain an eating schedule.    At school he doesn’t always eat like he’s supposed to and that impacts him dramatically. 

It also seems the people at school are unable (or sometimes I think unwilling) to recognize his cues and they keep pushing him.  It just gets ugly, and most recently he had an anger surge and ended up grabbing scissors and threatening his teacher.  He is on an IEP and is in a “special” more structured therapeutic program within the school but now they want to remove him because they think they “can’t meet his needs." They want to move him to a completely different school.  I know you probably can’t give advice but I’m hoping you would be able to let me know whether you think homeschooling for a year or two to help him mature and learn anger management would be more beneficial than an alternative school.  I honestly worry about who he will be exposed to in one of those schools.

Hi, It all depends on what the alternative school is like.  If it is a school for aggressive, acting out children, often labeled a BD classroom, it may not be best for your son.    Many children in BD classrooms are oppositional toward adult authority, whereas many children with anger overload are compliant and friendly toward adults.  Oppositional children tend to get in regular conflict with adult authority figures, and these children would not be good role models for your son.  On the other hand, if the class has children with emotional issues, like depression, anxiety, or Asperger's, then the class may be okay for your son.  Often these ED classes have nurturing teachers and social skills groups to help with developing peer relationships.  It would depend on what other emotional needs your son has, and whether there is a fit with the kind of class the school is offering.  You would want to observe any class before making a decision, and you might want to hire a child advocate or mental health professional to help at your school meeting. 

Ideally, the school would learn about anger overload and how to work with these children.  My parent's manual can be adapted for school use.  In previous recent posts, I have given some examples.  The key is to understand the episodic nature of anger overload, to observe some of the triggers, and to develop a three part plan:  1) prevention, 2) early anger phase, and 3) overload phase.  You would want to work with the teacher and support staff to write out a plan for each stage.  Like you do at home, the teachers could cue your son in order to head off difficult situations.  For stage one, were possible, the idea is to work around trouble spots for now.  For stage two, there could be a "go to place" for your son if he began to get agitated, where he could calm down.  Distraction and relaxation techniques are important at the early stages. 

Furthermore, if there are some academic  or social areas that are frustrating for your son, hopefully the school could develop a plan to give your son more assistance in those areas, because if you can head off frustration, you can head off anger. 

If all else fails, there would need to be a plan for the overload phase.  This usually involves a time out room, or some place where your son could calm down but not receive a lot of attention until he were calmer.  There should be clear consequences also for physical threats or violence.  So there would be consequences for threatening the teacher with a scissors.  You want to draw a line at physical threats, and the consequences could be losing all privileges at school and/or home for 24 hours, or longer if necessary to change your son's behavior.

Once you have the three part plan in place, and the frequency of anger has been reduced, you would want to apply the strategies in part two of my manual.  Part two involves teaching children strategies they can use themselves to deal with anger.  The school social worker or a private therapist could help with this.

The school principal and staff are probably concerned about violence in the school, and not knowing how to deal with anger overload, they feel your son should be in a more protected environment.  Try to engage them around the anger issue:  agree with them that violence will not be allowed, and then urge them to read my manual and to consider the issue of anger overload. 

If however you decide to home school your son, be sure to provide regular activities for peer interaction.  Examples would be a sports, music or art club, scouts, or a religious group.   

All the best, Dr. Dave Gottlieb

Monday, January 20, 2014

7 yr old restrained or removed from class

Hi Dr. Dave,
     My family has been through a nightmare in my child’s school for the past two years with my youngest daughter who is very bright, kind, sweet, and well-mannered most of the time. She began having problems mid-year in Kindergarten in school. At that point we enlisted the help of a private therapist and psychiatrist where she was diagnosed with anxiety NOS with the possibility of a mood disorder.

  Her problems have mainly occurred in school where she had been restrained on multiple occasions by multiple staff members,  and removed frequently from her class despite the advice given to her school by her psychiatrist and therapist. In her last few weeks in school, her teacher evacuated the students in her class six times when she would “not do her writing” because it   "effected the learning of her classmates," or because she was “hiding under her desk” as this was perceived as by her teacher as a “danger”. It seemed as though her school district just wanted to push her out  into a behavioral school and wash their hands of her. My daughter never hurt her peers and in fact is popular with many varying groups of friends in school and during recreational activities. She continues to attend many recreational activities and works cooperatively when “part of a team.”
   Her therapist, psychiatrist and I do not believe a behavioral school placement would best suit her needs due to her level of intelligence, and the nature of her disorder. After spending years of being physically ill  wondering what type of mental disorder my daughter has, being constantly called by her school and going through therapists, doctors, etc. I feel your description of “ anger outbursts” very accurately describes her. Often the adults at school perceive her as being “disrespectful or rude,” and this has often coincided in scenarios when my daughter feels she is “inadequate”, or specifically, “in trouble.” My daughter’s main priority is to be “good”, be viewed as “good in school,” and wants very much to be a “high achiever inside the classroom.” By constantly being “in trouble” and removed from her class, she has become ashamed and embarrassed. She has seen a few psychiatrists and therapist, and in each visit she describes her past experience inside of the classroom as becoming, “embarrassed, mad or sad” when they take her out of the class. She feels as though everyone is “looking at her,” and her one wish is that she could be viewed as a good student and not a bad student. My daughter is a seven year old who has been under a lot of pressure and watchful eyes. All of her testing has indicated that she above average to average intelligence levels. 
   My daughter has been on home instruction for two months and her school district has only provided her with 30 hours of instruction although she is classified as special needs. I should mention I am a teacher myself, for the past 15 years and I work in the inner city. The reason why we do not see these behaviors at home very often is because I do apply many of the strategies that I have read you suggested in your blogs and articles. I work with children who have behavior problems all day so these behavior strategies are inherent in me. However, there have been times intermittently where I have observed her go into an anger outburst that seems uncanny to what you have described with this diagnosis.

    I had the opportunity to take my daughter to my school for about one month where we did not observe the extreme behaviors she had in her public school. I had many people take a look at her behaviors inside of the classroom, including the LDC and special education teacher. When she was met with positive reinforcement, gentle teachers who were treating her respectfully, none of the behaviors that were noticed in her public school were prevalent.  It became somewhat of an enigma to us all as she was noted by our staff members as being very well-behaved, listening to directions the first time, and following the school rules. The main pattern noticed with my daughter is that when she perceives she is “in trouble,” inadequate, or inferior, she will act out by fighting back thereby presenting itself as being “disrespectful” and ill-mannered.

      My question for you is how can I further help my daughter become successful inside of a school without having to send her to a behavior school for the emotionally disturbed? Also, are they any medications that would be recommended specifically for anger overload? I certainly plan to bring this to the attention of her treating therapist and psychiatrist who originally were the people that suggested my daughter be placed in a new academic setting as expediently as possible (not necessarily an alternate setting but a different classroom that would be equipped to handle my daughter’s unique needs). Thanks for listening!
A Mom in Need of a Miracle 

Hi, I can see how frustrated you are and wonder whether her school has tried some of the techniques you have used at home or in your school.  If not, it sure sounds like they should try to work with you.  In order for your daughter to do well in school it will be important for the teachers and you to form a working alliance.  I wonder if your child's therapist can help bring everyone together on a plan of action.

Most children with anger overload do not need to be in a special school for emotional or behavior problems, but it is important to use strategies that help reduce the frequency of angry eruptions.  While my manual on anger overload focuses on strategies for the home, the same kinds of strategies can be adapted for school.  In some previous posts about anger issues in school, I have given examples of how this can be done, and I give some more examples for your daughter below.  

First,in answer to your question about medication, there is no one medicine for anger overload.   Sometimes psychiatrists will try medication if there are other symptoms that are contributing to the anger issues, like anxiety or depression.  With young children, I recommend first trying behavioral interventions, but sometimes medication is added and can be helpful.  You mention your daughter has anxiety.  If the doctor feel her anxiety is contributing to her outbursts, then medication could be considered.  You could discuss this further with your child's doctor, as it is difficult to diagnose and make specific recommendations about issues like medication without a psychiatrist evaluating your daughter in person.  

One important question to consider is what kinds of situations trigger your daughter's outbursts.  Keep track of what is happening right before she loses it.  While there will not be patterns to explain all her outbursts, are there some themes that emerge?  Then you would try to eliminate or reduce the triggers. For example, you mention that one time she got angry was during a writing assignment.  Is writing particularly hard for her?  Have you ruled out a learning weakness in writing or language?  Or is she somewhat perfectionistic about her writing?  Can the teachers address the underlying issue with her writing, and thereby reduce the likelihood that she will erupt?

You also mention that she erupts when she feels inadequate or in trouble.  And you mention she responds well to positive reinforcement.  I would suggest the school try to keep track of the situations when she feels inadequate, and then try to cue your daughter in advance to prevent her from feeling inadequate.  For example, if the teacher's tone becomes somewhat negative if your daughter is not keeping up in some way or if your daughter is slow to make transitions from one activity to the next, what I would suggest is that the teacher (or an aide) cue her a few minutes in advance when a transition will occur.  It might also help to include a comment like "you've done a good job" or "you don't have to finish today" if your child is worried about her performance on a given task.  Encouragement and less pressure sounds like it would work better than negative consequences.

In addition, you and the teachers could help your daughter recognize areas of competence, if you are not already doing this.  If academic areas are stressful for your child, maybe she would enjoy an extracurricular activity, such as a sport, music, or art.  Again you may already be doing this, but continue to find areas of success for your daughter to help compensate for feelings she has of inadequacy.

One general strategy for dealing with anger overload is to change the child's expectations (for example reduce a child's feeling she has to be perfect, if this were the case) or to change the sequence (for example if writing is frustrating, then offer more assistance or reduce the writing load, or have something fun come right after she works on writing).  Look for early signs of frustration and try to intervene before the anger gets going.  The teacher could use distraction and relaxation techniques I describe in my manual.  Once in overload, it is usually wise to give a child some place to calm down, and not to talk a lot with the child until she is calmer.

I'm not sure why the teacher removes the entire class when your daughter is angry.  This may inadvertently reinforce your child's anger by giving your child the power to change the dynamics of the class.  Also, the more the teacher separates your child, the more other children are likely to see her as different or even consider her dangerous, and thus they may shun her.  This would only create feelings of isolation for your child.  

Hopefully, with your observations at your school and with the help of your child's therapist, you can work with the school staff to come up with a better plan.  If your daughter's current teacher is unwilling to give it another try, or is unwilling to consider new approaches, would the principal consider assigning your child to another class, or provide an aide to implement the new strategies with your daughter?  

All the best, Dr. Dave Gottlieb

Thursday, January 9, 2014

Is anger overload a lifelong condition?

One question I have that I cannot seem to get a firm answer on....Is "anger overload" a delay that a child will outgrow or is this a lifelong condition that requires aggressive treatment?  

Hi, You ask a very good question.  To my knowledge there are no long term studies of children with anger overload to determine what percentage of children might still have difficulties as adults.  In my clinical work, the great majority of children develop better self control.  But change can be gradual, sometimes over several months and sometimes over several years.  Research into anger issues implicates the structures in the brain known as the amygdala and prefrontal cortex.  These structures continue to mature throughout childhood and even into early adulthood.  While some children may improve without much help, it is my experience that a child's brain structures (like the prefrontal cortex) develop more significantly with "exercises," such as the strategies  in my parents' manual.  To some extent, it is similar to what happens to the muscles in a child's body as he/she matures.  As children age, their muscles get stronger, but one can make more significant changes in the body if the individual exercises.  It is important to add that what is different about muscle growth compared to normal brain development is that puberty brings an increase in muscle mass for every child (except under rare situations), while the brain needs exposure to the environment (life events that stimulate the brain's anger control mechanisms) to reach its full potential.  So while some children may improve without focused work on anger, it is very important in my mind to be aggressive about working on self-control strategies.  "Practice" is important for brain development.  Anger overload can interfere with family life as well as a child's functioning in school.  So it is better to work on it sooner rather than later.  

All the best, Dr. Dave Gottlieb