Sunday, February 16, 2014

Finding therapists for 4 yr olds

Here are a couple of e-mails I received recently asking about finding a therapist to help with their four year olds:

Hello Dr. Gottlieb, I recently found your article and book and it's like a light shining through the clouds. My 4.5 year old son has struggled with explosive anger since infancy/toddlerhood and continues to suffer as he gets older and stronger. We have explored several treatment avenues via evaluations-- sensory processing, psychiatric, parenting, but have not yet found a plan that addresses his unique situation (which I'm guessing is something you hear often, which is why you wrote your book, which I've just purchased on Amazon...)

Can you recommend a colleague in our area that could meet with us and our son to help implement some sort of plan/support through this hard time? 

Hi Dr. Gottlieb,
    I am reaching out to you because I believe that my 4 year old son might be struggling with anger overload. in general, he is a very intelligent, energetic, sweet but strong willed/ dominant child. He does do the "Hulk" thing up to a couple of times a day, but not every day. When he feels that he is being treated unfairly, especially when it is time to leave a situation where he is having fun, or if something is taken away from him that he wants he gets very angry. His face turns red. He will shout, say very unkind things, throw things, break things and if it he thinks he can get away with it, he will physically hit or grab people. Both his teacher's and I have noticed that there is a different look in his eyes when his anger overtakes him, and it's like he's not even there, only anger. When is anger is not stoked, he is thoughtful, caring, well mannered, and full of joyful exuberance.  Since a Christmas visit with his father's family, his angry behavior has escalated at his pre-school and has become a serious problem. As he is set to start kindergarten in the fall, I would very much like to address this issue now. I believe that a therapist, specifically a behavioral therapist that specializes in pediatrics and understands this diagnosis. Any suggestions on where I should begin and which doctor or local hospital I might be able to reach out to?
Thank you for you time.

Hi, With four year olds, a lot hinges on parents' strategies, such as a) early recognition of anger arousing situations (when possible), b) changing the sequence such that something fun comes after something the child does not want to do, c) changing your child's expectations, d) "emotional" distraction, e) calming strategies, f) not attending to outbursts (when no one is in danger).  I discuss these strategies on the blog and go into more detail in my book.  The first half of my book discusses what parents can do (This section is entitled "Parents as the agent for change").  This part of the book is critical for helping young children.  

If you want a professional to help, it is critical in my view that the professional be someone who works with the parents as well as the child.  In my experience, it is more useful to see the parents with their child, or to strategize with the parents alone, rather than to spend a lot of time with the child alone.  It is helpful to see the child in one of the initial sessions in order to rule out possible diagnoses that can affect anger control, but then the focus in therapy should be on how to implement strategies in your household.  Children cannot implement anger control strategies on their own. They usually do not become aware that they are getting angry until they have already reached the overload phase. There is a  better chance that the parent will recognize a possible frustrating situation and will be able to implement one of the strategies.  Thus, you want to pick a professional who will work with you, and not a therapist who focuses on meeting with your child alone.

Furthermore, it would be best if the therapist has experience in working on anger issues and who has some experience in cognitive behavioral approaches.  You want someone who helps you with a concrete plan, and will adjust the plan as needed, not someone who just reassures you that things will be all right in time.  While brain maturation may help, many children benefit from targeted strategies that promote self control.   Teaching your child these strategies can change his behavior and his brain.

I would recommend asking at your school or asking your child's doctor for therapists in your area who work with families of young children.  You can ask over the phone if the therapist meets regularly with the parents and not primarily with the child alone.  In one of the initial sessions you will get an idea of the therapist's approach to anger issues.   If the therapist does not outline a plan early on, ask him/her what his plan will be.  You could also show the therapist this blog or my book on anger overload, and ask whether it is consistent with their thinking about how to help children with anger issues.   

If you do not feel it is the right therapist for you, check with another therapist.  Mental health professionals have different backgrounds and different experience, so it is perfectly okay to get a second opinion.  But if you find a therapist who is a good fit, stick with the person.  Remember there may not be improvement in just weeks; it can take several months or more to see significant changes in self control.  Once your child is better able to deal with anger, it will help him not only in the family, but also as he begins elementary school in the coming year.

All the best, Dr. Dave Gottlieb



Sunday, February 2, 2014

Angry 4 yr old lives part-time with Mom

Hello Dr. Dave,
I am a single mother of a 4 year old boy, who I believe has anger overload. I am going through the process of getting him evaluated through the school district to see what my next step should be. As of right now his dad and I were never together and we share our time with him. However its a weird schedule and it's not a set schedule.  I believe he needs to spend time with his father but when he is over there for 4 or 5 days and comes back it seems his anger is heightened. I'm not saying anything bad is going on but I do see a difference when he returns. So I guess my question to you would be: should I have a set schedule like every other weekend and maybe one night a week? Right now it's all over the place (ex:  I will have him for 5 days, then he will have him for 2, then I will have him for 4 days and he will have him for 4...and so on..) I worked in a school district with kids with behavioral issues, and structure and schedules helps. I'm just confused on how I should be going about this and what's best for my son and where to start.

Hi, Generally, it is helpful for children if the parents have a good parenting relationship with each other, so that they can talk over things, like how to handle a child's anger.  Ideally, you could talk with each other about what is going on when your son gets angry and then discuss how you each handle it. You do not have to have the exact same strategy in each household, but you would not want to have contradictory approaches.  

First, you would want to try to identify what some of the triggers might be.  If one trigger is switching between households, then you would want to think about why.  Is there a big rules change from one household to the other?  Is your child feeling sad or torn between you and his Dad?  Do either of you say negative things about the other parent in front of the child that may make your child anxious or angry?  If your answer to any of these questions is in the affirmative, then you would want to work on that issue.  Often it can be hard to talk about these issues without a neutral third party, such as a mental health professional who can look at the situation and give guidance.  You sound like you are trying not to assign blame and you are trying to find the best solution for your son.  Is your child's father also open to looking at situations when your son gets angry?

Having a predictable schedule may be helpful for all of you, and might reduce whatever tension your son might be feeling, but it may not be the underlying problem. Transitions may continue to be hard for your son, even if the number of days in each household is altered.  That is why it is so important for you to all work together, if possible, to identify the stressors for your son and to work together on strategies.  Try to involve your son's father in the evaluation process; if he has input from the beginning he is more likely to cooperate with whatever plan emerges.  See what the school evaluation shows.  I would recommend you both try to go the the meeting at the school when the results are discussed.  Maybe reading my parent's manual will give you each a starting point for working on strategies together.  If you both can agree on the issues and how to deal with them, your son will likely benefit.  

All the best, Dr. Dave Gottlieb