4 yr with anger overload, not ADHD

Dear Dr. Dave,

I have a four year old daughter that I have been having a problem with since she was 2 years old. She gets very angry, throws things, kicks, hits, destroys property, tells me she hates me, scratches, etc. She will even go as far as trying to hurt our family dogs. I have had her in behavioral therapy on and off for the past 2 years. We moved her to a psychotherapist who put her on quillivant, but that only made the angry outbursts worse. I took her off the medicine immediately. I just don’t know what to do anymore.

Hi, Quillivant is used for ADHD, but your daughter probably does not have ADHD.  Symptoms of ADHD include hyperactive behaviors, impulsivity, and distractability.  A child can have all or just some of these symptoms.  The difficulty with making an accurate diagnosis is that children prone to anger outbursts do have some characteristics of impulsiviity, at least when they get angry.  Thus, doctors may sometimes think a child is exhibiting ADHD when they have angry outbursts.  However, most of these children are not impulsive all the time, just when they get angry.  Thus, anger overload is a better fit than ADHD for many of these children.

The other diagnosis to rule out is pediatric bipolar disorder.   These children are prone to frequent changes in mood, including angry outbursts.  But with bipolar disorder there are other signs of manic behaviors, such as a) always being on the go, b) impulsivity, c) disregarding other people's feelings, and d) grandiose thinking.  It is difficult to diagnose with 4 year olds, because many children at that age are self-centered, somewhat grandiose, and sometimes moody.  So it is hard to determine, unless you are a clinician who has seen a lot of these children, whether a young child truly has pediatric bipolar disorder.  

More common than bipolar disorder in young children is anger overload.  In my parent's manual I explain that there can be delays in the development of the prefrontal cortex, which is the part of the brain that modulates angry emotions that emanate from the limbic system of the brain.  So when these children get angry, it can be extreme.  My manual goes over strategies that parents can use to lessen the frequency of outbursts.  The first half of the manual is appropriate for four year olds.  

When a child is in the overload phase, the best thing is to say or do little, unless someone is in danger physically, or unless something of value is about to be destroyed.  Then some form of physical restraint is called for.  Generally, children in overload need time to settle down, and the more parents engage them at that time, the longer the outburst usually goes on.

The manual explains how to intervene earlier in the cycle before the overload phase occurs.  This is not always easy because children with anger issues can escalate so quickly.  So it is important to observe some of the patterns (not that every outburst will follow a pattern) and either 1) change the sequence, 2) lower a child's expectations in order to lessen disappointments, 3) use "emotional distraction" or 4) develop a calming station in the house.   In the manual I explain each of these steps in more detail.  It takes several months or more sometimes to determine the best set of strategies and to learn when to use which approach for each child.  I would suggest using the manual, and if you have difficulty implementing the strategies, bring the book to a therapist who works with parents and who knows about cognitive behavioral strategies for anger, and work together on fine tuning the approaches for your child.

All the best, Dr. Dave Gottlieb