Saturday, June 28, 2014

How do you teach self-control?

I found your blog while looking for info on excessive anger in children and the person’s post on June 23 is where I am as well.  I am a “retired” Pediatrician who now home schools and the angry child is the youngest of 4.  I’m at my wit’s end and also looking for therapists. My child is bright, even precocious, and he’s always “hated being the youngest”.  I know his older brothers like to tweak him, too, and that’s normal, but his response is not.   The thing is, I feel like I’ve tried most of what I see suggested online. He does get physical, though, and I often have to pry him off of his sibling before I can send him to his room or talk to him.   I also know how sweet the child is after he’s calmed down, alone in his room.  Is my child going to be any more likely to try the “control methods” because a therapist suggests it?  Will going to an outside, objective person be more effective?  We just want the yelling/outbursts to stop—we’ve given him so many alternatives to that. 

I’ve heard there are some who “enjoy the rush of their anger”.  I struggle with anger, so I have some understanding of what this may mean, but a child?  I remember this child at around 2yo, with a viral illness, giving a guttural yell in an attempt to not vomit…which of course ultimately failed.  It was funny at the time.  I was sitting with him and the bucket for a few hours---and he did it every time the urge to vomit came.  So this makes me think some of this is “innate” and not a learned/developed behavior.  Am I looking for excuses?

This child is in his room today, grounded all day, which means he lies in his bed, no books (the height of torment in our house), staring at the ceiling.  This was my husband’s idea and I rejected it at first (the length of time, not the punishment), but maybe this will get the point across.  He is out for meals and some chore work only.  I just worry that an angry child will stew and get angrier with this, though—as opposed to something immediate and short.  But besides spanking, I don’t know of anything else like that.  I’ve been toying with a calendar of anger-free days with a large-ish reward at the end of a month.  Is that reasonable?  The only way it would work is if it restarted after each “failure”, but I honestly think this child would just give up—it would be “too much”.   One month to create a habit, right? 

I saw your blog and the opportunity to email.  I have a list of counselors but honestly am scared stiff about finding a “good fit”.  It seems more like a parenting/spiritual development issue which we should be able to handle at home.  I appreciate you taking the time to read this and would be interested in any comments or suggestions.   Thank you.  

Hi, The problem with rewards and punishments is that once in the overload phase, most children are not thinking rationally; that is their emotional brain (the limbic system) has temporarily overwhelmed their rational self-control mechanisms ( "powered" by the prefrontal cortex).  In order for rewards and negative consequences to work, a child would have to think to himself:  I've got to control this outburst because I don't want to lose this privilege or potential reward.  Most children in overload will be extremely emotional and not be thinking this way.  Even adults when highly emotional say and do things they later regret.

So the key is to build up a child's self-control mechanisms over time and to focus on techniques that can be used early in the anger sequence when a child is thinking more rationally.  I realize this is not always possible because children can "heat up" so fast.  In my parent's manual, I outline ways to pick up signals that a child is close to "blowing up" and I suggest ways to "re-route" a child's thinking and behavior.  First, it is important to  observe what happens before a child explodes.  Try to identify some of his triggers (though sometimes the outbursts will come out of the blue).  You mention that his brothers "tweak" him.  When you see this happen, one approach would be what I call in my book "emotional distraction."  You try to come up with a remark or an activity that your child finds amusing, stimulating, or in some way grabs your child emotionally. It is hard to get angry if you are laughing or excited about something else.  This strategy works best if you can catch the "frustration" before your child is in the overload phase.  Once a child is in overload, it is usually best to say or do as little as possible until the child is calmer.  You do not want to inadvertently "reward" the outburst by giving your child a lot of attention at that time.

Other techniques that parents can use (and that I explain more about on the blog and in my manual) are a) change the sequence to avoid the anger-arousing stimulus, b) lower expectations (if anger comes from high expectations that a child has), c) create a relaxation station in your house, d) teach your child a jingle that helps him change his mood, e) intervene with your older children when they "tweak" your younger son.  All these approaches are initiated by the parent.  I'm not sure how old your child is, but as he gets into his pre-teen years (and sometimes before that) you can teach him ways a) to change his perspective (or to consider other people's perspectives in addition to his own), and b) to use "cue words" or a "mantra" to help him relax, and c) to work on compromise with other people.  The second half of my manual explains how to help children develop techniques that they can use themselves when adults are not around to prompt them.

Basically, what all the techniques are designed to do is stimulate the self-control centers of the brain.  It is like exercising a muscle in a sense.  It takes time and continued practice, but you can help your son develop self-control.  Once he sees he can have some success, he will feel better about himself and he will be more engaged in the process.  So start with the techniques in the first half of the manual (that are directed by the parent) and then after a few months when you see some progress,  consider moving to the second half of the manual (where you teach him techniques to use himself).  

All the best, Dr. Dave Gottlieb

Monday, June 23, 2014

Finding a therapist who knows about anger overload

I have been struggling to find out what causes my 8-year-old's anger issues since he was a toddler. I recently discovered an article written by you about "anger overload" and it seemed like you were writing this about my son. I have never felt like anything else has explained his behavior before so reading your article really helped me feel like we're not alone. I also just purchased your manual on amazon and I should receive it Wednesday.

I am emailing you for advice because after my son's anger outburst last night I have realized that our family needs help. It's not fair to our family or my other son (10 years old) to spend our lives walking on eggshells because we're afraid to set off our 8-year-old son. Therefore, I'm now online researching therapists or counselors who can help us get a handle on the situation. None of the ones I see use the words "anger overload" in the descriptions of the types of issues they treat. How do I find a therapist who knows about anger overload??? I really feel like that 'diagnosis' is 100% accurate. It's uncanny to me how on the money it is.... But if a therapist hasn't heard of it, I wonder if they can help?

Any advice is appreciated.

Hi, I coined the term "anger overload" about 15 years ago after seeing a number of children with this problem, and finding that there were no books to help parents with this issue.  It has not been covered in the mental health manual put out by the American Psychiatric Association, though the new 2014 diagnostic manual comes closer with the diagnosis of "disruptive mood dysregulation disorder" (abbreviated as DMDD).  You could ask if the therapists in your area have worked with children who have this diagnosis or with children who have "repeated angry outbursts."  In my manual I explain the difference between anger overload and disruptive mood dysregulation disorder, but the psychological treatment approaches would overlap.  

Also, I would suggest showing the therapists my manual and ask if they use some of these strategies in their work.  Most child and family therapists who have some background in "cognitive behavioral therapy" will be familiar with some of these techniques.  It is important that you pick someone who strategizes with parents (or with the entire family)  in addition to talking with your son, because children often have trouble implementing the strategies on their own at home.  Their anger occurs so quickly and so intensely that they need assistance for a number of months in order to learn to change their mental set quickly before their anger reaches the overload phase.  

You will see in my manual that the first half teaches parents how to implement strategies without the direct involvement of the child in the planning stages.  The second half of the manual has strategies that parents and children work on together.  All the best, Dr. Dave Gottlieb

Tuesday, June 17, 2014

Is anger overload a biological problem?

Hi, I have a now 8 yr old son with every year becoming more aggressive and angry. He shows signs of ODD (oppositional defiant disorder) and by learning just now of this anger overload I believe that is a factor. He has had rages since toddler yrs. He would bang his head in tantrums progressing by age 2 to throwing chairs in fits. He is brilliant and the loving one when not angry. He cannot simply say no. He will scream in your face, sassy, and not a care of earning or losing anything. The rages are continuous throughout the day and just had one episode ever in a school when a girl knocked down stuff of his: he screamed right in her face till she cried and he knocked all of her things down. He said it is very hard to keep control throughout the school day. At home there is no control. I have been working in behavioral health with children and cannot help my own child. Is this a chemical thing or just plain rage? Thank you.

Hi, When anger overload has been an issue for years, it is likely that there are developmental delays in the brain such that there may be a) "weak" communication between the emotional centers of the brain and the self-control centers of the brain, or b) the emotional centers of the brain may be overactive, or c) the control centers of the brain may be underactive.  The amygdala is one part of the brain that is aroused when we get angry, while the prefrontal cortex is a part of the brain that helps us exercise self-control.  We do not know yet exactly which part of the brain is not responding adequately in children with anger overload.  With new imaging equipment (like CAT and PET scans) we hope to know more in the years to come.

However, "exercise" can help brain development.  That is why it is important to work with your child on self-control strategies.  In my parent's manual, I explain ways to help children develop better self control.  It takes time and practice, since we are dealing with brain development and with strong emotions.  But it will make such a difference in your child's life once he can control his anger better.  Look through other posts on my blog or check out the strategies I describe in my parent's manual, and see which ideas make the most sense for your child.  Sometimes it also helps to consult with a mental health professional in your area to rule out any other issues and to fine tune the strategies for your situation.

All the best, Dr. Dave Gottlieb 

Tuesday, June 10, 2014

Punching bag and violent cartoons

Hello,  I am the mother of an 11 year old daughter.  Her diagnosis included ADHD and Auditory Processing Disorder. She has a severe reading disability with a reading level 2 years behind her class.   She is a sweet, well mannered, animal loving girl, with difficulties negotiating social interactions. 
My daughter has had difficult emotional outbursts through out her life.  Usually they are an explosion of built up anger, typically a month or two. They include screaming, hitting the bed, crying and then an utter break down and last about 1/2 hour.  She discusses these episodes frankly and asks "Why am I an angry girl?"  We have many discussions about anger control and management.  She has come a long way.  But, she is one of the biggest girls in her 5th grade class and strong.   And, when she is in her rage,  she talks about hitting people in the face.  Although, she knows this is wrong, and has thus far been able to control it, my concern is mounting as she approaches Jr High. 
Yesterday she saw a boxing match on TV and decided she would train to become a boxer to release her anger.  (much to her parents dismay)  She has found Pokemon, Teenage Mutant Ninja Turtles and Power Ranger as her favorite TV shows and often acts them out in her alone play times. 
Your article about Anger Overload sounds like my daughter.  Thank you so much for describing this issue in such clear terms.  I will be getting your book on Anger Overload.
My question is:
Are the fighting cartoon shows an acceptable outlet for her emotions, or are they to her detriment? 
After the outburst this week, she told me she wants a punching bag for the basement.  Would this be helpful, like an in home OT session? 
I would really appreciate your help.  Thank you so much.

Hi, A key issue is helping kids understand that feelings are okay but hurtful actions are not.  I help children understand what caused them to feel angry and also help them feel that anger is a normal emotion, but I also explain that while it can be hard to control, it is very important that we work on ways to control it.  We then talk about alternative actions that are socially acceptable. For some children, a physical outlet is helpful, while others prefer to talk out their feelings, and still others prefer to distract themselves with music or computer games.  I try to help children think of several possible actions and empower them to pick the one that they want to try on a particular day.  So their reaction can vary depending on the circumstance.
Boxing and a using a punching bag are socially acceptable alternatives.  It is important though that your daughter understand  that it is not okay to use punching against other people in school or at home.  It is okay to practice and let out tension so long as no one is hurt.  Then I would monitor her behavior over the next month to determine whether there is a change in her acting out her anger against others.  As long as there is not an increase in aggression (and hopefully it helps her with self control), then continue to allow her to use the punching bag. Maybe she can learn to use it effectively as a tension reliever before she gets to the anger stage, and thereby lessen the likelihood of her reaching anger overload.

Fighting cartoons are a favorite of many children.  Some studies suggest they do not increase violent behavior of children, and other studies say there can be an increase in aggression for some children, particularly children with poor self control to begin with.  Since your daughter has not been overly aggressive towards other people, I would lean toward letting her watch the shows she wants.  You might also talk with her sometimes about a cartoon, and discuss why the character reacted the way he/she did.  Then you could talk briefly about the difference between fantasy (cartoons) and reality (school), and discuss what she could do if threatened is some way in school.  I generally suggest parents be aware of what their kids are watching on television and join them sometimes, because then after the show parents can sometimes talk about the theme of the cartoon and how it might relate (or not relate) to everyday life.  Do not overdo the discussions though, or your child may only want to watch her cartoons alone!  See how your child reacts (don't push it if she doesn't want to talk sometimes)  and pick cartoons that seem more relevant to everyday life.

All the best, Dr. Dave Gottlieb

Tuesday, June 3, 2014

Bipolar disorder? 6 yr.old outbursts since age 2

Hi Dr. Dave,

My son is 6 years old and trying to complete his first year of kindergarten. He was diagnosed with ADHD and ODD in September 2014 after a series of issues he was having in the classroom.

Some history: He was asked to leave several preschools since the age of 2. Many discussions were about his inability to control his impulses, and was simply too much to handle. He started becoming more violent over the last 2 years, picking up chairs and throwing them across the room, turning over book cases, throwing anything he could get his hands on in the heat of the moment. It does not seem that he is trying to hurt anyone, he just looses it.

Recently, he has been suspended from school because of an angry outburst. His outbursts at school range from yelling, ripping up his classwork, throwing chairs, throwing his shoes, etc. Teachers have struggled trying to figure out what triggers him. He does express this behavior occasionally at home, but we have only seen him triggered by something that gets him angry; his little brother getting something that he wanted, loosing at a board game, getting privileges taken away if he had a bad day at school, etc. We have also seen him triggered by being embarrassed or asked to go into a large and loud crowd of people (i.e. school plays). We as well as multiple teachers have seen him get a glazed over look, like he isn't there when he is going through a rage. The rage will last less than an hour. Typically after it seems like he looks around at a destroyed room and doesn't know what happened; that he did it. He can't express why, even when asked to draw a picture of what upset him; his answers are always "I don't know". He will start to trigger again if we press the issue, as if he is getting increasingly upset that he did the things we are telling him.

We tried Ritalin and Concerta, but he would be extremely tired and over emotional (crying for no reason). We stopped the meds and have been to multiple physiologists/psychiatrists and behavior therapy and have found little help. The school seems to be loosing their patience and it feels like they are giving up on him. We don't know where to go from here.

Any advice would be more than helpful.

Hi, I can see you have been working on this issue for several years with little success.  It does sound like anger overload, and I can suggest some strategies, but you would also want to rule out additional diagnoses:  a mood disorder, high functioning autism, and fetal alcohol syndrome.  The latter two are unlikely, but make sure the doctors have ruled them out.  It is possible that your son has a mood disorder, namely pediatric bipolar disorder, and while this is not a very common disorder, it can occur along with anger overload.  With bipolar disorder, the changes in affect (such as angry outbursts) alternate throughout the day with periods of calm or periods of dysphoria ("down" mood).  The bipolar child is impulsive and wants his needs met immediately.  Often these children are "revved up" and on the go.  So it is not unusual for doctors to first consider ADHD, because it is a more common diagnosis and is also marked by impulsivity and hyperactivity.  Since your child did not respond to ADHD medications, it is possible that there is a different underlying biological pathway, such as what can occur with bipolar disorder.  Some studies of bipolar children have found weaker connections between the amygdala (one of the emotional centers of the brain) and the frontal cortex (that helps to control emotional responses).  Several major medical centers in the country have pediatric mood disorder centers investigating this diagnosis and its biological underpinnings.  The University of Illinois in Chicago is one such center. 

Whether or not your child has pediatric bipolar disorder, there are strategies that I outline in my parent's manual and in this blog that can help.  But if there is the additional bipolar diagnosis, medication may be helpful too.  You have observed some triggers at home, and it would help if the teachers could record what is going on before an outburst happens in school.  The idea is not to try to interpret what is going on at school right away, but just record what is going on in the classroom before an outburst occurs.  Then look back over several weeks, and try to notice patterns.  The reason is that if you can avoid some triggers, or at least see early signs, interventions will be more effective.  As you have noticed, once a child is in the overload phase, it is extremely difficult to reach them, and then it is usually best to say or do as little as possible, as long as the child is safe and not hurting anyone else. 

For young children, in my manual I write about a) changing the sequence to avoid a trigger, b) lowering expectations (as high expectations can lead to frustration and then to an outburst), c) emotional distraction, and d) developing a calming station.  You can read more about how to implement these strategies in my parent's manual and in other posts on this blog. 

All the best, Dr. Dave Gottlieb