Wednesday, September 17, 2014

7 yr old reacts to "negative" comments

Dr. Gottlieb,

It was great to read your blog and finally find a description of our 7 year old daughter.   We have been in therapy for about five months with a diagnosis of ADHD.  The therapy was split into two sessions - one for us as parents and one for my daughter with the therapist alone. We recently experimented with family therapy as well.  While the therapist seems to be a good listener, we have tried many different methods but have not seen much progress.

In August, we decided to explore medication and have not had much luck.  The stimulants we have tried, seem to make her more hyper and bring a higher rage level and the non-stimulant did not seem to do anything.  It is interesting that she seemed to have no side effects from any of the medications such as sleep or eating issues.

Based on our limited success, we are questioning the ADHD diagnosis and wanting some answers.  While our daughter expresses some traits of ADHD, she is not an antsy kid and does have some focus issues but that is not her main struggles.  However, her fuse is extremely short and when she goes down the angry path, she is impossible to bring back. She is very sensitive to any negative comments or what she perceives as negative comments and lashes out.  In addition, we have difficulty disciplining her because she expresses no remorse and she seems to not care if we take anything away.

In our last meeting with the therapist, she recommended a psychiatric analysis to determine next steps.

At this point, we seem to be at a cross roads.

Hi, You mentioned that negative comments are a trigger for her anger.  You also mention that sometimes this is her perception though the remarks may not be intended to be negative.  One thought I have is to try to anticipate her reaction and preface your remarks with "you know you are a terrific kid" or, better yet, point out something she has done well that day before you mention something she might perceive as negative.  Hopefully, the balance of positive and "negative" comments will help her to not feel criticized.  Keep track over the next two weeks of comments that seem to trigger her rage, and then try to preface similar comments in the future with a positive remark.

Down the road, you could also try a technique I write about in the second half of my parent's manual:  teaching your child about other points of view.  With this technique, you show your daughter how two people can look at something in different ways.  Once she understands this concept, you help her see how a comment's meaning may be perceived differently, e.g. those "negative" comments may not be intended as negative, though the person receiving the comments may still feel hurt.  Help her see how you, her parents, have sometimes felt hurt by comments someone has made that may not have been intended as hurtful.  Also, confirm for your daughter that sometimes people do get frustrated and make a negative remark.  Help her to understand that people say things when they are frustrated that are not necessarily true and are not necessarily the person's true feelings.  

The reason why I write that I would not use this technique right away is because it requires a child to be able to recognize other points of view and apply that to her situation.  Not many seven year olds can do this.  But once the frequency of outbursts is less, and once you feel she may be ready, then try this technique.  It takes time for a child to internalize this way of thinking, so practice over time when she is calm.  

Other techniques in the near term would be to use emotional distraction, which is useful if you can catch the anger before the overload phase.  This is not always possible because anger can increase so quickly.  The idea of emotional distraction is to make a remark that changes your child's emotional disposition:  it could be a funny saying, or a silly comment that your child reacts to.  It can be trial and error to find a remark that your child might find funny or exciting.  But if your child laughs, this will interfere with, or interrupt, her angry feelings.

There are other techniques that I describe in my parent's manual.  Some do not require the child's direct participation, and these are described in the first half of the manual.  These techniques are particularly useful for younger children under the age of 10.  Some of the techniques in the second half of the manual can be tried with young children, but the effectiveness depends on the ability of the child to observe his/her behavior.  You will notice improvement over months, rather than days, as children with anger overload fire up so quickly that it takes time for children to internalize coping strategies.  As I mention in the beginning of my book, there are biological pathways that underlie anger overload, but improvement will usually occur with practice over time.   If there is an additional diagnosis, it will need to be addressed as well.  Since the ADHD medications did not work out, it is not a bad idea to get a psychiatric consult regarding the diagnosis.
Best, Dr. Dave Gottlieb

Thursday, September 11, 2014

11 yr old is disrespectful, rips books, picks up knives

I have twin eleven year old boys.  About three years ago we moved countries and it seems during the day that everything is going well- they bike ride to school, they hang out with their friends, they play soccer after school, they chat on their phones, they play games and talk “normally.” Twin A sometimes reacts over the top when denied certain items, activities, or when he thinks he is being treated “unfairly.”  He also has recently added in that he and Twin B are angry about where we moved and want to move back.  When Twin A gets angry there have been moments where he has picked up a knife - not harmed anyone but  is definitely trying to get my attention, ripped up a school book, screamed incredibly disrespectfully at me or my husband, etc.  He is very difficult to bring down from these scenarios.  They usually end with me saying that his phone is being taken away and he saying that he doesn’t care, me saying that he needs to pay for his school book and he saying that he doesn’t care he will rip more, etc.  Throughout the episodes there might be a flicker here and there of a logical response but then almost as quickly as it appears it is gone.  Over the years he has had random outbursts but especially the past few weeks these have escalated.  I need help.  I am worried about him hurting himself or anyone else around him.

Hi,  It is worrisome when children pick up knives.  If he acts like he might harm himself or someone else, it would be important to get a consult from a mental health professional in your area.  Generally, when children have outbursts that are verbal, I recommend not responding while they are heated up.  Since they are not thinking rationally at those times, they are unlikely to consider what you say, and they often will continue to argue and rage.  Wait to impose consequences until everyone is calmer.  You would tie the consequence to a particular behavior, like picking up knives, rather than targeting the anger per se.  For verbal outbursts, only use a consequence if you feel he was very disrespectful of adults, as you mention he often is.  If he can blow off steam without using the disrespectful language, then I would not recommend consequences.

What I would work on with him is looking for early warning signs and issues that are more likely to trigger him.  I explain in other posts and in my manual how to work on this with your child: to observe triggers and to develop strategies to change your child's expectations (if that is a trigger) or change the sequence (so that what he enjoys come after what he resists doing, if task compliance is a trigger).  Then there is a natural incentive for him to cooperate.  Also, I write about how to use "emotional distraction" and calming strategies before an outburst occurs.  Once an outburst is in overload mode though it is best to say as little as possible, unless someone is being physically harmed.

I write about a child in my manual who like yours erupts when he feels things are "unfair."  I explain how to help children look at other points of view (not during, but after an outburst subsides).  I also suggest families use catch phrases to alert their child when they feel he/she is getting frustrated (if you can catch anger before it erupts). The catch phrase would remind the child of a different way of looking at things.  For example, for children who get mad about sometimes performing below their standards, a catch phrase might be "everyone makes mistakes.." One other strategy that might help you is teaching your child a compromise technique, and I explain how to do that in the last section of my parent's manual.

All the best, Dr. Dave Gottlieb

Thursday, September 4, 2014

Multifaceted plan for 9 yr old

I've had a number of questions over the years about when to use rewards and also about dual diagnosis. I've been working with a boy (with multiple issues) and his mother for the last six months in my office, and wanted to share some approaches that have been helpful.

First of all, he had psychological testing to evaluate his learning disability (LD), and we suggested modifications in school to help lessen his stress and anger in school.  Mother also recently hired a reading specialist to help him twice a week after school.  In addition, a pediatric psychiatrist was contacted, and the boy recently started on ADHD medication.

During the last six months while the evaluation was going on, we began to work on his anger overload issues. Anger would erupt around turning off a computer game, starting homework, or doing his chores.  The themes had to do with schoolwork (which activated his frustration with reading) and with tasks that he was not expecting and that he did not like having to do.  We worked on a schedule together (so he could predict when chores would occur) and also a "mantra," or saying, that he would practice repeating to himself when he was frustrated:  we chose the saying "crap happens."  We chose these words because he felt it was "cool" to use those words, and because it captured the idea that not everything is easy or predictable.  We want him to learn to expect that things will not always go the way he wants.  We also established a "chill space" in his room.  If he went there either on his own or when cued by Mom, he would later receive a lot of praise.  If he did not "chill" but continued to rage, his mother tried to ignore him the best she could until he was calmer.

When there was a conflict with the babysitter (because she made him pick up toys that he said he had not used), we empathized later with his frustration, and talked about how people sometimes look at things from different perspectives.  We talked about how the babysitter did not see who played with the toys and just wanted things picked up before everyone went home, while he felt the other children made some of the mess so should help more.  It was difficult to talk about the issue calmly, and we stopped talking about it when he started to get wound up.  We will try again to talk about different perspectives that people have when similar issues come up in the future.

Recently, the boy protested going to tutoring, and got into a heated argument that led to pushing his mother. In our therapy session, we set a firm limit about physical contact with adults and talked about a significant consequence were it to happen again.  We explained that voicing his displeasure in a loud way would not trigger the severe consequence, just pushing, hitting or kicking.  Since then there have been no further incidents of pushing.  Notice that we did not punish anger per se, just the physical expression of it.

His anger outbursts have been lessening, and we decided to add a reward for his cooperation with the reading specialist.  He earns a small amount of money each week that he can use toward a purchase of his choice in the future.  He wants an action figure, and is saving up for it.  The reward is for cooperation, and at the same time eliminates a source of anger in the past.  Rewards can work when the frequency of angry outbursts has been lowered already with other strategies, and when the target is socially appropriate behavior that prevents anger from arising.  We did not establish a reward for never exploding verbally, because this would be too difficult and would probably lead to more frustration.  Hope this gives you some idea how to apply strategies (that I  discuss in more detail in other blog posts and in my parent's manual) and when to use consequences and rewards,

David Gottlieb, Ph.D.