Tuesday, October 20, 2015

Medication versus behavioral strategies

Our "small for his age" and academically gifted 7 year son suffers from frequent anger outbursts and a co-worker recommended your Anger Overload manual to us. The 8-year-old you describe in the book could be our son. He can be a delightful boy when everything is going his way, but he cannot cope with even minor frustrations and disappointments without flying off the handle and turning verbally and physically abusive. It is severely impacting our family life and, though he generally keeps it together in school, has started to bleed into his social life.

In addition to seeing a CBT therapist, we have been diligently applying the strategies you recommend. Our son has great self-awareness and insights into his own behavior so he has been good at the worksheets, but when he's in anger mode he cannot stop and think rationally. Also, while we have learned to recognize his triggers and head off a lot of problematic situations at home, we can't protect him from every frustration and disappointment in life. 

This brings me to my question. Our son has a NOS diagnosis because he does not meet the full criteria for ADHD, ODD, or any mood disorder. Do you ever recommend medications like Intuniv for children like this? Our therapist is pushing for it, but we are reluctant. Do we just need to give these strategies more time, or will the medication help him leap forward?   Do you find, in your practice, that children tend to outgrow anger overload as their brains mature?

To my knowledge Intuniv is sometimes used for ADHD and has a "slowing down" effect on hyperactive behavior. I would check with a psychiatrist if you are considering it. The strategies in my manuals take time, often several months to begin to see changes, and may not work as well when his anger rises real quickly. If you can catch the frustration early sometimes, the cognitive strategies in the second half of the manual will be easier for your son to use. Otherwise you will need to rearrange the sequence, or lower the expectations, or use emotional distraction, or use mantras and imaginary stories (described in volume 2) ahead of time. The work you do with your son before an outburst, or when you review the day at night, is key for teaching children to have better self control.  I haven't had a child with anger overload take Intuniv so I'm not sure how it would work, but I suppose if it lessens his quick anger response it could be helpful. But this is new territory and I'd check with an M.D. who is familiar with these medications and who works with children.

Regarding changes in self control as a child matures, it is hard to say for sure how much is maturity and how much is due to practice because there are no controlled longitudinal (long term) studies of anger overload. Short term studies of anger indicate that cognitive behavioral strategies like I outline in my manuals are effective. Keep using strategies like labeling levels of anger and discussing options when he is calm, and developing mantras (sayings) that you can use before he gets upset to remind him to lower his expectations or to look at an issue in a different way, It may not help prevent overload immediately but it keeps the importance of self control in his mind and helps him begin to think about a frustrating situation in a different way. Let him know this is important, and you and he will keep working on it with him. Empathize that it's not easy but "seed" the idea that as he matures he will be able to do it, You want to communicate repeatedly that you are going to work as a team, and praise him (when he is calm) if he tries to use the strategies.  When he goes into anger overload, say as little as possible and wait until later, and then calmly review the trigger and how else he could think about that situation in the future.

Best, Dr. Dave Gottlieb

Tuesday, October 6, 2015

11 yr old escalates despite rewards

Dr Dave,

I have been reading your blog and everything sounds like my son.  My son is an 11 year old.  Mr popular at school, every person who meets him instantly falls in love with him.  He has this thing about him that instantly attracts people.  He is an amazing little boy, respectful, listens and follow the rules.  Teachers LOVE him and do not believe me when I explain his behavior at home.  I almost get the look of "What are you doing to him"  

The issues we have with him is his anger issues and how he treats his sister, myself and my husband.  Generally he is a great kid BUT when he gets angry....Watch out world.  I have changed some of the things I am doing with him and the major one is he has to earn his electronic / internet time on a daily basis.  His behavior in the morning, before school, after school etc.  

Yesterday morning we had an issue when it was time for him to leave for school (he walks); he decided it was too cold for him to walk and I needed to drive him to school.  I told him he needed to wear his jacket and he will be fine.  Apparently, he left his jacket at school so he felt he did nothing wrong and I needed to drive him.  I explained he could wear a sweatshirt and there were multiple excuses why wearing a sweatshirt would not work.  At this point his anger is set into high gear and he starts walking around the house in a circle almost in a panic mode looking for something to wear as if something was going to fall from the ceiling.  He is crying and carrying on like a toddler and insisting I drive him to school.  I explained calmly that this is not my fault he left his jacket at school and I will not drive him to school based on his behavior.  After screaming and crying and carrying on he finally left for school. 

When he came home from school he was angry with me and tried fighting and arguing again because he believed he was not in the wrong and wanted his gaming time.  I continued to stay calm and tried talking to him but his anger and the things he was saying I knew there was no point.  We have talked and agreed upon when he gets that way he needs to go into his room and calm down for a bit and then we can talk about it.  This time he REFUSED to go to his room to calm down and was screaming at me and telling me he was calm and we were going to talk about this NOW.  At this point I said well I am not calm so I need to walk away.  In his angry voice with attitude he said fine walk away you do not love me and you are not a good mom.  

After I was able to calm down I came back inside and he immediately hugged me and apologized for the way he acted.  I hugged him and told him I love him.  Things were fine at this point until I caught him on his IPOD playing on the internet.  He made up reasons on why he was on it and was justifying why he felt it was ok he was on it and that I should have not left his IPOD anywhere he could find it. 

At this point I reminded him of our agreement that he will be be able to go to the Homecoming Parade after school and the Homecoming football game ONLY if he had good behavior for the week and since he was unable to follow the rules and his was not showing good behavior he was not going.  That is when the anger started again and it was nearing time for bed and told him he needed to go to bed.  He attempted to argue with me and I just pointed to his bedroom.  

He finally went and laid on his floor punching his fist on the floor (when he gets to his rage part he will stand with his hands in a fist and shake) I did not say a word to him.  Next he turned his bedroom light on, screamed at his sister for no reason, and started doing sit ups in an angry way.  I went to his bedroom and turned his light off.  He turned his light back on and I turned it off again.  He screamed why are you doing that and I said you need to get in bed.  Of course he yelled saying he was not tired and was not getting in bed.  I did not respond and eventually he did get into bed. He cried and screamed for over an hour.  This morning he was calm when he first woke up and tried debating with me a different punishment for him so he could go to the game and parade.  I told him that was impossible and he needs to learn that when he has his anger fits he is not going to get any privileges.  He cried, punched things, tried telling me he was not going to go to school and how I hate him and tried telling me things his sister had done so I would ground her also.  

This is just an example of what happens.  Most of the time  the problem with his anger is when he does not get his way.  He feels everything he does is fine and he should just do whatever he wants.  And if things are not going to his plans then everyone around him needs to suffer.  I have been watching his anger get more and more severe.  He has not ever hit my husband or I, however, he has hit his sister which is more a sibling hitting type of behavior (not that I think it is ok).  I worry his anger problems are going to turn into more of a rage that becomes violent towards others.  

I read trying to turn the child's attention to something else but it happens so quickly and there is no reasoning with him.  I know this takes time and A LOT of energy which I am willing to do but I am not sure I am handling everything the best way or the way it should be.  It is also very hard for me to stay calm sometimes.  This is why I have started to walk away and not raise my voice.  Do you have any other suggestions or ideas of what we can be doing better.  This also tends to happen when my husband is not home (in the mornings after he leaves for work, or after school when he is not home etc.)  He has been around when it does happen but majority of the time it occurs when he isn't here. Sorry this is such a novel any help would be appreciated.

P.S. We have started using a code word when he gets upset and that worked for 2 days and now today he decided he does not care about the code word and will not use it anymore.  Of course I let him know that this is my home and my rules and these things are not for debate that we are using them to help all of us out. He didn't like that answer either.

Hi, I can tell how hard you are trying, and many of your ideas are excellent.  I like that you are walking away when you get upset; I might even walk away sooner, and talk less with your son when he is angry.  It is okay to review with him the day's events when everyone is calm, but do not start explaining things if he is still angry, because then he will escalate (as you have noted).  

I would rely less on week-long incentives and consequences.  Anger overload can happen several times a day, and it is too hard for a child to try to hold it together the whole week. Furthermore, your child will be less willing to work on his anger if he has already blown the reward for the week (e.g. homecoming).  If you are going to use incentives, I'd prefer you use the daily ones, like what you are doing with the IPOD.  I would also encourage you to still offer the reward if he makes an effort.  Children with anger overload are not always going to be able to calm down. There is a biological part to their anger, so you will need to use various strategies, and over time, the frequency and intensity of outbursts will lessen. I would establish a signal, like what you are doing with the code word.  If your son can go to his room when you give him the signal (within a minute or two) then he could still earn the reward, i.e. IPOD time.

If you can catch his anger at a lower level, apply the signal then.  Many of the strategies in my manual are more effective the sooner you can see signs of a child getting upset.  Once he is in overload, say as little as possible.  The more talking you do, the more he is likely to escalate.

The second half of the parent's manual explains cognitive strategies you can use, and volume two of the manual offers additional cognitive strategies.  One goal is to teach your son to be able to observe his own emotional state.  I recommend using labels to categorize anger as low level, medium, and overload.  If you can catch his anger at low level, you might mention out loud whatever label you choose and implement a calming strategy at that point. The strategy could be to distract him, like saying "wait a second, I need your help lifting this in the kitchen and then we can talk."  By re-directing him to do something immediately, it gives everyone a chance to catch their breath.  You'd have to have something in mind that you need help with, or you can use other forms of "emotional distraction" such as pointing out something funny you heard on the radio or television that day.  Or asking him about his favorite sports team.  

Whether or not you catch his anger at a low level, you would later that evening (when everyone is calm), help him see why you labeled his anger as low, medium or high, and suggest to him that over time you will work together to help him prevent overload.  You can explain that the more he can identify the level of anger he is feeling, the more control he will have (someday when he is older, he will be able to implement strategies on his own), and the more respect and appreciation he will receive form you and from other people he lives with someday.  

You might also think about why overload happens less when your husband is around.  If he is doing something that works, try to adapt it for you to use when he is not there.  

Other sections of the manuals explain how to teach your son about other points of view,how to use catch phrases and mantras, and how to look for patterns.

Best, Dr. Dave Gottlieb