Tuesday, June 20, 2017

9 yr old has meltdowns at bedtime

Hi,

Stumbled over your report and blog a few weeks back and a lot of things fell into place regarding our now 9 year old daughter. We're now trying to work through some of your suggestions. 

Thinking there may be a dietary trigger in that the last few meltdowns have followed chocolate or very sweet puddings at restaurants. Could this be a trigger?

One other question. Tonight's meltdown came after a lovely day when we told her it was bedtime. She instantly switched off to us and became increasingly agitated. Despite trying to explain and to reason with her she focused on any negativity. Left alone she has calmed and gone to bed. However she shares a room with a younger sister - something she wanted to do - and has scared her to the point we had to remove the younger sister to our room in order to resettle her. This is not ideal. So, any bedtime meltdown tips please?

Grateful for any help.


Hi, bedtime can trigger a meltdown because a child may not want to stop whatever she is doing that is fun.  Generally, if some fun activity follows a boring activity, then a child is more likely to do the boring activity.  But nothing fun follows bedtime, except maybe for the parents, who get a breather when their children are asleep!  What I recommend is doing something the child enjoys after she gets in bed, like a story or a card game.  If this engages your child, she will be more likely to get into bed.  Pick a relatively calm activity so that your child is more likely to wind down.  

Rewards do not usually work well because a child isn't concerned with a reward that will come tomorrow when she would rather do something with you tonight!  

What happens if you successfully get your child into bed with a fun activity, but when the activity is over, she does not want to stay in bed and sleep?  That's a tough one.  You could do another more calming activity, such as have your child lie down and read her a story in dim light.  The other option, if she continues not to drop off to sleep, is to try a later bedtime when she is more likely to be exhausted.  

Once you have determined it is time to leave, do not talk a lot or spend much time in her room.  If she has a meltdown, you do not want to "reward" it by giving her a lot of attention. Usually these meltdowns tail off after a week or so, when the child sees that you will not spend more time with her. 

As for sugar, there is controversy in the literature about its effects.  More doctors feel that hunger (or a lack of sugar and other nutrients) is more likely to trigger irritability than an excess of sweets.  However, chocolate does contain caffeine, so if your child is sensitive to caffeine, that could delay sleepiness.

Best, Dr. Dave Gottlieb

Wednesday, June 7, 2017

PANDAS, an autoimmune disorder

Dear Dr. Gottlieb,

At age 4 or 5, my once happy child started having more angry outbursts and oppositional behaviors along with anxiety. Since the initial episodes were fairly low in intensity and frequency and were easily mitigated with humor or social-emotional strategies, I didn't think much of it and chalked it up to growing older and being faced with increased frustrations. 

But that all changed this winter, when he morphed into a very angry and anxious child. The smallest frustration caused huge angry and aggressive outbursts. Separation became a problem. Any strategies previously learned were useless in the moment and did not seen to stick for long. I was at a complete loss and motherly instinct told me there was something seriously wrong that was not externally based. 

After lots of research, I had him checked for strep due to behavioral symptoms. He was positive and to my shock and relief after a few days of antibiotics, I was seeing my old articulate and happy son returning. He was diagnosed by 2 doctors (pediatrician and neurologist) with PANDAS and with longer term antibiotics, we are continuing to see our son's emotional health returning. 

I am writing to you because, as a psychologist myself, I had the tendency to believe all behavior is trigger-based (because if we look hard enough we can always find some connection, right?), but it is not necessarily so. I am glad I considered medical issues and did not continue to search for external causes, which would only have shortchanged my child.

While of course not all children with anger issues have this disease, I think it is important to rule possible medical causes (e.g., PANDAS) in or out first, especially when coexisting symptoms, such as separation or the anxieties are seen and a child has changed significantly. Of course trauma must be ruled out as well. That being said, your strategies are well-thought out and help countless people. Continue your great work, but please alert parents to this very real disease that, if caught early, can be fully treated with antibiotics (in conjunction with CBT, if indicated. I am attaching a link to a brand new documenary on PANDAS, which as both a psychologist and parent has opened my eyes to the possible medical side of behavioral issues and has enriched my repertoire when helping families. In fact, this knowledge has already been useful for me in assisting parents in recognizing and treating early emotional signs of strep.


 Thank you for reading. I would love your feedback.


Hi, In my clinical work of 30 years, I have had one case of PANDAS; I am not an expert on the disease.  Research results on the prevalence of PANDAS varies but a study referenced by the National Institute of Health found 1 case of PANDAS per 3,000 throat cultures positive for strep.   PANDAS is an acronym for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Children who develop a strep infection occasionally develop severe behavioral symptoms. Usually there will be a tic disorder (sudden involuntary motor movements or repetitive sounds or words) and/or obsessive-compulsive symptoms (OCD).  Basically the strep infection causes an abnormal autoimmune response that includes these behavioral symptoms.  The behaviors can last for months, but these children often respond well to antibiotics and cognitive behavioral treatment. Sometimes other medications are used depending on which behavioral symptoms are prominent.  (For example, serotonin reuptake inhibitors can be used for OCD symptoms.) Problems can recur especially if the child develops strep again.  

There can be other symptoms like anxiety and temper outbursts, but in my experience and from what I've read about the disorder, anxiety and anger are not in themselves definitive characteristics of PANDAS.  Tics and OCD symptoms following a strep infection are currently seen as key symptoms.  Research is ongoing, and we will know more in coming years.  

If there is a sudden increase in behavioral symptoms, and your child may have had strep recently, it is wise to get a medical evaluation from your child's pediatrician or family doctor. For more information on PANDAS, the National Institute of Health has an informative website: https://rarediseases.info.nih.gov/diseases/7312/pandas.

For most children with anger overload issues, there is a different biological pathway that makes children susceptible to anger overload.   As I write in my parent's manual, the prefrontal cortex of the brain and amygdala are structures most likely implicated, and the most effective strategies I have included in my parent's manuals and children's workbook. Cognitive behavioral strategies can help children develop better self-control. 

Best, Dr. Dave Gottlieb 

Tuesday, May 23, 2017

Using the anger overload workbook

My son is 9.  He has many diagnoses over the years, from autism to bipolar to anxiety.  Anxiety is the one that has stuck and we have since found out he is gifted.  The problems with anger started when he was 3.  He had a flip switch and would rage for hours, run away from us, destroy daycare classrooms, etc.  He has gotten better over the years.  His IEP and behavior plan were removed this year due to his progress.  He has also gone off of his Risperdal and is tapering off and almost off of Trileptal.  However, starting at the beginning of May - his anger came back at school.  His triggers are during recess mostly (90%) and related to people not playing by the rules as he deems them.  For example, four square.  He knows all the rules because he has researched them and gets mad if others do not play that way.  He has hit, kicked, shoved.  The school  year ends in a few days and summer camp starts.  Summer camp is outside and has many of the games which have been his triggers this month.

I am thinking of having him complete the kids' workbook.  Any other thoughts to help?  Much thanks in advance!


Hi, in the beginning of the anger overload workbook, I ask children to keep track of their anger:  who did you get angry with, what did they say or do, and what did you say or do. Then I have children fill out worksheets that help them see patterns.  In your child's case, one pattern is when the rules are broken during playground games.  

Then the workbook explains strategies to deal with anger.  One chapter looks at how to prevent anger from starting, and another section of the workbook looks at what to do for early signs of anger, and then there is a section for the high anger stage.  Later I discuss more advanced techniques, like how to deal with different points of view and how to compromise.

For your son, he could prevent anger on the playground by playing a different, non-competitive game, but he probably would not like that idea.  So then I would work with him on mantras that would help him look at the game differently.  For example, one mantra could be "other kids won't always follow the rules, and I can't change that" or "some kids will make up their own rules, and if I want to keep being allowed to play with them, I have to play by their rules sometimes, even if I am right."  You would want your son to come up with a version that he thinks would help him remember how to deal with the kids during four square.  Then you want to practice it with him each night, or each morning before school. Remind him to repeat it during the game if he is starting to get aggravated.  

The next section of the workbook deals with low levels of anger.  We teach children how to be aware of body signals that they are getting frustrated. We also explain various coping strategies: a) physical activities, b) "chill" activities, c) reaching out to others, d) sensory activities, or e) mindfulness.  We explain how a child can implement these various techniques.  Some are more adaptable to a school environment.  Basically we want your child to have a toolbox of strategies, so that he can pick what he wants in a given situation. Then we recommend giving him a lot of praise for trying a strategy, whether it always works or not.  

If his anger gets to the overload phase, finding a "go to" place to calm down is important.  

As your child gets more reflective about what is happening, there are advanced techniques that we recommend toward the end of the workbook.
.  

Best, Dr. Dave Gottlieb

Tuesday, May 9, 2017

12 yr old in residential setting

Hi Dr Dave I wondered if there was any research to prove that positive parenting strategies were more effective in the long term than restraining?

My daughter is 12 with a diagnosis of autistic spectrum disorder (ASD) with Anxiety, ADHD, and she was also recently been diagnosed with the new DMDD (Disruptive mood disregulation disorder) as she spends so much time 'bubbling' with no clear understanding herself of why she feels on edge. She is fully verbal and high functioning but loses all logic once she gets too wound up.

She was hospitalized at age 9 for 9 months because she was simmering nearly all day and erupting 1-2 times a day lasting approx 2 hours - regularly hurting herself, others and causing breakages, smashing holes in the wall etc.

We now have her in a good specialist school where she is residential Mon-Fri and is getting Anger Management therapy and OT. I am learning lots.

I have been using de-escalation / positive re-enforcement with calm empathetic techniques for the last 2 years (not sure if there is a 'formal' name for these strategies and her therapist is confident we are on the right track.

But a few weeks ago she had a couple of mammoth meltdowns at the boarding part of school and was restrained.

There seems to be some discrepancy between the boarding staff, school staff and therapeutic staff about the best strategies during crises. Boarding  have stated that her place there is in jeopardy. This has thrown me as it has opened the door for doubting relatives.

I am wondering if there is any research to back up strategies to help me feel confident we are on the right path.

We are in danger of her being sectioned. She is like Jekyll and Hyde tho, in that when sensory issues and anxiety are reduced she can seem very logical. She is actually above average intelligence - but her emotional age is several years below.

I hope you can help. She appears to be quite a 'unique case' with many experts being stumped when confronted by her over whelming rage. 


Hi, A good research study in the field of anger and aggression in children has been conducted by a professor at Yale University.  His name is Denis Sukhodolsky.  He advocates cognitive behavioral strategies, many of which I advocate as well in my parenting manuals.  In my view restraint should be a last resort to be used if a child is physically harming herself or others.  I prefer to ignore screaming and tantrums if they are not destructive. The more you talk with a child in overload, usually the longer overload continues.  However,in a community setting, it can be disconcerting to other children if a child is screaming, and then it is up to staff to think through whether they can isolate the child (will she move to her room?), or whether they can remove the other children from that space.

Early detection of her triggers is ideal, because then a child is more rational.  I outline in my parents' manuals and the children''s workbook, how to record triggers and how to look for patterns.  That allows for early intervention. Then empathy and/or distraction and/or using catch phrases will help more often. (The latter is part of teaching a child to keep perspective.)   I'm wondering what specifically set her off recently since you mentioned she was having fewer tantrums until recently. Is she worried about losing her space in the residence?  Structure and stability are important for a child with severe overload issues. If she has some awareness that her position in the residence may change, she may be more anxious and prone to outbursts. 

Given her mood and anxiety issues, and the ADHD diagnosis, I wonder if medicine has helped.  Sometimes if the other symptoms lessen, there is less anger overload, and/or the anger will respond to empathy, or distraction, or to cognitive interventions to help keep one's perspective.  For the latter, see the later sections of my parent's manuals or children's workbooks. 

Best to you and your daughter, Dr. Dave Gottlieb


Tuesday, March 21, 2017

Therapy recommended for self harm behaviors

Hello Dr. Dave,

My 9-year-old daughter suffers from anger overload and her episodes have gotten more frequent and pretty scary. My husband  and I are wondering if we should follow the course you recommend in your book on our own, or seek professional help. Some background…

We can trace E’s angry outbursts back to when she was a newborn and would get so mad when we would put her in her carseat that she would hold her breath and turn purple. As a toddler, she was more volatile than my older daughter, but we figured her behavior was in the range of normal for her age. Between the ages of 5 and 7, she had several over-the-top reactions to seemingly small disappointments or when she would not get her way. The summer after she turned 7, things got worse. Practically every day, something would set her off and she would scream at the top of her lungs, cry, say nasty things to her parents and sister, and throw stuff around. Once she pulled out a clump of hair and once she banged her head on the floor, before realizing it wasn’t a great idea. In desperation, I searched the Internet and came across your book, “Anger Overload in Children: A Parents’ Manual”. I ordered it and quickly read through the introduction. Your description of anger overload fit E to a tee. Before i could get farther into the book, the summer ended, school started, and the horrible episodes disappeared. I filed the book away, hopeful that we didn’t need it after all.

During the winter of 2nd grade, E had a struggle with anxiety, and we ended up seeing a LCPC, who helped us identify the problem, label it, and taught E some basic skills to deal with it. E has not had to deal with anxiety interfering with her life since then.

E continued to have infrequent anger episodes, though few stand out in my mind, as I reflect back on that time. Fast forward to February 2017. E is now 9-1/2. Without warning, she began to have more frequent and more intense episodes. The triggers are different - once she was struggling with homework, another time she received a piece of modestly disappointing news. The reactions are often fierce. She screams, cries, throws hurtful words at her family, and is modestly destructive. Of most concern, she has hurt herself by pulling out her hair and hitting herself in the head. She says that she wants to kill herself or wishes we would kill her. After the episode passes, E acknowledges that she does not want to hurt herself and is generally a sweet, happy kid.

We went back to the therapist she had seen for anxiety, but I realized that the therapist was not equipped for this type of problem and it was no longer a good fit. I also met with a psychologist, who E is supposed to see for the first time later this week. However, the psychologist didn’t seem to have any experience with behavior like this and I am a little concerned that she will take the wrong path. E does not want to see anyone.

In the midst of all this, I remembered your book and once again read through the introduction. I am certain that anger overload is descriptive of E’s condition. I am unsure, though, if we should handle this on our own, following the recommendations of the book, or if we should be working with a professional, given the threats of self harm. 



Hi, Yes, given the self harm behaviors, I would recommend you consult with a mental health professional who works with children and their parents.  Many of the strategies in my parent's manual may be helpful and woven into the course of therapy.  Continue to record what some of your daughter's triggers are.  That will help you and the therapist anticipate some of her outbursts and devise the best strategies to help.  

In reading your e-mail, I wonder if your daughter expects too much of herself.  You wrote that she experiences anger overload when she struggles with homework or gets modestly disappointing news.  I would recommend cuing her before she starts homework that some of it will be hard, and that it's good she does not know some answers.  If homework were too easy, she would not be learning anything new.  You could shorten this into a catchy mantra that your daughter helps to create.  An example would be "mistakes are good. It means I'm learning new stuff."  Or "everyone makes mistakes."  This would be practiced daily, until it gets internalized (i.e. until your daughter can deal better with disappointments, like homework difficulties).

Beyond the mantra, the parent's manual has other strategies to help her with self control. In addition, therapy can help identify further the source of her upsets, and help your daughter feel better about herself.  Therapy helps with underlying issues as well as helps a child develop self control strategies.  

Best, Dr. Dave Gottlieb

Tuesday, March 7, 2017

5 yr old trashes the classroom

Dear Dr Dave

I came across your article on anger overload after desperately in tears reviewing the internet. It is the first time I have actually read something that sounds like what my just turned 5 year old has!

We are waiting for proper Assessments to be carried out at the moment but first discussion with Pediatrics & we were asked to complete Conners 3 & the social communication checklist. Neither myself or or the teachers at my sons school think he has ADHD or Autism. He is a very intelligent little boy & is extremely loving especially to animals & younger children & his no problem with attention. They have witnessed his sweetness & had great conversations with him over lunch.

From an early age he has what we call a flip switch, where he just  loses his temper. It's usually linked to frustration, what he thinks is unfairness or just not getting his own way.
Sometimes we can distract him out of it, normally with something that requires thinking & sometimes we can't. Outbursts at home are limited probably as we have learned to control them or just tackle major stuff but at nursery (where the changes began in preschool room lashing out at adults) & now school it is has been a real problem.

First two weeks at school he struggled to settle (separating from me) but then after this, he had great first term & even got certificates & awards for his good work. The teachers have said he is ahead with his work. It all changed in 3rd week in December last year. None of us know why.

He has taken to lashing out at the teachers & walls mainly, shouting, hitting, kicking in an anger episode. He also sometimes runs off when he gets cross down the corridor. The outbursts are short in time & never normally over 30 minutes.

He was taken in from the playground one day in January due to fighting with two other boys & he wouldn't calm down. He deemed this to be unfair & he then trashed the classroom. Throwing things off pegs, pen pots, books etc, kicking teachers & hurting them. The teachers called me to collect my son. This happened again later that week & the whole classroom was trashed. I was devastated & he was then excluded & then put on a reduced timetable since the end of January. This is when we reached out to our GP.

Outbursts have reduced in intensity & he has not wrecked classroom since (he didn't like mummy crying & being upset) but ED psychologist linked to school has suggested a few things like 1:1 supervision & to give him choices out of two options & they now use now & next cards to prepare him. This strategy has seemed to back fire. This last week he has started to refuse more & more direction at school & the anger outbursts (hitting staff) have returned almost daily. One day he was great until he was asked to use soap to wash his hands & he got angry & lashed out. I asked him later, & he said they don't usually have soap available in the toilets to use & so he has to usually use just water.

He is not allowed playtime with the other children as the staff are worried that another child may get hurt in his outbursts. It is difficult for us to understand as we have play dates, go to parties etc & if he ever gets cross we are able to manage it but this is rarely.  We suppose we are in a fun setting, we are there & can intervene & he knows this.

We have tried reinforcing how he should behave at school, no hitting, kicking & reading books together on how he should act & rule following. Even sticker charts don't seem to be working.

Have you ever come across anger overload happening more often in a controlled setting? And refusal of direction? Do you have any advice as how I can help the school?
We are not sure if there is anything underlying linked to school that is increasing the anger episodes there.

After reading your parent guide I am planning to start recording occasions at home. I was going to ask school to do this too?

Any advice you can give I would really appreciate it.

Hi, You have done a good job of trying different techniques and worked well with the school. It must be so frustrating that your son's outbursts at school increased in December.  Do you have any idea whether something changed in your son's life at home or school at that time? 

I try to get clues about the triggers from what is happening when a child gets angry.  As I read through your email, I was making notes of some of your son's triggers: separation when you drop him off, when there was a dispute on the playground with two other boys, and when he was asked to use soap to wash his hands (when he was used to only washing with water).  Transition times seem to be a trigger sometimes, and unexpected changes seem to be another trigger.  Keep trying to make a list of triggers and then see if you and the teachers can anticipate a stressful situation for your child and intervene before the overload phase.  It will be difficult to anticipate all things that will trigger his anger, but if you can anticipate some, and work out a strategy ahead of time with the school, it may reduce the frequency of outbursts.  I outline how to use emotional distraction and relaxation strategies in my parents' manuals.  The second manual has a section specifically on applying the strategies to anger in school.  Also in the second manual, I explain how to develop jingles or mantras that you would practice with your child ahead of time.

I like the ideas of the school psychologist: offering a choice of two options sometimes helps head strong children.  But if a strategy stops working, then the school may need to try something else. I find that mantras, early emotional distraction, and relaxation "stations" (a place separate from the other children with relaxing objects) are often helpful.  In answer to your question, structure usually helps, but not always with children who are head strong. 

If you try again to use positive reinforcement, keep the chart brief--one or two items--and have a daily, exciting reward.  Sometimes it helps to teach your child how to "go with the flow."  The teacher could use a hand signal when she wants your son to "go with the flow." Then if he does that once or twice a day, he earns a fun activity at home or school. Keep in mind that it is sometimes trial and error to find what rewards motivate a child.

I would continue with the evaluation by your child's doctor to see what else may be contributing to the outbursts.  The frequency and intensity suggest that psychotherapy is a good idea.

Best to you, Dr. Dave Gottlieb


Tuesday, February 28, 2017

10 year old runs away at school

Dr. Dave,
I am in tears as I write this. I have my 10 year old grandson living with me because of his anger issues.  His Mother is in trouble at work for missing often to go get him due to running from school or trying to hurt someone.  My grandson is in trouble with the law - AT 10 YEARS OLD! - because he tried to get away from the cop and bit him when they forced him to get in their vehicle.

Then he comes to live with us. Most of the time he is so much fun.  He is kind and caring and smart and funny.  But when he gets that "look in his eyes" be careful.  He is going to blow. When he got here, we had so much to overcome.  He was scared to do anything because he would make a mess or fall or break something. He had a lot of anxieties. When he would go into the anger overload he would want to run.  We got that down to running to his room.  He slammed the door a couple times but we got over that.  Then it was down to yelling and running to his room (in the basement), then down to running to the top of the stairs.  He sits down and puts his head in his arms and works to get through it.  Now we are to the point of him doing that in his chair next to me.  Seems like great progress but suddenly school is a mess.  

We are two weeks from being off probation and now he is suspended.   Last week he ran out of the school because he got all the questions wrong on a math assignment (and I hear he is doing so well!).  Then some kids got candy because they did well.  The anger came quickly!  Yesterday they were playing a game in the gym with jump ropes.  His team lost and a kid says "See, just ANOTHER game you loose to".  He lost it.  Took the jump rope and hit the teacher in the legs.  The principal took him and held him down in front of everyone and then had them leave.  My grandson could not calm down needless to say.  They called the cops.  I was 1 1/2 hours away at a doctor appointment.  They don't help kids like this.  They go to juvenile detention or a mental hospital.  They are put on probation.  This just adds anxiety to an already anxious child.  

I am at wit's end.  My husband lost his job of 27 years and I have to work.  We were left with taking him home and he can't come back "for at least 3 days".  We don't know what that means.  Are they going to kick him out? What can we do? This boy is such a great kid 95% of the time but the other 5% is what defines him as a person.  And the family is blamed for him acting like this and being a small town....well, no friends for him and ours are falling away.

I found your information last night and would welcome your advice to move forward.  We moved so far back yesterday that I don't know if we can move forward.  Too many dead ends and brick walls for him.Thank you for listening.


Hi, You are doing a good job, as evidenced by the changes in his "running" behavior at home when he is angry.  Your calmness and your positive attitude toward him comes through to me and must come through to your grandson.  He does not feel put down by you, so his anger does not spiral further at home. 

It sounds like at school, your grandson is easily hurt when he is teased or when he feels like a failure.  Maybe the teachers can help him feel better about himself by intervening quickly when he makes mistakes on an assignment and reassure him that it is okay to make mistakes and they will help him.  Similarly in gym if he loses a game, the coach could be ready to intervene right away and compliment him on his efforts, reassure him everyone loses sometimes, and give him a job to do in gym so he can feel like a leader.

Also, it would be a good idea to try to find a mental health professional in your area who works with children and families (and/or see if the school has a psychologist who could work with your grandson).  The goal would be to work on his self-esteem and help him learn to cope with mistakes and with negative comments from peers.  This seems to be one of the main precipitants of his angry outbursts.  One idea would be to practice a mantra with him each night, such as "Everyone makes mistakes, and you are still a smart boy even if you make mistakes."  Then help him see some of his strengths.  And if the teachers could point out positive aspects to his work at the same time that they point out mistakes, that might also help him keep things in perspective.

Once he is in overload, is there a safe space he can go to in school, like he does at home? Work with the school staff to see if there is an alternative like this at his school.

Best, Dr. Dave Gottlieb


Tuesday, February 14, 2017

9 yr old melts down over missing legos

Dr. Dave - 

I ran across your article several months ago and thought - he just described my son! I am pretty sure my 9 year old son has anger overload. Tonight's episode went something like this: Him, his younger sister and I go downstairs to work on a Lego set he received for Christmas. I move the set we are working onto the table, he begins to look for the figurines that go with it - he asks his sister where they are, she says she doesn't know. He starts moving things around looking for them, blaming her for loosing them and then it begins - he totally looses it. He starts crying and yelling that it is ruined - without those figurines, the set is worthless. I tell him they are here - we'll find them (they have a lot of Lego's and aren't good about keeping them confined to an area). He continues on saying that they are lost and now the sets are ruined. 

This quickly escalates to him lamenting about tearing down multiple Lego sets when a friend of his tricked him (a friend convinced him to take apart several sets a couple of years ago and the parts are all mixed together making it difficult to put them back together) and how everything is ruined, that he can never fix them and how stupid he is for falling for that trick. He is screaming and crying and ready to throw completed Lego sets. I go to him, take the Lego set he has out of his hands and guide him away from the area. He falls to the floor, continuing to yell and cry that everything is so unfair and that in heaven he'd have all the room for his Lego's he wants and all the sets would be complete.  

He continues on with how unfair life is this for several minutes when it starts morphing into how his classmates are treating him at school, that they don't want to play with him, that they go out of their way to leave him out, don't pick him because he only has one grandparent alive (his dad and I are older and he lost a grandmother unexpectedly in 2015 and a grandfather in 2013), that when he tries to fit in it only makes it worse (all of this is contrary, for the most part, to what he tells me about school on a regular basis - that he played X with such and such and today he did X with this group of kids, etc), this then leads to basketball being horrible, that his team isn't any good (which they really aren't, although he is athletic) and it isn't fair that they play teams that are so much better than them (which they do) and it isn't any fun. This continues on for almost an hour (or longer in some instances), until he is completely worn out.  

Sometime later he came to me and said he was sorry for lying - when I asked what he was lying about he said everyday when I come home from school and say things were good. So I ask to clarify - so when you were upset and telling me stuff about how the kids treat you at school you're saying those things are true and when you come home from school and say your played bombardment with X and Y and did this with A and B, those things are not true? He says, yes, for the most part.

He doesn't have these meltdowns on a regular basis, they tend to be sporadic. They can be months apart or they can be weeks or even days apart. But I liken them to a volcano - building, building, building and you don't know when it is going to blow. That is exactly what happens - he seems to bottle every little slight to him and it builds until he can't take it and the smallest thing sets him off. Sometimes it happens when he is being disciplined, sometimes like in situations of not being able to find something or feeling he has failed at something. 

He generally appears to be a happy kid with a touch of orneriness.  He is in a private school with 15 children in his class, several have learning disabilities and behavioral issues that demand a fair amount of time from the teacher. According to his teacher he interacts well with the kids in his class. He is bright and gets good grades, but sometimes has trouble with accepting responsibility for his actions and following classroom rules. From what I understand from his current and past teachers he has never had an outburst like I described above at school. 

I have your book and workbook for kids, but haven't attempted the workbook with my son. I feel like some counseling is needed, but don't know how to even approach that - I guess I'm afraid of him being diagnosed as something he isn't - bipolar, oppositional defiant disorder, etc. I spoke to his principal last year (a former guidance counselor) and she mentioned bi-polar disorder. After reading your article and book and reading about bi-polar and ODD, I really felt like his issue was more anger overload. I am concerned for my son - that he has difficulty controlling this and he feels like a failure for not being able to control his anger at times.  His comments about heaven also concern me.

Any thoughts from you are appreciated.


Hi, You are a good observer of the sequence of behaviors leading up to you son's angry outbursts.  One thought I have is to try to intervene early in the sequence, using "emotional distraction" or a "mantra" (both of which I discuss in my books that you have).  Be on the look out for early signs of frustration.  In the example you give, your son asks his sister "where are the figurines" before he escalates.  You can anticipate from past experience that if he does not find them, he will get upset.  So when he first asks about the figurines, you could employ a distraction strategy.  You could suggest you all take an ice cream break, or point out one of his favorite shows is on television, or wonder out loud about some other interest of your son's, like wondering what would happen if Michael Jordan could play for five minutes on his team. However, if your son is determined to go on with the legos, then he may not be easily distracted.  Another alternative would be for you to take your daughter up for a bath (or some other activity) at this time, so that your son does not get into an escalating discussion with you or his sister about where the figurines are. 

Another approach would be to create mantras that you would practice with your son once or twice a day (before he gets involved in an activity that has caused anger overload in the past). The mantras would be focused on activities, like legos, that can lead to anger overload. Examples would be:  "Lego pieces always get lost." or "When we play legos, there are always some missing pieces.  Let's try to be creative and find another way to build things then."  

When kids are angry they will sometimes talk negatively about themselves or about other activities, like your son's comments about his friends.  Wait to see if the comments are similar when he is calm. My guess is that your son has mixed feelings:  he likes playing with his friends, but sometimes feels angry like when his friend tricked him into breaking apart some of his legos.  You could explain that friends can be fun but sometimes can be a pain.  You could practice this once a day as another mantra.  The idea is to help your son look at the situation with peers in a new way, that is more objective.

Other possible mantras could aim at his high expectations about legos and basketball. Examples would be:  "Some years our teams lose and other years we will win a lot."  Here's a possible mantra focused on discipline issues:  "Sometimes I will make a mistake and get in trouble. No one is perfect."  But if your son continues to put himself down, then you might consider checking with a therapist in your area to help him further with his self esteem.   

It is a good sign that he does not have outbursts at school.  That indicates he has some self-control mechanisms that work for him.  You note that the teachers confirm that he gets along well at school.  ODD and bipolar are not likely given his even temperament at school.  

When your son does reach the overload phase, be sure not to talk with him then.  Give him time alone to settle down.

Best, Dr. Dave Gottlieb  

Monday, January 16, 2017

What type of classroom is best for 6 yr old?


I have an almost 6 year old (about 2 months shy) who for the most part is a sweet, amazing child, but when angry, will hit, kick, throw, scream, run.  It started surfacing when he was about 3.5 years old.  We went through a number of preschools and finally settled on a part time parent participation preschool with a nanny present at all times.  We took him to a developmental pediatrician and it ended up more about ruling things out (autism, ADHD) than knowing the root cause.
He's now in kindergarten and officially on an IEP, and in a specialized class with onsite behavior specialists and therapists, and on a shortened day.  As a part of the IEP, we're about to get in-home services with a therapist as well.  As a part of my search for answers, I stumbled upon your articles on anger overload, which is the first time I felt like someone was describing my son.  My husband and I have learned to change how we interact with him (our developmental pediatrician recommended "The Explosive Child" which helped us understand that blaming him for his behavior was like blaming a dyslexic child for not being able to read), and while we still have our moments, we've been able to really minimize his severe anger at home.
This is not the case at school.  Even with all the additional support, he's having problems where an incident report is written up multiple times a week.  What more could we be doing to help him?  Are there therapeutic programs we should be looking into?


Hi, Yes there are day schools for children with emotional problems, but that may not be ideal for your child.  The programs vary in what emotional issues they deal with and in what approaches they use.  So if you someday consider that option, check with your school district to see what day schools they work with and what types of problems the schools are designed to help.

It sounds like your school system is trying to help by placing your son in a specialized program within your home school district.  The advantage of that approach is your son does not have a long bus ride, and may eventually be able to be mainstreamed gradually once he develops better self control.

The second volume of my manual offers strategies for helping children with anger overload in the classroom. I show how to apply the core principles from the first volume of my parent's manual to the school setting.  The first step is looking for patterns:  are there some themes or triggers that precede your son's outbursts?  While you will not be able to categorize all of the situations, if you, or the teacher, notice some patterns in school, you can then try to prevent anger overload by either changing the child's expectations or changing the sequence of activities.  For example, if a child expects to be called on when he raises his hand, or in another example say he expects to use the computers when he arrives at school, the teacher may be able to cue the child before these situations occur.  In the first example, the teacher will explain to the child ahead of time that he will only be called on occasionally, or, in the second example, he will be able to use the computer after the class does something else first.  The teacher could develop a short verbal or visual cue to help remind the child of what to expect, and could compliment the child any time he shows self restraint in those situations.  

There are also ways to set up relaxation stations or use emotional distraction techniques if the child's frustration is caught at an early stage before anger overload is reached.  I explain more about these strategies in other blog posts and in volume two of my parent's manual.

The most difficult stage for the teacher to manage in the classroom is if the child reaches the anger overload phase.  When a child is in this phase the teacher will usually need the help of an aide to help the child leave the classroom.  The school should plan in advance where this place would be in the school, so that the child is able to settle down without too much attention from the aide.  This can be hard to do when there is a classroom full of other students, so that if there are frequent outbursts, a smaller class with a "go to" calming place would be needed.

I explain in my manual that rewards and consequences need to be used carefully, because children with anger overload are usually not able to stop their behavior to avoid a consequence.  Children are not thinking rationally during anger overload.  Also, writing up an incident report may not be helpful, unless it is used to identify patterns, and not used to hand out punishments.  Determining patterns and triggers, as I mentioned above, is a useful first step toward developing a plan to help forestall an outburst.  Generally speaking, it is important to develop a good working relationship with your son's teachers and therapists. The more everyone is working together, the more likely your child will learn to develop better self control.

Best, Dave Gottlieb, Ph.D.

Wednesday, January 11, 2017

12 yr old loses it playing video games

Hi Dr. Dave,

Unfortunately, our 12 year old son has had a disappointment trigger for several years which causes intense rage. When he was younger (around 5 to 8 years old), it was tied to arcade claw games. When a prize wasn't grabbed and won, he'd throw a huge tantrum.

He's conquered that situation now that he's older, but now it occurs while playing a video game and something unexpected happens - usually tied to his perception of fairness (i.e. someone is thought to be cheating, loses when a win appears imminent, spends a great deal of time collecting materials within the game but is lost, etc).

Rage is almost instantaneous, not appropriate in terms of severity of the situation and can last for an hour or two if we don't distract him with something else. He often tries to break items around the house and appears to be unable to think rationally during these episodes.

His mother is bi-polar, but he doesn't display the same symptoms as her - except for the actions described above in very specific situations. Otherwise, he's a great kid that makes friends easily and does well in school. Also, I can only recall that he's displayed this behavior in front of someone other than family once, typically happens just in front of his parents, if that helps.

In short, what do you feel is the cause and what can we do to greatly reduce or eliminate this negative behavior?


Hi, What you describe sounds like anger overload--your child' has an angry outburst when he feels a something happens that is unfair in a video game. Many children are very excited and invested in the outcome of video games.  One approach you are already using is distraction.  While distraction can help in some situations, the problem with this approach with video games is that video games are so exciting (captivating for many youth) and your child's disappointment is so strong, that it will be hard to come up with a distraction that will capture his attention and change his emotional state. 

With video games, what I usually recommend to parents is to come up with a mantra that you repeat many times over the course of a month or more that describes the "unfairness" of video games. For example, one idea for a mantra is to explain that video games are made so that you will lose most of the time.  They want you to lose so that you will feel challenged to play again.  The game purposely leads you down blind alleys, or suddenly makes something happen to frustrate you.  If the game were always fair, you would win most of the time, and you would lose interest in the game.  Now the hard part is putting that idea into a succinct mantra.  You want it short and memorable so your child is more likely to remember it at the point he loses the game.  Practice explaining the issue when he is calm and ask him to help you come up with a sentence that he likes and that will help him remember when he plays that he is going to lose most of the time, because that is way the games are made.

Then each time he is about to play, you want to repeat the mantra in front of him, or ask him to remember what the mantra  is.  It is important for him to recall the mantra before he gets upset, while he is thinking rationally. The more often he repeats it over time, the more likely it will help.  It may take a month or more to have an impact, and it may work sometimes more than other times.  But you will see a gradual decrease in excessive outbursts if your child uses the mantra each time he plays.

Another approach some parents use is to specify certain unacceptable behaviors, like breaking or throwing things, and also specify more acceptable behaviors, like saying "this game can be so unfair" or "this game can be a pain." Then you explain while everyone is calm that if your child exhibits an unacceptable behavior during a game, he loses video game privileges for 24 hours, or some amount of time that is not endless!  You do not have to enforce the limit while he is raging, but later that day, explain that the 24 hour limit will start some time that day (whenever you have decided).  Sometimes this behavior modification (incentives or consequences) approach can help when used in conjunction with a mantra.  The potential consequence helps motivate a child, while the mantra helps a child learn what to expect when playing a video game.  

I lean more heavily toward the mantra approach, but each child is different, so you want to try different approaches until you find one (or a combination) that works best for your child. If you want to read more about devising mantras, check out other blog posts or my parent's manuals and my workbook for older children and teens.  There is a section about mantras in the workbook as well as in volume two of my parent's manuals:  "Anger Overload in Children: Additional Strategies for Parents and Teachers,"

Take care, Dr. Dave Gottlieb