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