Tuesday, June 20, 2017
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
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