Thursday, June 28, 2018

Questions about therapy, consequences and long term outlook

Hey Dr. Dave,
So many things running through my head, so I'll try to narrow them down. Our son is soon to be seven and exhibits behavior consistent with anger overload, though we've never seen a professional and thus no diagnosis. Frankly, I'm hesitant to have him diagnosed/labeled. Instead, we've done our own research, read your book and blog posts, and are convinced this is what we're dealing with. We've taken your advice to heart, even changing our own behavior to model appropriate anger, and have seen improvement in the few months since we started. Are we wrong in that approach? Are we depriving him (and us?) of help? Can you share your thoughts on this?

Our main challenge, lately, has been consequences. For the most part, we do well to recognize his triggers, attempt to distract, use coping words and techniques (e.g. 3 slow breaths), ignore him while he rages, give him a place to cool down, etc. But when it comes time to enforce the consequence for his inappropriate behavior, it seems so insignificant compared to the fit he threw. Additionally, he doesn't seem to care. He accepts the consequence as a matter of fact (disobedience = consequence), but it doesn't seem to serve as a warning the next time he gets angry. We need help determining what kinds of consequences are appropriate and will help teach the lesson. Should the consequence be proportional to the anger? Time out seems inconsequential when he's destroyed a bedroom or living room. We've taken away toys, had him sit out during pool time or other fun activities his siblings do, but none of it seems to stave off the next outburst. In fact, some of the consequences have triggered a new outburst.

Finally, is there information regarding how kids with anger overload turn out as adults? Are they more prone to mental health issues? Or to be verbally or physically abusive in relationships? Do they have trouble transitioning into adulthood from adolescence? I guess we're looking for reassurance that he can grow out of this.

Thanks for your work - it's been helpful!

Hi, you are effectively using a number of strategies outlined in my parent's manual, and you ask some good questions about where to go from here.  Let me start with your first question.  If you reach a point where the frequency and intensity of outbursts does not diminish over a month's time, then getting a professional consult might be helpful.  In that case, you would want a mental health professional who works with children and families on anger issues.  "Anger overload" is a term I coined to describe these outbursts; your clinician may not use that term, but what is important is that he/she works with anger issues.  The other thing a clinician can help with is to determine if there is another psychological issue that is contributing to anger overload.

In answer to your second question:  Consequences only help if the child has enough self control such that he is motivated to control his anger in order to avoid the consequence.  The problem is that most children in the overload phase are not thinking rationally and are on "automatic pilot" so to speak.  This is why consequences are not particularly helpful for anger overload.  Sometimes if you catch the anger before overload, the child can hold on in order to achieve an incentive or avoid a consequence.  I would recommend if you continue to try consequences that you also try incentives.  Some children respond better to incentives.  The incentive should be something short term and something the child really wants to do.  But incentives, like consequences, only work if the child is thinking rationally at the time of anger.

There are no longitudinal studies of anger overload that I am aware of.  However, from my experience and from articles written by other clinicians, I think most children improve significantly in self control as they get older, and these strategies help the process along.  Repeated use of emotional distraction, using calming techniques, developing self observation skills, and learning mantras all help with development of self control.  There is likely biological underpinnings of these changes.  We think there is better coordination with practice between emotional centers of the brain, like the amygdala, and the control centers in the prefrontal cortex.  

Best, Dr. Dave Gottlieb

Monday, June 11, 2018

Learning issues and anger overload

Dear Dr Dave,

We are writing to summarize some of the difficulties we are facing as a family in the hope that you can assist us, or direct us to the help we need.

Our daughter is in year 3 at school and is the elder of our 2 children.

She has presented some behavioural difficulties in the home for years (we would probably say she was “born like this”). Recently we have reached an impasse as a family and we fear what will develop in the future if we don’t tackle it now.

80-90% of the time she is a happy loving child, but intermittently she is very unhappy, dissatisfied with our parenting, angry and abnormally egotistical. Asking her to “do” anything can involve extensive negotiation and bribery. She can occasionally extract a high price for co-operation and pushes the boundaries of what is acceptable. She finds it hard to “empathize” and consider the feelings of others. She states that she is not given enough freedom or choice, that we are “mean” and that we constantly criticize her or tell her “no” all the time. Her relationship with us often feels “transactional”. She states that other families are “nicer” and that her friends “get what they want” whereas we are too strict. We are trying to give her more responsibility in life (which she enjoys) but continues to push the boundaries on what’s acceptable.

In opposition to us, she occasionally flies into uncontrollable rages lasting about 30 minutes to an hour. She shouts (loudly) and can be rude during these outbursts. Often the rages are preceded by a discussion about doing written homework (which is a major flash point), or more commonly by some perceived “unfairness” in relation to her sister. Often the issues that “set her off” seem quite trivial from the outside.

The rages are most common at bedtime when she is tired but finds it very very difficult to get to sleep. (She goes to bed at 8pm but is rarely asleep before 9.30/10pm.)

We find that in these rages she spirals out of control, unable to self-regulate her behaviour or return to a balanced emotional state. We have always tried “reasoning” and discussion, but with age she has only used this time to create narrative explanations that justify her point of view, rather than accepting any wrong-doing or the need to calm-down / apologise. We end up in lengthy conversations where she challenges us. This pattern seems unproductive.

Recently we have smacked her to bring an end to tantrums. We have then apologized to her but it is clear that she is upset and that it has caused more harm than good. This is not how we intended to parent and we are both mortified it has come to this.

We are working within fairly fixed routines at home to avoid these escalating confrontations. She has always responded best to routines and to discussing (often at length) what is involved with any trip or activity. However, slight changes to plan can be met with outbursts and angry talk. We are unable to confidently leave her in the care of others, including most of the grand-parents, who cannot “cope” with her over night.

We are particularly concerned about the impact of food on her behaviour. She has a limited diet and has never taken to eating much hot food. To avoid confrontation we have accepted that she will only eat familiar foods and only eat sandwiches after school. She prefers packaged foods, hates nearly all fruit and vegetables, is upset by “texture” and is obsessed with sugar. We try to restrict this because we see a strong link between it and her more challenging behaviour. This is now another flash-point because she “hates” us for limiting her access to sweets. This is especially difficult because many of her friends are now given more control over their food (and larger treats). Her best friend has very relaxed permissive parents who rarely discipline or limit sugar and this is an increasingly difficult situation.

She is particularly critical of our parenting in relation to school-work, claiming that we “push her” and try to make her “better than other children.” If we ever did imagine that we would invest / contribute to her learning, then we have long since dropped this view in favor of modest objectives such as completing home-\work. We also know that we are doing much less with her than many of our friends do with their (very happy) children, so it is hard to understand why she hates us and feels so inadequate.

In reality we are worried about her reading (phonics has been a disaster), hand-writing (messy, not joined) and spelling (dreadful and random), and no doubt we have been mistaken in allowing her to know we are concerned. However, the school assures us she will “get there in the end” and we have decided to trust in their judgement.

Indeed the school reports that she does “meet expectations.” She has mild dyslexia, which seems to be enough to make her dislike written work, but not enough to merit any extra help or interventions within the school budget.

She is on the national average for most subjects. She is certainly well behaved in class and liked by teachers but has needed “pushing” to get her started on tasks which she tends to procrastinate.  She is naturally “efficient,” putting in the least amount of work to answer the question. She is also a funny mixture of “relentlessly logical” and intense, whilst also being very messy / disordered / forgetful.

We observe that she is mostly on-track and very ordinary in all her development. She has a few personal “quirks” that include vocalizing (loudly) by talking to herself, singing, clicking and whistling at home. That has been difficult to live with and sometimes causes tension. She likes to hang off furniture, is quite clumsy with herself and her toys and finds it a challenge to do things that require a good understanding of “left and right” or any dexterity (such as cutlery.) She finds it hard to copy from the board or follow straight lines while reading. At one point we wondered if there might be something else wrong but have dismissed the thought because the extent of it is all quite mild and is improving.

However, the rages are an ongoing issue and because of them we are not enjoying the parenting experience. We feel our relationship with her is slightly broken. The whole environment is placing enormous stress on an otherwise happy marriage.

Our younger daughter has an entirely different character and is very upset by the negative environment that can develop at home. At the moment she is coping but shows signs of stress. She hides from her sister, takes the brunt of the anger (verbally) and tells us that she does like the “shouting.” A sad state.

We might need to speak to someone.

Any advice you can give much appreciated.

Hi, Sounds like you have tried a number of things, and it must be very frustrating to see little or no change in her angry outbursts.  While I will mention a few strategies to try, it sounds to me like you should meet with a mental health professional in your area who works with children and families.  

One concern is that there are various signs of subtle developmental lags, and these lags are probably causing her frustration with schoolwork.  You mention the dyslexia which will affect her interest in reading, writing, and schoolwork generally.  Maybe it is a reason why she resists homework.  You also mention her difficulty with distinguishing left and right and with fine motor tasks.  I would recommend a complete psycho-neurological evaluation that looks at her cognitive strengths and weaknesses, as well as a pediatric occupational therapy evaluation that looks at her fine motor skills and her ability to distinguish left from right.  Sometimes when kids get help with these skills, it reduces the frequency of temper tantrums as they feel less frustrated and feel more adequate in relation to their peers (and her sister).  What if testing shows she is bright but struggling in school because of learning disabilities?  You would want to address those issues while she is young and her brain is growing.

In terms of anger, I like your use of routines to try to head of outbursts.  If there is a change in routine, try to let her know early in the day.  If you discuss reasons, keep it brief, and stop if she escalates.   In regards to her relationship with her sister, I would try to ask the local children's librarian for books about jealousy with siblings, because indirect stories may help her gain perspective, whereas when it is about her, she may get emotional and not be able to reason.  Also try to play games where she and her sister are on the same team against you or her father, and encourage cooperative activities both kids enjoy.  

When she feels things are unfair, I would avoid a discussion because it is hard to change a child's mind if she feels it is unfair.  Sometimes children will work for "go with the flow" points.  I would mention ahead of a possible conflict that this is a "go with the flow" opportunity.  You could tie one or two points into earning a special game or baking a fun dessert.  This may or may not help because sometimes children debate whether they earned a point or not.  And it only works if you give a signal to earn a point before she gets angry.  If you forget, wait for another occasion before she gets mad.

Lastly consider making a funny comment if she is just starting to get angry.  Sometimes humor changes a child's mood.  If she giggles, she won't be mad at the same time.  Sometimes ridiculous comments work well--like "hey there is a gigantic elephant pooping in our backyard"  or "I think I hear our cat is saying 'feed me.'" I mention other ideas in my parent's manual and children's workbook on anger overload.  

Best, Dr. Dave Gottlieb