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

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