Finding therapists for 4 yr olds

Here are a couple of e-mails I received recently asking about finding a therapist to help with their four year olds:

Hello Dr. Gottlieb, I recently found your article and book and it's like a light shining through the clouds. My 4.5 year old son has struggled with explosive anger since infancy/toddlerhood and continues to suffer as he gets older and stronger. We have explored several treatment avenues via evaluations-- sensory processing, psychiatric, parenting, but have not yet found a plan that addresses his unique situation (which I'm guessing is something you hear often, which is why you wrote your book, which I've just purchased on Amazon...)

Can you recommend a colleague in our area that could meet with us and our son to help implement some sort of plan/support through this hard time? 

Hi Dr. Gottlieb,
    I am reaching out to you because I believe that my 4 year old son might be struggling with anger overload. in general, he is a very intelligent, energetic, sweet but strong willed/ dominant child. He does do the "Hulk" thing up to a couple of times a day, but not every day. When he feels that he is being treated unfairly, especially when it is time to leave a situation where he is having fun, or if something is taken away from him that he wants he gets very angry. His face turns red. He will shout, say very unkind things, throw things, break things and if it he thinks he can get away with it, he will physically hit or grab people. Both his teacher's and I have noticed that there is a different look in his eyes when his anger overtakes him, and it's like he's not even there, only anger. When is anger is not stoked, he is thoughtful, caring, well mannered, and full of joyful exuberance.  Since a Christmas visit with his father's family, his angry behavior has escalated at his pre-school and has become a serious problem. As he is set to start kindergarten in the fall, I would very much like to address this issue now. I believe that a therapist, specifically a behavioral therapist that specializes in pediatrics and understands this diagnosis. Any suggestions on where I should begin and which doctor or local hospital I might be able to reach out to?
Thank you for you time.

Hi, With four year olds, a lot hinges on parents' strategies, such as a) early recognition of anger arousing situations (when possible), b) changing the sequence such that something fun comes after something the child does not want to do, c) changing your child's expectations, d) "emotional" distraction, e) calming strategies, f) not attending to outbursts (when no one is in danger).  I discuss these strategies on the blog and go into more detail in my book.  The first half of my book discusses what parents can do (This section is entitled "Parents as the agent for change").  This part of the book is critical for helping young children.  

If you want a professional to help, it is critical in my view that the professional be someone who works with the parents as well as the child.  In my experience, it is more useful to see the parents with their child, or to strategize with the parents alone, rather than to spend a lot of time with the child alone.  It is helpful to see the child in one of the initial sessions in order to rule out possible diagnoses that can affect anger control, but then the focus in therapy should be on how to implement strategies in your household.  Children cannot implement anger control strategies on their own. They usually do not become aware that they are getting angry until they have already reached the overload phase. There is a  better chance that the parent will recognize a possible frustrating situation and will be able to implement one of the strategies.  Thus, you want to pick a professional who will work with you, and not a therapist who focuses on meeting with your child alone.

Furthermore, it would be best if the therapist has experience in working on anger issues and who has some experience in cognitive behavioral approaches.  You want someone who helps you with a concrete plan, and will adjust the plan as needed, not someone who just reassures you that things will be all right in time.  While brain maturation may help, many children benefit from targeted strategies that promote self control.   Teaching your child these strategies can change his behavior and his brain.

I would recommend asking at your school or asking your child's doctor for therapists in your area who work with families of young children.  You can ask over the phone if the therapist meets regularly with the parents and not primarily with the child alone.  In one of the initial sessions you will get an idea of the therapist's approach to anger issues.   If the therapist does not outline a plan early on, ask him/her what his plan will be.  You could also show the therapist this blog or my book on anger overload, and ask whether it is consistent with their thinking about how to help children with anger issues.   

If you do not feel it is the right therapist for you, check with another therapist.  Mental health professionals have different backgrounds and different experience, so it is perfectly okay to get a second opinion.  But if you find a therapist who is a good fit, stick with the person.  Remember there may not be improvement in just weeks; it can take several months or more to see significant changes in self control.  Once your child is better able to deal with anger, it will help him not only in the family, but also as he begins elementary school in the coming year.

All the best, Dr. Dave Gottlieb

  

 

Angry 4 yr old lives part-time with Mom

Hello Dr. Dave,
I am a single mother of a 4 year old boy, who I believe has anger overload. I am going through the process of getting him evaluated through the school district to see what my next step should be. As of right now his dad and I were never together and we share our time with him. However its a weird schedule and it's not a set schedule.  I believe he needs to spend time with his father but when he is over there for 4 or 5 days and comes back it seems his anger is heightened. I'm not saying anything bad is going on but I do see a difference when he returns. So I guess my question to you would be: should I have a set schedule like every other weekend and maybe one night a week? Right now it's all over the place (ex:  I will have him for 5 days, then he will have him for 2, then I will have him for 4 days and he will have him for 4...and so on..) I worked in a school district with kids with behavioral issues, and structure and schedules helps. I'm just confused on how I should be going about this and what's best for my son and where to start.

Hi, Generally, it is helpful for children if the parents have a good parenting relationship with each other, so that they can talk over things, like how to handle a child's anger.  Ideally, you could talk with each other about what is going on when your son gets angry and then discuss how you each handle it. You do not have to have the exact same strategy in each household, but you would not want to have contradictory approaches.  

First, you would want to try to identify what some of the triggers might be.  If one trigger is switching between households, then you would want to think about why.  Is there a big rules change from one household to the other?  Is your child feeling sad or torn between you and his Dad?  Do either of you say negative things about the other parent in front of the child that may make your child anxious or angry?  If your answer to any of these questions is in the affirmative, then you would want to work on that issue.  Often it can be hard to talk about these issues without a neutral third party, such as a mental health professional who can look at the situation and give guidance.  You sound like you are trying not to assign blame and you are trying to find the best solution for your son.  Is your child's father also open to looking at situations when your son gets angry?

Having a predictable schedule may be helpful for all of you, and might reduce whatever tension your son might be feeling, but it may not be the underlying problem. Transitions may continue to be hard for your son, even if the number of days in each household is altered.  That is why it is so important for you to all work together, if possible, to identify the stressors for your son and to work together on strategies.  Try to involve your son's father in the evaluation process; if he has input from the beginning he is more likely to cooperate with whatever plan emerges.  See what the school evaluation shows.  I would recommend you both try to go the the meeting at the school when the results are discussed.  Maybe reading my parent's manual will give you each a starting point for working on strategies together.  If you both can agree on the issues and how to deal with them, your son will likely benefit.  

All the best, Dr. Dave Gottlieb  

12 yr. old threatens teacher

I have a son that is exactly as you describe and he is now being expelled from school due to one of his rages (he’s 12 and on an IEP).  The school has recommended a more therapeutic placement for him but I am afraid it’s just going to make matters work.

Also, my child struggles at SCHOOL much more than at home (which seems like the opposite to the parents described on your blog).  My wife and I have worked to provide structure for our son and we are able to recognize when he may be getting triggered and get on top of them.  One thing we know is that food is critical to his success and we help him to maintain an eating schedule.    At school he doesn’t always eat like he’s supposed to and that impacts him dramatically. 

It also seems the people at school are unable (or sometimes I think unwilling) to recognize his cues and they keep pushing him.  It just gets ugly, and most recently he had an anger surge and ended up grabbing scissors and threatening his teacher.  He is on an IEP and is in a “special” more structured therapeutic program within the school but now they want to remove him because they think they “can’t meet his needs." They want to move him to a completely different school.  I know you probably can’t give advice but I’m hoping you would be able to let me know whether you think homeschooling for a year or two to help him mature and learn anger management would be more beneficial than an alternative school.  I honestly worry about who he will be exposed to in one of those schools.

Hi, It all depends on what the alternative school is like.  If it is a school for aggressive, acting out children, often labeled a BD classroom, it may not be best for your son.    Many children in BD classrooms are oppositional toward adult authority, whereas many children with anger overload are compliant and friendly toward adults.  Oppositional children tend to get in regular conflict with adult authority figures, and these children would not be good role models for your son.  On the other hand, if the class has children with emotional issues, like depression, anxiety, or Asperger's, then the class may be okay for your son.  Often these ED classes have nurturing teachers and social skills groups to help with developing peer relationships.  It would depend on what other emotional needs your son has, and whether there is a fit with the kind of class the school is offering.  You would want to observe any class before making a decision, and you might want to hire a child advocate or mental health professional to help at your school meeting. 

Ideally, the school would learn about anger overload and how to work with these children.  My parent's manual can be adapted for school use.  In previous recent posts, I have given some examples.  The key is to understand the episodic nature of anger overload, to observe some of the triggers, and to develop a three part plan:  1) prevention, 2) early anger phase, and 3) overload phase.  You would want to work with the teacher and support staff to write out a plan for each stage.  Like you do at home, the teachers could cue your son in order to head off difficult situations.  For stage one, were possible, the idea is to work around trouble spots for now.  For stage two, there could be a "go to place" for your son if he began to get agitated, where he could calm down.  Distraction and relaxation techniques are important at the early stages. 

Furthermore, if there are some academic  or social areas that are frustrating for your son, hopefully the school could develop a plan to give your son more assistance in those areas, because if you can head off frustration, you can head off anger. 

If all else fails, there would need to be a plan for the overload phase.  This usually involves a time out room, or some place where your son could calm down but not receive a lot of attention until he were calmer.  There should be clear consequences also for physical threats or violence.  So there would be consequences for threatening the teacher with a scissors.  You want to draw a line at physical threats, and the consequences could be losing all privileges at school and/or home for 24 hours, or longer if necessary to change your son's behavior.

Once you have the three part plan in place, and the frequency of anger has been reduced, you would want to apply the strategies in part two of my manual.  Part two involves teaching children strategies they can use themselves to deal with anger.  The school social worker or a private therapist could help with this.

The school principal and staff are probably concerned about violence in the school, and not knowing how to deal with anger overload, they feel your son should be in a more protected environment.  Try to engage them around the anger issue:  agree with them that violence will not be allowed, and then urge them to read my manual and to consider the issue of anger overload. 

If however you decide to home school your son, be sure to provide regular activities for peer interaction.  Examples would be a sports, music or art club, scouts, or a religious group.   

All the best, Dr. Dave Gottlieb

7 yr old restrained or removed from class

Hi Dr. Dave,

 

     My family has been through a nightmare in my child’s school for the past two years with my youngest daughter who is very bright, kind, sweet, and well-mannered most of the time. She began having problems mid-year in Kindergarten in school. At that point we enlisted the help of a private therapist and psychiatrist where she was diagnosed with anxiety NOS with the possibility of a mood disorder.

  Her problems have mainly occurred in school where she had been restrained on multiple occasions by multiple staff members,  and removed frequently from her class despite the advice given to her school by her psychiatrist and therapist. In her last few weeks in school, her teacher evacuated the students in her class six times when she would “not do her writing” because it   "effected the learning of her classmates," or because she was “hiding under her desk” as this was perceived as by her teacher as a “danger”. It seemed as though her school district just wanted to push her out  into a behavioral school and wash their hands of her. My daughter never hurt her peers and in fact is popular with many varying groups of friends in school and during recreational activities. She continues to attend many recreational activities and works cooperatively when “part of a team.”

 

   Her therapist, psychiatrist and I do not believe a behavioral school placement would best suit her needs due to her level of intelligence, and the nature of her disorder. After spending years of being physically ill  wondering what type of mental disorder my daughter has, being constantly called by her school and going through therapists, doctors, etc. I feel your description of “ anger outbursts” very accurately describes her. Often the adults at school perceive her as being “disrespectful or rude,” and this has often coincided in scenarios when my daughter feels she is “inadequate”, or specifically, “in trouble.” My daughter’s main priority is to be “good”, be viewed as “good in school,” and wants very much to be a “high achiever inside the classroom.” By constantly being “in trouble” and removed from her class, she has become ashamed and embarrassed. She has seen a few psychiatrists and therapist, and in each visit she describes her past experience inside of the classroom as becoming, “embarrassed, mad or sad” when they take her out of the class. She feels as though everyone is “looking at her,” and her one wish is that she could be viewed as a good student and not a bad student. My daughter is a seven year old who has been under a lot of pressure and watchful eyes. All of her testing has indicated that she above average to average intelligence levels. 

 

   My daughter has been on home instruction for two months and her school district has only provided her with 30 hours of instruction although she is classified as special needs. I should mention I am a teacher myself, for the past 15 years and I work in the inner city. The reason why we do not see these behaviors at home very often is because I do apply many of the strategies that I have read you suggested in your blogs and articles. I work with children who have behavior problems all day so these behavior strategies are inherent in me. However, there have been times intermittently where I have observed her go into an anger outburst that seems uncanny to what you have described with this diagnosis.

    I had the opportunity to take my daughter to my school for about one month where we did not observe the extreme behaviors she had in her public school. I had many people take a look at her behaviors inside of the classroom, including the LDC and special education teacher. When she was met with positive reinforcement, gentle teachers who were treating her respectfully, none of the behaviors that were noticed in her public school were prevalent.  It became somewhat of an enigma to us all as she was noted by our staff members as being very well-behaved, listening to directions the first time, and following the school rules. The main pattern noticed with my daughter is that when she perceives she is “in trouble,” inadequate, or inferior, she will act out by fighting back thereby presenting itself as being “disrespectful” and ill-mannered.

      My question for you is how can I further help my daughter become successful inside of a school without having to send her to a behavior school for the emotionally disturbed? Also, are they any medications that would be recommended specifically for anger overload? I certainly plan to bring this to the attention of her treating therapist and psychiatrist who originally were the people that suggested my daughter be placed in a new academic setting as expediently as possible (not necessarily an alternate setting but a different classroom that would be equipped to handle my daughter’s unique needs). Thanks for listening!

Sincerely,

A Mom in Need of a Miracle 

Hi, I can see how frustrated you are and wonder whether her school has tried some of the techniques you have used at home or in your school.  If not, it sure sounds like they should try to work with you.  In order for your daughter to do well in school it will be important for the teachers and you to form a working alliance.  I wonder if your child's therapist can help bring everyone together on a plan of action.

Most children with anger overload do not need to be in a special school for emotional or behavior problems, but it is important to use strategies that help reduce the frequency of angry eruptions.  While my manual on anger overload focuses on strategies for the home, the same kinds of strategies can be adapted for school.  In some previous posts about anger issues in school, I have given examples of how this can be done, and I give some more examples for your daughter below.  

First,in answer to your question about medication, there is no one medicine for anger overload.   Sometimes psychiatrists will try medication if there are other symptoms that are contributing to the anger issues, like anxiety or depression.  With young children, I recommend first trying behavioral interventions, but sometimes medication is added and can be helpful.  You mention your daughter has anxiety.  If the doctor feel her anxiety is contributing to her outbursts, then medication could be considered.  You could discuss this further with your child's doctor, as it is difficult to diagnose and make specific recommendations about issues like medication without a psychiatrist evaluating your daughter in person.  

One important question to consider is what kinds of situations trigger your daughter's outbursts.  Keep track of what is happening right before she loses it.  While there will not be patterns to explain all her outbursts, are there some themes that emerge?  Then you would try to eliminate or reduce the triggers. For example, you mention that one time she got angry was during a writing assignment.  Is writing particularly hard for her?  Have you ruled out a learning weakness in writing or language?  Or is she somewhat perfectionistic about her writing?  Can the teachers address the underlying issue with her writing, and thereby reduce the likelihood that she will erupt?

You also mention that she erupts when she feels inadequate or in trouble.  And you mention she responds well to positive reinforcement.  I would suggest the school try to keep track of the situations when she feels inadequate, and then try to cue your daughter in advance to prevent her from feeling inadequate.  For example, if the teacher's tone becomes somewhat negative if your daughter is not keeping up in some way or if your daughter is slow to make transitions from one activity to the next, what I would suggest is that the teacher (or an aide) cue her a few minutes in advance when a transition will occur.  It might also help to include a comment like "you've done a good job" or "you don't have to finish today" if your child is worried about her performance on a given task.  Encouragement and less pressure sounds like it would work better than negative consequences.

In addition, you and the teachers could help your daughter recognize areas of competence, if you are not already doing this.  If academic areas are stressful for your child, maybe she would enjoy an extracurricular activity, such as a sport, music, or art.  Again you may already be doing this, but continue to find areas of success for your daughter to help compensate for feelings she has of inadequacy.

One general strategy for dealing with anger overload is to change the child's expectations (for example reduce a child's feeling she has to be perfect, if this were the case) or to change the sequence (for example if writing is frustrating, then offer more assistance or reduce the writing load, or have something fun come right after she works on writing).  Look for early signs of frustration and try to intervene before the anger gets going.  The teacher could use distraction and relaxation techniques I describe in my manual.  Once in overload, it is usually wise to give a child some place to calm down, and not to talk a lot with the child until she is calmer.

I'm not sure why the teacher removes the entire class when your daughter is angry.  This may inadvertently reinforce your child's anger by giving your child the power to change the dynamics of the class.  Also, the more the teacher separates your child, the more other children are likely to see her as different or even consider her dangerous, and thus they may shun her.  This would only create feelings of isolation for your child.  

Hopefully, with your observations at your school and with the help of your child's therapist, you can work with the school staff to come up with a better plan.  If your daughter's current teacher is unwilling to give it another try, or is unwilling to consider new approaches, would the principal consider assigning your child to another class, or provide an aide to implement the new strategies with your daughter?  

All the best, Dr. Dave Gottlieb

Is anger overload a lifelong condition?

One question I have that I cannot seem to get a firm answer on....Is "anger overload" a delay that a child will outgrow or is this a lifelong condition that requires aggressive treatment?  

Hi, You ask a very good question.  To my knowledge there are no long term studies of children with anger overload to determine what percentage of children might still have difficulties as adults.  In my clinical work, the great majority of children develop better self control.  But change can be gradual, sometimes over several months and sometimes over several years.  Research into anger issues implicates the structures in the brain known as the amygdala and prefrontal cortex.  These structures continue to mature throughout childhood and even into early adulthood.  While some children may improve without much help, it is my experience that a child's brain structures (like the prefrontal cortex) develop more significantly with "exercises," such as the strategies  in my parents' manual.  To some extent, it is similar to what happens to the muscles in a child's body as he/she matures.  As children age, their muscles get stronger, but one can make more significant changes in the body if the individual exercises.  It is important to add that what is different about muscle growth compared to normal brain development is that puberty brings an increase in muscle mass for every child (except under rare situations), while the brain needs exposure to the environment (life events that stimulate the brain's anger control mechanisms) to reach its full potential.  So while some children may improve without focused work on anger, it is very important in my mind to be aggressive about working on self-control strategies.  "Practice" is important for brain development.  Anger overload can interfere with family life as well as a child's functioning in school.  So it is better to work on it sooner rather than later.  

All the best, Dr. Dave Gottlieb

Helping 6 yr old in school

Hi,

Thanks for publishing this article. My 6 and 1/2 yr old son seems to be exhibiting the behaviors associated with anger overload. He has no other diagnosed medical issues, his grades are phenomenal and is a loving kid most of the time. Once he gets in this state of rage, usually over something minuscule that he takes offense at, it becomes difficult to get him out of this or redirect.  I have just started him in therapy and we will be visiting his primary care doctor after the new year. The school he attends is not helping that much. They are only focusing on punishment and tracking despite my best efforts to work with them.  I need redirect and coping advise. I realize that every kid is different, but would like to try something so that alternative placements will not be put on the table.  What is urgent is appropriate responses and preventive measures for teachers and other staff during school hours. Happy holidays sir. 

Hi, My parent's manual has suggestions for home that can be adapted for school.  The first step is to observe the situations when he loses control.  Can the teachers keep track of them, and then look for some patterns.  Does the anger overload occur when he is frustrated or disappointed with certain assignments, tests, grades, comments from a peer or teacher, or some other precipitant?  There will not necessarily be a pattern for every instance of anger, but try to find some types of situations when he is more likely to get angry.  

The next step is key.  Can the teachers anticipate or catch early signs of frustration?  It is difficult to do because anger overload can occur so quickly and with little warning.  But if you have identified certain situations when the child is more likely to get frustrated, your radar can be up when theses situations occur again.  If you can catch anger in the early stages, it is easier to prevent overload.  If your son gets frustrated by certain grades, for example, then the teacher could try to lower your child's expectations ahead of time, let him know he is supposed to get some wrong because he is just learning.  Another option is to change the sequence.  If the grade is going to disappoint him, hold off on the grade until a fun activity is about to begin, or leave the grade off the paper altogether.  A fun activity, like gym or recess, can be distracting and help change your son's emotional state before anger gets too difficult for him to handle.

A related suggestion would be to have in place some distracting activity, such as helping the teacher with something, running an errand, or going to a place in the school where he could calm down.  Some schools have an OT room with a mat or exercise ball, where a child can go to relax if he is beginning to get stressed.  It is not a punishment, and should be a place the child is familiar with and has enjoyed.  The distraction needs to be engrossing--it doesn't have to be fun but needs to be something the child is really interested in doing.

Once a child is in anger overload, the teacher would engage as little as possible.  The goal is to provide a setting where the child will not disturb others and not get a lot of staff attention.  This place could be inside or outside the classroom and would not be the same place as the OT room, or the activity that is used for distraction.  If the child is loud and bothering others, there would need to be an aide to escort him out of the room.

There are other strategies I describe in the manual that aim to reach children how to recognize their emotional state and how to develop self-soothing strategies.  These strategies would be taught when your son is calm, and could be worked on with the school social worker or psychologist in conjunction with the teachers.  For example, some young children can learn to use verbal labels for different degrees of anger or frustration.  The second half of my manual outlines six different skills to teach children to help them better manage their anger.  The difference is that these strategies involve teaching the child skills over time, and the first set of strategies I mentioned in the above paragraphs are directed by the adults and do not require the child to anticipate or understand his reactions. I would recommend starting with the adult directed strategies because these can be implemented more quickly.

All the best, Dr. Dave Gottlieb

9 yr old: Anger Overload or Explosive Disorder?

We have a nine year old boy who struggles with anger. He's always been a challenging child, requiring more consistency, consequences (both positive and negative), and supervision than his older two siblings. Until second grade, he did not act up in school. Now, however, he's had a number of incidents where he's become so angry that he's hit a classmate. Often it is because of perceived "fairness" - a foul at recess.  We've tested him for ADHD and he shows impulsivity but doesn't fit that diagnosis completely. We did start him on ADHD medications in the fall (Concerta/Intuniv) and that seemed to work for a couple of months, in conjunction with therapy.

We've had some good success, but not enough - this week, he completely lost his temper at school, tried to hit the classmate and then tried to run away from the teacher and refused to listen. Therapy alone isn't enough. Do you know of another class of medication which we should consider? And would you consider "Anger overload", as you describe it in one of your articles, a classification of intermittent anger disorder as described in the DSM V?

Hi, Anger overload is an intense reaction to frustration that can sometimes be physical, but often is verbal.  By contrast, to be diagnosed with intermittent explosive disorder, there must be physical violence:  there are serious physical assaults and often destruction of property, which you usually do not see with anger overload.  Anger overload is more common in children in my experience.   

Children with ADHD can have a) hyperactive and impulsive behaviors, or b) distractability, or c) both.  So your son may meet criteria for the hyperactive-impulsive type. 

You mention the issue of "fairness" as a concern of your son.  I have seen this issue for other children with anger overload.  What I would recommend is "priming" your son before he goes to school.  Explain that children often "foul" at recess and it is not called because there is no referee.  If he wants to play a competitive game at recess, this will happen often.  Is it worth it to him to play?  What are his alternatives?  Try to discuss these issues when he is calm in the mornings, or if there is not time then, try to do it at bedtime.  Empathize that there is unfairness when fouls are not called, but explain that it probably will keep happening.

Another strategy is to talk with him about how people can have different points of view.  There is a section in my parent's manual that explains a way to do this.  As a last resort, I would consider talking with the school about taking away the privilege of playing a competitive game at recess for a day or two and then try again.  If there are repeated problems, then see if the school can have an adult nearby to intervene early.  Once your child gets real upset, it would not be advisable to talk with him until he calms down.  If possible, there could be a space away from the action where he can settle himself.

As for medications, there are anti-agitation medications, but they can make children tired and/or gain weight, among other possible side effects.  Sometimes low doses can help with minimal side effects.  However, some of these medications are not FDA approved for pre-teens.  Talk it over with your child's psychiatrist or medical doctor to see if he or she thinks another medication is indicated.

All the best, Dr. Dave Gottlieb