10 year old with multiple diagnoses

I have just been assigned as a case manager for a ten year old girl
that is showing signs of anger overload. She has been diagnosed with
everything from ADHD, Bi-Polar, ODD, Conduct Disorder and has been on
a variety of medications. She has had three psychiatric
hospitalizations in the past year. She was severely neglected and
physically abused prior to age three. Sexual abuse is suspected, but
was not confirmed. Her mother used marijuana, alcohol, and possibly
methamphetamines while she was pregnant. She has lived with relatives
since age three. She has been in therapy for most of that time and
been on a variety of medications. Her current meds are Tenex, Vyvanse,
Abilify, and Celexa. She rages at school and at home. Her triggers are
almost any situation that she is not in control of, any change, or any
thing she encounters that she doesn't know how to do. She rages
without prejudice and has harmed school personnel and family. Rewards
and consequences do not work. After a tantrum, sometimes she is
remorseful and sometimes not. She is on a behavior plan with the
school, but rages when she does not score perfectly on that. Teachers
have stated that sometimes she goes so quickly to anger that they are
unable to see it coming. Other times they try to diffuse her or talk
to her. She has no ability to calm herself once she starts getting
angry. She has no fear of going back to the hospital or of any
consequences. I have been gathering information for an assessment and
trying to work with the family and school on strategies to help her
learn to recognize her triggers and to develop skills to keep from
harming others and from getting into trouble. Most techniques that I
have read about encourage distraction, which would work sometimes at
home, but not always practical in school, especially in the middle of
class. The school has had to clear the classroom around her when they
could not get her to go to the school safe room. The school has had to
restrain her and they usually results in staff being kicked, hit, bit,
etc. I read that the children with anger overload show an increase in
chemicals in the brains such as epinephrine, dopamine, etc. Is this
due to the rages causing this to surge as it would with anyone or do
they have higher levels to begin with and this makes those levels more
likely to rise higher than an average person? The school and family
are looking for answers and I would like to be able to point them in
the right direction. I would like to figure out if the medications are
helping or making things worse and what direction therapy needs to go.


Hi, This is a very tough situation.  The strategies which I recommend on my blog are intended for children who do not have other serious diagnoses and who have not been abused.  Also, it is worrisome that the mother used drugs and alcohol while pregnant.  That and the abuse could have seriously affected her and caused changes in her brain.  One interesting book about the effects of abuse is by Dr. Bruce Perry called "The Boy who was Raised as a Dog."  You might also want to read about fetal alcohol spectrum disorder.  When mothers drink a lot during pregnancy, especially during the first trimester, there can be profound effects on brain development.  One possible result can be behavioral problems, such as emotional outbursts, impulsivity and social problems beginning at a young age.

So what do you do?  All of the strategies you describe make some sense.  I agree that distraction would be high on the list, as would be anticipating triggering situations and trying to change the situation before she erupts.  The key to distraction is to change the emotional set; any words, funny sayings, or the first lines of a favorite melody could distract her.  However, you cannot always anticipate what will set a child off, as you write, and she may not respond to distraction at times.  Once she has a meltdown, there is not much you can do, but not to talk with her then and to restrain her like you are doing when she is hurting someone or herself. 

I know of one case where the parents use a PRN (as needed) benzodiazepine that can be administered under the tongue so that it is absorbed quickly when the child is beginning an outburst.  I am a psychologist and not a medical doctor, and you could have a child psychiatrist review the meds if you want.

It sounds like everyone is trying hard and providing as much structure as possible.  I would keep working on a chill space, and have her practice going there when she is calm.  Make it a "cool" place for her to go to, where she can lie on a mat or hold a comfortable blanket or stuffed animal.  You want it to be a chill zone, not a punishment.  Ideally you would have a different space when she is in total overload and when you have to take her there by force.

I use other strategies like developing self-observation skills, teaching children to re-evaluate situations, and teaching children how to compromise. But all these are way down the road for this child.  It is not a bad idea to begin to go over triggers with her and to use a simple labeling system for her level of anger, like red hot for anger overload, orange hot for mid level anger, and blue hot for lower levels of anger.  You would start by going over the labels and triggers for incidents after she has calmed down.  After a number of weeks, if she is working with you after the incidents, you can gradually use the colors as a cue when she is heating up and suggest when her anger is at lower levels she use the chill space.  Use a lot of praise if she tries the chill space. Once she is in complete overload she is unlikely to want to try anything you suggest.

In answer to your question, research does show effects in the prefrontal cortex among other areas of the brain when there has been fetal alcohol syndrome or profound abuse.  The prefrontal cortex is where a lot of the executive functions are based--like planning and organizing our responses to stimuli.  This helps explain why it is so hard for your 10 year old. The brain can change in response to medications and therapy, but it will be slow.   All the best, David Gottlieb, Ph.D.

9 year old with intense periods of anger overload

Dear Dr Dave,

I have just been reading your blog on Anger Overload. 

My son will be 9 in March and has extreme anger outbursts that include direct violence towards myself and my husband that are currently lasting for up to 3 hours each time, and are presently at least 4 days of the week.  

We have two children, an 10 year old daughter and our son. We have three small pets and we/he has never been exposed to domestic violence, drugs or alcohol addiction, so there is no learned behavior.

The symptoms for Anger Overload appear to match my son. Triggers can be as basic as being told he cannot play on the wii, to as minor as getting three words wrong during spelling practice.  

He is however very intelligent, in the top sets at school for maths and English. He enjoys school and is a well liked member of class, not overly surrounded by true friends but he has a couple of close friends. 

He is very strategic and plays chess and war games to a high level, but on and off for 4 - 5 years we have had sporadic outbursts of anger from my son, we can go weeks even months without any outbursts, yet they are currently escalating to approximately 4 times a week and are including violence and behavior which is starting to endanger himself (violently shaking the balustrade/banister trying to rip it out of the wall/floor). Pushing us backwards at the top of the stairs, kicking, biting, punching, being rude, plus many more. His stance is more often very tense, arms crossed and an intense look of hatred on his face.  When he is not having an episode he is a loving caring thoughtful child.

He doesn't however, allow anyone else other than us to witness his behavior, he does not exhibit any anger at school or cubs or with friends and in fact everyone else thinks our son is a very placid, quiet child - but he gets very defensive if we talk about it to others,  and when we discuss behaviors with him he claims he can't remember the outburst occurring. What he never has is any remorse or guilt after the outbursts.

We attended brief intervention when he was about 5 years old where we had three discussions with a social worker, but; because he doesn't allow any other people to witness the behavior we were fobbed off and told there was nothing wrong with him. We have now started to discreetly video his outbursts in an attempt to be believed.

Last night we ended up attending out local Accident/Emergency unit at the local childrens hospital and they have admitted him until Monday when we can see someone from the Childrens Mental Health Team.  However, tonight reading your blog makes me think he could have anger overload.

I think if he does have Anger Overload, then we have been dealing with the problem all wrong,  he presently has some toys confiscated as a punishment and is banned from the computer or wii for a number of days after major episodes, we have also been trying to talk it through with him mid-event!  I think your Parents Manual would be a wonderful tool for us to try and would be very interested in getting hold of a copy.

Any guidance would be gladly received.

Dear parent of 9 year old,

I can see how difficult and upsetting the anger episodes are for all of you.   While your son is in the hospital, the staff will rule out any other diagnosis, such as bipolar disorder or other mood disorder.  Does your son act impulsively for his own pleasure with total disregard for what other people are doing? Does he get revved up, or driven, when he wants to do something?  If there are frequent signs of these behaviors in addition to anger overload, I would recommend consulting with the doctors about pediatric bipolar disorder.  It is unlikely, but you would want to rule it out, as then a particular medication protocol might be indicated.

I would be glad to make my manual available to you as soon as it is ready.  One suggestion I would have for now is to talk about a "chill" place in the house where your son or anyone else could go when they are upset.  It would not be a punishment, and would have interesting activities there to help distract him and help him calm down.  Your son will likely refuse to go there when he is extremely angry, as he is not thinking rationally at those times.  The emotional side of his brain has flooded his prefrontal cortex, which is the executive area of the brain.  However, if you can sometimes catch him before he totally rages, he may be willing to try the chill place.

You would be better off not talking with your son while he is in an anger episode, as he will not listen to reason and may escalate in response to your comments.  Try to tune him out and get busy in the house.  However, if your son physically harms someone or breaks something of value, then you will need to restrain him.  Can someone hold him on the floor or bear hug him until he is calmer, if he is hurting someone?  It may turn out that going to the hospital will help you in the future, because your son may be able to hold off from hurting someone if he knows this will involve another trip to the hospital.  Though children have limited reasoning capacity during an episode, they often can re-direct their anger (express it loudly but non-violently) if they know what behavior will trigger returning to the hospital.

My manual will describe ways to change the sequence in the house to limit future outbursts and will prescribe a method to teach your child how to look at trigger situations differently.  To start, you will want to chart anger overload situations for a couple of weeks, noting what is said and done, and what happened right before your son got angry.  You will look for some themes, and this will help you then work with your son while he is calm to think differently about the triggers.  This will become clear in the manual.   In the meantime, hopefully the hospital staff will help you get started.  

By the way it is a good sign that your son shows self-control in school and in public.  He will likely be able to learn self-control at home eventually too. 

I hope this note is helpful,  Dr. David Gottlieb

Parent's manual for anger overload

I have been working on a parent's manual for children who have anger overload.    The manual comes in two parts:  the first part has strategies you can use right away, and the second part is a packet you do with your child in order to teach him new ways of looking at anger-provoking situations.   The manual  is implemented over a 10-12 week period.  You should begin to see changes in your child's behavior over the 12 weeks.   If you like to be notified when the manual is published (in a couple of months), please e-mail me at drdavegot@gmail.com.  Your name and personal information will be kept confidential.  I will personally let you now when the manual is ready.

Are pets helpful?

Dr. Gottlieb,

I'm sorry I didn't thank you for your reply sooner.  Your comments are helpful and we will keep working through the issues.  I was also wondering if you had any thoughts on the use of pets to help give the child focus and help calm them down.  I think I have read where in some cases the "unconditional love" that a pet (i.e. dog, cat) provides can give the child a more calm place to go emotionally when they are upset.  

 

Hi, Pets can be a mixed blessing for children with anger regulation issues.  Yes, sometimes a pet can be a source of comfort when a child is angry, but sometimes a pet can also be a source of friction in a household.  For example, I have worked with families where the child forgets to walk her dog, and when parents remind the child, there was an angry explosion (e.g. "why do I have to do it now?" or "I'm in the middle of my game.  Can't you do it?")  Pets can be a support but also a stressor in a family, and since you and your wife may have added responsibilities too, think about how everyone in the family feels about it and think carefully how your child will handle it once the newness wears off.  Take care, David Gottlieb, Ph.D.  

11 year old with anger overload

Hello Dr. Gottlieb,

 

When I came across your article on anger overload I finally felt like I had found an accurate description of what my 11 year old daughter and we have been going through (for 1-2 years).  She doesn't have the risk-taking behavior you mention but otherwise many of the characteristics are the same.  What drew me to your work was the distinction you made between anger overload and other clinical issues (defiant, ad/hd, autistic, etc) which do not seem to apply.   I am wondering about the relevance of your new book for our situation.

 

We have been unsuccessful in treating her/our issues, and in fact there is a pattern of escalation that is worrisome.   She had a period of depression (seemingly related to school) for several months last year that accompanied the anger overload but in large part that has subsided--leaving us with "just" the anger overload. We have seen counselors and read books on defiant children.  But after many, many months, we have achieved no real progress in this area. 

 

Our daughter is otherwise well behaved, does very well in school, has many friends, and plays sports well.  Her issues are generally confined to our home (although the disturbing behaviors do from time-to-time creep outside the home).  My wife tends to placate my daughter's behavior in order to avoid conflict, I tend to be the disciplinarian (especially when she is physical), and our other daughter gets stuck somewhere in the middle.

 

There have been many factors that could have influenced our daughter's behavior.  While our "middle class" home situation is generally calm and stable (no abuse, no alcohol or drugs, no divorce, not overly strict or loose), our daughter has certainly faced changes in her life over the last couple of years.  Her sister (age 15) was diagnosed with type one diabetes in 2009, there was a period where I was unemployed, her teachers have changed, there is a growing distance between her and her teenage sister, some friends have moved away etc.  She does not articulate any explanation of her emotions, and while not terribly apologetic about anger episodes, does share that she feels out of control at those times.

 

My response:

  In my new book I have a chapter which discusses strong willed children and anger overload.  Not sure how strong willed your daughter is, but if this also applies to her behavior, then this part of my book may be helpful to you.  Also, I will keep writing on this blog about how to work with children and teens with anger overload, as this is the topic about which I get the most questions.  In 2012,  I may publish a step by step guide for parents.

A few comments before I make a suggestion about working with anger overload.  If her episodes of anger overload occur more frequently when there is a downturn in mood, it would be wise to check with a professional to rule out a co-existing mood disorder.  Also, you mention some previous causes (changes in her life), but suggest the anger problem continues even though there do not seem to be any particular causes right now.  You might want to chart the next three episodes (I discuss this in an early chapter of my book as well), and then look for any patterns.  Does it happen when the attention is on someone else in the family, or when she is feeling lonely?  You mention her sister's diabetes and her friends moving away, so I wonder if any of these issues might still affect her.  Or you may find there is another issue which precipitates your daughter's outbursts.  If you see a particular type of trigger, then you can try to address that.

Whether or not there is an obvious pattern, you would want to enlist your daughter's help in understanding this problem.  As I suggested in my last post, there are ways to bring your daughter's attention to the problem without being critical of her.  When she is calm, you could point out any possible trigger you see, and ask her to consider if this seems correct.  If she disagrees, ask her if she has any ideas. Also, help her see when she is "heating" up next time by labeling the level of her anger (as I discuss in last week's post).   You are trying to get her to continue to think about the problem.  Bring this up as an issue you can work on together in the next few months.

For pre-teens and teens, it can be helpful to head off outbursts by discussing potential pitfalls and alternative solutions.  You can do this if you see some patterns.  You can talk about an issue from both your point of view and hers.  State what your concern is (for example if there is tension about homework or curfew, state why you have a certain rule) and then ask her what her point of view is.  You are trying to head off major conflict (assuming this is a cause of overload--let me know if there is some other cause and I'll try to advise you), and help your daughter begin to think about how there are different points of view.  Then you pose the question: how can we work this out?  You try to engage her in a discussion (when she is calm) about an issue and see if you all can come up with an alternative (compromise, if the issue is negotiable) that meets everyone's concerns.  You are helping her then not only identify an issue but practice working it out ahead of time. 

When overload occurs, it is best to avoid these kinds of discussions and encourage "chill" time.  Some kids chill with music, some by physical sensations (squeezing or holding something), some by music or drawing.  It may take some time for your daughter to discover a way that works for her, and you do not want to suggest too much, because it is best if she comes up with something herself.  After she calms down, ask her how she did it and reinforce her approach if it was effective and if it did not involve harming herself or anyone else.

One possible biological change that my help in the coming years is the continued growth of her frontal cortex, the part of the brain that controls emotions.  This growth will continue even into her twenties, but the strategies I have outlined can help this process along.  I will continue to post more strategies in the coming weeks.

In your addendum (which I just read but did not print above), you mention she gets headaches and feels tired sometimes before or after anger overload.  I have noticed that anger overload sometimes occurs when kids are tired, but have not noted any correlations with headaches at this time.  Certainly when kids are tired or not feeling well, they have fewer "resources" to deal with stress.  Furthermore, anger overload can be draining (like running an emotional marathon), especially if it goes on for more than a few minutes.  If you continue to note a correlation with headaches, I would mention it again to your doctor, and follow his lead, as he knows your daughter's situation better than I.  Hope this is helpful.  Take care, Dr. Gottlieb

 

Helping your child develop self-control

So far in the blog I have been mostly advising you what to do once your child is already in "tantrum" mode.   Another set of strategies is to to help your child develop self-observation skills.  Once your child recognizes he is "over-heating," then you can teach him strategies to deal with frustrations in a more mature way.   Your child has to recognize first there is a problem (his anger is sometimes "over the top") before he will be willing or able to work on the problem.  In this post, I will write about how to help your child learn to observe his emotional state.  In the next post, I will begin to outline strategies which your child can use to alter his emotional state.

The first step is to label his emotional level with colors or numbers.  You can use blue for "low" level of anger, yellow or orange for "getting hotter," and red for "scorching hot."  When your child is getting angry, try to use these labels in a non-critical way to help him see the differences in his emotional state.  You can also use the labels to point out your own level of anger at times, so that your child does not feel singled out.  Also, by pointing out your emotional state, you are modeling what you hope your child will be able to do for himself someday. 

You would explain the color system to your child when he is calm.  Then when he is angry you gently point out in just a few words the color of anger he is expressing:  "you are blue hot," "you are getting hotter, kind of orange now," or "you are red hot now."   An alternative is to use numbers (1-5) or the speed of cars, if you think these labels would appeal more to your child.  For example, you could say you going 10 miles per hour (for low levels of anger), or you are at 40 miles per hour (for mid range), or now you are going over 80 miles an hour!

This will not in itself lead to dramatic changes in your child's behavior.  But you are setting the stage for change by  helping him see the differences in how he expresses his angry feelings.  You will need to do this over a period of months for your child to recognize accurately how he is responding in different situations. 

Another self-observation skill to work on with your child is identifying triggers.  When your child is calm (after an outburst has subsided) point out what you think the trigger was.  For example, you could say "you got mad when you had to stop playing your game," or "you got mad when it was bedtime."  You are labeling the trigger in concrete words for your child.  You want him to begin to see the pattern.  Then in the future he can learn alternative ways to deal with his frustrations.  More about that in future posts.

Anger Overload in Children: Diagnostic and Treatment Issues

Anger Overload in Children: Diagnostic and Treatment Issues

This is an article I wrote in 2002 on anger overload which was originally published in "Attention!" magazine.  You can read it by clicking on the link above. The article is available at the website for greatschools.org