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

7 yr old explodes over minor frustrations

My wife and I have been "under siege" by our nearly 7-year-old daughter (Simone) for a few months now (off and on).  Besides one incident where she hit a boy on the bus and made him cry, she gets along fine and school (has a lot of friends, seems really happy when she's picked up, no serious discipline problems at school besides that one hitting incident).  In public, she's also self-controlled and generally level-headed -- but she regularly ignores all other adults (never says hi or answers questions, even close family friends).

 

The real problems are always in the home. First of all, my wife and I have a very close and loving relationship.  We seldom argue and are a "united force" when it comes to privileges, discipline, etc.  We also have a 2 and 1/2 year old son. For the past couple of months, nearly each day for the past couple of weeks, Simone has had intense, sometimes violent reactions to things like (1) not being able to watch a TV show; (2) dinner time (in general -- she regularly claims that the food is "yucky" and then demands something else, often chanting it over and over again; (3) being asked to clean her room or pick up her belongings, (4) even extremely minor things like having difficultly pulling off her tights when changing into her PJs.

She doesn't seem to have a filter.  She "turns it up to 11" for everything -- whether she falls and gets a scrape or can't find the perfect pair of socks to wear for school.  She also FREAKS OUT if we try to show our son a "Curious George" video and she's doing something else ("I want to watch it!!! Don't start it yet!!!" ... then she may start sobbing loudly and uncontrollably).  And in general, she often tries to sabotage things when we're trying to have fun as a family.

She digs in deep and opposes us regularly (not always) for minor requests and instructions.  She has an amazing vocabulary and performs at a high level in school -- but it's really, really difficult to engage her in conversation.  I can usually sense when the "dark cloud" is about to descend over her. She'll get a really cross look on her face, with a frown, and seems intent on being miserable and making people around her miserable.  Even if we provide a decent solution, she makes sure it doesn't solve her problem.  

She often punches and kicks when she gets a surge of angry energy, often while frothing at the mouth and sobbing loudly.  

It's not fair to our youngest, especially when we have to stop a fun family activity in order to deal with Simone's outbursts, while my wife and I are feeling particularly shell-shocked by it all.  I'm not an objective source, but I feel like we've been incredibly patient and calm and have tried many methods.

Again, she's well-adjusted at school and in public, and is sweet to her brother (most of the time -- all siblings squabble sometimes), but very hard on us way too often.  

I plan on purchasing your book but wondered if you could be so kind as to provide some direct feedback as well.  My psychiatrist (I've been treated for depression/anxiety) suggested she may have oppositional defiant disorder, which has a high probability of turning into sociopathy in adulthood. That freaked me out, but upon further investigation it just doesn't seem like a fit. Thank you for your time and expertise.

 

Hi,

 

It sounds like your daughter has anger overload, rather than oppositional defiant disorder (ODD).  For the latter, you would expect to see argumentative or disagreeable behavior toward adults in multiple settings, e.g. school as well as home.  Your daughter gets along fine at school you wrote, so I would be reluctant to use the ODD diagnosis.  Furthermore, in my experience most ODD kids do not become sociopathic.  Sociopaths exhibit a lack of empathy for others, and you describe your daughter as kind and likable when she is not angry.

 

The diagnosis you might want a mental health professional to rule out is pediatric bipolar disorder.  In this disorder there are also repeated outbursts.  In addition, there would be signs of grandiose thinking, frequent mood changes, risk taking behaviors, and impulsive decision-making.  It does not sound like your daughter exhibits risk taking or impulsivity, and it is unclear whether she exhibits grandiosity (feeling she is the most important and best most all the time).  From your description, she does have mood fluctuations, but this can occur with anger overload as well.  It sounds like your daughter frequently gets highly emotionally aroused by frustration.  Like you said, she has extreme reactions to so many frustrations and disappointments, and can't seem to dial it down.  This fits with anger overload:  these children get overheated, and we think there is a biological underpinning--the frontal cortex is not able to control the arousal of the emotional parts of the brain, mostly the amygdala. 

 

But with development and practice, there can be improvement.  The strategies in my parents' manual are intended to help that development along.  It will take time and practice, but your daughter can learn to have better self control when angry.  Part of the manual describes strategies you and your wife would use to help avoid tantrums.  Early detection here is critical.  You enumerate a number of situations when your daughter loses it.  You would want to anticipate these and try to find ways around them.  For example, getting dressed sounds like a frustrating time.  I would recommend being present, if possible, during these times, and be ready to assist or divert her if she starts to get frustrated.  Because of her low frustration tolerance, you may need to assist with tasks that you might otherwise leave a 7 yr. old to do on her own.  The same for cleaning up her room.  Be around to help; maybe making it a joint activity will remove some of the frustration for now.

 

For meal times and television, I would suggest trying to have a regular schedule as much as possible, and cue her with five or ten minutes to go that the next "activity" is about to start.  Try to arrange the schedule so that something fun comes after something she does not like.  Then there are natural incentives to follow the schedule.  If she does not cooperate, try not to engage her in a discussion at that point, but make sure the next activity does not start until she completes the one before it.  Talk as little as possible if she is in the overload phase.

 

In the second half of the manual, I explain strategies to try to engage your child in the process of learning self-control.  A first step is to assign a neutral word to each of three levels of anger:  low, medium, and overload.  I often use colors with kids:  blue for low, orange for medium, and red for real hot.  Once you arrive at the words to use together, you or your daughter could use the colors to point out when someone in the family was getting upset, preferably at the early stages.  Once this system is in place, you would tie diversions or relaxation exercises to the lower levels of anger.  The idea is to teach your child how to self-soothe.  This is a long process, admittedly, but it is worth the time and effort.  If children learn to self-soothe, it will make it so much easier for them to deal with the frustrations of everyday life!

 

All the best, Dr. Dave Gottlieb

 

 

 

 

5 yr old hits and bites if does not get his way

Hello .  I am hoping you can provide me with resources or maybe some feedback regarding my son.  He is 5 years old and gets very angry ( only towards close family members and most usually me ).  If I use a tone he doesn't like, doesn't feel listened to, or if I say No to somewhat he considers a "need," he will hit me and at times say that he wants to hurt me badly .  He has bit me and thrown objects at me .  He is cautious what he throws and usually will pick up a hard object put it down and then throw a soft object . 

 He is very sensitive .  He picks up on every emotion in the home .  My husband and I can bicker and I have been dealing with some complicated grief since losing my mom abruptly almost 4 years ago .  He has lots of energy and fidgets a lot but I don't think he fits the criteria for ADHD as he is focused and sits nicely in kindergarten .  He will take his time with his school work if he cares about it .  If he doesn't he rushes through it and if corrected ( by me typically) he yells at me that i am a mean mommy or says " be quiet , don't talk to me , I hate you , I want to hurt you ".    His outburst are very short lived ( thank god ) and I usually can redirect or distract him onto something desirable .  But this is a lot of work and emotionally draining for my husband and I . 

I don't know what makes him so angry .  He is an only child . He is pretty spoiled by my husband and immediate family who often give him many tangible items .  He feels that he should get something in every store we walk into and will wheel / deal any way he can to try get this "need" met .  Generally he is a very spirited boy who loves nature and noticing the seasons changing , he is pretty creative with art or even ideas about things, and his vocabulary is exceptional .  He is very loving and affectionate .  He loves our dog and is gentle with her . He is 5 ( six in April).  He shows little interest in reading but appears to be keeping up with his peers .  If he feels he has received genuine praise for something he is very prideful .  He picks up on "bullshit" easily . 

It is beginning to make me anxious as i don't know what will tick him off .  Additionally he needs us to always engage him .  Running errands or cleaning the house makes him irritable if he can't have an active role in it.  Watering down the cleaning to his level doesn't work, he wants to do whatever the adults can do .  He has recently been doing more mischievous things he knows is wrong as if he is looking for negative attention .   I feel terrible that I can't find a strategy of parenting that resonates with him.  He is acting out for a reason .  I don't think this is biochemical . I pray it's not .
Thanks in advance for any feedback you can provide .


Hi, I can tell you are trying real hard to understand your son, and it sounds like you are still grieving the loss of your mom. You mention too that you and your husband bicker sometimes.  Do you feel you need more emotional support at this time of your life?  I wonder if your frustration with your son is aggravated by your disappointment that he is another source of stress.  Maybe if you had more support (friends, support group in the community, or therapist), you could make limits stick better with your son.  You mention that he is spoiled.  Maybe you are trying too hard to please him.   It can be hard to say no when you anticipate a child will explode!

It is good that this is only happening in the home, because it means your son does have some self control.  Then the question is how you can get him more in control at home.  One thought I have is that it is going to be important to set a firm limit about physical violence. Do not talk to him while he is having an outburst.  When he is calm, however, you could all talk briefly about how dangerous this is.  Explain a couple of alternatives: saying "I don't want to" or "I don't like that." This does not mean he will get to do what he wants, but you will at least consider it.  And explain that in the future there will be serious consequences for violence.  Think with your husband what immediate, short term consequence might be meaningful for your son, e.g. no television for the day if this is important to him.  You do not have to announce the consequence right away if he is hitting or throwing things.

But when he calms down, let him know that it was dangerous, and he needs to find something to do other than television for today, and that if he does not hit for the rest of the day, he can have television tomorrow.  This may set him off at first, but in the long run you will establish a limit about violence.

The other approach to violence in the home for a young child is to restrain him when he becomes violent.  Bear hug him and hold him until he calms down (this could take many minutes).  It is reassuring to a child to know that you will not let him hurt anyone and that you are powerful enough to keep him and everyone else safe until he calms down.  Do not talk to him a lot during this time.  But talk with him after he calms down.

You want to pick your spots when it comes to discipline.  Think whether the issue is important to the functioning of the family.  For example, if his school work is rushed or incomplete, maybe you could let the teacher handle that with him.  If he cares about pleasing his teacher, her/his comments may help motivate him, and then you do not have to be the enforcer for homework.

I like how you distract him at times.  Also, consider ways to avoid tantrums.  For example, maybe don't take him to the store for a while if this is one of the battle grounds.  Maybe one of you go shopping and the other parent stay home with your son for now.  Or clean the house while he is in school, or while one of you takes him out for a walk.  You want to cut down on the number of possible conflicts until he learns better self control.

My manual for parents on anger overload explains some of these and other strategies you could use.  If you do not see some improvement in a few months, ask your school or family doctor for a referral for a child psychologist to help you. 

All the best, Dr. Dave Gottlieb

14 yr old breaks things, smacks mother

My husband and I have 3 daughters and we are raising 3 of my brothers children.  We are a poor but proud family that is in dire need of some serious help.  Our middle daughter, who will be turning 14 in November, has been seeing a developmental pediatrician at a local hospital. He has told us that our daughter suffers from ADD/ADHD combo, social and educational anxiety and oppositional defiance disorder.  I've tried all but 1 of the methods that he has offered and they are not helping.  Unfortunately we can't find a cognitive therapist that will accept her medical card and I honestly am at my wits end!!!  

We can't handle her any more and it is causing a lot of problems in our home.  One minute she is the sweetest most helpful person and in the blink of an eye, she's throwing things, breaking things, yelling and screaming.  My husband tries to get control of her but all it does is cause fights and things end up broken and holes in the walls. Just tonight she broke a fairy figurine that my aunt gave me and she upset her dresser, put a huge hole in her wall and she smacked me so hard on my bare chest and neck that it left a welt.  

The other kids are on edge and scared when she starts to act out and I'm ready to have a nervous breakdown. Our daughter is at her wit's end too.  She just left a few minutes ago to go to my mom's house for a few days.  My mom just texted and told me that our daughter was very upset and said that she feels like she really needs help and that she has prayed to God and asked him to help her.  She's like a yo-yo!  When she's with my mom, she says she feels she needs help, but when she is home with us, she thinks she's fine and refuses any help.  

I have thought several times about having her admitted to a major psychiatric hospital.  She has been to the ER at our local hospital and admitted at the local psychiatric unit a few times.  I don't know if putting her in a psychiatric unit would help resolve the issues or not.  I guess what I'm hoping for, is that you might know of something we might be able to do, or somewhere we might be able to take her, to help our daughter take control of her anger and help us all to be a family again.


Wow, you have been though a lot at home and have tried getting her professional help.  Yes, ongoing outpatient therapy with someone trained in dealing with anger issues is a good idea.  The psychiatric hospital you mention might help too, especially if she continues to be out of control and physically endangering family members.  One question I have is about the diagnosis.  The way you describe the intense and rapid changes in mood make me wonder if pediatric bipolar disorder has been ruled out.  There are medications especially helpful for bipolar disorder if she were to have that condition.  Maybe ask your pediatrician, or check with a psychiatrist who sees teenagers to help decide about the diagnosis.  

The fact that your daughter said recently she wants help (at least when she was with your mom) is a good sign.  You would want to talk with her at times when she is reflective and wants help, and talk about strategies she could develop to recognize and head off her angry outbursts.  The second half of my parent's manual outlines strategies you can teach your daughter.  These are cognitive behavioral strategies, which is what your doctor recommended.  The first step is to develop your child's observation skills.  I explain in the manual how to help your daughter identify when her anger is rising, and to identify some of her triggers.  Then she would try different calming strategies.  It is hard work to identify triggers and to intervene early enough to head off an outburst.  But if your daughter is motivated, it would be a good time to try some of these strategies. 

See if she will let you work together.  Explain you would be the assistant coach, who might notice triggers and help her develop calming strategies, but that she would be the head coach and could decide whether she agrees or not.  The more you can get her thinking about the triggers and alternative strategies, the more likely she will be able to slow down her impulsive outbursts.  It will not always work out because anger is a powerful emotion, and when in full force, it is hard to get the rational part of our brain to act.  But at early stages, when a trigger is just beginning, it is easier to head off anger.  So one key is early identification of situations that cause frustration or disappointment for your daughter.

If one cause of the outbursts is arguments with you or her father, then you would work on teaching your daughter about different points of view and ways to compromise.  There are sections in my manual about how to help children recognize that there are different ways of looking at things.  Often new information about other people's motives help children to see others (you and your husband) as benign and as trying to help them.  Many teens think their parents are just trying to manipulate or control them, and that perception makes their anger worse. You want your daughter to see that there are different ways of looking at things, and that you are not trying to manipulate her.  For example, parents' rules about curfew are intended to help children to stay safe and to get to sleep at a reasonable hour.  Many teens think parents are trying to prevent them from having fun with their friends.  Once teens understand there are different ways of looking at curfew, there is a chance they will react less angrily and learn to compromise.

Lastly, if your daughter can calm down at your mother's house, this might be a good place to start with a family discussion about the strategies I outline in the manual.  Your mother could be in on the discussion if your daughter is less likely to explode in her presence.  Sometimes having a neutral party present helps teens to think about things rather than react emotionally.  All the best, Dr. Dave Gottlieb 

What to do when there are additional problems

Hi, I wanted to let my blog readers know that you can find brief articles I have written about other parenting issues on a website for the Chicago parents' network.  So far I have written about how to handle these issues: temper tantrums (usually an expression of anger overload), potty training, divorce, and most recently shyness.  Sometimes children with anger overload have additional issues, and if any of my blog readers would find these articles useful, below is a link to the Chicago parenting website.  This link gets you to my recent article on shyness, but once you are on that website you can search the blog posts for my other articles.  To find my other articles, go to the left side of the parents' webpage and look under these blog categories: "children and divorce,"  "diapers and potty training," and "behavior and discipline."  Take care, David Gottlieb, Ph.D.

If you first click the link below, and you do not get immediately to the article, a message should appear that you then click on again.

http://www.npnparents.org/posts/722,is-your-child-shy

Parent uses manual and 6 yr old hits in school

Dear Dr. Gottlieb,
I have a 6 year old son that seems to fit your description of a child that experiences anger overload. I've been following your advice outlined in your manual along with using strategies described by Dr. Ross Greene in The Explosive Child. Thank you for your manual. It feels like a god send as I live in a small town where it is very hard to find quality health care.

I have two main questions about what we are experiencing in the early stages of our new approach. We’ve only been trying these techniques for about 3 weeks.

(1)  While it seems like we are improving with avoiding overload altogether by detecting triggers and sensing his body language when he is getting frustrated, it now seems like he is triggered more often. His episodes are shorter and less intense, but it seems like there are more of them now. An example would be that just this week he hit a fellow student. School has never been a setting where he acts on his anger. It’s always at home or when he is with me and/or his father. He is triggering in more situations now at home too. Is this a common phenomenon that you experience with your patients as they start the techniques you prescribe?

(2)  The second question I have is concerning a broader pattern. Sometimes he seems to go for weeks without much of a struggle even in the face of his usual triggers. We often think of his triggers in terms of ultimate and proximate. He might be upset because his spelling his hard, but if he is hungry, it’s a greater challenge to control his anger during difficult homework exercises. There are times when he is fed and rested and has had play time (all ultimate triggers covered) ….but he is still excessively trigger sensitive. And then in other times, he can control his anger fairly well with the same triggers in play. In your opinion, is there is evidence to show that there are periods where hormones can affect his trigger sensitivities for weeks on end? Or is there another situation that could cause this?

My deepest appreciation!

Hi, You ask good questions.  Generally, there is not an increase in anger overload in new situations when you apply the techniques in the manual.  Do you know what was going on before he hit the student in class?  What was the trigger?  Sometimes a child struggles to contain his anger in school (and is usually able to exhibit self control), but then there is a day when he is more sensitive (tired or hungry).  When in addition on those days there is an unusually difficult situation, he may have a melt down.  For example, sometimes a child does not do well on a test or assignment, and is feeling down about it, and then the same day a fellow student is verbally provocative.  The combination of triggers is overwhelming and leads to hitting.  My guess is that this will not happen often for your child in school.   If it recurs, it would be important to try to figure out the triggers, and also apply the strategies you are using successfully at home.  You might meet with the teacher and explain what you are doing at home, and see if the teacher would apply similar techniques (or one of the other techniques in my manual--the teacher might feel a different technique might work better in her class).  Usually over time a child develops better self control and there are fewer explosions at home and school.  

I don't know the answer to your second question.  I have also observed that some children have better control some weeks, but I do not know of any research that looks at fluctuations in hormones or brain chemicals over time and their effect on anger.  There have been some studies on violent behavior in adults that show that low levels of a brain chemical called serotonin are associated with more violent behavior.  But even these studies have not looked at week to week fluctuations in serotonin.  Furthermore, the correlation between serotonin and violent behavior does not mean that low levels of the brain chemical cause violence.  It is possible that there is a third variable that causes changes in violent behavior and changes in serotonin.  It is also important to keep in mind that violence is not the same as anger overload.  There are various contributing factors to violence that have nothing to do with anger.

  

My guess is that there can be week to week fluctuations biologically that affect anger overload.  Also, there can be fluctuations in environmental stressors, and we don't always know our children are feeling stressed until they explode.  But that doesn't mean your child still can't develop better control even during those weeks where he is biologically vulnerable.  He may need more help with the strategies those weeks, and over time (several months) there will often be a decrease in explosions, though not necessarily a total cessation.  As your son gets older, you will be able to apply more of the strategies in the second half of the manual that will help him become more aware of his triggers and how to use strategies himself.   Usually at age six, the strategies in the first half of the manual (that involve parents directing the child) are more effective.

All the best, Dr. Dave Gottlieb