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arrow Management Guidelines

Anger Overload in Children:Diagnostic and Treatment Issues

Date: 8 May 2008

Anger reactions in some children are quite frequent and troubling to parents and teachers who witness them. The child's intense anger may erupt quickly and intensely in reaction to limit setting by adults, to teasing or to seemingly minor criticism by peers or adults. This is a distinct psychological problem in children which is separate from diagnoses such as attention deficit/hyperactivity disorder, bipolar disorder and oppositional defiant disorder. It can co-occur with AD/HD or learning disabilities, but may also occur separately from these diagnoses.

At this time, the diagnostic manual, DSM-IV, does not consider anger disorders as a separate category like depression and anxiety. However, many mental health professionals feel it is a category unto itself and are devising treatment strategies for anger problems. Daniel Goleman (in Emotional Intelligence) and John Ratey and Catherine Johnson (in Shadow Syndromes) offer cogent reviews of this' literature. Goleman uses the term "anger rush" to describe anger problems in adults, while Ratey and Johnson refer to a shadow syndrome for "intermittent anger disorder" in adults. Anger disturbances in children need to be classified as a discrete psychological problem as well, and they require particular treatment strategies. This article defines the syndrome and outlines effective treatment strategies.

Diagnostic issues

The term "anger overload" is used to refer to the intense anger response which has been the presenting problem for a number of young children and preadolescents seen in a suburban outpatient practice. There is an intense and quick reaction by the child to a perceived insult or rejection. The rejection can seem quite minor to parents or others. For example, a parent saying "no" to something the child has been looking forward to doing can trigger an intense period of screaming and sometimes hitting, kicking or biting. Another common situation which can trigger anger overload may occur in a game with peers. It can involve a disagreement on how the game should be played or its outcome. Parents often explain to the mental health professional that these reactions have been going on since early childhood in one form or another. It is frequently reported that these children become sassy and disrespectful: they will not stop talking or yelling when they are upset. At other times, when their anger has not been stimulated, these children can be well-mannered and caring.

The problem is called anger overload because it is more severe than a temporary anger reaction lasting only a few minutes. With anger overload, the child becomes totally consumed by his angry thoughts and feelings. He or she is unable to stop screaming, or in some cases, acting out physically, even when parents try to distract the child or try to enforce limits and consequences. The anger can last as long as an hour, with the child tuning out the thoughts, sounds or soothing words of others.

Another significant characteristic is that these children are sometimes risk takers. They enjoy more physical play than their peers and like taking chances in playground games or in the classroom when they feel confident about their abilities. Other children are often in awe of their daring or scared of their seemingly rough demeanor. Perhaps most interesting is that these very same risk takers can be unsure of themselves and avoid engaging in other situations where they lack confidence. A number of these children have mild learning disabilities, and feel uncomfortable about their performance in class when their learning disability is involved. They prefer to avoid assignments where their deficits can be exposed, sometimes reacting with anger even if the teacher privately pushes them to do the work with which they are uncomfortable.

One diagnostic fallacy is to assume that these children have bipolar disorder. Dr. Dimitri and Ms. Janice Papolos recently devoted a full book to the disorder (The Bipolar Child, 1999).

The rages of children with bipolar disorder are more intense and lengthy than for the children 'we are currently discussing. The Papoloses describe (page 13) that for children with bipolar, these explosions can go on for several hours and occur several times a day. In children with bipolar, there is often physical destruction or harm to something or someone. In children with anger overload, the outburst is often brief, less than half an hour, and while there may be physical acting out, usually no. one is hurt. In addition, children with bipolar have other symptoms such as periods of mania, grandiosity, intense silliness or hypersexuality.

Anger overload is also different from attention-deficit hyperactivity disorder. Children with AD/HD have significant distractibility, which occurs regularly in school and/or the home. By contrast, children with brief outbursts of anger often pay attention well when they are not "overheated" emotionally. In addition, children with AD/HD may have hyperactive movements throughout the day; whereas children with anger overload only seem hyperactive when they are over-stimulated with feelings of anger. Finally, children with AD/HD are often impulsive in a variety of situations, many of which have nothing to do with anger.

It is possible, however, for children to have symptoms of AD/HD and anger overload. This combination is especially difficult for parents to manage. Behavioral strategies for AD/HD are not as effective because the child becomes excessively angry despite efforts by others to focus his attention elsewhere. Sometimes, professionals then tell the parents or teachers that they are not applying behavior modification techniques properly. What may work for a child who has AD/HD may not be as effective for a child who also has the problem of anger overload.

Another diagnostic category which can be differentiated from anger overload is oppositional defiant disorder. Oppositional children have a continuing pattern of disobedience to adult demands, whereas children with anger overload are only defiant when their anger is stimulated. The situations which trigger their anger are more restricted. There are I am certain areas which have special importance to them, such as winning a game, buying a toy or being seen as successful in school. In most other situations, they are described by their parents as sweet and cooperative. Few, if any, oppositional defiant children are described by their parents in this manner.

Treatment techniques: Behavioral strategies

When these children first come to a professional's attention, there may be a tendency to think that the parents must learn to ignore their children's tantrums. But this will not work reliably for children with anger overload. Their angry outbursts will not be extinguished this way. Behavior therapy for these children involves working with the parents as much as, or more than, the children themselves. Parents and teachers can learn strategies to teach their child self-control in a shorter period of time than the therapist can teach the child alone. By coaching the parents, the therapist has an impact on the child throughout the week. In addition, children cannot apply therapeutic strategies themselves at home when the anger is building. They need someone to cue them on what to do - usually a parent or teacher.
The first strategy is for the adult to recognize when the child is about to experience anger. This is sometimes difficult for anyone to predict. However, over time, parents and teachers begin to recognize signs that an angry outburst is impending. The look in the child's eyes, the tone of his voice or the tightness in his body tells the adult that the child is beginning to get upset. The time from when the child gets upset to when he shows full-blown anger may only be a few seconds. If it is caught in time, the child is much more likely to achieve self-control than if the adult tries to intervene once the child is overflowing with emotion. It is as if the child's brain has reached overload then, and it takes some time to cool off.

One technique to use before reaching this point is distraction. The parent should try to turn the child's attention to something else that is interesting to him/her. It is important that the distraction be interesting to the child - something he/she likes and that involves some action. The child is unlikely to immediately choose a quiet, sedentary activity like reading. A more effective distraction technique is going outside to ride a bike or playing catch. For example, if the family is at a park and the child does not want to leave the swings, then suggest he try the slide - which is an activity with a more natural ending point. Once he comes down the slide, the activity is at a possible stopping point. That is a good time to direct him to the car.

To help motivate the child, some behavior modification mechanism should be in place. Choose incentives and consequences that are brief and preferably immediate. A colorful chart or poster can be used to track two or three behaviors which the child needs to demonstrate during the day in order to earn a reward. Select one or two behaviors and review a behavior plan for these situations with your child.

The basic principle is to offer an alternative behavior that is more socially acceptable than an angry reaction. If the child does not use the alternative behavior, and moves into a rage, a negative consequence may be imposed. The principle for negative consequences is similar to rewards: brief and immediate, where possible. A brief consequence such as being grounded from going outside and/or playing computer games for a few hours (or up to a day long, depending on the severity of the offense) is helpful in getting the child to recognize the importance of using self-control. If, instead of using a strong verbal response, the child hits back when teased, a consequence will send a message better than trying to talk to the child. Children take consequences more seriously than "lectures." They are more likely to remember a consequence later and to choose a more appropriate response the next time. Parents need to be firm about applying negative consequences because they send an important signal to the child. While such enforcers do not help shorten the immediate anger, they can help lower the frequency of angry outbursts in the future.

Another key principle when applying negative consequences is to eliminate discussion at the moment the child is raging. Giving the child attention, even talking, is a reward for negative behavior. Plus, the child who is raging is not rational at the moment, and the rage is likely to escalate further if consequences are mentioned while he is having a meltdown.

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