Treatment of “Rage Attacks”
by Leslie E. Packer, PhD, 1998
Last Updated February 2009
There are different approaches to treating “rage attacks,” and it is important to remember that different children or adults may have different causes for their “storms.” What works for one child or adult may not work for another.
The treatment of “rage attacks” is complicated because “rage attacks” generally do not represent a discrete disorder, but can be symptomatic of a number of different conditions (not all of which are even medical) or their interaction. Indeed, “rage attacks” may be linked to neurocognitive and/or social skills deficits and the effective “treatment” isn’t pharmacological at all but rather remediation of the neurocognitive and/or social skills deficits.
There are two main lines of treatment for “rage attacks,” then: psychopharmacological and therapeutic. Some cases will require one or the other; some cases will require both. We’ll begin by discussing medication approaches and the use of herbals or supplements, but then turn to a non-medication intervention approach.
All of the medications that are used to treat OCD, ADHD, mood disorders, or their associated conditions may be of value to individual patients, depending on their particular history. Determining which medication class or specific medication to try requires that the clinician take a very thorough and comprehensive assessment of situations in which the patient is experiencing explosive dysregulation to determine if there are any factors that need to be addressed pharmacologically or if the treatment plan needs to focus more on treatment interventions and accommodations for factors such as sensory integration problems, cognitive rigidity/inflexibility, nonverbal learning disabilities leading to frustration, etc.
Budman and Bruun (1998) reported that paroxetine (a selective serotonin reuptake inhibitor, SSRI) was of some benefit to some patients; this is consistent with their previous finding that such attacks correlated with increased obsessive-compulsiveness. But not all patients who have explosive outbursts have OCD. In some cases, the clinician will find that treating any depression or anxiety may reduce the problem. SSRIs are also the first line treatment for those disorders, so if a child or adult has any of those disorders plus explosive outbursts, treatment with an SSRI might be of some benefit. In a more recent retrospective study, Budman, Coffey, et al. (2008) found that aripiprazole (Abilify®) produced improvement in explosive outbursts of children and adolescents with Tourette’s Syndrome comorbid with ADHD and OCD.
Atypical neuroleptics, particularly risperidone (Risperdal®), have been anecdotally reported to be of benefit in managing such behavioral symptoms in some patients, as have mood stabilizers. When Bipolar Disorder is present, medications such as lithium and depakote may be prescribed (although the latter may be complicated in the use of females). Some research suggests that olanzapine may also be of benefit.
Morant et al. (2001, translation of abstract) also investigated the behavioral effects of risperidone on children and young adolescents with serious behavioral problems who had not responded well to other medications. The 16 participants had been treated for ADHD, mental retardation with nonspecific behavior disorder, Tourette’s plus ADHD and generalized disorder of development. Risperidone doses ranged from .01 to .05/mg/kg/day. Ten of the 16 patients responded to the medication in terms of improved behavior, two did not complete the study, and there was no change in the remaining four patients. The investigators report that the children with mental retardation showed the most improvement with risperidone when compared to other diagnoses.
While some clinical data suggests that at least some children may benefit from risperidone, more controlled research is needed. At the present time, there is insufficient research to suggest any algorithm for prescribing for patients who may have a lot of comorbidity.
What about children or adolescents with diagnoses of autism or Asperger’s Disorder who have explosive aggression? The available clinical literature suggests that in some cases, SSRIs or clomipramine (Anafranil®) may be of benefit, but in a head-to-head comparison of clomipramine and haloperidol with autistic patients, haloperidol produced significantly better results (Remington et al., 2001). There are also some data suggesting that an anticonvulsant medication such as divalproex may be of benefit in patients with Autism Spectrum Disorder (Hollander et al., 2001).
HERBALS AND SUPPLEMENTS
Given the problems inherent with adverse effects and polypharmacy, is there any nonpharmacological alternative that might be equally or more effective? In my opinion, the answer is “yes.” But before turning to psychological or language-based interventions, let’s consider one other question: could malnutrition be the problem for some of these children, and if so, could vitamins help?
In February 2000, Stephen Schoenthaler and Ian Bier reported that for some children, vitamin-mineral supplementation might be just the thing.*
Using 6 – 12 year-old school children, the investigators randomly assigned children to either the vitamin-mineral or placebo conditions; neither the children nor the observers knew which condition the children were in. Children in the vitamin-mineral supplement group received daily supplementation at 100% of the U.S. recommended daily allowance (USRDA) for four months.
The measures of interest were measures of antisocial behavior on school property, with records kept of threats/fighting, vandalism, disrespect, use of obscenities, defiance, refusal to work or serve, endangering others, and nonspecified offenses. Of the 468 students in the study, 80 who were disciplined at least once between September 1st and May 1st served as the research sample. During intervention, the 40 children who received active tablets were disciplined, on average, 1 time each, a 47% lower mean rate of antisocial behavior than the 1.875 times each for the 40 children who received placebo.
Their data provide some confirmation for the notion that dietary issues need to be considered if a child is disruptive or engaging in a lot of antisocial behavior, but it is important to note that: (1) they were not studying the explosive kinds of outbursts colloquially referred to as “rage attacks,” and (2) there was no attempt to identify whether any of the students had neurobehavioral diagnoses. The sole question was whether there would be a reliable difference between those getting vitamin-mineral supplements and those who didn’t.
In terms of herbals, there is no controlled research showing that they would be of benefit specifically for explosive outbursts. Be a cautious consumer in investigating any claims about efficacy.
Keeping in mind that there are many possible pathways to “rage attacks,” the selection of an intervention approach requires a thorough assessment to see which factor or factors are contributing to the outbursts.
If you are parenting a child or adolescent who has “rage attacks,” what assessments have you had conducted? If your child is having “rage attacks” in school as well as at home, or if you believe that it is the school situation that is triggering your child’s rage attacks in the home, you might want to consider asking the public school district to fund any necessary assessments as part of any obligation they might have to develop an appropriate program and interventions for your child. School districts may be willing to fund neuropsychological evaluations, psychiatric consultations, speech and language evaluations for pragmatic communication skills, and a variety of other tests or assessments if they are needed in order to provide the child with a free appropriate public education.
In any event, if you, your child, or your spouse is having recurring rage attacks, you need a more comprehensive assessment that will involve professionals from a number of disciplines. While for some people, it is possible that simply pharmacologically treating a condition like OCD or depression may resolve the problem of rage attacks, for many others, there will be no “silver bullet,” and a comprehensive multimodal plan will need to be developed.
While all these formal assessments are being arranged or conducted, parents, teachers, or family members can take almost immediate steps to reduce rage attacks by altering the environment. To do that, you need to do a bit of assessment, described in the next section.
Reducing “Rage Attacks” by Changing the Environment
One of the most important — and effective — things parents, family members, and educators can do is to create an environment where rage attacks are less likely to occur — an environment that reduces exposure to those stimuli or situations that are likely to trigger a ‘rage attack.’ In order to create such an environment, you need to assess the child or adult’s past behavior, consider the antecedent conditions, and begin to systematically rearrange the environment.
To accomplish the above, consider the following process:
- Start by assuming that there is no such thing as “random” behavior and that every ‘rage attack’ has a cause. The cause may be a single event or it may represent a more complex interaction, but there is a cause.
- Review past episodes. What was going on prior to the ‘rage attack?’ Make a list, being as specific as possible, and including as many observations as you can (such as, “Johnny was tired and then…..”).
- Look at all the episodes you’ve recalled or described. What elements do you see? Sometimes the specifics aren’t as important as what they represent. For example, if you noticed that prior to one outburst, Johnny had been obsessed about getting a classmate punished for something the classmate had done, and that he exploded when the teacher told him to return to his seat, there are two elements there that you will “flag” for future action: any scrupulosity obsession and the frustration/thwarting in the presence of the obsessiveness. As another example, you might discover that many of Johnny’s outbursts in school occur during a particular class or time of day. What is going on in those settings that is different than other settings? The differences may give you important clues as to what needs to be modified for him.
- Revise your list of triggers or antecedents and express them in general form (for now). Your list may look something like:
- Classmates making fun of his vocal tics.
- Being asked to do homework when he’s tired.
- Wearing shirts with buttons.
- Being told ‘no’ when he’s ‘stuck’ on something.
- Being asked to switch between activities when he’s enjoying the first activity.
- Being asked to switch between activities when he feels he has to finish the first activity.
- Hearing the word “[trigger word].”
- Being in a large crowd.
- Going to the supermarket, no matter what time of day.
- Family get-togethers, even when he’s not dressed up.
The above are just some examples, of course. Your own list may be quite different, and may be quite short or quite long, depending on your child, student, or family member. In a number of cases, an important part of the assessment will be to get a neuropsychological evaluation and/or a speech and language evaluation of the student.
Now here comes the next important piece:
For each of the things you’ve listed, take action to change the environment to either avoid altogether or reduce exposure to the trigger or antecedent conditions.
One of the things that has ceased to amaze me is how often parents actually know what environments are likely to be problematic and yet keep taking their children into those environments. Why should they then be surprised or caught off guard when their child responds as they could have predicted they’d respond?
Being “proactive” involves being aware of the child (or adult’s) needs and limitations, respecting those limitations and supporting them by creating an environment that doesn’t push them past their limits.
Thus, the first thing I often do (after the psychoeducational piece) is work with the parent (and/or the school or employer) on altering the environment so as to reduce the triggers or situations that are likely to result in explosive outbursts. Often that’s enough to produce a dramatic change or dramatic reduction in the number of explosive outbursts.
Once things have calmed down, then it is easier to get cooperation with the hard work that needs to be done. And what needs to be done generally involves a two-pronged approach: changing the family’s (or teacher’s or colleague’s) response to the patient’s behavior while simultaneously teaching the patient cognitive skills and strategies to enable them to function in situations that make it difficult for them to function. In other cases, speech therapy or other interventions will also be required, but for now, we will focus on the psychological interventions. And the first interventions will be on ourselves.
CHANGING OUR THINKING AND BEHAVIOR
Changing the responses of others is a crucial piece in any intervention plan, as it is often others’ responses that either push the patient past their limits or otherwise escalate a situation. Because many people misunderstand the individual’s behavior and erroneously attribute it to voluntary misbehavior or “oppositionalism,” they may speak to the individual in ways that are counterproductive. In my dealings with parents and educators, I often hear, “All he needs is a firm hand and more discipline,” or “Well, I understand that he has a neurological problem, but I still can’t let him just get away with that.” I generally start by nodding my head to show them that I do understand their thinking, but then say, “OK, but let’s get real. Is your strategy working? Is he learning not to do that?”
At that point, they’ll usually acknowledge that their approach hasn’t worked at all, and that’s my opportunity to start showing them another way to think about or understand the child’s behavior and another way to approach the problem — an approach that begins not with trying to change the child, but with creating a more supportive environment that reduces frustration, learning to read the ‘warning signs’ that the child is about to “lose it,” and being able to immediately shift gears to restore the child to some equilibrium so that they can problem-solve with you.
Educators are often reluctant to embrace this kind of alternative approach. Having been exposed to some semblance of behavior modification in their training, and often feeling vulnerable because of how their administrator may be critical if they do not appear to be in total control of their classroom, they may say something like, “But there have to be SOME consequences, don’t there? if I let Dennis get away with just running out of the room when he’s upset, then all the other children will be learning that they can get away with it too. How do I help Dennis without turning the whole classroom into chaos?”
Now I may be a bit naive, but I am personally and professionally hard-pressed to envision 20 other middle school students suddenly developing panic attacks and learning to run out of the room. Yes, fairness is an issue to children and they need some kind of explanation for why one student may have accommodations that they don’t have, but students are pretty sharp and can generally detect when a peer has a serious problem. They can also be brought into the whole game plan to provide support for their classmate so that things don’t get to that point.
Applying “consequences” under the often-misguided notion that such “consequences” will boost the child’s motivation so that they will learn to behave differently often tends to lead to punitive strategies that worsen the situation. They also lead to the parent or educator becoming as inflexible as the child/teen is at that moment. Locked in a power struggle with the child, the teacher or parent will invariably lose. Hence, in my experience, one of my key functions is to provide support to the parent, educator, or colleagues so that they can remain calm and provide support to the child or adult.
If the child is not cooperating with you at the moment, instead of assuming that the child doesn’t want to cooperate with you, assume that they DO want to cooperate with you but are unavailable to do so, through no fault of their own.
Most children really want to keep the good opinion of their parents and teachers. If they are saying “no” and getting explosive, assume that they have a problem that is preventing them from shifting from what they were doing or thinking about and what you want them to think about or do, and that the problem is not one of motivation.
Many children with neurological conditions need more time to make shifts (transitions), and they often need a good amount of support to make shifts. If you simply demand or even politely ask them to make a shift that they cannot make, they will be frustrated. And frustration can lead to explosiveness. As intelligent as many of these children are, they simply cannot see their way out of what appears as an overwhelming conflict or dilemma (e.g., “I really need to finish this game and Mom is saying I have to do my homework.”). Because they cannot “see” anything other than those two options, they are likely to either ignore the mother’s request or say, “no.” The mother, if she interprets the ‘no’ as “No, I’m not going to do my homework now because [I’d rather play, or I don’t care about my homework]” is likely to become frustrated and insist more strongly, “Come, it’s time to do your homework NOW.” Under conditions of increasing stress, the child will respond, “NO!” more forcefully or “In a minute…..” And so it goes.
One of the first things I teach parents in my clinical practice is to change their understanding of what “no” means when their child says it. I teach them to mentally respond by thinking, “When he says ‘no,’ he really means, “Mommy, I’d really love to cooperate with you right now because I think you’re the most wonderful mother in the world, but as much as I want to, I’m not available to cooperate with you.” Now of course, there are times when the child really means “No, I don’t really care what you want because I have to have what I want when I want it, and I want to play this game,” but if we are going to err, it is probably safer to err on the side of giving the child the benefit of the doubt for the moment.
With that revised interpretation in mind, what can the mother do or say? Well, there are actually many things she could say or do, but what she won’t do is keep insisting or start arguing. If she simply acknowledges her child’s experience and respects it by saying, “OK, but I’m concerned about your work getting done, so can you just put that on ‘pause’ a moment to tell me when you’re going to be able to do your work?” or if she says, “OK, I understand that you need to keep playing that right now. Please come tell me as soon as you are available,” there will be much less chance of an explosive outburst. And reducing the explosive outbursts is a priority.
HELPING THE CHILD CHANGE
While the parents and teachers are learning alternative ways to talk to the child so as not to provoke or escalate a situation, the child is also learning to think flexibly when they are thwarted or encounter frustration. These skills can generally not be learned when the child is in a state of heightened arousal if they are over-aroused, but if the child has some level of increased arousal, they also may be more motivated to work with you (if they think that it will lead to them getting more of what they want at that moment). The learning and rehearsal also take place in the home and office with therapist and parents, so that the child develops skills that they will be able to access when they really need them — when they are in a situation where they may be in a state of heightened arousal or starting to get dysregulated due to thwarting from teachers or the environment.
As the child masters simpler exercises in problem-solving and begins to identify solutions to their problems, the challenges or tasks are progressively increased. When your child (or patient) comes to you with a problem, that is a wonderful opportunity to help them learn some strategies, because if the strategies are successful, then the next time they have a problem, they will be more likely to try the strategy. The following example from my clinical practice may illustrate this point:
“A.” was 8 years old and had really florid TS+ when I met him. The first time he came to my office, I saw immediately why his mother was exhausted. Not only was he really ticcy, but he could barely sit for more than a few seconds, was running, jumping on the furniture, punching it and kicking it, and tapping his mother. When his mother said something he didn’t like, he would run to her and hit her or kick her or get right in her face. When I quietly asked him not to open file cabinet drawers, he burst into tears and ran out of the office. He picked up objects and threatened to smash them, threatened to kick me, and opened and slammed every door he could find. By the end of the first session, I knew we had our work cut out for us.
Over the next few months, “A.” cooperated in therapy, but was still extremely impulsive and easily frustrated, often getting into trouble with others. One of the major concerns at the time was that “A.” couldn’t even get off the school bus without running and kicking or hitting other children or any parents who might be standing at the bus stop waiting for their children. His mother was exhausted from trying to prevent him from hitting or kicking others and felt scorned by other parents for her perceived failure to control her son. During a family session, their exchange went something like this:
A: I want to walk home from the bus by myself. I don’t want you meeting me there anymore. Some of the other kids walk home by themselves.
Mother: I can’t let you do that because I’m afraid you’ll kick other children or parents.
A: I won’t. I promise!
Mother: I can’t take the chance.
A: (starting to dissolve in tears) But I promise! I’ll be good!
Mother: I’m sorry, but no.
A: (crying and starting to hit mother) Let me, let me! I’ll be good!
CONFLICTS BECOME OPPORTUNITIES
Rather than letting the cycle continue, I responded to “A.” by saying, “I can see that you’re upset right now. You would like to walk home by yourself. It must be frustrating that Mommy is telling you ‘no.’ Would you like to talk about that so we can work on it?”
Seeing the possibility that he might actually get what he wanted, “A.” immediately started to calm down. Using simple language, I helped “A.” see that although he felt frustrated, he could change things. I told him that there are two facts in life: (1) mothers worry, and (2) children generally don’t get to do things on their own until they demonstrate that they’re responsible and can keep themselves safe.
“A.” enthusiastically approached the task of figuring out what he was supposed to do to be more responsible so he could walk home alone. When I asked him “What do you think you could do to show Mommy that you are safe walking home by yourself?” he paused, thought for a while, and said, “I could walk home very quickly without talking to people and without kicking or hitting anyone.” He looked at his mother and asked, “Would that work?” His mother agreed that that would be a great way he could show her he was being responsible in keeping himself safe.
Having reached some agreement, his “homework” was to practice that for the next week, while his mother’s “homework” was to wait inside their building instead of meeting him at his bus. As part of the interaction, I had “A.” ask his mother if she was feeling anxious. He did, and she told him that yes, she was. We talked about him understanding her anxiety (“Fact #1: Mothers Worry”) and what he could do to be supportive of her. For the first time, “A.” really seemed to notice his mother’s feelings and respond to them.
“A.’s” first venture was not totally successful. At our next session, “A.” reported that he had had every intention of walking home quickly and knew what he was supposed to do, but there was this truck parked at the curb and the back was open, and he was curious to see what was on the truck, so he had climbed up into the back of the truck.
Now for most of us, that kind of report would strike terror in our hearts (and have professionals running to check our malpractice insurance!) but because “A.’s” mother had understood that this might take some time and had given a commitment to try, we simply calmly reviewed what “A.” was supposed to do, made sure he understood the danger in doing what he had done, and mentally rehearsed what he would do if the same situation arose again.
The following week, “A.” and his mother reported total success. “A.” was now walking home directly and quickly from the bus and both were feeling great about his accomplishment (indeed, since starting this task several years ago, “A.” has never kicked or hit anyone getting off the bus and has even been able to walk with another child or pause to talk to other children, while still getting home promptly).
Over the next months, “responsible” became a key word for “A.” If he was asked if he would like to take more responsibility for something, he invariably responded with an enthusiastic “yes,” as at all stages each increase in responsibility led to more freedom for him as well as tremendous praise from his family. At the same time, he learned to recognize when his mother was feeling anxious and tried to reduce her anxiety by his own responses while his mother worked on learning to say “yes” even when she might be experiencing anxiety.
ELEMENTS OF THE APPROACH
The elements of a comprehensive prevention and treatment program might include:
- Increasing your own awareness and understanding of how neurobehavioral conditions affect your child (student, or family member). That may mean getting a neuropsychological evaluation, a speech and language evaluation, a sensory integration evaluation, as well as other more obvious evaluations and assessment procedures.
- Identifying situations or stimuli that are more likely to provoke or trigger such attacks and eliminating as many of these sources as you can. At the beginning, preventing rage attacks has to be your top priority. Later on, as coping skills improve, you may be able to reintroduce certain environmental conditions on a gradually increasing basis so that the skills can generalize to more situations.
- Learning to pick and choose your battles.
- Helping the individual stay calm when they’re started to get agitated or too aroused.
- During calm periods, help them develop any deficient cognitive skills and/or social skills, including a vocabulary to communicate their emotions and needs. Parents are often surprised to discover that it may take their child an incredibly long time to think of any options — and indeed, the child may not see what appear to be “obvious” solutions. You may need to wait quite a while for your child to see even one option or solution, but be patient. If they really can’t come up with any options, ask them if they’d like you to tell them some options that you can think of. If they say “yes,” give them one option and ask them if they can think of any others. If they say “no” when you ask them if they’d like to hear your ideas, just drop it. If you keep doing that, sooner or later they will probably ask you what your thoughts are, but they may not be ready for that at the beginning. Keep rehearsing the cognitive problem-solving skills — particularly the skill of seeing compromises or alternatives when things aren’t going the way they feel they “have to” go.
- Work with the child to develop some key phrases that they can use to communicate, and share those with your child’s teachers. For example, in my practice, I often teach children or teens to not only recognize when they’re mentally ‘stuck’ on something or unable to shift gears, but to tell their parents and teachers, “I’m stuck.” In the presence of that communication, the parents and teachers can generally shift into a different mode to help the child get un-stuck. (Note: my use of ‘stuck’ is comparable to what Dr. Ross Greene refers to as “vapor lock” — the state in which the child or teen is starting to lose their ability to think coherently and solve their problem).
- If the child has a rage attack, give them space. They will know when the attack is over, and they may need to sleep or just withdraw for a while afterward. Allow them to sleep or to engage in a highly motivating task — the latter will help focus them and bring them “back.” Do not rush to have a discussion with them about what happened, and if they say they don’t really remember, don’t push.
- For many families, family therapy is an important component as old patterns of interacting will need to be significantly altered. If you can’t get your spouse to go with you, though, all is not necessarily lost. I have seen reluctant family members decide to start coming when they started noticing changes in the home that were improving things. Nothing succeeds like success.
- Medication may be also be an integral piece of the plan, depending on what the comprehensive assessment indicates.
Schoenthaler SJ, Bier ID: The effect of vitamin-mineral supplementation on juvenile delinquency among American schoolchildren: a randomized, double-blind placebo-controlled trial. J Altern Complement Med 2000 Feb;6(1):7-17.