Tourette Syndrome Plus - Conditions - "Rage Attacks" Treatment of "Rage Attacks", p. 2

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Information Section: Conditions
Condition: Rage Attacks
Article: Treatment of "Rage Attacks:" Medications and Non-Medication Approaches
Source: Leslie E. Packer, PhD
This File Last Updated: December, 2004

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NON-MEDICATION APPROACHES

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.

Assessment

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:

1. 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.

2. 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.....").

3. 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.

4. 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 neurobehavioral 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.

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