Tourette Syndrome Plus - Conditions - "Rage Attacks" Treatment of "Rage Attacks", p. 3

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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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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:

1. 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.
2. 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.

3. Learning to pick and choose your battles.

4. Helping the individual stay calm when they're started to get agitated or too aroused.

5. 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.

6. 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).

7. 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 afterwards. 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.

8. 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.

9. Medication may be also be an integral piece of the plan, depending on what the comprehensive assessment indicates.

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