Helping Children Hospitalized for Rages
Temper Outbursts: Rages
Temper outbursts, also called rages, qualify for both inpatient and outpatient care. Frequently associated with mania, intermittent explosive disorder, conduct disorder, autism/Asperger disorder, and other conditions, rages are a part of severe mood dysregulation, by which there is an increased reaction to negative emotional stimuli that occurs at least three times per week. Oftentimes, symptoms of rages co-occur with symptoms of attention-deficit/hyperactivity disorder (ADHD) or anxiety.
Director of Child and Adolescent Psychiatry at Stony Brook University School of Medicine, Gabrielle Carlson, M.D. and colleagues collected data over a period of 18 months to better understand rages. They examined 130 children for 151 hospitalizations, and after analyzing first admissions, found that 71 were admitted for rages but only 44 had an outburst while hospitalized.1 Of the 44, 23 had just one episode of rage and 21 had between two and nine.1 Carlson and colleagues defined a rage as beginning when the child became verbally loud and defiant when asked by the staff to do or cease doing something.1 Outbursts were observed at 5, 15, 30, 45, 60, 90, and 120 minutes after the onset, and behaviors coded included verbal acts (whining, verbal threats, cursing, screaming), physical acts (stamping, pushing, throwing, biting, scratching, hitting, kicking), and psychomotor behaviors (tearful/sad, anxious/fearful, and withdrawn/unresponsive).1
After 18 months of data collection, Carlson and colleagues recorded 117 outbursts for 49 patients.1 Coded behaviors most frequently seen were yelling, screaming, cursing, violent threats, stamping, kicking, hitting and throwing objects, which occurred in 93 percent of the observed episodes.1 An episode usually lasted over 45 minutes; however, length did vary greatly, with 19 percent of outbursts lasting less than 30 minutes, and 19 percent lasting longer than 60 minutes.1 Carlson and colleagues found that younger children were more likely to have rages, and their IQ, history of abuse, and living status seemed to have no effect.1 Regarding psychiatric diagnoses, children with rages were five times as likely to have ADHD than children without rages.1 Also, they were more than five times as likely to have a learning/language disorder and three times more likely to have three or more concurrent disorders.1
How to Treat Rages
Treatment for ADHD and aggression typically consists of medicine and behavior modification.1 If treatment resistance should occur, an atypical antipsychotic is usually added, followed by lithium or divalproex. Although treatment does have a positive impact upon patients with ADHD and rage, it is rare for those patients to see complete remission.1 Carlson and colleagues state that in their sample, children with rages had a wide variety of treatments as outpatients, including ADHD medicine, atypical antipsychotics, and mood stabilizers.1 Also, many improved with a combination of behavior modification, family treatment, academic intervention, and medicine.1
Carlson and colleagues’ inpatient behavior modification approach focused on teaching children self-control and helping parents learn correct responses to their child’s behavior. Children who were hospitalized could earn points towards fun activities or home visits in appropriate behavior was seen.1 Also, children were taught to take a time out by sitting quietly in a chair for 10 minutes and then talking about their feelings with a therapist or staff member.1 This way, children are able to learn what triggers their rage and how to mitigate an episode.1 Those who are unable to take a time out are brought to a quiet room where the door remains open (as long as the child stays in the room) and a nurse observes until the child has been quiet for 10 minutes.1 Then, the child will talk with a therapist or staff member about their feelings and behavior. Some children are completely unable to calm themselves are require an immediate medication intervention. Oftentimes, an oral alternative, such as risperidone, is offered first, but if it is unsuccessful, an injection of diphenhydramine is given.1
Controlling Rages at Home
To enable parents to maintain their child’s progress after hospitalization ends, parents begin to work on skills with a therapist immediately upon admission.1 The therapist explains to the parent that they did not cause their child’s behavior, eliminating any defensive feelings, and discusses how the behavior requires a particular approach to handle.1 Parents are taught how to use the time out procedure when the child is not following directions or has become verbally or physically aggressive. The parent needs to be able to successfully guide their child into time out before they are able to have home visits.1 Also, their child should be returned promptly to the hospital should the child not agree to time out at home. A confident and well-trained parent helps the child succeed after discharge.1
 Carlson, G.A.; Potegal, M.; and Grover, P.J. (2009, July 10). Helping Children Hospitalized for Rages. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/childhood-schizophrenia/content/article/10168/1427190
 Connor D, McLaughlin TJ. Aggression and diagnosis in psychiatrically referred children. Child Psychiatry Hum Dev. 2006;37:1-14.
 Leibenluft E, Charney DS, Towbin KE, et al. Defining clinical phenotypes of juvenile mania. Am J Psychiatry. 2003;160:430-437.
 Pliszka SR, Crismon ML, Hughes CW, et al; Texas Consensus Conference Panel on Pharmacotherapy of Childhood Attention Deficit Hyperactivity Disorder. The Texas Children’s Medication Algorithm Project: revision of the algorithm for pharmacotherapy of attention-deficit/hyperactivity disorder (ADHD). J Am Acad Child Adolesc Psychiatry. 2006;45:642-657. Rages.