"RAGE ATTACKS"

PREFACE

"When [he] has had rage attacks, they can be set off by what seems to be the most minor events. Maybe we didn't have something he wanted to eat for supper. Maybe I asked him to brush his teeth. He would start ranting and raving and wouldn't stop. Any attempt to cut him off would escalate even faster. It seemed that until he reached a certain point, he could not calm down. By then he was swearing at me and breaking things. He was totally out of control..... After the incident it was as if nothing ever happened. And if I tried to talk about it, he thought I was overreacted, and of course, said he didn't do anything. Those episodes were exhausting physically and emotionally."

-- A parent describing his teenager's "rage attacks"

WHAT ARE "RAGE ATTACKS" OR STORMS?

"Rage attacks" is not a recognized diagnostic disorder or term, and yet anyone who's parenting a child with them or working clinically with a child or teen with such outbursts can probably immediately relate to the phrase. As I use the term, a "rage attack" is a sudden, out-of-control explosive outburst that appears -- to the observer and the individual experiencing it -- to be without warning and totally out of proportion to any triggering event in the environment. It is also experienced as being a somewhat (but not completely) uncontrollable event that once it's started, just has to run its course.

A "rage attack" is not a "tantrum," because tantrum behaviors are goal-directed. The purpose of a tantrum is to get someone who is not doing what you want them to do what you want. If there is no one around, a tantrummer generally stops tantrumming because their tantrum isn't working. With a "rage attack," the "goal" seems to be to discharge or release some tension that's been built up. Some people describe them as "storms" that come without warning. Others describe them as a "meltdown." In many cases, however, once we get to know the child or teenager, we find that there are frequently early warning signs that a problem is brewing.

WHAT DIAGNOSES ARE LINKED TO "RAGE ATTACKS?"

About 10 years ago, some people talked about "Tourettic rage" as if rage attacks were associated with Tourette's Syndrome. In case anyone has heard that myth, let me take this opportunity to correct it yet again: there is no evidence (and never has been) that people who have Tourette's Syndrome without any other conditions are more likely to have "rage attacks."  If they do have Tourette's Syndrome and rage attacks, it appears to be due to the presence of comorbid conditions -- and the more comorbid conditions they have, the greater the likelihood of having rage attacks. Does that mean that every person who has Tourette's plus comorbid conditions will experience such problems? No, it doesn't. While a significant percentage of individuals seen with TS+ in clinics have or have had problems with anger or outbursts at some point in their history, we need to be mindful that: (1) these are not random samples but clinic samples where you are more likely to encounter individuals with more serious symptomatology, and (2) in some cases, people who experience difficulty with anger without having these explosive outbursts may be included in the estimates.

That said, it is probably true to say that about one-third or more of patients with Tourette's Syndrome plus comorbid conditions seen in clinics have experienced problems managing anger or explosive outbursts and that these problems are often the primary reason for them seeking medical attention. But it bears repeating that there is no evidence that Tourette's alone increases any risk of such problems.

So what are the comorbid conditions that appear to be associated with "rage attacks" or increased risk of such explosive outbursts? If one were to ask what diagnoses are more likely to be associated with anger outbursts, explosive aggression, rage attacks, or Intermittent Explosive Disorder, the answer would probably be: depression, bipolar depression, OCD, ADHD, Conduct Disorder, temporal lobe epilepsy, head injuries, Oppositional Defiant Disorder, and sensory integration disorder (although not necessarily in that order). As but one example, du Toit et al. (2001) compared OCD patients with and without comorbid conditions commonly linked to OCD spectrum disorder. They reported that the highest prevalence rates were compulsive self-injury (22.4%), compulsive buying (10.6%), and intermittent explosive disorder (10.6%). Since OCD, ADHD, and mood disorders are all highly comorbid with Tourette's Syndrome in clinical settings, it is not surprising that a subset of Tourette's patients would experience explosive outbursts.

"I DON'T SEE ANY OF THESE 'RAGE ATTACKS' THE PARENTS REPORT!"

Rage attacks or storms often occur in the home but not at school, a fact that often misleads teachers into thinking that the parents are doing something wrong in the home. While there are cases where the problem does relate to parenting skills, often the explosive outbursts are related to school demands (homework demands are a common trigger).

If your student is having explosive outbursts in the home but not in school, instead of harboring doubts about the parents, you should thank the parents for having taught their child to somehow manage the problem in school, and you need to support the parents. And you all need to sit down together to figure out if school is contributing to the problem in some way.

RAGE ATTACKS IN SCHOOL - DO THEY KNOW WHAT THEY'RE DOING?

When a child or teenager has a rage attack, are they aware of what they're doing? Some children and teens report that they have no awareness of what they're doing, while others say that they have some awareness, but as if they're seeing it from a distance, as the following first-person account demonstrates:

"I used to have rage-episodes as a child. I remember very well how awful it felt to be stuck in a rage when I knew (on some level, at least as an older child) that there was no excuse for it. I knew, I mean, that my response (unrestrained expression of rage) was completely disproportionate to the trigger. The horrible part was that I could not get out of it or even indicate in any way (to my targets) that I knew I was being unfair, I could only wait for it to pass. It was as if a cloud of rage had floated by and seized upon me, filling me up for a while before it drifted off on its way again."

The awareness may not be evident to those observing the attack. A teacher once commented to me on how scared she was by the look in her student's face -- it was if he had no recognition of the other children as his friends and didn't care about them at all as he kicked them or screamed at them. And yet when I spoke with the student, he had been aware of what he was doing, but felt that he couldn't stop himself.

CAN THEY STOP THEMSELVES ONCE A RAGE ATTACK HAS BEGUN?

Does the student have any control over themselves once the attack has started? As suggested above, many children I've spoken with tell me that they really feel that they have no control once a rage attack has started. For some students, it may be possible for them to modulate the attack in terms of relocating it or focusing on something that minimizes damage to property, others, and helps prevent erosion of significant relationships, but they will need our help to do that.

If your student has already "lost it," then the best thing you can do is give them space. Most of the children and teens I know would rather not be "on display" when they have totally lost control, and the stress of trying to deal with others may only worsen the episode for them. If they're already into a full 'rage attack' (or what Dr. Ross Greene calls a "meltdown"), then your priority is to protect safety -- theirs and yours. When they are not in the middle of an attack, then you can ask them what they'd like you to do if it ever happens again, but as one psychologist once commented, "You don't do an arson investigation while the fire's still raging."

Should a child who's having a rage attack be restrained? In my opinion and experience, that is not only counterproductive, but possibly dangerous. The only exceptions would be if the child is self-injuring or harming others.

The suggestion of "give them space" should not be taken as an empirically validated approach. And it is not to say that no intervention should ever be tried, but that most educators may not know what to do and may only make things worse.

Many people seem to think that there is some value in having a place to "let it all out safely," but many parents note that they can't get their children to those safe places in time, and the same problem may occur in the classroom: once the child has started an attack, they may not be willing to -- or able to -- leave the classroom to go to their designated "safe place." The value of the safe place, though, is tremendous if you can help the student make a "graceful exit" to get to that place before they totally lose control.

Two other tips:

1. Do not try to reason with the student who is in the middle of the rage attack, as that may make it worse. And

2. If the student decides to go for a walk to calm themselves before they get to the "lose-control" point, do not talk with the student if you are walking with him, unless he initiates the conversation or indicates to you that talking to him is okay at that point. Just walk with the student.

The last comment above deserves especial emphasis. All too often, as I've listened to parents describing their children's behavior, I've noticed how the well-meaning parent was literally following the child from room to room and/or providing additional stimulation when the child kept running away or going to another room. Although the parent's intention may be to help calm the child, the act of following the child around generally serves to dysregulate the child more. If your student has gone into a closet or under furniture or out into the hallway to get away, their behavior is telling you that they need to be left alone, and you probably should not follow them unless you want to escalate the situation even more.