RAGE ATTACKS - PATHWAYS AND TRIGGERS

PATHWAYS TO RAGE ATTACKS

In the overview article in this section, I explained how I use the word "rage attack" and how it is different than a "tantrum." Although school personnel often erroneously believe that the purpose of a "rage attack" is "attention-seeking" behavior or to escape some unpleasant class activity, most rage attacks are not really future-oriented that way. Rather, they are a reaction to internal events or an impulsive or compulsive reaction to something in the environment. In many cases, they are indicative of a neurologically based problem in self-control.

If a "rage attack" episode has a "Jekyll and Hyde" quality to it, and if there are indications that something just seemed really "off" with the student prior to the explosive outburst, I'd be more inclined to look for a neurological explanation. Assessment is crucial in determining the cause of a student's "rage attacks" and to what degree they may be 'voluntary' or purposeful or not. Some possible pathways to "rage attacks" include:

• Medication side effects
• Language processing deficits
• Executive dysfunction (such as difficulties making transitions or difficulty multi-tasking)
• Nonverbal learning disability (such as not reading facial expressions or other cues)
• Difficult temperament
• Social impairments
• Anxiety
• Sensory integration dysfunction
• Mood lability
• Obsessions and/or compulsions
• Mismatch between environmental demands and preferred style of learning or working
• Frustration due to learning disabilities that have not been addressed
• Mismatch between characteristics of the individual and characteristics of "significant others" in the individual's life
• Teacher provocation

In some cases, I've had parents tell me that their child had a "rage attack," but when I ask them for the particulars, they are not really describing anything that comes close to my definition of "rage attacks."  They may be describing a tired or frustrated child who lost control, and the behavior may be in reaction to something school personnel have done to the student or may just be due to the student not having the resources to control himself or herself at the moment, but I would not describe that student as having "rage attacks" unless there was a pattern of a recurring episodes that seem grossly out of of proportion to any triggering event or situation and that seem to come without any warning.

SPECIFIC TRIGGERS

For some children or teens, there seem to be fairly specific or predictable triggers, but for many, almost anything can serve as a 'releasing stimulus' if the individual's tension or stress levels have been building.

Even when you can't identify the 'reason,' if you start by assuming that there is a reason, then efforts can turn to identifying the causes so that proactive steps can be taken and the student can be helped to deal with the causes. Recognizing that sensory stimulation that seems mild or innocuous to others may be experienced as intense by the student who has sensory integration problems may be an important step for school personnel. Recognizing when a child has slower auditory processing and can't respond immediately to demands may help the teacher simply give an instruction and wait. Recognizing when a child or teen is irritable and overtired from a mood episode or sleep disorder may help prevent explosive outbursts. There are many possible triggers.

One parent's recognition that there were causes that could be identified was expressed this way:

"For a long time I would have said that there was no reason for them, that she would "take off" for no reason at all. Little by little we have realized that, for her, there are causes though her reaction is about a bezillion times larger than even those causes call for.

Now she tries to deal with anger/situations/people as the conflicts arise. It calls for a lot of honesty with herself. And many things that I would never see as a reason for any anger she reacts to because of her need for things to be just so, or because she dwells on thoughts, or thought just attach themselves to her or the impulse control stuff happens. If she lets these things mount, then the rage is huge."

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Here are some firsthand accounts or observations about what triggers "rage attacks" for other children or teens, in the parents' own words:

 ..... His last worse ones were during the fall of last year-tore off towel bars,broke his brothers toys,threatened me,etc. out of control anger.Finally he was able to speak and it was that school kids tormented him and he was being scrutinized so much at school that he did not want to go anymore. I told him I would help fix school and I still update him as I try to fix things for him at school.

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Another parent comments how on the frustration in school led to similar rage outbursts in their home:

"This sounds very much like my 10yo son. We, too, had a problem with being tormented at school. This led to rages and waxing of his tics. When he finally told us what was going on and we took steps to correct it, he became his normal sweet self. And I can't emphasize enough the importance of remaining calm during his rages. This makes a distinct difference in the amount of stress I experience and helps him calm down much faster."

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The following situation demonstrates how a child can lose control if they have been stimulated and are overly tired or have too much stimulation:

"My son, 9 1/2 had a very bad rage attack today and it was at the end of our day,and we had just finished a wonderful family game of socceer. I feel that at times him being physically tired brings on a rage attack-today was one of them. He had a great day, we all had great family time,visiting my grandmother, icnic lunch,shopping for comic books, and then spontaneously playing soccer for maybe 45 minutes- AM verbally ranting,threatening,throwing himself-truly I felt all my previous advice to this group regarding rage went in front of me and flew away. I calmly spoke to him and all I could get was that he never gets the ball,he did not want to do anything today but play socceer(it was spontaneously thought of by me to play and he was passed the ball the most)we tried to change the subject,and eventually only suceeded in getting him in the car to go home.At home I was able to involve him in making pizza as he enjoys helping with that, and then he was fine like nothing ever happened.Talking to him just now about his anger he said he does not like it when he does not have the ball.I told him we share it and try to have each of the boys play equally and he actually had it more today. But he sees it that he is involved less than the rst of us .Anyway I don't see exhaustion as a factor for having less rages, I actually see them as worse and more intense from my son. My husband feels the rage attacks from my son are worse if we have a great family day, yet I feel it only feels worse to us because we feel so mystified that there occurring after a great day."

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Often it seemed to me there was an background theme of being stressed out, typically faced with having to do homework, or perhaps something during the school day bugged her but she hadn't dealt with it. But the actual trigger that provoked the rage could be the smallest thing.

Her sister gets angry too but there's definitely a qualitative difference; a strong wind to a hurricane comes to mind."

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Other parents also describe the relationship between increased OCD symptoms and rage:

"I've also noticed a correlation at times with the OCD. My son has especially run into this at school, where he might be silently obsessing on some subject and then the teacher 'interrupts' the obsession with the reality of schoolwork! Yet he was afraid to admit to the teachers that he was obsessing in his mind, because the subjects of obsession were often bizarre or frightening. The teacher would intervene, he would explode in rage, and the teacher would then be completely bewildered.

Usually he shows some signs of agitation - extra movement, extra chatty, etc. when he starts to get into this stage. The teachers are starting to learn to recognize that when he starts showing signs of extra 'anything', it is time to send him to resource and get him out of the regular class - rather than wait for the crescendo and rage."

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"my 11-year-old daughter, [D], has suffered from rage attacks since about age 3. we kept thinking her "tantrums" would decline with age, but were sorely mistaken. the first time we got any real relief was after she started on prozac for ocd and depression at age 7. (our neuro informed us that depression in children typically takes on the form of severe anger and not the depression as seen in adults, i.e.: low mood, sleeping, etc.) the prozac worked like a miracle drug and served us well for about 2 years. at that point, it interfered with her sleep pattern and caused problems at school. :(

... one thing to keep in mind that helped me to be more understanding...when [D] doesn't get her way, it's because, i've come to realize, that her ocd is in control. not just the hand washing and repetition part of ocd, but the fact that she is fixated on whatever she wants and has to relieve her obsession/compulsion by getting whatever she is after, i.e.: toys, candy, playmates to visit or spend the night, etc. the problem is, as soon as she gets what she wants, it's not enough and she moves on to the next thing. i read in a book one time where a mother wrote, "if my son has 100 pieces of candy he wants 101." it's not about needing more, they just get so obsessive and impulsive. "

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So the answer to the question, "Are there any warning signs of a rage attack?" appears to be "yes, but that doesn't mean that the student or others around him or her will always be able to spot the triggers or warnings." With time and careful observation, the triggers or antecedent conditions can usually be identified.

Many parents have noted that there are some days when they can tell by how their child wakes up what kind of a day they're going to have, and then they readjust their strategy for the day. Helping the child or teen learn to recognize sensations or feelings or thoughts that precede such attacks is an important component to helping them self-manage.

While another parent writes:

"I have learned to sense [M] .When he seems off in the morning,or is getting frustrated and can't seem to find anything right, I know that I need to monitor closely what is going on in our home.I try to keep his brothers from irritating or getting close, I try to see if he wants to do an activity that will place him a way from the main activity in the home.

If he gets more and more agitated and it is things others may not get upset about, I tell [him] very clear and calmly that he needs to find someting to do or go somewhere else as he is getting upset; I offer him to talk (usually he can not when he is getting more and more upset). If things escalate and he is going to do something dangerous or hurtful, I will move him to a safe place or go with him somewhere. We have left the beach after just arriving in the past because he just went into a rage over a sandwich,and we can't stop the anger right a way."

TEACHERS TRIGGERING RAGE ATTACKS

When a student reportedly has 'rage attacks' in school, one of the first questions I always ask is whether this is also happening in the home. If it is, then is it only happening when homework or school-related matters arise, or is it happening in other situations as well? Thinking about under what conditions the child loses control can help us determine where to start looking, what accommodations might be needed, and what other assessments and/or interventions might be needed.

Suppose that the child is not having 'rage attacks' at home, but is having them in school. While it is still possible that it is the child's disability that is the primary contributor the problem (e.g., a child with depression may "explode" in school when asked to concentrate or produce for long periods of time), we also need to look closely at how the school is handling the child. Have they made enough accommodations? If there's a plan in place, have they followed it?

In my experience, it seems that in some cases, school personnel have been responsible for triggering a rage attack or pushing the child past his or her limits. Consider the following (and unfortunately true) example where a teacher knows a child has Obsessive-Compulsive Disorder and that one of the child's symptoms is that he "has to" finish something she is reading. On a particular day, the teacher instructs the class to put their books down as it is time to do another activity. The child with OCD doesn't comply, and the teacher cues him again to put the book down and start the next task. The child with OCD continues reading and tries to leave the room to go finish the book. The teacher refuses, blocks the doorway, and tries to take the book away . The child with OCD "explodes," and swings at the teacher.

In the preceding example, one could argue that we should hold the student responsible for his behavior and that he has to learn that no matter what, he can not take a swing at people. And on some level, I'd agree with that. The problem with the school disciplining the child for it, however, is that such consequences may not reduce the likelihood of it happening again if the student's compulsion is that severe, and it fails to discipline the teacher who failed to respect the student's limits. If teachers "get in the face" of students who are known to have deficits in neurobehavioral regulation, then aren't they as responsible for what happens as the student?

In my opinion, when it comes to school, the teachers, as the adults, have the responsibility to manage themselves so that they don't engage in an escalating pattern with the student. And one of the most effective ways to help school personnel recognize the limits and what to do in particular situations is staff development. Teachers are often concerned that they will lose their authority with the class if they don't "discipline" a dysregulated student. The reality is that their "discipline" is often punitive consequences that escalate a bad situation into a full-blown "rage attack."

Even when teachers are not provoking or causing the student's problems, they may be the student's last hope of restoring themselves to a calmer state. Learning how to stay calm, recognize the signs of impending dysregulation, and helping the student make a graceful exit so that they can calm themselves are important skills. Realizing that you are not "rewarding the student for misbehavior" if you allow them to switch to an activity that is inherently interesting to them and that helps them focus and calm themselves is also important. Maintaining your empathy for a dysregulated child can make all the difference.