+ Helping Children Hospitalized for Rages

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Temper outbursts, sometimes called rages, have been associated with mania, Tourette disorder, intermittent explosive and conduct disorders,  and Autism/Aspergers, as well as other disorders.

The term “rage” implies that outbursts consist solely of high-intensity anger, but in fact, experts know little about their content or structure.

Researchers at Stony Brook University School of Medicine studied 130 children aged 7 to 11, one fifth female. 

Researchers were Gabrielle Carlson, MD, a professor of psychiatry at Stony Brook School of Medicine; Michael Potegal, PhD, University of Minnesota associate professor of pediatrics and neurology; and Paul Grover, RN, who is a parent educator in the department of nursing at Stony Brook University Hospital.

 Diagnostic and behavioral data was collected over 18 months.  A rage observed in the hospital setting was defined as having started when the child became loudly verbally defiant and out of control when asked to do or stop doing something by the staff.

The outburst was observed at 5, 15, 30, 45, 60, 90 and 120 minutes after onset by the nursing staff.  Behaviors coded during each rage included

  • verbal acts — whining, verbal threats, cursing, yelling, screaming
  • discrete physical acts — stamping, posturing, pulling, throwing things, biting, scratching, punching the wall, hitting, kicking
  • expressive psychomotor behaviors — tearful/sad, anxious/fearful, withdrawn/unresponsive

Researchers note that of observations in the hospital, manic behaviors were not seen.

During the study  the most common behaviors observed were angry behaviors (93 percent).   Tears and anxiety occurred in fewer than half.  An episode of rage generally lasted 45 minutes, although it could vary from longer than 60 minutes (19 percent) to less than 30 minutes (19 percent).

The number of rages correlated positively with length of stay in the hospital; rage episodes added at least 2 weeks to the duration of hospitalization.  Most children improved with a combination of behavior modification, family treatment, appropriate academic intervention, and medication.

The inpatient behavior modification approach focuses on teaching children self-control, as well as helping parents learn suitable responses to their child’s behavior.

Hospitalized children who behave appropriately earn points toward fun activities and increased time for home visits.

Time Out

It’s especially important, researchers feel, for children with a history of rages to learn to take a Time Out.

By sitting  quietly in a chair for 10 minutes and then talking with a therapist or staff member, the child learns to identify the triggers that lead to a rage outburst and alternative behaviors for mitigating an episode of rage.

Many children, they say, respond favorably to the unit structure and the Time Outs from the time of admission.  Staff members who observe children starting to lose control will also teach them to “chill out” before a full-blown raging episode occurs.  This technique places self control in the child’s hands.

Children who are unable to take a Time Out are escorted to the quiet room where the door remains open (as long as they stay in the room and don’t try to hurt themselves).  A nurse unobtrusively observes until the child has remained quiet for 10 minutes and can subsequently talk about alternatives.  This option has cut the use of closed seclusion and physical restraint dramatically.

It is true that some children simply can’t calm themselves and require medication; a few children become so unreachable when they are angry or distressed that no corrective intervention has been successful.  Researchers say alternative strategies such as collaborative problem solving may be an option, but these have not been studied sufficiently.  These children require the longest duration of hospitalization.

Parental Involvement

To maintain gains made by the children, the staff begins to work with parents immediately on admission.  To ensure cooperation and reduce defensiveness, the therapist helps parents understand that while they didn’t create the child’s problems, these problems nevertheless require a particular approach.

Parents who feel sorry for the child may think any form of consequence is unfair, so the social learning paradigm (behavior modification) is reframed to state that behavior that causes failure has a negative consequence.  Behavior that ensures success earns a positive consequence.  Most parents want their children to succeed.

Parents are taught to use the Time Out procedure when the child is not following directions, or when he or she exhibits verbal or physical aggression.

In optimum circumstances, parents learn the procedure and are able to get their child to take a successful Time Out before the child has a pass for a home visit, and certainly before discharge.  Like the children themselves, parents have different learning curves in understanding and responding consistently and appropriately to their children.

Time  on therapeutic passes provides plenty of opportunity for parents to practice skills with the option of bringing the child back from home pass if the child is unable to take successful Time Outs.  This step is vital to support the parents’ effort to gain the child’s cooperation.  A confident, reasonable, and well-trained parent helps the child after discharge.  Some children need a readmission before they understand that coercing caregivers into capitulating is not an option.

Discharge planning included smaller, special education class placements.  Ninety percent of children with rages received an ADHD medication and/or an atypical antipsychotic/mood stabilizer.   They were 4 times more likely to receive both than children without rages.

Multidisciplinary treatment was partially successful for most children, but children continued to  need many services and polypharmacy.  Successful parenting was necessary but rarely sufficient in and of itself to manage children with rage behaviors.

Researchers feel that much additional research is needed in order to develop a more consistently successful series of options.  Rage behaviors are a condition that is not only common but disabling — this is a situation that needs solutions.

source: for  the complete article, visit www.psychiatrictimes.com.  Article was in the Psychiatric Times, Vol 26, No7.  Authors are Gabrielle A Carlson MD, Michael Potegal, PhD, and Paul J Grover, RN.

tutoring in Columbus OH:   Adrienne Edwards   614-579-6021   or email  aedwardstutor@columbus.rr.com

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