Helping Children Hospitalized for Rages

Another study of outpatient children with ADHD in a ummer treatment program revealed that the combination of stimulant medications and rigorous behavior modification reduced symptoms on the Young Mania Rating Scale (YMRS) from 23.7 ± 3.5 to 15.4 ± 6.1.17,18 Aggression and irritability were shown to be decreased by almost 45% with treatment; ADHD symptoms improved as well, but to a lesser extent. The data specifically address comorbidity and suggest that the combination of ADHD and irritability/mood symptoms improves with treatment but does not completely remit with strategies directed at ADHD alone. Four “manic” symptoms (elevated mood, sexual interest, sleep disorder, and thought disorder) decreased from mild to even less impairing. There is no evidence that children with severe mood dysregulation respond to lithium alone.¹⁹

In our sample, children with rages had had a range of treatments as outpatients, including ADHD medications, atypical antipsychotics, and mood stabilizers. In addition, 88% of children with rage outbursts had been in special education, and almost half had been hospitalized previously.

The number of rages correlated positively with length of stay in the hospital (r = 0.32; P < .001): rage episodes added at least 2 weeks to the duration of hospitalization (median, 36 days for children with rages compared with 22 days for children without). Most children improved with a combination of behavior modification, family treatment, appropriate academic intervention, and medication.

Our inpatient behavior-modification approach focuses on teaching children self-control and helps parents learn suitable responses to their child’s behavior.²⁰ Hospitalized children who behave appropriately earn points toward fun activities and increased time for home visits. It is especially important 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.²¹ Many children respond favorably to the unit structure and 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.

Some children simply cannot calm themselves down and require immediate medication intervention over and above whatever medication they are taking. An oral alternative (eg, liquid risperidone or a rapidly dissolving oral atypical antipsychotic) is offered first.²² When oral medication is unsuccessful, an injection of diphenhydramine is used.

A few children become so unreachable when they are angry or distressed that no corrective intervention has been successful. Alternative strategies (such as collaborative problem solving) may be an option, but most have not been studied systematically.²³ This group of children is the most difficult to manage and requires the longest duration of hospitalization. Some children may require out-of-home placement, depending on psychosocial circumstances.

Parental involvement
To maintain the gains made by children, work with parents begins 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. For parents who feel sorry for the child and think any form of consequence is unfair, the social learning paradigm (which underlies behavior modification) is reframed so that behavior that causes failure has a negative consequence and behavior that ensures success earns a positive consequence.²¹ Most parents want their children to succeed.

Parents are taught how to use the Time Out procedure when the child is not following directions, or when he or she exhibits verbal or physical aggression.²¹ In optimum circumstances, parents learn this 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 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 (for 75%); 90% of children with rages received an ADHD medication and/or an atypical antipsychotic/mood stabilizer and were 4 times more likely to receive both than children without rages.

Conclusion
Rage behaviors may represent a disease modifier (such as psychosis) that complicates a number of disorders. A precise and accurate diagnostic label is needed to be able to undertake further studies. To date, successful treatment has required a combination of psychopharmacology and nonmedical interventions. Although most children stopped having rages once hospitalized, or perhaps had only 1 episode, children who had continued outbursts remained difficult to treat. Conceptualizing children with rages as having mania or bipolar disorder was not consistent with our observations. Few hospitalized children were observed in an episode of mania; however, we did see children with severe language-processing problems.

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. Some children required readmission and a very small percentage needed residential placement after discharge. For a condition that is as common and disabling to children as rage outbursts, a more consistently successful series of options is sorely needed.