Temper outbursts, sometimes called rages, are a major reason for outpatient and inpatient referral. These behaviors have also been a focus of assessment in child psychology and psychiatry since rating scales were developed. In fact, items consistently loading on the same factors in frequently used behavior rating scales for children reflect negative mood (mood changes quickly/explosive, easily angered/ stubborn, sullen, irritable), oppositionality (being demanding, uncooperative and disobedient) and aggression (argumentativeness, having temper tantrums).1
Rages have been associated with extreme irritability or mania, Tourette disorder, intermittent explosive disorder and conduct disorder, autism/Asperger disorder, and other conditions.2-6 Rages are part of a syndrome of severe mood dysregulation, which is defined by markedly increased and frequent reactivity to negative emotional stimuli (eg, response to frustration with extended temper tantrums, verbal rage, and/or aggression toward persons or property) that occurs at least 3 times a week in the context of chronic anger or sadness.7 This co-occurs with other symptoms, such as those related to attention-deficit/hyperactivity disorder (ADHD) or anxiety (ie, hyperarousal, distractibility, rapid speech/racing thoughts, insomnia).
Jordan, 8 years old, has been referred for psychiatric evaluation because of his restless, distractible, impulsive, unpredictable, oppositional, and defiant behavior. He has difficulty in following directions; sometimes he refuses to do a task, other times he doesn’t seem to understand what is needed. His frequent frustration often results in prolonged outbursts at home. In school, he has to be removed from class because his behavior becomes dangerous. When he is restrained by his parents or a classroom aide, he becomes even more agitated, and rages violently.
The term “rage” implies that these outbursts consist solely of high-intensity anger, but we actually know little about their content or structure. It has been suggested that outburst content and/or structure might vary with psychiatric conditions, such as oppositional defiant disorder, depression, and mania.2
Our team at Stony Brook has studied rages by direct observation (rather than parent interview), measuring the duration of outbursts, the kinds of behaviors that occur in them, and their diagnostic specificity.8 We examined rages in inpatients at a pediatric psychiatric service, which cares for children aged 4 through 12 years—rage outbursts precipitated admission in over half the children. The median length of stay of about a month gave us ample opportunity to observe behavior. Because of our long-standing interest in bipolar disorder and because rages have become synonymous with bipolar disorder, we were interested in whether these rages reflect a manic rapid cycle and/or occur disproportionately in children with mania.2
Behavior during rages
To understand rages better, we collected diagnostic and observational data for more than 18 months. The study involved 130 children aged 9.7 ± 2.1 years (one-fifth female), for 151 hospitalizations.9 Examining first admissions, we found that 71 (54.6%) were admitted for rages, but only 37 (52.1%) had an outburst of rage while hospitalized. (Seven other children also had rages but had been hospitalized for different reasons.)
Of the 44 children with rages observed in the hospital, 23 had just 1 episode; the remaining 21 had 2 to 9 outbursts. No significant gender differences were found. Half of the children with serious dysregulation at home or in school were able to maintain self-control on a structured inpatient unit that had clear expectations, positive support, and a less stressful environment than at home or in school.
A rage 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, pushing, pulling, throwing things, biting, scratching, punching the wall, hitting, kicking), and expressive psychomotor behaviors (tearful/sad, anxious/fearful, withdrawn/unresponsive). Notably, manic symptoms were never seen.
