Parents are not overly concerned when a two year old toddler has a temper tantrum. They know that the "terrible twos" are notorious for this type of rage behavior. But temper tantrums at age five, six or seven become a greater concern, and rage behavior in an older juvenile is a source of serious disruption to any family. Many ADHD children have a short temper, and show little tolerance for frustration. When a parent says "no", or says "you have to wait", the child becomes frustrated and may display a temper reaction. The typical ADHD reaction to frustration is one of yelling and slamming doors. The frequency of such anger outbursts is higher in the ADHD population because they have such short tempers. For the purposes of this presentation we will refer to this type of short temper as "irritability" in order to distinguish it from a more serious type of explosive outburst which we will call "rage" behavior.

The problem with irritability goes beyond anger management of a short-tempered child. The real problem is that irritability can wear a parent down to where they give in to the child rather than put up with the anger outburst. The child then learns that anger behavior works to get the parents to give up. It is this "learned" anger behavior, not the actual irritability itself, that is the most distressing part of the child’s bad conduct. In mild cases, irritability can be controlled with a technique called Anger Management (to be described later). In other cases the irritability can be improved with the class of medications called Stimulants, frequently prescribed for ADHD children. However, no medication will remove learned anger behavior. For this learned behavior, the parents need to employ a method of Behavior Management. So, for the irritability itself the parents may consider Stimulants, or Anger Management techniques, but for the learned anger reaction the parents need Behavior Management. These interventions will be described in more detail after a discussion of "rage" behavior.

For a small percentage of ADHD juveniles, a "hair-trigger temper" is the precursor to a violent rage episode where the child may become out-of-control and assault family members, teachers, or peers. In some cases they turn their violent anger on themselves in the form of self-injury. In other cases they destroy property, threaten homicide, or barricade themselves in a room. They may try to jump from a moving car or run directly into traffic. These are not planned events, but sudden and explosive episodes.

This type of explosive anger, or rage, is pathological. The presentation today concerns itself with these three anger problems: irritability, learned anger reactions, and the less common, but more serious, rage behavior. They can be a critical concern for families, teachers, or mental health professionals. Since the authors have extensive experience in the management of anger in juveniles, the presentation will review the intervention strategies that they have found to be most effective over the years.

Although anger problems may be a common aspect of ADHD, it is important to be sure about the cause. Mood swings and explosive behavior can be a symptom of a number of psychiatric disorders. The first step is to conduct an assessment to rule out a Bipolar Disorder, Psychotic Disorder or Depressive Disorder or other medical disease that can produce neurobehavioral symptoms. Also, violent behavior that is premeditated can sometimes look like a temper reaction when, in fact, is part of a larger pattern of antisocial behavior referred to as Conduct Disorder. This is more than just a learned anger reaction, but a more significant psychiatric disorder which can be a precursor to a lifelong Antisocial Personality. This needs to be ruled out as well. We need to be certain that the violence is not part of gang behavior or due to other psychosocial causes (e.g.; revenge for teasing or self defense to ward off bullies at school). Lastly, we need to rule out the possibility that substance abuse, acute or chronic, may be fueling this violent behavior. When these other factors have been eliminated, we are left with a juvenile with anger problems association with ADHD (irritability or learned anger reactions) or with pathological rage behavior. If the pattern is one of explosive, violent, and out-of-control rage, then we need to identify the cause of this pathology.

The most common cause of pathological rage is a brain disorder. Sometimes it can be an acute brain disease or it can be a long-standing, chronic brain disorder. Chronic brain disorders are generally developmental brain disorders that occur due to problems during pregnancy, during

delivery, or during early childhood. For example, developmental brain disorders include fetal alcohol effects, deprivation of oxygen during birth, or traumatic brain injury in early childhood. Commonly, these rage behaviors are associated with temporal lobe disorders, because deep within the temporal lobe of the brain there are a group of structures (part of the limbic system) that are critical for emotional stability. This includes the amygdala (sometimes referred to as the rage center) and the hippocampus (which is also critical for memory). Unfortunately, these are deep structures and they do not show up on typical brain scans (e.g.; CT or MRI), nor do we see standard electrical disorders on the EEG.

However, for pathological, explosive rage episodes a special type of electrical brain test, or EEG test has been helpful. It is called a Long Latency Evoked Response. This is the brain’s response to either a sound, or a flash of light, measured during a computerized type of EEG study. These evoked responses pass through the deep limbic region (emotion brain) and can signal the presence of an electrical disorder in the emotional control system. This is a type of limbic epilepsy, but is diagnosed as a complex type of partial seizure. Once diagnosed, the treatment that has been the most effective for this disorder is a medication called Carbamazepine (e.g.; brand name Tegretol). This medication has also been used successfully in treating explosive rage behavior following a traumatic brain injury. However, it is interesting to note that even in those cases, this medication is most effective when there is a history of developmental brain disorder. Therefore, brain problems that occur during pregnancy, delivery, or early childhood appear to make people much more vulnerable to later development of pathological rage behavior. For most of the population, this vulnerability, from a developmental brain disorder, may not be expressed until a traumatic brain injury occurs. However, for ADHD children, there does not have to be any traumatic brain injury. The ADHD condition itself is sufficient, in combination with this developmental vulnerability, to result in the expression of explosive rage behavior as the child grows up. For this rage condition, when diagnosed as described above, the intervention of choice has been Carbamazepine. Sometimes, additional interventions are needed to treat the residual irritability and any learned anger reactions.

For the irritability associated with ADHD, the treatment of choice is Anger Management. This involves several steps. The first step is prevention. Since frustration is the most common trigger factor in ADHD it is helpful to try to control the frustration level. One method is to establish rigid routines so that the child learns that 10:00 o’clock always means bedtime. Once this is firmly established, there is much less frustration about turning off the TV or video game. If there is going to be a change in the routine, giving the child advance notice can also be helpful. Another method is to avoid overstimulation of the ADHD child. Two playmates may be fine, but five may be too stimulating. Too much noise or too many people can be overwhelming and cause more irritability. Keep tasks (including schoolwork) within the child’s ability level. Pushing too hard, when a child finds the task very difficult, is a common form of frustration that leads to a temper reaction. Helping the child take frequent breaks, or rest periods (where relaxing activities are available) is also helpful. Early intervention, when the child just starts to raise his or her voice, is the most effective. Have the child "chill out" by discontinuing the discussion until the child calms down. The parent might say "we can’t talk when you are excited, so calm down, and then we will talk again". This child should be encouraged to learn "chill-out" as a self-management technique. Teach them that when they feel themselves getting angry to walk away, go someplace quiet, do something relaxing, and return when calm. Giving the child choices, rather than a fixed "no", may also help.

The second step is to teach the child anger reduction techniques. These include deep breathing, counting backwards, using pleasant imagery ("imagine yourself lying on a relaxing beach") and positive self statements ("stay in control...take it easy"). Once the child is calm the parent should encourage calm, verbal expression of feelings so the child learns to talk about anger rather than displaying it. Some parents suggest that the child use a punching bag or other safe method to ventilate the anger. However, in some children this can cause the anger to wind-up and become out-of-control. It is best to deescalate the anger rather than to try to ventilate it in this manner.

Other skills can be taught to a child as part of Anger Management. Assertiveness skills give the child a more socially appropriate, and less aggressive method to ask for what they want. Conflict Management skills are also helpful as are Relaxation and Stress Management Skills. Problem Solving is another skill that can be taught. Moral training is another component of Anger Management when the child learns that physical aggression is only to be used in self-defense, and even then it is the last resort. After each episode of temper, when the child calms down, it is helpful to debrief the incident to see if parent and child can search for ways in which similar situations in the future can be prevented.

For control of learned anger reactions, parents need Behavior Management techniques. The first Behavior Management rule is that the parents must make sure that angry outbursts never work (the child will never get what is desired by an angry reaction). There is no exception to this rule, no matter how violent the temper reaction. Parents should never give in to yelling, threats, throwing things, or even violent aggression, no matter how distressing or embarrassing it may be at the time. This avoids the possibility of rewarding, and encouraging, more anger reactions. The second Behavior Management rule is that the child needs to learn that angry reactions do not work, but that there is some more socially appropriate behavior that may work to get what they want. Parents may need to realize that it is most important to give the child another way (a better way) to get what they want. A child who loudly demands, screams, or threatens to get candy or a toy (or a computer game, or a driver’s license, etc.) may be told "I will not do what you want". If there is another more appropriate way to get what is desired, then it is less frustrating, (which helps the irritability), but it also teaches the child a positive social behavior that works. The child learns that keeping calm, talking it over calmly without yelling or threats, and negotiating with the parent really works to get their heart’s desire. These are positive pro-social behaviors that are learned, instead of the aggressive antisocial behaviors. It is not enough to use Behavior Management strategies that discourage antisocial or aggressive behaviors. It is critical that these inappropriate behaviors are replaced by pro-social or non-aggressive behaviors. In other words, the parent does not just teach the child what to stop doing, but teaches the child what to do instead. It is this positive teaching that is the most productive use of Behavioral Management techniques.

In this regard, the parents may want to learn about Behavior Contracting, where the child’s wish list and the parents’ wish list are tied together in a written contract. Once the child does what is on the parents’ wish list, the parent does, or gives, what is on the child’s wish list. This is a very positive, win-win arrangement that avoids a power struggle and can teach the child how to negotiate in a pro-social manner. Behavior Management techniques can include the simple use of points earned for chores, good hygiene, homework, etc. (later points are traded for rewards).

The parents can also use more formal Behavior Modification programs (which may include rewards as well as mild punishments such as time-out, being grounded, or loss of points). Natural consequences are best, but any negative consequence will discourage inappropriate behavior. However, it is not a good plan to have Behavior Management programs that are overly punitive. In fact, the most effective behavior techniques are positive, reward-based techniques, and this should be the primary method used with ADHD children. Punishments should be reserved for safety issues such as isolation of curfew or use of street drugs. All other non-safety issues, such as chores or homework should be reward-based, not punishment-based for maximum effectiveness. Even rude behaviors such as cursing can be turned around into a positive but rewarding polite language (rather than punishing use of swear words). When the parent feels that negative consequences must be used, they should avoid the use of long-term punishments. Short-term (one or two day) restrictions are more effective for ADHD children than long-term interventions ("you’re grounded for a week"). It is best for the parent to calm down before choosing any consequence and not punish in the heat of an argument. The parent needs to act like a coach, spending time re-directing and cheering, rather than constantly scolding, lecturing, or punishing. Lecturing to a child or trying to reason with (or talk sense into) a child, without consideration of Behavior Management techniques is not only ineffective, it is often counter-productive. Do not use guilt or other manipulative techniques with ADHD children. Also, do not use physical or corporal punishments. Professional neuropsychiatrists, who treat the most violent children in the country, do not use physical punishments at all, and to do so would be considered unethical. Parents do not need to resort to spanking if they have developed good parenting skills. In this regard, it is very helpful for parents to improve their communication skills in dealing with children. Parent training classes or Family Therapy sessions can be much more effective than just buying a book on parenting.

Parent training is a very valuable tool, even if the parent is competent. ADHD children are more challenging and parents need to sharpen their skills. Even simple things like how to give an ADHD child a directive (e.g.; get eye contact, use firm voice, etc.) can be important. When the child’s behavior becomes too violent for the parents to manage, it is time for professional help. Sometimes a child will use terroristic threats or start becoming obsessed with weapons. For dangerous behaviors we must consider psychiatric hospitalization to stabilize the individual. Factors that can contribute to dangerously violent behavior include depression and low self-esteem, access to weapons, and parental abuse. Certainly, a child who is a victim of physical abuse or sexual abuse is at risk for psychiatric disorders as well as anti-social and violent behavior. If the home is violent and children witness this in their parents, or in the media, or in their community, they are also at greater risk for violence. The warning signs for violence are described in detail in the web site of the American Psychological Association (http://helping.apa.org/warningsigns/index.html).

This presentation has described a number of effective interventions, but it is important that each intervention be directed at the correct subtype of anger outburst. We discussed irritability as a common problem in ADHD children who show poor frustration tolerance. We have discussed the learned anger outbursts which are independent of the biologically-induced irritability. We also discussed the more violent and explosive type of rage behavior which occurs in a small percentage of cases, most of which have a developmental brain disorder. In each case, we presented specific interventions targeted to that particular type of anger problem. However, these are not mutually exclusive categories and it is certainly possible to have all three types in one child. In such a case you would first stabilize the rage (perhaps in a hospital setting for safety), then you would treat the irritability, use anger management strategies, and manage the learned anger reactions. After that you would employ parent training and prevention techniques to minimize the triggers to that behavior. The last step, but perhaps the most important step, is to teach the child alternative pro-social skills and anger replacement skills.

The bad news is that the ADHD child is at risk for anger problems. The good news is that the ADHD child with an anger problem can be helped. This problem can certainly be overcome and the child should be able to lead a normal life. Today’s presentation will, hopefully, serve as a road map for the path to the most effective management strategies.