with Tapani Ahola
Aggressive outbursts of anger by a child–also called tantrums, meltdowns, or hissy fits–refer to sudden violent fits of uncontrolled rage, which are typically provoked by a subjective experience of disappointment or frustration. During the fit the child or young person (we will use the word ‘child’ to refer to both children and young persons) screams, hits, kicks, spits, curses and throws things around or destroys property. An aggressive outburst of anger can last for several minutes, sometimes up to a half an hour. Parents often report that their attempts to calm the child down during the aggressive outburst of anger have no effect at all, and sometimes only make things worse. Children who have aggressive outbursts of anger suffer from their problem and, while this may not always seem evident, want help to overcome it.
Outbursts of anger are common in small children aged 3-5 years. In this age group, three quarters of children display this type of behaviour. In the age range of 6-8, a fifth of children exhibit aggressive outbursts of anger, but once children have reached the age of 9- 12, only 4% of them have the problem. Boys are three times more likely to suffer from aggressive outbursts than girls (Bathia 1990).
Parents and educators often feel helpless in the face of children’s aggressive outbursts. Children who have this problem are often referred to pediatric or psychiatric services for evaluation and treatment. In these services they are likely to receive a psychiatric diagnosis, most commonly conduct disorder (CD), oppositional defiant disorder (ODD) or Attention deficit disorder (ADHD). In the past few decades it has become increasingly commonplace, particularly in the US, to ascribe the diagnosis of pediatric bipolar disorder (PBD) to children suffering from aggressive outbursts.
In schools, children who have aggressive outbursts cause a lot of worry and dismay. Teachers feel powerless in the face of children’s outbursts and have few tools at their disposal. They may remove the child from the classroom, inform the parents, send the child to the principal’s office, or refer the child to counselling. The principal may talk to the child, organize a meeting with the parents, or expel the child temporarily or permanently from the school. Oftentimes social services becomes involved, which can lead to the child being taken into foster care and placed in an institution, or with a foster family.
None of these standard solutions work very well. Despite the efforts that have been tried–punishing or medicating the child, or excluding the child from the school, or taking the child into custodial care–the aggressive outbursts may continue. In residential treatment centers and alternative schools, a child’s aggressive outbursts are a huge challenge to the staff. Common responses include medication, restraining, seclusion, or punishing the child retroactively.
The Psychiatric Response
Aggressive outbursts are one of the main causes for psychiatric referrals. It is also the reason why so many children these days end up being medicated. The seriousness of the problem is well recognized: children suffering from aggressive outbursts have a high risk of drifting into delinquency later in their life.
Medication has become, particularly in the US, but increasingly also in Europe, the treatment of choice for children suffering from aggressive outbursts. Commonly used drugs include psychostimulants for children with ADHD, such as Ritalin or Concerta; and neuroleptics such as Risperdal or Abilify that may be used to treat aggressive behaviour regardless of diagnosis.
The push for medicating children who suffer from aggressive outbursts comes from many directions. Schools demand something be done, parents are desperate, psychological treatment is scarce or unaffordable to families, and physicians don’t usually have the time, or the know-how, to offer counselling to families. Since the therapeutic effect of drugs is very limited, it is common these days for children suffering from aggressive outbursts to be on a cocktail of two or more psychiatric drugs. In the US it has been estimated that 40% of children of children using psychotropic medication are on more than one psychotropic medication (Farmer 2011).
However, there are many effective psychosocial interventions that can be used instead of drugs to help children overcome the problem of aggressive outbursts.
Cognitive therapy for children
Cognitive behaviour therapy, or CBT, is an evidence-based method to help children overcome their tendency to have aggressive outbursts (Sukhdolsky 2016). In CBT, a trained therapist works with children – either individually or in a group format – teaching them emotional and behavioural skills that they can use in challenging situations to avoid losing their temper. The goal is to help children learn to control their aggressive impulses by becoming better at problem-solving and regulating their own emotions.
Even if CBT is focused on the child, the parents are also involved in the treatment. They may provide information to the therapist about their child, and reward the the child with praise or stickers when the child succeeds in using their newly acquired CBT skills at home.
There are various types of CBT programs. An anger coping program (ACP) and Aggression Replacement Training (ART) are two well-known programs. Another increasingly popular approach is called “The Explosive Child.” This is a collaborative problem-solving approach developed by Ross Green and his colleagues (Greene & Ablon 2006) based on the idea of figuring out what skill the explosive child is lacking, and then helping the child acquire that missing skill.
Parent management training
Another evidence-based psychosocial approach to helping children who suffer from outbursts of anger is parent management training. With this method, a trained therapist helps parents learn better techniques and more constructive ways to cope with their child’s out-of-control behaviour. Parent management training takes the form of a series of meetings, or workshops, where parents are taught a variety of skills such as praising the child for good behaviour, noticing good things about the child, avoiding escalations, ignoring the child’s undesired behaviour, being consistent, etc. Incredible Years and Triple-P are widely used, internationally distributed examples of such training programs.
Non-violent resistance ( NVR), is a different kind of evidence-based parent management training program. The approach was developed by Haim Omer, an Israeli psychology professor and family therapist from Tel Aviv University, and is becoming increasingly popular in many central European countries. A trained therapist coaches the parents to end the secrecy surrounding the child’s aggressive behaviour; to get support from their extended family and friends; and to employ gentle, respectful and non-violent ways to encourage the child to abandon his or her aggressive patterns of behaviour.
David Epston is a social worker and narrative therapist from New Zealand who developed in the 1990s a creative approach to helping children suffering from aggressive outbursts that he called “temper taming” or “temper taming parties.” . Unlike many other methods that aim at changing the behaviour of the child or that of the parents, or both, in this approach the goal of therapy is to change the child’s reputation in the community. The therapist assumes the role of a ‘reputation coach’ who helps the child and his or her parents think of ways for the child to restore his or her damaged reputation. The therapist may advice, for example, a child to write letters to teachers or friends apologizing for his/her aggressive outbursts and informing them of his/her sincere intention to learn to control his/her temper. At home, the child’s and the child’s parents are advised to use role play to help the child learn to keep cool in situations that have customarily led to explosions.
In one of his fascinating articles, Epston tells a story of a 9-year old boy who on repeated occasions had violently attacked his classmates. The boy explained that he didn’t want to hit anyone but that he was unable to stop himself when his classmates called him offensive names such as ‘hypo’, ‘maniac’ or ‘nutcase. Epston instructed the boy to write a letter to all the classmates who bullied him telling them about his determination to stay away from trouble and to learn to keep cool no matter what names they called him. He also gave the family a homework assignment to help the boy develop the skill of remaining calm regardless of whatever names his classmates called him at school. Every day, at dinner, a card was to be placed in front of each family member’s plate with one of the offensive names his classmates written on it. Epston’s instruction was: “When you speak to one another during dinner, you address the other person using the name that is written on their card. You say, for example, ‘Nutcase, is your back still sore after digging the garden over the weekend?’ or ‘Maniac, please pass the butter’ or ‘Hypo, did you get wet on the way home in the rain?’” In this way, the entire family participated in helping the boy become desensitized to offensive words that had previously triggered his violent rage.
A solution-focused therapy
Solution focused therapy (SFT) is a brief therapy method developed in the USA in the 80s that has since become an established modality of therapy in many countries around the world and is considered to be an evidence-based approach. The method lends itself well to working with children and adolescents and many books are currently available describing how this can be done (eg. Selekman 2010, Berg & Steiner 2003, Furman 2016, Ratner & Yusuf 2015, Milner & Bateman 2011)
Inspired by various CBT and parent management training programs, by Epston’s narrative therapy approach, and above all the guiding principles of solution-focused therapy, we developed in the 1990s, in collaboration with two special education teachers, a user-friendly method called Kids’Skills for helping children overcome emotional and behavioural problems. Kids’Skills is a simple step-by-step protocol that offers not only therapists and educators, but also parents, straightforward guidelines of how to talk to children in a way that fosters their collaboration and inspires the children to come up with their own ideas of overcoming their problem with the help of family and friends. Since its inception, Kids’Skills has become known in many countries around the word. Books about the method have appeared in more than 20 languages and hundreds of professionals have been trained in the use of the method.
The three key steps in applying the Kids’Skills method are:
Step 1. Ask the child to think of some simple method to calm down in situations where they notice that they are getting so angry that they may lose their temper. For example, the child may come up with the idea of walking away from the situation, of counting to five, or sticking their hands in their pockets. It doesn’t matter what method the child comes up with – what matters is that the child feels that they themselves have chosen the method they are going to use.
Step 2. Help the child draw up a custom-made training program that will help them practice their calming-down method and to become so skilful at it that they can use it in not only in simulated role-plays but also in challenging real-life anger-provoking situations.
Step 3. Convince the child that, in order for the unique training program to work, the child will need think of some way for the important people in their life, (e.g. parents, grandparents, siblings, teachers and friends) to help them learn to use their calming-down method. This step of involving the child’s social network supporters ensures that not only the child’s behaviour changes, but also that of everyone around the child.
The following example is an abbreviated case report that we received from a participant of one of our international Kids’Skills training courses. It illustrates how the three steps work in practice. (Ethan is not the real name of the boy.)
9-year old Ethan’s problem was that if things didn’t go the way he wanted them to go, or if anyone opposed his suggestion, he could become mean and explode in a vicious way. He could scream at his teacher, hit his peers, throw things around, or rip a notebook or a book into pieces. His teacher talked to him and asked him what things he would want to improve at school. Ethan said he needed to learn to get along better with his schoolmates.
Teacher: What do you need to learn to get along better with your schoolmates?
Ethan: I need to learn to stay calm.
Teacher: What could you do to stay calm when you are mad at something?
Ethan: I need to learn to go away and be by myself for some time and then go back, or go to ask you or some other teacher to help me.
Teacher: Suppose you learn to do that; what good will it do to you?
When this question was discussed the teacher became convinced that Ethan was fully aware of the many benefits of learning to calm down in situations that made him mad.
Teacher: Do you want to give your skill a name?
Ethan: It can be called ‘Snow’.
Teacher: I am sure you understand, Ethan, that if you are supposed to learn the snow skill, you will need to practice a lot. You will need to practice every day and you will need to ask other people to help you.
Ethan nodded in agreement.
Teacher: Which people will you ask to help you?
Ethan: I will ask my mom, my dad and my sister to help me.
Teacher: How were you thinking they could help you? They are not at school with you, are they?
Ethan: They can ask me every day when I come home from school how I have done that day when it comes to the Snow skill.
Teacher: That’s a great idea but don’t you think you also need to have someone at school who can help you and support you in learning your skill?
Ethan thought about the question for a moment and then said that he intended to ask Ben and Ron, two of his classmates, the teacher, and two other teachers to help him.
Teacher: How can they help you when they notice that you are getting so mad that they are afraid you will lose it and explode?
Ethan: I don’t want anyone to criticise me. That only makes me madder. But they can say to me ‘snow’. That’s all.
Teacher: And what will you do if they say to you ‘Snow’?
Ethan: I will say to myself ‘stop’ and then I will tell them ‘sorry’.
The teacher was surprised to hear those words coming out of Ethan’s mouth. It sounded almost too good to be true.
Teacher: If you want, you can have an imaginary supporter too. Do you have a superhero that you are particularly fond of?
Ethan wanted a superhero from his favourite video game to be his imaginary supporter. He showed the teacher a picture of the character in his smart phone and later the same day printed out several black and white pictures of it that he coloured with crayons and glued to various places to remind him of the skill he was determined to learn.
Teacher: How would you want to celebrate when you master your skill? You might want to do something cool with all your supporters once you have become a ‘master of snow’.
Ethan: Can I go for a burger with Steffi and Val and then to see a movie with them?
Teacher: That sounds like lovely idea. We will have to ask your parents thought but if they say yes, so you can do just that.
The plan that the Ethan’s teacher helped him to draw worked surprisingly well, probably because his two classmates, Ben and Ron, were eager to help him. A few weeks later it was evident for everyone that Ethan had turned a corner. He had gained control over his aggressive impulsivity to the degree that both his friends and his teacher agreed that it was time to allow him to invite his friends for a burger and a movie.
In this example the teacher did not need to suggest to the child that he would need to learn the skill of calming himself down when he got cross, as the idea was brought up by the child himself. The teacher then reinforced the boy’s motivation by discussing with him the benefits of learning the skill. When they both agreed that learning the skill was important, the teacher asked him to name the persons he would ask to help him learn the skill.
The child’s supporters play an important role in solution-focused child therapy; their part is to help the children learn their skill by praising the children for their progress and by reminding them whenever necessary about their cooling-down method. The plan also included a discussion about the name of the boys calming-down method and about how he wanted to celebrate learning the skill. These details add to the child’s motivation to work hard to learn to use his calming-down method when there is a risk of an aggressive outburst.
The following example, also a case report provided by one our Kids’Skills trainees (a principal of a small private alternative school), illustrates how the same approach can be used with a child who has been diagnosed with both conduct disorder and attention deficit disorder.
Sam (not the boy’s name) was a 12-year old boy with many learning difficulties who had been expelled from his regular school and was now attending a small special needs school for children suffering from so called neurodevelopmental disabilities. Sam used to get vicious outbursts of anger during which he would shout, curse and throw things around. After having calmed down, he usually cried, feeling ashamed of what he had done. One day he had an outburst of anger, but this time his rage was worse than ever before. He ran into the kitchen, grabbed a bread knife, and flailed it in the air during his fury. Luckily, he didn’t hurt himself or anyone else, but everyone, including the other pupils of the school, were shocked. The situation was so serious that in the name of the security of the staff and the pupils, the principal had to seriously consider excluding Sam from the school. Before doing that, however, he decided to have a frank heart-to-heart talk with Sam to find out if there was anything that could have been done to ensure everyone’s safety. Sam was now sitting in the principal’s office with tears running down his cheeks.
Principal: You know very well Sam that this can never happen again. We cannot have you here in our school if you don’t learn to control your temper. You will have to come up with something that you can do when you become angry that will prevent you from exploding. What can you do when you notice that you are getting so mad that you may lose your temper?
Sam: I can run into the video game room and bang the big pillows there.
(The school was small, it only had five small classrooms and in the centre of the floor there was a room with a glazed wall where pupils would sometimes rest on big cushions, watch TV, or play video games.)
Principal: That might work. Show me how you’d do it. Let’s pretend that you are furious about something and you are at the verge of exploding. Show me what you would do in that situation.
Sam stood briskly up and darted to the TV room where he started feverously to bang the cushions. The principal followed Sam and observed the entire demonstration. When Sam was done banging on the cushions, the principal explained to Sam that the method could work on the condition that Sam would diligently rehearse it and everyone, both staff and the pupils of the school, were aware of his method and would be able to remind him should he become angry and forget to use his method.
Principal: How do you want your teacher and everyone else here at school to remind you of going to the TV room if they see that you are so upset that you need to calm yourself down?
Sam thought for a moment and then said that they can show him a gesture of banging cushions with their fists in the air. That would signal to him that he needed to dart to the video game room to cool himself down.
The principal asked Sam to show, first to his teacher and then to other staff members, and finally to the other pupils of the school, what he was going to do from now on if he became so angry that he was in danger of exploding. Every time Sam showed people what he was going to do in case he became mad, he was, in effect, already rehearsing his new response. Sam also explained to everyone how he wanted them to remind him of his solution if there were any signs of his beginning to lose his control. When Sam’s parents came to pick him up later that day, Sam told them about the plan and had one more opportunity to rehearse his solution by showing it to them.
Sam’s method worked. He never had another outburst of anger in school. Instead, he often used his cooling down method, either of his own initiative or by responding to a cue from his teacher or someone else. Sam had many other learning problems to grapple with, but his tantrums were no longer an issue.
An essential feature of Kids’Skills is the child’s active and responsible participation in the process. Children decide what calming down method they want to use, they recruit their supporters, and they practice their method to learn it. The following example, also a case report from one of our students, demonstrates how motivated parents can be coached to use the approach at home to help their child learn to calm down when at risk of losing his or her temper.
Five-year old Julia (not the girl’s real name) was a beloved child but her temper tantrums had become more and more vicious over the years. During one of her recent outbursts she had broken a window by throwing a stool against it. Julia’s desperate parents contacted Jason, a counsellor trained in Kids’Skills, with the hope of getting advice on what do with their daughter.
Jason told the parents that they should both sit together with Julia and explain to her in calm voice she had now reached an age where she was needed to learn to calm herself down when she would get furious about something. He told them to explain to her that by learning to keep calm, she would be better able to express what she was disappointed about, and how her parents could help and support her.
The parents were told to ask Julia to think of something she could do to calm herself down when she was angry. Should Julia not have any suggestion, Jason instructed the parents to suggest that she should pick a particular spot in their home that would be called the ‘magic calming down square’. This would be a place where Julia could go to and spend time when she needed to calm herself down. The magic square could be marked on the floor with painter’s tape and Julia could decide for herself what toys, books or other things she would keep the magic square that would help her to calm down.
Jason explained to her parents that it was important that going to the magic square would not be experienced by Julia as a punishment, but a means she had invented that would help her calm down when she was very angry. That is why it was important for Julia to decide where the magic square would be located and what she intended to do inside the square to calm down. Likewise, it was also important that Julia tell her her parents how they would remind her of the magic square when they saw her getting so angry that they were afraid she’d have a tantrum.
When the parents came home they sat down and talked calmly with Julia. They explained to her that they wanted her to learn to calm herself down when she got so angry that she thought she could explode. They told her about the magic square and were delighted to find out that Julia liked the idea. She participated in thinking about what was the best place for the square and had many creative ideas about which toys and books she wanted to have in her square that would help her calm down. When her parents asked her how she wanted them to remind her of the magic square, she came up with a gesture, a gentle hand movement, that her parents could use to remind her of her magic square.
During the following weeks, Jason spoke with the parents a few times on the phone in a conference call supporting them and encouraging them to stick to the plan they had drawn together with their daughter. Once the arrangement had been in use several weeks, the parents informed Jason that they believed that their daughter had grown out of her bad habit of responding to disappointment with tantrums.
The approach described above has much in common with the other psychosocial interventions mentioned in this article. It shares with them, among other things, the idea that children are willing to get help to overcome their aggressive outbursts; that to overcome tantrums children need to practice skills; and that parents need guidance and advice to be better able to deal with their child.
The Kids’Skills approach has some noteworthy advantages that deserve to be mentioned:
Our impression of the effectiveness of the Kids’Skills’ approach to helping children suffering from aggressive outbursts is based on our own clinical experience as well as a substantial number of case studies submitted to us by trainees who have participated in our training programs in our own country as well as abroad. It is our hope that this article will catch the attention of researchers who are interested in conducting statistical studies to determine the efficacy and efficiency of this approach.
If by reading this article, you have become inspired to try the Kids’Skills approach with a child who suffers from aggressive outbursts – be it your own child or a child that you work with – you may want to read a blog describing a dialogue between a counsellor, a 7-year old girl and her mother that has been written for teaching purposes. You may also want to familiarize yourself with an illustrated story available for free in English at the international Kids’Skills website telling the story of a girl named Linda who succeeds in overcoming her tantrums using an approach suggested by her grandfather.
About the authors
Ben Furman, psychiatrist, and Tapani Ahola, social psychologist, are both state certified psychotherapists and senior trainers of solution-focused therapy and coaching. They are also the founders of Helsinki Brief Therapy Institute. Their collaboration spans over three decades during which time they have developed various clinical and non-clinical applications of solution-focused psychology, and co-authored several books on the topic.