Anger Overload in Children: Diagnostic and Treatment Issues

By David Gottlieb, Ph.D.

Anger reactions in some children are quite frequent and troubling to parents and teachers who witness them. The child' s intense anger may erupt quickly and intensely in reaction to limit setting by adults, to teasing or to seemingly minor criticism by peers or adults. This is a distinct psychological problem in children which is separate from diagnoses such as attention-deficit/hyperactivity disorder, bipolar disorder, and oppositional defiant disorder. It can co-occur with AD/HD or learning disabilities, but may also occur separately from these diagnoses.

At this time, the diagnostic manual, DSM-IV*, does not consider anger disorders as a separate category like depression and anxiety. However, many mental health professionals feel it is a category unto itself and are devising treatment strategies for anger problems. Daniel Goleman (in Emotional Intelligence) and John Ratey and Catherine Johnson (in Shadow Syndromes) offer cogent reviews of this literature. Goleman uses the term "anger rush" to describe anger problems in adults, while Ratey and Johnson refer to a shadow syndrome for "intermittent anger disorder" in adults. Anger disturbances in children need to be classified as a discrete psychological problem as well, and they require particular treatment strategies. This article defines the syndrome and outlines effective treatment strategies.

Diagnostic Issues

The term "anger overload" is used to refer to the intense anger response which has been the presenting problem for a number of young children and preadolescents seen in a suburban outpatient practice. There is an intense and quick reaction by the child to a perceived insult or rejection. The rejection can seem quite minor to parents or others. For example, a parent saying "no" to something the child has been looking forward to doing can trigger an intense period of screaming and sometimes hitting, kicking or biting. Another common situation which can trigger anger overload may occur in a game with peers. It can involve a disagreement on how the game should be played or its outcome. Parents often explain to the mental health professional that these reactions have been going on since early childhood in one form or another. It is frequently reported that these children become sassy and disrespectful: they will not stop talking or yelling when they are upset. At other times, when their anger has not been stimulated, these children can be well-mannered and caring.

The problem is called anger overload because it is more severe than a temporary anger reaction lasting only a few minutes. With anger overload, the child becomes totally consumed by his angry thoughts and feelings. He or she is unable to stop screaming, or in some cases, acting out physically, even when parents try to distract the child or try to enforce limits and consequences. The anger can last as long as an hour, with the child tuning out the thoughts, sounds or soothing words of others.

Another significant characteristic is that these children are sometimes risk takers. They enjoy more physical play than their peers and like taking chances in playground games or in the classroom when they feel confident about their abilities. Other children are often in awe of their daring or scared of their seemingly rough demeanor. Perhaps most interesting is that these very same risk takers can be unsure of themselves and avoid engaging in other situations where they lack confidence. A number of these children have mild learning disabilities, and feel uncomfortable about their performance in class when their learning disability is involved. They prefer to avoid assignments where their deficits can be exposed, sometimes reacting with anger even if the teacher privately pushes them to do the work with which they are uncomfortable.

One diagnostic fallacy is to assume that these children have bipolar disorder. Dr. Dimitri and Ms. Janice Papolos recently devoted a full book to the disorder (The Bipolar Child, 1999). The rages of children with bipolar disorder are more intense and lengthy than for the children we are currently discussing. The Papoloses describe (page 13) that for children with bipolar, these angers can go on for several hours and occur several times a day. In children with bipolar, there is often physical destruction or harm to something or someone. In children with anger overload, the outburst is often brief, less than half an hour, and while there may be physical acting out, usually no one is hurt. In addition, children with bipolar have other symptoms such as periods of mania, grandiosity, intense silliness or hypersexuality.

Anger overload is also different from attention-deficit hyperactivity disorder. Children with AD/HD have significant distractibility, which occurs regularly in school and/or the home. By contrast, children with brief outbursts of anger often pay attention well when they are not "overheated" emotionally. In addition, children with AD/HD may have hyperactive movements throughout the day; whereas children with anger overload only seem hyperactive when they are overstimulated with feelings of anger. Finally, children with AD/HD are often impulsive in a variety of situations, many of which have nothing to do with anger.

It is possible, however, for children to have symptoms of AD/HD and anger overload. This combination is especially difficult for parents to manage. Behavioral strategies for AD/HD are not as effective because the child becomes excessively angry despite efforts by others to focus his attention elsewhere. Sometimes, professionals then tell the parents or teachers that they are not applying behavior modification techniques properly. What may work for a child who has AD/HD may not be as effective for a child who also has the problem of anger overload.

Another diagnostic category which can be differentiated from anger overload is oppositional defiant disorder. Oppositional children have a continuing pattern of disobedience to adult demands, whereas children with anger overload are only defiant when their anger is stimulated. The situations which trigger their anger are more restricted. There are certain areas which have special importance to them, such as winning a game, buying a toy or being seen as successful in school. In most other situations, they are described by their parents as sweet and cooperative. Few, if any, oppositional defiant children are described by their parents in this manner.