Children who are out of control pose one of the most serious management and treatment problems for residential programs. In twenty-five years of working with children in a variety of settings, I have used and seen others use a variety of approaches to treat the temper problems of children and adolescents. All approaches had their successes. All had their failures, as well. No single approach successfully addresses all of the problems that children may have with their anger and their angry behavior.
Behavior is always a problem when children get angry. Who would notice that children are angry if not for their misbehavior? Who would care? Problems with behavior suggest behavioral interventions. But behavioral interventions are rarely sufficient in helping children learn to manage their tempers. Behavioral interventions may even contribute to making things worse. That’s because feelings and emotions are involved, along with expectations, perceptions, cognition, values and beliefs. Behavioral interventions have little positive effect on feeling and emotions, expectations, perceptions, cognition, or values and beliefs. Any effects are most likely to be negative.
Behavioral psychologists suggest four principles that are relevant to changing children's misbehavior.
Anger is often an unpleasant emotion for children. It may even scare them. They often want help, what Redl calls “emotional first aid on the spot.” At the least, they want someone to notice that they are in pain and to care. When misbehavior is the only way they know to let people know they are angry, they are going to misbehave. When adults impose punishment, it’s a sure sign that they have noticed. The children's goal (on some level, perhaps unconsciously) is to get noticed. Punishment is the indicator that the goal has been achieved. Punishment reinforces the angry misbehavior.
Sometimes, angry children want to retaliate, saying or doing things to hurt adults or make them angry. They know they are going to get punished if they succeed. Again, punishment tells them that they have been successful and serves to reinforce the misbehaviors that were successful at "getting" adults.
When adults impose punishment while children are feeling angry, the punishment may become associated on some level with the anger instead of the misbehavior, making children feel that it is wrong to get angry. Children sometimes feel that they deserve to be punished for letting themselves get angry and behave in ways to punish themselves, hurting themselves or destroying their own property. Other times, they behave in ways that get others to punish them. We can wait until children have become calm before imposing punishment, but then what does the punishment get associated with – getting calm?
So. If punishment might make things worse, should we just concentrate on making sure that children's misbehavior receives no reinforcement? Perhaps. But when adults are too wary of providing reinforcement while children are misbehaving, it makes it very difficult and perhaps impossible to teach and to reinforce more appropriate behavior. The most effective strategy for changing behavior is teaching competing behaviors. A competing behavior is a behavior that makes another behavior impossible. You cannot sit and walk at the same time. Nor can you have a temper tantrum while you are talking calmly and rationally about your feelings.
Teaching competing behaviors to children who hit and kick and spit and bite and smash things when they are angry often requires shaping and reinforcing successive approximations. Slamming doors instead of punching holes in walls and breaking windows is a successive approximation to refraining from property damage. Yelling and cursing instead of hitting and throwing things is a successive approximation to talking calmly.
It is much easier to talk with children who are yelling and cursing than it is to talk with children who are hitting and kicking and spitting and biting and smashing everything in sight. If the behaviors related to talking and refraining from attacking others and destroying property do not receive reinforcement when they occur, they will extinguish; hitting and kicking and spitting and biting and smashing things will return.
If we want children to talk about their feelings instead of acting them out, we have to notice that they are feeling angry before they lose control and show them that we care. We have to give them permission to talk and help them to develop the vocabulary to talk about feelings. We have to listen, and we have to refrain from imposing punishments on them. Punishments do not communicate caring about children, they communicate caring about behavior, instead.
Does this mean we should let children get away with misbehavior? Of course not. Children rarely "get way with" temper tantrums. There are plenty of consequences that can serve to punish their misbehavior without adults imposing more punishment. The temper tantrum itself is nearly always unpleasant for children. It may make them feel embarrassed in front of staff and peers. They may have received some injuries (hopefully very minor and not at the hands of adults who intervene) or damaged their own property. And they may be encouraged to make some sort of restitution for damages or injuries they have caused to others, a strategy related to principles of restorative justice rather than punishment.
But the real problem with responding to misbehavior with behavioral strategies is just that – they are responses. Responses are "back end" solutions. They involve waiting until children become irrational in order to respond. Once we get children talking about being angry, we can assess more carefully what may be contributing to their problems – unrealistic expectations, misperceptions, distorted thinking, irrational beliefs and problematic values – and develop strategies to address each of those problems.
Addressing unrealistic expectations
It is normal to feel disappointed when your expectations aren’t met, to feel frustrated when you’re disappointed, and to feel some anger when you’re frustrated. When children have unrealistic expectations, they are going to be disappointed.
It is especially important to make sure that children have realistic expectations when they come into treatment. When children come for an interview, they come with expectations based on what others have told them – parents, state workers, or others who want children to cooperate with placement. Those expectations are not likely to be accurate or realistic. You may be able to address children's unrealistic expectations in the interview, but you can’t effectively change them. Children need time to think, digest, and change their expectations. Usually, overnight is long enough. When children are admitted immediately following the interview, they base their decision to cooperate with the program on the expectations they came with and thought about for days, not the expectations they just received in the interview. When they are disappointed after they are admitted, they (and everyone else) may experience problems that are difficult to over come.
Reviewing expectations with children throughout treatment is also essential – for various situations, special activities and events, home passes, and discharge. It is also essential to review expectations for treatment and discharge with parents. I have seen several discharges blow up because of the unrealistic expectations of both children and parents. Home passes are not like living at home. Children are often treated like guests on weekend home passes. They have few chores and responsibilities. There’s no need to wake up early and little competition for the bathroom when no one has to get ready for work and school. Two-week trial discharges with a return to the program can be very beneficial in helping both children and parents develop more realistic expectations about discharge.
Cognitive therapies such as Rational Emotive Therapy (RET) or Rational Behavioral Therapy (RBT) can be helpful for children who have problems with misperceptions or irrational thinking.
But I have seen highly intelligent children embrace Rational Behavior Therapy to the extent that they appeared capable of leading a group themselves, then have a major meltdown with a peer on the playground within minutes of leaving a therapy session. That’s because cognitive therapies have little effect on deeply held values and beliefs or strongly conditioned emotions.
Values and beliefs
Deeply held values and beliefs produce especially strong emotions. Just try to convince someone that a child who has misbehaved should not be punished. Many people become outraged at the thought. I often have trouble convincing myself that children need not be punished, even when I know intellectually that imposing punishment may do more harm than good. Punishing people for misbehavior is an especially strong value in the culture in which I was raised and even stronger in the culture in which I now live. Many children believe strongly in "paybacks," that they must retaliate whenever they feel that someone has treated them unfairly. For them, retaliation and revenge are strong values, learned in their families, peer groups, and communities.
Strategies that target unproductive or antisocial values and beliefs are difficult and challenging. Values and associated beliefs are learned socially from other people, from people we like or admire, from people we want to like or admire us, from groups to which we belong or from groups in which we aspire to membership. Imposing punishment reinforces values related to retaliation and revenge. If we want children's values to change, we have to model and teach forgiveness. And deal with the values of peers in the program.
Feelings and emotions
Emotional responses that have been strongly conditioned by experience to certain situations or events pose special challenges for treatment. The conditioning of emotions often is not a rational or conscious process. It is more likely to occur on an unconscious or preconscious level. When children learn that criticism often precedes severe punishments, they tend to become anxious and even fearful when adults criticize them. When children who are slow to process verbal information get punished because they take too long to respond to adults who demand instant obedience, they learn to react with anxiety and fear when adults start to give them instructions. When children become angry and misbehave and get severely punished, they become fearful when they feel themselves becoming angry. Children who are both angry and scared are highly irrational; their behaviors are highly resistant to any interventions.
When children's emotions are conditioned to certain situations on an unconscious or preconscious level, cognitive interventions are of little benefit. Behavioral therapy interventions, specifically deconditioning strategies, may help to reduce children's inappropriate and dysfunctional emotional responses. Having them practice such things as following instructions or accepting criticism during role plays in non-threatening situations helps. So does giving them warnings so that they can prepare – "I’m going to give you an instruction. Are you ready?" "I’m going to give you some criticism. Are you ready?" Punishment only strengthens previous maladaptive conditioning.
Dare I say “psychotherapy?”
Psychotherapy has fallen into some disrepute in this era of behavior management, cognitive therapies, social skills training, and medication management. But there is another problem with emotions that I’ve encountered in children who have problems with their anger that doesn’t seem to respond well to these “tried and true” strategies – the chronically angry child.
A few children in residential settings seem to be chronically angry. Anger seems to be their normal emotional state, their baseline. Their anger may not be evident when something is going on. They may smile and laugh appropriately when there is something to stimulate them, but when they are sitting alone by themselves, when they are not engaged in anything, they look angry. And feel angry. These are often the children who can’t go home, for whatever reasons. Children who have been abused, abandoned, neglected. Children who have bounced from one placement to another.
These children are often very good at controlling their anger and behavior much of the time. When their defenses break down, perhaps due to fatigue, or stress, they lose control, often with little or no apparent provocation. They erupt out of all proportion to what has happened. They are driven by their underlying anger rather than anger over what has happened. People diagnose Intermittent Explosive Disorder, a label that explains nothing.
Chronically angry children require therapy to help them to come to terms with their past and their present and to begin to take action to change their future. Behavioral interventions have little effect except possibly to increase their underlying anger.
A variety of medications may be beneficial in helping children to control their emotions. But medications are more of a symptom management strategy than a treatment strategy. They are often disempowering rather than empowering, teaching children that there is something wrong with them that is beyond their control. They can actually interfere with treatment strategies when children get the message that their problems are beyond their control or not their responsibility. And children often do not continue with their medications after leaving treatment so that untreated symptoms return.
I do believe that medication may be indicated temporarily as part of a treatment strategy for those few children whose emotions are so out-of-control that they are unable to respond to other interventions. In such cases, I believe that medications should be viewed as a temporary intervention designed to facilitate other interventions, and that this should be clearly communicated to children.
Many interventions have been shown to be effective in helping in helping children with anger management problems. Generally speaking, all that "evidence-based" means is that group of children who participated in the intervention showed improvement that is statistically significant. It doesn’t mean that every child in the group benefitted. Nor does it mean that those who did benefit solved all of their problems with their anger management.
Employing an intervention that has been shown to be effective is certainly sound practice. Provided that we do not assume that we are doing enough because we are providing an evidence-based intervention. Provided that we do not blame the children who do not benefit from our evidence-based intervention. Provided that it does not limit our efforts, resourcefulness, creativity, and commitment to find and provide what each child needs.
Successful treatment of children who have serious problems with anger management requires:
The first step is to teach children to talk calmly and rationally about their feelings.