“Rage attacks” in children with tics

A couple of our recent study volunteers had serious problems with what you could variously call sudden tantrums, explosive outbursts, or brief violence. Of course, kids with tics can have all the problems anyone else can have. But about 1 in 5 children with Tourette syndrome have experiences that have been called “rage attacks.” These rage attacks seem to differ from other causes of childhood agitation. They tend to come on quite suddenly, be very intense for maybe 15 minutes, and then when it’s over the child tends to be penitent and regretful. A world expert on the subject published a nicely written article discussing these issues, including alternative diagnoses and treatment options.¹ I highly recommend that article to anyone interested.

I would add a couple of brief comments to that review article.

• OCD can be one treatable cause of episodic anger that I think is underappreciated. Often, children with OCD get terribly frustrated when something in the schedule changes, or when otherwise the world doesn’t fall in line with the child’s compulsions. When anger seems frequently to be prompted by surprises, changes to routine, asymmetry, or hurrying, a careful interview with the child and parent is needed to look for OCD. The beauty of OCD is that it is relatively treatable, both with medications and behavior therapy, with other options available for treatment-resistant cases. You want a psychiatrist for OCD assessment and treatment.
• Irritability is one of the diagnostic criteria for major depression in children. Irritability that comes with tears or comments indicating low self-esteem or hopelessness suggests investigation for the possibility of major depression. Again, major depression is quite treatable with both psychological and pharmacological approaches. You want a psychiatrist to manage major depression.
• A behavior therapist can help observe to see whether there are hidden triggers or rewards that are perpetuating the rages. For instance, it makes sense to remove a child from a classroom if he is swinging at people. But if he hates the classroom, that means he’s being rewarded every time he threatens others, and he’s unlikely to stop until a better solution is found.
• Often parents worry that punishment is inappropriate because it’s not the child’s fault … or, they wonder, is it? I don’t think that question matters. Rather than a crime-and-punishment viewpoint, I find a rehabilitative approach much more helpful. Punishment per se is usually not a great idea, but you don’t let a 2-year-old into a china shop. So, show steady love towards the person, but show consistent, reasonable consequences for the behavior. Again, a behavior therapist can be invaluable here as an external observer and treatment expert. Two tic experts wrote a book for therapists on this subject.²
• Keep hoping! Even when our treatments don’t help, kids with problems grow up, their brain matures, and time may provide the needed healing balm.

Best wishes!

References

1. Budman CL, Rosen M, Shad S: Fits, tantrums, and rages in TS and related disorders. Curr Dev Disord Rep 2015; 2:273-284. DOI 10.1007/s40474-015-0059-1.
2. Sukhodolsky DG, Scahill L: Cognitive-Behavioral Therapy for Anger and Aggression in Children. New York: Guilford Press, 2012. ISBN: 978-1462506323.