Nobody likes to feel angry, but we all experience the emotion from time to time. Given that many adults find it hard to express anger in ways that are healthy and productive, it’s unsurprising that angry feelings often bubble into outbursts for children. Most parents find themselves wondering what to do about tantrums and angry behavior, and more than a few wonder whether the way their child behaves is normal.

At the Yale Medicine Child Study Center, we work with children and their families to develop plans for each behavioral goal. We offer a variety of evaluations and treatment plans. 

It’s not unusual for a child younger than 4 to have as many as nine tantrums per week. These can feature episodes of crying, kicking, stomping, hitting and pushing that last five to 10 minutes, says Denis Sukhodolsky, PhD, a clinical psychologist with Yale Medicine Child Study Center. Most children outgrow this behavior by kindergarten. For children whose tantrums continue as they get older and become something that is not developmentally appropriate, professional help may be in order. According to Sukhodolsky, anger issues are the most common reason children are referred for mental health treatment.

Multiple factors can contribute to a particular child’s struggles with anger, irritability, and aggression (behavior that can cause harm to oneself or another). One common trigger is frustration when a child cannot get what he or she wants or is asked to do something that he or she might not feel like doing. For children, anger issues often accompany other mental health conditions, including ADHD, autism, obsessive-compulsive disorder,  and Tourette’s syndrome.

Genetics and other biological factors are thought to play a role in anger/aggression. Environment is a contributor as well. Trauma, family dysfunction and certain parenting styles (such as harsh and inconsistent punishment) also make it more likely that a child will exhibit anger and/or aggression that interferes with his or her daily life.

Young children may be taken in for a psychological or psychiatric evaluation by their parents or be referred by a pediatrician, psychologist, teacher or school administrator. Older children with behavioral problems that bring them in contact with the law may be sent for evaluation and treatment by the courts or juvenile justice system. (Sukhodolsky notes that this is exactly what earlier treatment aims to prevent.)

When assessing the breadth and depth of a child’s anger or aggression, a provider will look at the behaviors in the context of the child’s life. This includes obtaining input from parents and teachers, reviewing academic, medical, and behavioral records, and conducting one-on-one interviews with the child and parent. “We look at the full spectrum of mental health disorders and how they are affecting a child’s life,” Sukhodolsky says.

Sukhodolsky adds that research-based measurement tools, such as answers parents and child give to specific questions, are used to determine whether a child meets diagnostic criteria for a behavioral disorder. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which is considered the “bible” of diagnoses, potential diagnoses for a child with anger, irritability and aggression include:

• Oppositional defiant disorder (ODD), a pattern of angry/irritable mood, argumentative/defiant behavior and/or spitefulness that lasts six months or more
• Conduct disorder (CD), a persistent pattern of behavior that violates the rights of others, such as bullying and stealing, and/or age appropriate norms, such as truancy from school or running away from home
• Disruptive mood dysregulation disorder (DMDD), characterized by frequent angry outbursts and irritable or depressed mood most of the time

Sometimes clinicians may use terms that are not part of the DSM but have been used in research, education or advocacy. For example, “severe mood dysregulation” is a term that refers to a combination of irritable mood and angry outbursts/aggressive behavior in children with mood disorders and ADHD. In the area of Tourette’s syndrome, the term “rage attacks” has been used to describe the anger outbursts that are often out of proportion to provocation and out of character to the child’s personality.

Behavioral intervention is the first line of treatment for childhood anger and aggression. Though there are quite a few therapies that can be helpful, the Child Study Center emphasizes two primary approaches that focus on changing the interpersonal dynamics that lead to and result from angry outbursts. These are complementary therapies that address a child’s behavior problems from different directions.

• Cognitive behavioral therapy (CBT) is a three-pronged approach that helps a child acquire new and more effective strategies for regulating angry emotions, thoughts, and behaviors.
• Emotion regulation, which allows the child to learn to identify anger triggers and preventive strategies.
• Learning alternate ways to express and address frustration will help the child and parent weigh the potential consequences of each choice and minimize conflict.
• Developing new communication strategies, via with role-play for practice, helps to prevent and resolve anger-provoking situations.

Even though CBT is conducted with the child, parents actively participate in treatment and support child’s progress towards learning anger management skills.

• Parent management techniques (PMT) helps parents limit outbursts by teaching alternative ways to handle misbehavior. The focus is on using positive reinforcement for what a child does right, rather than punishment for transgressions. PMT emphasizes positive interaction in families as rewards. “We help families enjoy spending time together. It becomes a child’s biggest motivation for reducing angry outbursts,” Sukhodolsky says.

Some children also take medication to help manage other mental health conditions (such as ADHD, anxiety, or depression). But cognitive behavioral therapy and parent management techniques (which have a 65 percent success rate in reducing the frequency and intensity of outbursts) are the primary treatments.

Other approaches may be tried if a child doesn’t respond, Sukhodolsky says, adding that some children need more intensive outpatient services or even inpatient treatment. “A life of emotional intensity doesn’t feel good so our focus and treatment goal is to help the child feel better and not suffer,” he says.

Anger and aggression are complex problems. A key benefit of seeking treatment from us is being able to access the resources of Yale University and Yale New Haven Hospital. “Oftentimes, one approach doesn’t work in isolation,” Sukhodolsky says, adding that Yale provides access to a wide range of mental health services for children with complicated mental health conditions and behavioral problems.

Also notable is the Child Study Center’s commitment to treating children within the context of the family, with great sensitivity to culture and to each family’s values and lifestyle. For example, Sukhodolsky says, showing respect for grandparents may be culturally important to a particular family. “Some kids need a bit of extra training in how to be respectful,” he says, “so we develop a plan for each and every behavioral goal.” Parents also learn to be respectful of things that matter to the child, and siblings are sometimes included in the treatment.

Whether the goal is accomplishing chores or getting to school on time, the approach is the same. “We develop a realistic plan that takes about three months or so of weekly effective therapy to change behavior and that includes behaviors of the child and the parents and often the behavior of the siblings,” Sukhodolsky says.

Yale is widely known as a preeminent research institution exploring, creating and shaping new treatments for children with mental health challenges. Doctors at Yale are focused on understanding the efficacy of treatments with the goal of predicting who is most likely to respond to which approach. “A lot of what we do here at the Child Study Center is randomized control trials to understand which forms of psychotherapy are effective,” Sukhodolsky says.