Many of the children in Shorehaven’s In-Home or Outpatient mental health and psychiatry programs display aggressive or hostile behaviors. We work to change these behaviors, to replace them with more effective, appropriate behaviors.
In this essay, we are going to go over seven steps for parents to take when a child has persistent aggressive behavior. Such behaviors may be mostly verbal threats or negative remarks, such as “I hate you,” “You’re the worst parent,” “You’ll pay for this.” The behaviors may be mostly physical abuses, such as throwing or breaking objects, holding kitchen knives while make threats, or hitting. The behavior may be frequent or intermittent. The behaviors may be in several environments such as home, school, and with peers, or only in one environment, such as at mother’s house, but not at father’s house.
You may have tried everything you can think of to change the behavior on your own. Or you may have sought treatment or medications without seeing the behavior change. If this sounds familiar, then consider these steps.
Get a good assessment. A ‘good’ assessment is one in which the mental health professional can explain how almost all the child’s symptoms and problems are related. The assessment leads to recommendations which make sense. The professional should let you know what recommendations are supported by evidence and how to get access to the care needed.
For example, Attention Deficit Hyperactivity Disorder includes a variety of symptoms which parents rarely see as related to one another until a professional shows them how the behaviors are connected. Fidgeting, forgetting to bring home one’s homework, getting so absorbed in a TV show that the child does not hear instructions to perform a task he is told to do, losing a jacket at school, and not remembering the details of a paragraph the child has just read are among the behaviors which do not seem connected to one another; but they are all related to the difficulty an ADHD child has managing attention and distractibility. Over time, a professional can see how the behaviors are related and make that clear.
The assessment must include observing the way the family interacts with the child. We know certain family patterns can make such behavior better or worse. For example Expressed Emotionality (EE) is a major factor in causing relapses. EE means being critical or disapproving of the child and having high expectations the child cannot meet. To cite another example, parents who contradict one another often set up a situation in which the child does not obey either parent. For one more example, parents often pay a lot of attention to negative behaviors and pay little attention to positive behaviors when in reality, parental attention should be given in the just the opposite way. It is critical that the assessment includes observing the family interaction.
2. PSYCHOLOGICAL TESTING.
If the diagnoses are inconsistent, ask for a psychological work-up. Often, a child receives different diagnoses from different professionals. This could be because each had a different set of data to work from or because one saw the child in an acute situation, such as the emergency room, while another saw the child in an outpatient setting where different behavior was observed after the situation calmed down. A child receiving different diagnoses for aggressive behavior is a frequent situation. Common diagnoses for aggressive children are Oppositional Defiant Disorder, Conduct Disorder, Intermittent Explosive Disorder, Bipolar Disorder, or Adjustment Disorder with Disturbance of Conduct.
Most importantly, aggression does not automatically mean the child has a psychiatric disorder at all. The child’s behavior could merely be a response to some recent events, losses, or changes in life or to circumstances in the family or to some stressor in school.
In a full work-up, a psychologist will interview you and the child separately and together and then will give the child a group of psychological tests, known as a test ‘battery.’ This could take from 2 to 8 hours. The professional will often gather information from other professionals who have worked with child. If an Individualized Education Plan, or IEP, is on file at the school, the psychologist will want to review that as well. After going over all that information, the psychologist will give you an overview of the child’s problems, probable causes, and recommended steps to take.
3. CHILDREN OFTEN ARE NOT WILLFULLY AGGRESSIVE.
Some mental health disorders are associated with aggressive behavior in some children. The child’s behavior is driven by the disorder. The child is NOT doing it willfully and cannot help it. The most common conditions which may produce such behavior include
- Reactive Attachment Disorder [RAD]
- Bipolar Disorder, especially in a manic episode
- Autism Spectrum Disorder, but only when the child is over-stimulated or his or her routine is disturbed, and the behavior is not directed to harming anyone
- Substance Abuse, which can produce highs and lows or intoxication or withdrawal symptoms
These disorders are found less frequently than defiant behavior which most commonly has its roots in some change in the family which the child finds difficult to resolve, inconsistent standards and management of the child’s behavior, parents who contradict or undermine one another, or even identification with the behavior of a defiant parent.
A word about Autism and Aspergers Disorder. These children rarely harm others. Their behavior is not aggressive, per se, but a reaction to a neurological problem in which the child is overstimulated by sounds or touch or to changes in routine. Two novels which do a remarkable job of explaining these children from inside their own experience are Jodi Picault’s House Rules and Mark Haddon’s The Curious Case of the Dog in the Night-Time.
4. LIMITATIONS OF MEDICATION AND PUNISHMENT.
Medications and punishment are merely a part of the answer. While there is no drug for aggression, per se, there are a few medications which can dampen aggressive behavior. If the behavior is part of Bipolar Disorder, mood stabilizing medications help reduce aggression; but behavior management and ‘disease management’ are important therapeutic interventions in Bipolar Disorder. Depressed children can be very irritable and touchy; so anti-depressants can help in that case. Unfortunately, far too often, medication is the main intervention parents seek or receive. Below we will discuss a variety of additional interventions from a psychological point of view.
Punishment does not teach the child the self-control and frustration-tolerance skills which are crucial to curbing aggression. Punishment may work with a healthy child, but it often makes things much worse with children who have mental disorders or display oppositional behavior. Punishment delivered emotionally is like adding a match to gasoline. Increasing the punishment usually does not help.
Another problem with punishment is that parents are inconsistent about following through on the punishments they give. Children become clever at evading punishment or talking parents out of following through. Often punishments are given in a rage; later they are modified or dropped, so children learn not to take them seriously. One parent may undo the punishment given by the other, so children learn to go to the more indulgent parent and to downplay the message of the more strict parent. Below we will discuss a variety of alternatives.
5. CHANGE AND NEW SKILLS.
Change means finding the child behaving well, then lavishly and consistently reinforcing desirable behaviors. The object is to increase desirable behaviors and skills. We are looking to increase a group of helpful skills.
- compliance with parental rules, obeying requests and demands, completing chores, cooperating with authority figures, doing what is expected the first time asked
- self-control over impulses
- stop to think before speaking, tact
- delay of gratification
- keep hands to self
- respect others’ possessions
- prosocial skills, such as helping, generosity, warmth, thoughtfulness, reading faces, empathy, eye contact
- social interaction skills, such as carrying on a conversation, taking turns, listening to others, building friendships, playing by the rules, tracking conversations, sharing, waiting one’s turn
- problem-solving skills, such as taking things out, asking for help, accepting consequences, handling peer pressure
We list the first seven skills together since they have the most to do with reducing aggression by building the skills needed to control one’s impulses and to behave in effective, functional, successful ways which are incompatible with aggressive behavior.
Whenever the child shows any of these skills, parents should be reinforcing those behaviors with praise and affection. In addition it is helpful to articulate the name of the skill. For example, “When I told you to put your coat and shoes away, you did it right away. Doing things the first time I tell you helps save time and then you know where to find them when you go to school the next day. Good work.”
6. FAMILY TREATMENT.
Treatment must include the family. This does not mean the family caused the problem, but the family is essential to the treatment.
*A professional with family therapy training is preferred. Often you need a team of professionals working together and consulting with one another – a child therapist, family therapist, psychiatrist, pediatrician. Sometimes a case manager is part of the team.
*If they expect to help the child do better, parents need to solve their own problems with alcohol, drugs, couple relationships, depression, health, and the like. Aggressive children will challenge or ignore parents who demand behavior of the child, but who do not change their own behavior.
*Be prepared to follow through. Believe it or not, yelling, criticizing, and making threats are no better than cajoling or pleading with children to change. These are a class of behaviors which reveal parental weakness. The child can withstand yelling. The child may hear these behaviors as the parent, in essence, begging for the child to behave. So when you say you are going to take a course of action, only do so if it is an action you are fully prepared to take and will take. Grounding a child for a month or canceling going to the prom are threats parents make, but on which parents are reluctant to follow through. Stick to actions for which you can follow through.
*Deliver consequences calmly, non-reactively. Emotional reactivity to the child is like letting the child’s behavior control you. Reactivity often makes us behave in ways which do not measure up to our best efforts.
*Parents need to learn to be very consistent. Consistency means three things. First, every time you tell the child what you are going to do, do it. Every time the undesirable behavior occurs, take the action you said you would. If you planned to withdraw a privilege or introduce some other negative consequences for aggressive behavior, do it consistently. So choose consequences on which you can follow through.
Second, when desirable behavior occurs, consistently reinforce it. A common error is to let positive behaviors go by and only comment on negative behaviors.
Third, all the adults in the child’s immediate circle must be consistent with one another. One of the primary contributing factors to defiant behavior is when one adult contradicts the efforts of another adult to influence the child’s behavior.
7. UNDERLYING EMOTIONS. Anger is sometimes called a secondary emotion. That means it is a reaction to other emotions, such as fear, anxiety, threat, hurt, or loss. A psychotherapist will help identify such underlying emotions and their causes. Then the child can learn to cope with those feelings in a new way rather than by aggressive behavior.
Many of these steps work best under the supervision of a professional. If you can hit a baseball, you can learn to do it better under the supervision of a coach; similarly, you can parent, but under the supervision of a professional, you may learn to manage a child’s difficult behaviors better. If you have tried hospitalization, medication, and even outpatient therapy without success, in-home family therapy may be the next step.
If you are trying to locate a family therapist, check out the therapist locator at http://www.therapistlocator.net/iMIS15/therapistlocator/
© Don Rosenberg 2012