As hypothesized, rages accounted for many admissions, but only half the children with rages necessitating hospitalization had another rage while hospitalized. These children were a younger, diagnostically complex group with even more co-morbidity and prior treatment failure (i.e., had more medications, special education classification, or prior psychiatric hospitalization) than their hospitalized peers. The fact that treatment with an atypical antipsychotic predicted in-hospital rage was a testimony to failed treatment in these difficult children, not to the medication causing rages. Other medication trials had also failed. The fact that 21 of 130 children (16.2%) had more than one rage while hospitalized and could not gain self-control with the structure and support of the hospital and school staff further suggests that more than nonmedical interventions are needed for some children with rages. A future publication will examine treatment during hospitalization. However, the extended stays necessitated by children with rages attest to the fact that their treatment is not simple.
ADHD complicated by co-morbid ODD/CD and language/learning disorders were the major diagnoses in children with any rages, and externalizing disorders occurred in 100% of children with multiple rages. Because intact attentional systems are important to shifting focus away from distress to decrease negative emotion, serious deficits like the ones experienced by these children will certainly impair their ability to self-regulate (Cole and Hall 2008
). The added academic failure, poor social skills, adversity, and neurodevelopmental delays such as those that occur with ADHD compromise these children even further. Given the developmental importance of language in mediating self control and moderating aggression in young children (Beitchman et al. 1996
; Brownlie et al. 2004
), it is not surprising that deficits in this critical sphere would be associated with rages. The occurrence and frequency of outbursts was likely to result from the inability to understand what was being asked, articulate needs and wants, or verbally negotiate the frustrations and/or provocations that eventually triggered the rages. Unfortunately, the co-morbidity with learning/language impairment is rarely acknowledged, let alone measured or controlled for, in studies of children with rages (Cohen 1996
; Greene and Ablon 2005
BPD I, currently manic, was diagnosed in 4 children; 4 more children were given a BPD NOS diagnosis. Although a preadmission diagnosis of BPD (type not specified) occurred three times more often in children with in-hospital rages versus those without rages, subsequent observation confirmed episodes of mania or “narrow-phenotype BPD” (co-occurring expansive and irritable mood, grandiosity and other symptoms of acute mania) in very few children with or without rages. Overall, children with rages were clearly irritable, i.e., highly reactive as well as disproportionately responsive. However, these explosive children were not generally elated, creative, grandiose, or especially pleasure-seeking nor were those behaviors “mixed” with depression in a sustained way. “Severe mood dysregulation” with sadness as well as anger, frequent marked reactivity to negative stimuli, and ADHD symptoms (restlessness, distractibility rapid speech, intrusiveness) (Leibenluft et al. 2003
), better characterized these children than narrow-phenotype mania. Instead, the DSM diagnoses likely to be associated with the rage behaviors in children include ADHD (with low frustration tolerance), ODD/CD (with irritability and loss of temper), and learning/language disorder (difficulty understanding the sequence of events or appropriately explaining them verbally). We suggest that the recent seven-fold increased rate of discharge diagnoses of BPD that has been reported elsewhere (Blader and Carlson 2007
) is at least partially accounted for by clinicians for whom rages are synonymous with BPD rather than narrow phenotype bipolar disorder.
With regard to the rages themselves, their duration was highly variable both across and within each child but was almost an hour long on average and could last up to 2 hours. The protracted nature of rages has been described in inpatients (Garrison et al. 1990
) and some outpatients (Bambauer and Connor 2005
). Both duration and extreme behaviors are what make rages so problematic at home, school, and in hospital. Nevertheless, it appeared that half the children with intolerable rages at home cease this behavior in hospital. Of those with in-hospital rages, half gain control of these behaviors over the first few weeks of hospitalization. Two conclusions can be drawn, in accord with other studies (Garrison et al. 1990
; Malone et al. 1997
). First, some children responded either to leaving home or being placed in a structured setting. These children were not well adjusted and easy to manage but were capable of self-control in hospital with considerable medication, educational therapy, behavioral therapy, and psychotherapy. However, the other half (21, 16.2%) of children had repeated outbursts in spite of expert management psychopharmacologically and psychotherapeutically. Such children pose ongoing, serious problems in terms of understanding etiology, treatment, and placement. The best diagnosis for these children has yet to be determined.
Our sample includes very disturbed children who had rages both at home and in the hospital. This study is unique in providing a definition and direct observation of a phenomenon that is usually only obtained by history. However, traditional structured interviews were not used for diagnosis. In previous studies from this site, the Kaufman Schedule for Affective Disorders and Schizophrenia–Epidemiologic version (K-SADS E) (Orvaschel et al. 1982
) was used to obtain specific information from parents and children (Carlson and Kelly 1998
; Carlson and Youngstrom 2003
) and this information then contributed to an overall clinical diagnosis made based on added hospital information. Data from past studies using both the K-SADS and the CSI (Grayson and Carlson 1991
) elicited similar information from parents. Diagnosis was based primarily on current psychopathology and observations, and a reliable multiinformant approach was used. A history of past psychopathology might have been overlooked, but as the emphasis was on diagnostic information observed concurrent with rage behaviors, this was felt to be less germane.
Best-estimate diagnoses were done only partially blind to information about frequency of rages (one author was blinded, the others were not), although diagnoses were done long enough after hospitalization that the specifics regarding number of rages were unlikely to be recalled. Diagnoses were made completely blind to specific behaviors and rage duration.
While this study did not find that explosive, raging children had classically defined BPD, it does not solve the problem of whether children with such outbursts constitute a subtype of mania/BPD. The point is only that when behavior is observed by a trained staff, day in and day out for more than a month for children who were felt to have BPD by others, criteria-meeting mania were not observed. Triggers or antecedents to the rages were not systematically recorded for this study. Why a child has rages may have diagnostic significance and future studies should address this question.
As noted earlier, a standardized language assessment was not part of the inpatient evaluation. However, it is more likely that the assessment missed children with subtle communication disorders rather than overdiagnosing them.