The Angry, Defiant Child: Mastery over Anger

Many couples report being surprised, hurt and stressed by the defiant and angry behaviors of the children. These parents often relate, "If I ever treated my parents as he/she treats us, I would have been severely disciplined. I would have never treated them as he/she treats us."  Unfortunately, most parents in our experience have little understanding of the nature of anger, how they can protect their children from excessive anger and also how they can teach their to master this powerful and complex emotion.  In this chapter the most common manifestation of childhood anger, Oppositional Defiant Disorder, will be examined in depth, as well as methods for mastering anger in children and in the home.

I was surprised in the early years of my practice that the history of these very angry children frequently did not reveal any serious emotional pain or hurts in their lives. Instead, these youngsters were overly indulged emotionally or materially by their parents who acted toward them in a permissive rather than in a responsible manner. The problem was that these children were not given appropriate correction and punishment for their hostile and disrespectful behaviors and were not taught virtues by their parents which can lead to the development of a healthy personality. In other children, however, angry and defiant behaviors are not the result of selfishness, but of serious emotional hurts from selfish, irresponsible or angry parents, siblings or peers or of modeling after angry parents, siblings or peers.

This chapter will attempt to help parents determine the origin(s) of anger and will describe an empirically proven, effective approach, forgiveness therapy, Forgiveness Therapy: An Empirical Guide for Resolving Anger and Restoring Hope (American Psychological Association Books, 2014, in press), to diminish excessive anger in children. 

Anger disorders in youth include Oppostional Defiant Disorder, Conduct Disorder, Intermittent Explosive Disorder and the new diagnosis, Disruptive Mood Dsyregulation Disorder (DSM 5).  However, excessive anger and anger attacks are also highly prevalent in depressive disorders and various anxiety disorders including obsessive-compulsive disorder, social anxiety disorder and PTSD from divorce and bullying trauma.  Excessive anger is also prevalent in ADHD and bipolar disorders although in the past chronic irritability in youth has been misdiagnosed as youth bipolar disorder (Krieger, et al. 2013).

The origins of angry, defiant behaviors in children (ODD)

Excessive anger and ODD can be the result of numerous unjust hurts and disappointments with parents, siblings and peers. A child may also acquire ODD from modeling after an angry parent, sibling or peers. In fact, ODD is more common in families where there is serious marital discord (DSM-IV TR) which results in both sadness and anger in children. We should not be surprised that children model after the excessive anger in a parent and later overreact in anger as did that parent.

Another major cause is selfishness that can lead to the regular overreactions in anger. This personality weakness leads to a determination to have things/relationships one’s own way, a lack of respect for parents and others, pride, impatience and a desire to control. These conflicts make the child vulnerable to become easily frustrated and uncooperative with resulting overreactions in anger and with an unwillingness to be cooperative with reasonable requests by parents, teachers and other authority figures such as teachers..

Other causes of excessive anger are jealousy, loneliness, lack of confidence and excessive television viewing that fosters selfishness.  In our professional opinion excessive selfishness precedes the development of ODD in many children.  Also, emotional, physical and sexual abuse results in significant sadness and anger that can be manifested in defiant behaviors. Engaging in violent video games is another factor in the overreactions of children in anger.

Also, a frequent cause of intense anger in children is the result of divorce trauma.  Most of these children are not aware of the origin of their anger and periodic rage that they often misdirect at others.

Children who have very strong personalities often have great difficulty in being obedient to parents and can defiant. They can overreact in anger when asked to be responsible. An effective parental response to these strong children can be communicating that it is good to be strong, but harmful to be controlling. These children can also be encouraged to grow in the virtue of gentleness that can balance their strength. Also, children with faith can be encouraged to consider that God is in control -- not them.  They may need to hear this many times daily.

 

In a number of studies of ODD, it has been shown that males were over represented, as were children of divorced parents and of mothers with low socioeconomic status (Kadesjo C, 2003.)

Identifying angry, defiant behaviors (ODD)

The first step in addressing anger in children is a careful history of the child that is helped by evaluating the degree of active and passive-aggressive anger, the degree of selfishness and the number of ODD behaviors.

Please identify the symptoms of ODD in your child by identifying the behaviors listed in the DSM IV-TR for this diagnosis:

The child must demonstrate at least four of these symptoms for at least 6 months to establish the ODD diagnosis. In our view a number of these behaviors are an indication of selfishness in the child. These include:

Based on over 35 years of clinical experience I believe that the following symptoms of the covert (sneaky) or passive-aggressive expression of anger should be added to the description of ODD symptoms.

Identifying Covert/Passive-Aggressive Angry Behaviors


Please consider completing the more extensive evaluation of anger in your child on the anger checklist and try to identify the number of active and passive aggressive angry behaviors in him/her.

Next, please complete the selfishness checklist for your child.

Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is the most common psychiatric disorder seen in children. Epidemiological data have indicated that by the age of sixteen 23% of children will meet the criteria for a behavior disorder, most frequently oppositional defiant disorder, 11.3% (Costello EJ, et al., 2003.)

As every parent knows, acts and words of defiance in direct or covert ways can begin at an early age. Unfortunately this anger often is not properly identified, understood and addressed by busy parents, family members, educators and mental health professionals. The failure to identify and address this anger has serious consequences for the child, the parents and family, schools and society.

Oppositional behaviors occupy a central position in the development of emotional and mental illnesses.  ODD can lead to the development of a conduct disorder in which children manifest intensely angry and even violent behaviors. This disorder in turn can lead to the development of a sociopathic or criminal personality disorder. Also, there is a substantial overall between ODD and ADHD. 

The wide range of association of ODD with other disorders is also reflected in the finding that it is one of the most common precursors for most psychiatric disorders in adolescence and young adulthood (Kim-Cohen, J. 2003 and Nock, MK, 2007.)

A major study estimated that children with ODD were 17 times more likely to have a depressive or anxiety disorder than children without ODD (Boylan, K, et al, 2007.)

Our professional experience indicates that if defiant and angry behaviors are dealt with effectively in young children the emotional and mental health of the child and the family can be protected and strengthened. The serious problems that develop if children do not learn how to control their angry impulses can be prevented.

The American Academy of Child and Adolescent Psychiatry offers excellent resources on ODD at www.aacap.org/cs/ODD.ResourceCenter.

Research on Children with ODD

In an important paper on ODD published in the leading journal of child psychiatry in 2007 Dr. Whittenger wrote, "It is imperative that clinicians ( and parents) pay specific attention to the presence of childhood ODD behaviors." Her research in England demonstrated the serious negative prognosis of ADHD with associated (co-morbid) conduct disorder (Whittenger, N.S., et al. 2007.) Since, ODD is the major precursor of conduct disorder, we believe that the effective treatment of ODD can prevent the development of conduct disorder and assist in the treatment of ADHD.

Preschool children with ODD are likely to continue to exhibit disorder with increasing association (co-morbidity) with ADHD, anxiety, or mood disorders (Lavigne JV , 2001.)

The Development of emotional pain in children and its relationship to anger

The diagram below attempts to demonstrate the relationship between hurts and the development of anger and sadness, anxiety/mistrust and insecurity.  Both research and clinical experience demonstrate the strong relationship between sadness, anxiety, insecurity and excessive anger.

The second diagram attempts to present how anger can "encapsulate" sadness, anxiety and insecurity and how it can interfere with the healing of these conflicts.

 

Unjust hurts and emotional pain

Prisoner of one's past when one doesn't forgive

 

Three methods of dealing with childhood anger

Parents can provide valuable assistance to children by helping them develop an understanding of the three basic mechanisms used to cope with anger. These are denial, expression and forgiveness.

1. Denial

During early childhood, the most common method for dealing with anger is denial. The dangers attached to denial include emotional harm to the child, increased feelings of sadness, guilt and shame, or the misdirection of the resentment toward others.

2. Expression

The next method commonly used for dealing with anger is either to express it openly and honestly or to release it in a passive-aggressive manner. It is of benefit to review with children the numerous ways in which anger can be vented passively. The therapist might consider having the young patient complete an anger checklist to identify these behaviors. Many parents can also participate in the evaluation of their child's anger by completing an anger checklist in relation to their son or daughter and thus provide the therapist with additional information on the degree of the child's anger.

It may be helpful to view actively expressed anger as encompassing three types: appropriate, excessive, and misdirected. Children benefit from learning the value of healthy assertiveness as well as the danger of responding consistently to situations in an excessively angry manner. It is important for them to realize that when they do not resolve their anger from a particular hurt, they may later misdirect the resentment toward others. Such anger can damage friendships, interfere with learning, harm family relationships, and limit participation in team sports. In clinical practice, we find that the most common recipients of misdirected anger are younger siblings, peers, mothers, and teachers.

Concepts of displacement and the consequences of displacing anger can be difficult for children to understand and accept so concrete examples need to be used. At times, it can be helpful if parents or a therapist relate stories of misdirected anger from their own youthful experience.

Some therapists believe they have been successful in treating anger in children and adolescents when their young patients express the anger they had previously denied. Actually, what has been accomplished is only one step toward actual resolution because, in itself, expression is incapable of freeing children from the burden of resentment which they carry. The experience of anger can lead to a desire for revenge which does not diminish until the existence of the resentful feelings are uncovered and subsequently resolved. Without this uncovering and resolution, anger can be displaced for many years onto others and erupt decades later in loving relationships. Anger may not be fully resolved until a conscious decision is made to work on forgiving the offender.

3. Forgiveness - the most effective way to master anger

Not surprisingly, what forgiveness is not needs clarification. We find that children need to learn the following issues. Specifically, forgiveness is not tolerating and enabling angry, abusive people to express their anger. It is not being a doormat or acting in a weak manner and it does not limit healthy assertiveness. It does not mean trusting or reconciling with those who are abusive, insensitive, or show no motivation to change their unacceptable behavior. Finally, forgiveness is not necessarily going to others and informing them that one is forgiving them.

As already stated, clinicians often discover that the relationship in which children experience the greatest degree of disappointment, and subsequently the greatest degree of anger, is in the parental relationship, especially the one with the father. This is particularly true at the present time when almost forty percent of children and teenagers do not have their biological fathers at home. Numerous studies have documented difficulties with resentment and aggressive behavior in the children of divorce (Block, Block, & Gjerde, 1988; Guidubaldi, 1988; Hetherington, 1989; Johnston, Kline, & Tschann, 1989; Wallerstein 1983, 1985, 1991; Wallerstein & Blakeslee, 1989). One study of parental love-deprivation and forgiveness revealed that most respondents implicated the father, not the mother, as being emotionally distant (Al-Mabuk, Enright, & Cardis, 1995).

The major cause of anger in the father relationship is the result of growing up with a father who had difficulty in communicating his love and in affirming his children. Misdirected father anger may be a contributing conflict in our schools and homes today. Many children who have intense father-anger present with conduct disorders, oppositional defiant disorders, attention-deficit/ hyperactivity disorders, and intermittent explosive disorders.

Difficulties in the mother relationship that lead to intense anger can be the result of not experiencing enough love and praise, feeling controlled or criticized, or being made to feel that one does not measure. Children also become very angry with mothers who give into the influence of selfishness and become less giving to them.  At times, too, the child may have felt overly responsible for the mother, or may have come to the conclusion that she was overly critical or mistrustful of the father.

Other sources of anger sometimes result from hurts and disappointments from siblings or rejection by peers. Often an older child misdirects anger at a younger sibling that is really meant for a parent or peers. Many children and adolescents crave peer acceptance to develop a positive sense of self and to protect themselves from loneliness. Those children who are scapegoated regularly in school rarely tell their parents how they are being treated because they are so ashamed or because they believe that their parents cannot protect them. Therefore, parents need to be aware of the various ways in which this conflict can manifest itself. These include: isolation, withdrawal, ventilation of hostility toward others, social anxiety, or depression.

Some children have difficulties with their anger as a result of modeling after a parent who could not control anger. This excessive expression of anger is then passed from one generation to the next. In our experience, this modeling occurs most often with the father.

Many in the mental health field believe that the excessive anger seen in ADHD and other disorders in children is biologically determined (see, for example, Hechtman 1991). However, at this time, no specific neurotransmitters have been identified which cause excessive anger. Also, the use of addictive substances can trigger excessive anger as well as personality conflicts, especially narcissism.

Parents can assist their children in their character development by teaching them to be understanding and forgiving when angry. We refer to this as an immediate forgiveness exercise. This does not preclude punishing a child for a display of excessive or misdirected anger, nor asking an angry child to apologize to the recipient of their excessive anger. Appropriate punishment for angry behaviors often helps a child learn to control anger.

After an angry incident the child can be recommended to try to forgive if they have been truly hurt by another. Also, children can learn to stop denying their anger and to resolve it by thinking at bedtime of forgiving anyone who may have hurt them on that particular day or in the past. In Ephesians 4, St. Paul recommends that we not let the sun go down on our anger. Unfortunately, many children and adults do because they do not work on developing and using the virtue of forgiveness at the end of the day.

Children are usually pleased to learn how the virtue of forgiveness can help them control and resolve their angry feelings.

The role of forgiveness in diminishing ODD

The psychotherapeutic use of forgiveness can play an important role in decreasing or resolving the hostile feelings, thoughts and behaviors seen in ODD. The acquisition of this virtue is most important and helpful for children to develop in order to control and resolve their anger.

The following case study on the treatment of a defiant child which is taken from our textbook, Helping Clients Forgive: An Empirical Guide for Resolving Anger and Restoring Hope, demonstrates the effective use of forgiveness in the treatment of ODD.

Sean, a seven-year-old, became increasingly angry and rebellious with his mother after his father left the family. He regularly lost his temper, refused to listen to his mother, and provoked his sisters. He also became much more defiant and narcissistic and demanded that his mother buy him new toys several times weekly.

In the sessions with his mother and sisters, Sean admitted, "I’m really mad at Dad. He doesn’t care about us. All he ever did was watch TV anyway." Sean’s mother told him that his anger was hurting her and his sisters and that it reminded her of his father’s selfish temper tantrums. Sean became tearful and remorseful during the session and stated that he did not want to hurt anyone. He agreed to try to let go of his anger with his father on a daily basis and thus attempt to avoid repeating his dad’s self-centered behaviors. This intervention seemed to motivate Sean and when he slipped back into oppositional defiant behavior, his mother would remind him to continue to forgive his father. Over the course of several months, the work of daily thinking that he wanted to understand and try to forgive his father helped Sean to gain more control over his angry feelings and behaviors. However, there were times when, after spending a weekend with his selfish father, it would take several days to gain control over his sad and angry feelings. Unfortunately, the attempt to engage his father was unsuccessful.

While employing forgiveness therapy in the treatment of the defiant anger in children, the major obstacles that therapists encounter include: the sense of control their anger gives clients over others, modeling after their parents, and a sense of strength and self-esteem derived from the expression of anger. It is not uncommon, either, for the process of forgiveness to be blocked by parents who excuse all angry behaviors in their children, claiming that their behavior is solely the result of biological factors over which their children have no control. Such parents may have serious problems with excessive resentment themselves and therefore they attempt to undermine efforts made to teach their children to be responsible for their anger and to resolve their hostile feelings. Subsequently, therapy often focuses on encouraging parents to identify their own anger and to work on forgiving those who have hurt them. However, the fathers, in particular of those whose children have excessive anger, are often highly resistant to participate in treatment and often have no desire to control their excessive anger. By modeling forgiveness, the majority of parents can bring about a marked improvement in the level of resentment and acting-out behaviors in their children.

Selfishness to ODD

It is our opinion that serious conflicts with selfishness often precede the full development of ODD. Most serious cases of ODD we treat are associated with a high level of selfishness. The repeated excessive expression in the home reinforces insensitive and selfish behavior patterns. These behaviors and emotional overreactions then contribute to the weakening of the personality and can lead to the development of strong narcissistic personality traits and later a narcissistic personality disorder (NPD.)

We caution parents that the failure to address selfishness in children can be the most important factor in the child’s failure to learn how to control angry impulses. If selfishness is properly corrected in many children by growth in numerous virtues and by proper parental education and correction, our professional opinion is that ODD may not develop (see the selfish child article.)

Selfishness and Co-Morbidity

The diagram below demonstrates that selfishness can influence the development of numerous other conflicts as the person grows. In this diagram CD refers to conduct disorder, SUD to substance abuse disorder and NPD to a narcissistic personality disorder which is diagnosed in young adulthood.  The ongoing sense of entitlement from selfish/narcissistic thinking can contribute to the development of inflated and grandiose thinking which is seen in bipolar disorders. Also, a number of our patients who had ODD and severe selfishness as children later developed bipolar disorder with severe irritability as adolescents.

 

Selfishness and Co-morbidity

 

Permissive Parenting, Selfishness and Angry Behaviors

In the permissive parenting style the adult overly indulges a child emotionally and/or materially and fails to provide healthy correction of character weaknesses. The parental failure to form character in a healthy manner results in a weakening of a child’s ability to control impulses, a lack of respect for others, an inflated sense of self, a sense of entitlement, an overreaction in anger when the child cannot have his or her way, etc.

Many factors contribute to permissive parenting and these include the desire to have the child as a friend, as well as weak confidence, selfishness, fear of losing the child’s love or a comfort seeking mentality with a dislike for correction. Psychologist Susan Linn, author of Consuming Kids: The Hostile Takeover of Childhood (2004), wrote that the parent-child relationship is being reversed by a trend that sees parents consulting their kids about everything from choosing a movie to the mother’s choosing a new partner. She attributes this change in parenting to the increase in single parent families, incessant marketing that gives children "the trappings of maturity", increased access to information children have because of the internet and Peter Pan parents who think they can stay young and relevant by swapping advice with teenagers.

Dr. William Doherty, professor at the University of Minnesota, in his book, The Intentional Family, 1997, criticized permissive parenting particularly in regard to family meals by stating, "We are talking about a contemporary style of parenting that is overindulgent of children. It treats them as customers who need to be pleased."

The Onset of ODD

ODD is usually diagnosed between the ages of 6 to 10. However, symptoms may appear much earlier. In addition, ODD angry behaviors may not emerge until adolescence. We have even seen these behaviors intensify after high school.

The later development of ODD is often the result of unresolved anger from childhood experiences that can no longer be denied. Another major factor in the later manifestation of ODD is growth in selfishness and in a tendency to want to control parents, siblings and others.

Victims of Misdirected Anger

The excessive anger in children is regularly misdirected at others either because they are not aware of how they can master their anger or because they enjoy its expression.  The expression of anger can be a source of pleasure from a feeling of revenge, from a false sense of strength it may give and from a sense of being able to intimidate or control others. They major victims of misdirected childhood anger are:

• mothers

• siblings

• peers

• teachers

• oneself

• society

• The Church/God (see Faith of the Fatherless: The Psychology of Atheism, P. Vitz)

The Serious Consequences of ODD

The manifestations of angry and defiant behaviors can harm the child’s and teenager’s family relationships, academic performance and friendships. ODD has been shown to have extremely detrimental effects in many areas of the lives of children.  Also, it is seen as occupying a central position in the developmental psychopathology (illness.)

One of the major studies of ODD in over 600 children from the Department of Psychiatry at the Harvard Medical School revealed that these teenagers and children had significant impairment in family functioning with parents and siblings and in social adjustment with problems with peers and at school. Also, families of ODD youth were characterized by significantly poor cohesion and high conflict.

In addition this particular study showed that children with ODD had high rates of associated disorders including ADHD, severe major depression, bipolar disorder, pervasive development disorder, multiple anxiety disorders, Tourette’s disorder and language disorders, Greene RW, (2002). In a national co morbidity survey replication of 3,199 individuals of those with lifetime ODD, 92.4% meet criteria for at least one other lifetime DSM-IV disorder, including: mood (45.8%), anxiety (62.3%), impulse-control (68.2%), and substance use (47.2%) disorders, Nock MK (2007).

ODD is a serious problem in children that impacts everyone in the family. In fact, parents of children with ODD are more likely to utilize child mental health services than parents of children with other disruptive behavior disorders.

ODD and Attention Deficit Hyperactivity Disorder

ODD is also often seen in children with ADHD. A number of studies reveal that 40% and more of those with ADHD also have ODD. Our clinical experience is that ODD may contribute to the development of the hyperactive and impulsive types of ADHD. We have found that treatment of the anger in ODD can also diminish the hyperactive and impulsive symptoms in these two types of ADHD.

ODD and Anxiety

ODD has been shown to be directly predictive of future anxiety and depression, and anxiety predicted future depression as well. (Burke JD, 2005). Anxiety in children with ODD can be the result of a difficulty in trusting from hurts with parents, siblings or peers and of a fear of his/her strong angry impulses.

ODD and Depression and Suicide

The most consistent adolescent or adult diagnosis made in children with ODD is depression (Nock MK, 2007.)  A major study in 2007 revealed that risk for youth suicide was strongly associated with current depression and ODD and current depression with anxiety, specifically generalized anxiety disorder (Foley DL, 2006.) Also, children with depression are more than 16 times more likely to have concurrent ODD than those without depression (Costello EJ, et al, 2003.) Our clinical experience confirms the research of Dr. Bob Enright at the University of Wisconsin, Madison, that diminishing excessive anger by the use of forgiveness also decreases symptoms of depression and anxiety.

ODD and Bipolar Disorder

ODD is strongly associated with bipolar (manic-depressive) disorders in children and in teenagers. In the Harvard study of children with ODD 45% of them met the criteria for bipolar disorder (Green R., 2002.) Another study demonstrated that 43% of children with bipolar I disorder had ODD (Birmaher B, 2006.) 

There is a veritable epidemic in the U.S. of the diagnosis of bipolar disorders in children with a 40 fold increase in this diagnosis between 1994 and 2004 - a jump to 800,000 children from 20,000.  Dr. Roger McIntyre of the Mood Disorders Psychopharmacology Unit at Columbia University as stated,“That’s a staggering increase, and it has rightly raised questions about whether there has really been a true increase of that magnitude.”

We have worked with teenagers with bipolar disorders with mania (bipolar I) who were diagnosed years earlier with ODD. It is also important to recognize that severe irritability has been shown to be the most common presentation of mania in the young (Wozniak, J. 2005.)

Also, research has shown that irritability in bipolar disorder is influenced by the severity of the oppositional defiant disorder (Rich BA, 2007.)

Growth in virtues in children and family therapy can help in a marked reduction of the ODD symptoms in children. We suspect that the successful treatment of ODD may possibly help in the prevention of bipolar I disorders.  Much more research is needed on nature of childhood irritability and its treatment given the serious possible long term side effects from the use of atypical anti psychotics in children.

Finally, we recommend that the parents of all children with severe irritability and rage rate the selfishness in these children because this conflict regularly predisposes children and adults to serious overreactions in anger.

ODD and Substance Abuse

In at least one community research study the number of ODD symptoms in childhood was a significant predictor of later alcohol use. (White, H.R., 2001). The results suggest that drug use prevention programs should target youths with early symptoms of excessive anger. Also, ODD in association with ADHD, is associated with elevated risk of drug use (August, G.J., 2006).

ODD to the far more serious Conduct Disorder in Children

The International Classification of Diseases 10th Revision (ICD-10) classifies ODD as a mild form of conduct disorder (CD), and it has been estimated that up to 60% of patients with ODD will develop CD. Therefore, ODD should be identified and treated as early and effectively as possible, (Turgay, A. 2009.)

Studies and clinical experience have demonstrated that ODD can precede the onset of conduct disorder (CD), the most serious anger disorder in children and adolescents, by several years. The angry behaviors in ODD can escalate into aggressive behaviors against people and property. CD in children is associated with the most intense expressions of anger and aggression against people and property. A significant percent of these youngsters with CD will go on to become criminals in young adult life and may be diagnosed with an antisocial personality disorder (ASPD).

Again, our clinical belief is that if the anger in ODD is properly uncovered and worked on in family and individual therapy that such an effort can prevent the development of conduct disorder in many youngsters.

ODD to Diagnosis of Conduct Disorder

The DSM-IV categorizes conduct disorder behaviors into four main groupings: (a) aggressive conduct that causes or threatens physical harm to other people or animals, (b) non- aggressive conduct that causes property loss or damage, (c) deceitfulness or theft, and (d) serious violations of rules. Conduct Disorder consists of a repetitive and persistent pattern of behaviors in which the basic rights of others or major age-appropriate norms or rules of society are violated. Typically there would have been three or more of the following behaviors in the past 12 months, with at least one in the past 6 months:

Aggression to people and animals

Destruction of property

Deceitfulness or theft

Serious violations of rules

Disruptive Mood Dysregulation Disorder (DMDD)

DSM-5 has identified a new disorder in youth, disruptive mood dysregulation disorder (DMDD), with chronic irritability and temper outbursts as the defining symptoms. The conceptualization of this entity is a work in progress. The diagnostic criteria for DMDD include severe recurrent temper outbursts manifested verbally or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation; the temper outbursts are inconsistent with developmental level; the temper outbursts occur, on average, three or more times per week; the mood between temper outbursts is persistently irritable or angry most of the day, nearly every day and is observable by others and these criteria have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the criteria.

Many of these youth were previously erroneously misdiagnosed as having a bipolar disorder (Krieger, et al. 2013)

Youth with DMDD are at elevated risk for anxiety and unipolar depressive disorders (Leibenluft, 2011). Treatment evidence includes cognitive behavioral therapy, especially parental intervention, but there is a pressing need for research on adjunctive pharmacological treatment. Forgiveness therapy should also be recommended in the treatment of DMDD (Enright & Fitzgibbons, 2014, in press).

 

Children of Divorce

The profound sadness with children from divorced families results in their regulalry overreacting in anger in the home, in school and in friendships.  Frequently, these children have no conscious awareness of the cause of their anger, in part, because divorce trauma is so severe.  In regard to their sadness many teenagers have commented that the only pain worst they can imagine that would be worse than the divorce of their parents would be the death of one of them.

We recommend that parents of these children teach them about the 3 options for dealing with the powerful emotion of anger, that is, denial, expression and forgiveness can be helpful in decreasing their anger which at times is severe.  Then, forgiveness is explained as the best option for resolving anger.  The child is told that forgiveness can occur by thinking of understanding and deciding to forgive, by emotionally feeling like forgiving or by giving one's anger to the Lord in prayer or in the sacrament of reconciliation. 

Some parents find it helpful to engage in this forgiveness exercise at bedtime with their children.  The child is asked then to consider thinking of forgiving anyone he/she may be angry with including either parent, a sibling, friends or others.  This forgiveness exercise opens children to admit the presence of their anger because it gives to them a method which can decrease it.  

The profound sense of the loss of an intact family in a home with a father and a mother can result anger that is so severe that it is difficult for a child to think of forgiving the parent he/she blames for the divorce.  In Catholic families these children experience significant relief from their anger by taking it regularly into the sacrament of reconciliation.

In some families wounded by divorce the intense emotional pain in the children of sadness and hopelessness, excessive anger, severe insecurity and a disabling mistrust in relationships can lead the parents to reconsider their relationship and the causes of the divorce.  We support this approach to help children because two-thirds of divorces occur in marriages with low levels of conflict, because in our clinical experience most marital conflicts can be resolved and because of the long term benefits to children of marital reconciliation.  If this approach is of interest to you, please consider viewing this divorce prevention webinar, www.maritalhealing.com/maritalwebinars.php.

A growing body of research is demonstrating the relationship between divorce and violent behaviors in the children of divorce, particularly males.   Dr. Brad Wilcox, sociologist at the University of Virginia, has written, "social scientific evidence about the connection between violence and broken homes could not be clearer."

http://www.aei.org/article/society-and-culture/sons-of-divorce-school-shooters/?utm_source=today&utm_medium=paramount&utm_campaign=121713.  

I have also written about this relationship, as one of a number of factors, in regard to the Sandy Hook tragedy in 2012,

http://www.mercatornet.com/articles/view/lessons_from_sandy_hook.

Disruptive Mood Dysregulation Disorder (DMDD)

DSM-5 has identified a new disorder in youth, disruptive mood dysregulation disorder (DMDD), with chronic irritability and temper outbursts as the defining symptoms. The conceptualization of this entity is a work in progress (Krieger, et al, 2013). The diagnostic criteria for DMDD include severe recurrent temper outbursts manifested verbally or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation; the temper outbursts are inconsistent with developmental level; the temper outbursts occur, on average, three or more times per week; the mood between temper outbursts is persistently irritable or angry most of the day, nearly every day and is observable by others and these criteria have been present for 12 or more months.  Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the criteria.

Youth with DMDD are at elevated risk for anxiety and unipolar depressive disorders (Leibenluft, 2011).  Treatment evidence includes cognitive behavioral therapy, especially parental intervention, but there is a pressing need for research on adjunctive pharmacological treatment (Krieger, et al. 2013).

Forgiveness therapy should also be helpful in treating the excessive and impairing irritability that is the defining feature of disruptive mood dysregulation disorder.   This disorder identifies children with severe levels of emotional and behavioral dysregulation that is highly comorbid with oppositional defiant disorder (Copeland, Angold, Costello & Egger, 2013).

Intermittent Explosive Disorder (IED)

Intermittent explosive disorder is a highly prevalent, persistent, and seriously impairing adolescent mental disorder that is both understudied and undertreated.  In one major study of 6483 adolescents, nearly two-thirds of adolescents (63.3%) reported lifetime anger attacks that involved destroying property, threatening violence, or engaging in violence.  Intermittent explosive disorder had an early age at onset (mean age, 12.0 years) and was highly persistent, as indicated by 80.1% of lifetime cases (6.2% of all respondents) meeting 12-month criteria for IED.  It was also significantly comorbid with most DSM-IV mood, anxiety, and substance disorders with 63.9% of lifetime cases meeting criteria for another such disorder. Although more than one-third (37.8%) of adolescents with 12-month IED received treatment for emotional problems in the year before the interview, only 6.5% of respondents with 12-month IED were treated specifically for their anger. Twenty-four percent met the criteria for ODD and for CD, while 19.6% met the criteria for ADHD (McLaughlin, Green, Hwang, Sampson, Zaslavsky & Kessler, 2012).

              The early age at onset of IED, the significant associations with comorbid mental disorders that have later ages at onset, and the low proportion of cases in treatment all make IED a promising target for early detection, outreach, and treatment (Kessler, Coccaro, Fava, Jaeger, Jin, Walters, 2006).

              In McElroy and colleagues’ (1998) study of  IED 88% of subjects experienced tension with their impulses; 75% felt relief from their aggressive acts, and 48% experienced pleasure with these acts.  Ninety-three percent had a life-time DSM-IV diagnosis of mood disorders; 48%, substance abuse disorders; 48%, anxiety disorders; 22%, eating disorders; and 44%, other impulse- control disorders other than intermittent explosive disorder. Finally, 60% receiving therapy with an anti-depressant or mood stabilizer reported a moderate or marked reduction of their aggressive impulses and/or episodes.

              A major focus of forgiveness therapy in youth with IED is to motivate the person to want to learn control of their aggressive impulses and to change behavioral patterns that harm others and the self.  Many have no interest in changing because of the secondary gain from the release of  anger.  For those willing to try controlling their aggression, the release of inner rage begins by incorporating some physical activity, such as hitting a punching bag.  While hitting the bag, the person is encouraged to reflect, “I want to let go of my inner aggression and rage without harming others”, or  “I want to let go of my rage and not seek revenge against others”, or  “I don’t want to hurt others as I was hurt when I was young”, or “I want to stop relying upon my hatred as a source of strength”, or  “I don’t want to continue to be as aggressive as my father was or peers are.” 

              This exercise is followed by a cognitive decision to try letting go of impulses for revenge.  As understanding the offenders deepens, they are encouraged to consider forgiveness.  This step can be difficult if they were neglected or abused as children.  However, if they persevere, even though they may not feel like forgiving, relief from aggressive and vengeful impulses slowly begins to occur.  The ability to control their aggressive symptoms usually requires many years of therapy and is marked by periodic relapses into aggression. The most difficult aspect of the treatment of males with IED is that of strengthening their self-esteem so that they do not need to rely upon anger and aggression as a source of strength.

              While employing forgiveness therapy in the treatment of the anger in ODD, IED and CD, the major obstacles that therapists encounter include: the sense of control their anger gives clients over others, modeling after their parents, and a sense of strength and self-esteem derived from the expression of angers.  Parents with excessive anger are also asked to engage in forgiveness therapy.   The fathers, in particular of those whose children have conduct disorders, are often highly resistant to participate in treatment and often have no desire to control their excessive anger.  By modeling forgiveness, the majority of parents can bring about a marked improvement in the level of resentment and acting-out behaviors in their children with ODD, IEP and CD. 

Chronic Irritabililty or Bipolar Disorder (BP)

              Between the mid 1990s and early 2000s in the United States, there was a dramatic increase in the rate of diagnosis of BD in children and adolescents, paralleling a discussion in the professional literature about the presentation of BD in youth.  The proportion of bipolar diagnosis of all psychiatric inpatient discharges in the United States rose from 10 to 34% in children and from 10 to 49% in adolescents in 8 years. In 1996, there were 1.3 discharges with a bipolar diagnosis per 10,000 children and adolescents in the general population, whereas in 2004 the ratio was 7.3 per 10,000, a five-fold increase.  (Balder & Carlson, 2007).  In outpatient settings, the increase was approximately 40-fold during that period (Moreno, et al., 2007).

              Retrospective studies showed that in 50% of cases BD begins during adolescence. (Kessler, et al., 2005). 

              Stringaris (2011) has stated that this dramatic increase in the diagnosis of BP in youth may have been the result of the assertion that irritability, which is continually present from a very young age, should be considered the typical mood of early mania (Leibenluft, 2003; Leibenluft, 2006). Yet, he stated that chronic irritability does not seem to conform to what is usually thought of as a mood that occurs within a relatively sharply demarcated episode.  In the words of the DSM:  “a distinct period of abnormally and persistently elevated, expansive, or irritable mood,” p.124.  He recommended that studying the distinction between episodic and non-episodic mood changes—and more generally the time scales and variability of irritable mood—is crucial for diagnosis and treatment.

             Krieger, et al. (2013) claim in their research that chronic irritability has been misdiagnosed as a pediatric bipolar disorder and, instead, support the new DSM-5 diagnosis of disruptive mood dysregulation disorder (Krieger, Leibenluft, Stringaris & Polanczyk, 2013.)

Parental Response to the Angry, Defiant Child

Parents benefit by understanding the nature of excessive anger and methods of being able to master this powerful emotion. Such knowledge is essential for their role in the development of healthy personalities in children. We recommend communicating to children that they have 3 options for dealing with their anger. These are denial, expression and forgiveness.

Parents play an important role in helping their children with defiant anger. In our clinical experience ODD is prevented in many children and resolved in others by their parents helping them to grow in early childhood in the virtues of forgiveness, obedience, orderliness, respect, generosity, gentleness and humility.

The following parental actions, some of which employ a faith component when appropriate, can be helpful:

Parental confidence is very important in correcting children with oppositional defiant disorder. Pope Benedict's writing on Collaboration Between Men and Women in the Church and in the World,2004, can help to strengthen this confidence.

He wrote that the "Genius of Women" include:


He wrote the "Genius of Men" include:

Parents with faith benefit from asking the Lord to strengthen their confidence so that they can correct early and often defiant behaviors in their children.  Such families can engage in a family forgiveness process in which they discuss their efforts cognitively, emotionally and spiritually to stop misdirecting anger and to resolve resentment.

Virtues for ODD

Parents can help their children learn how to grow in healthy personalities and avoid giving into angry and defiant behaviors by teaching them daily the following virtues:

Children can also fight against the tendency to be selfish and angry by regular visits the sick and the elderly and by giving to the poor.  Also, John Paul II has offered excellent advice for parents in The Role of the Christian Family in the Modern World (FC, n.37): "Children must grow up with a correct attitude of freedom with regard to material goods, by adopting a simple and austere life style and being fully convinced that ‘man is more precious for what he is than for what he has (Gaudium et Spes, n.35.)’”

Parental anger toward children

When a parent feels angry toward a child, the immediate expression of this anger can be harmful, especially if it is excessive. Instead of giving in quickly to the expression of anger, we recommend that a parent when angry with a child try to inwardly reflect a number of times, "I want to understand, forgive, and love" or "I want to be patient." This immediate forgiveness exercise usually diminishes anger.   Communication to child ideally should occur only after the angry feelings. If a parent works on the described immediate forgiveness's exercise, correction can be given to a child in an appropriate manner without excessive anger. Then a child feels safer and is often be more receptive to constructive criticism and is less defensive. Parents also need to be careful that they do not humiliate a child when giving a correction.

When parents overreact in anger, a number of emotional responses can occur in children including fear, anxiety, guilt, shame, sadness and intense anger. The physical responses often include muscle spasms, headaches, irritable bowel, nausea or diarrhea and weight gain. Also, excessive anger toward children can seriously harm the child and the trust in the child-parent relationship. Parents have a serious responsibility to protect the trust in their children since it is the foundation for all relationships.

At times a parent may recognize that he/she is repeating a negative parental pattern of angry reactions toward children. Repetition of a father's overreacting in anger or in impatience toward children is the most frequently identified pattern here, particularly in fathers. If this overreaction in anger toward children occurs in your family, I'd recommend your reading the parental legacies chapter on our sister web site. This chapter describes how one can break the negative parental legacy of overreacting in anger. 

Asking a child for forgiveness

After an overreaction in anger, the child can be helped by the parent apologizing and even explaining the reason for his/her behavior. The parental request for forgiveness of a child is not easy and requires a great deal of wisdom, humility and courage. The parent should request that the child respond to a request for forgiveness by stating, "I want to forgive you" or "I do forgive you."

The common reasons for parental overreactions in anger toward children include:

The most common conflicts leading to overreactions in anger toward a child are in men repeating their father's angry, critical behaviors and in women repeating their mother's controlling behaviors.  The healing of these harmful behavior patterns is presented in the parental legacies chapter on this site.

If overreactions in anger continue, then therapy should seriously be considered. If the angry parent refuses to seek help, then the other parent should try to understand the causes of the anger, clearly identify them, ask the spouse to work on these weaknesses and do whatever is necessary to protect a child from inappropriate and harmful anger.

Sibling Anger

Sibling conflicts are a major source of stress in many families. This disruptive anger arises from many factors including jealousy, selfishness, misdirected anger meant for a parent or for peers, excessive competitiveness, insecurity, poor body image, loneliness, materialism, a tendency to control, a failure to forgive and modeling after angry peers or an angry parent(s).

Parental conflicts are often uncovered which contribute to this anger. They include inappropriate anger, marital quarrelling and irresponsible parenting with either emotional neglect or excessive permissiveness or indulgence.

Parents can protect their children from the trauma of peer hostility by helping them grow in a number of virtues that can diminish these conflicts. These virtues include:

Anger in youth and violent video games

The feeling of pleasure in the expression of anger in many youth and adults contributes to the compulsive use of highly competitive and violent video gaming activities and to the significant difficulty parents have in attempting to restrict such activities.   Sustained violent video game play has been shown to be related to steeper increases in adolescents' trajectory of aggressive behaviors over time. Moreover, greater violent video game play predicted higher levels of aggression over time (Willoughby, Adachi & Good, 2012).  Also, a meta-analytic review strongly suggested that exposure to violent video games is a causal risk factor for increased aggressive behavior, aggressive cognition, and aggressive affect and for decreased empathy and prosocial behavior (Anderson, Shibuya, Ihori, Swing, Bushman, et al., 2010).

Parents should protect their children from growing in anger and aggressive behaviors by refusing to allow such games into their homes.  Youth might benefit from being informed that Anders Brevik stated that he had trained for his attack at the Norwegian youth camp that killed 69 adolescents by playing the video game “’Call to Duty 4: Modern Warfare.”

Also, Adam Lanza spent hours every day playing violent video games. On one of his favourites, Combat Arms, he had notched up 83,496 kills, with 22,725 head shots. He also played a game called School Shooting in which the player controls a character who enters a school and shoots students in which he also trained for his murderous attack on first graders and adults.

Cohabiting Homes - the Highest Risk for Children

The most dangerous home environment for a child is in a home with his mother and her live in boyfriend as documented by numerous studies.  In a major study in the journal Pediatrics in 149 inflicted-injury deaths during the 8-year study period children residing in households with unrelated adults were nearly 50 times as likely to die of inflicted injuries than children residing with 2 biological parents (adjusted odds ratio: 47.6; 95% confidence interval: 10.4-218). Children in households with a single parent and no other adults in residence had no increased risk of inflicted-injury death, Schnitzer PG, (2005)..

Forgiveness education in the classroom

Excessive anger and defiant behaviors are an increasingly serious problems in the classroom. One student refuses to do her/his work. Another lashes out at a teacher who tries to help. A third student deliberately disrupts the classroom making it impossible for the teacher to perform her job.

Research by Dr. Robert Enright and his associates at the University of Wisconsin, Madison, has shown that forgiveness education programs in schools can have a positive impact on the mental health of children by diminishing levels of anger in students (Enright, et. al., 2007.) We have described in an article, Learning to Forgive, in The American School Board Journal, www.catholiceducation.org, how educators employ the virtue of forgiveness in their classroom for angry students and how they can teach this virtue.

Heroic Goal - No Expressed Anger in the Home

We communicate to the families and couples who see us that a major goal in the protection of the psychological well being of children and parents is to help everyone in the family learn how to master their anger so that its expression can be brought to an end.  This goal can be attained by understanding the nature of anger, its origins and the most effective method of resolving it - forgiveness.  Parents and children can grow in their understanding and use of immediate and past forgiveness exercises that are explained in depth in the martial anger chapter at www.maritalhealing.com.

An essential aspect of protecting children from anger is to limit the significantly the amount of screen time in the home and to prohibit viewing violent movies and using violent video games.

Medication

Medication has been helpful in decreasing ODD while uncovering the causes of anger and working on growth in virtues. A 1999 study reported that stimulant medication produced significant improvement both in ADHD-related and oppositional behaviors (MTA Cooperative Group, 1999.) Other research has provided evidence for the effectiveness of mood-enhancing medication (SSRIs) in children whose oppositional behavior (Garland EJ, 1996.)  Atypical anti-psychotics have also been useful in some highly disruptive children with ODD, however, they must be used only for brief periods because of their association with type II Diabetes in youth.  Patients with ODD and CD with severe aggression may respond well to risperidone, with or without psychostimulants, (Turgay, A. 2009.)

A major concern in regard to medication in children is that from 1992 to 2002, the prescription of atypical anti psychotics for the treatment of aggressive and disruptive behaviors in children increased seven fold, (Correll, CU, et al. 2006 and Olfson, M, et al. 2006,)  This research clearly demonstrates both the growing problem of excessive anger in our children and the need for alternative approaches for teaching children how to master their anger. 

The Challenge of Medicating Youth and Type II Diabetes

Atypical antipsychotic drugs are regularly prescribed for the treatment of bipolar disorder and excessive anger in children and adolescents in addition to mood stabilizing drugs. In the United States, the estimated number of office-based visits by youth that included antipsychotic treatment increased from approximately 201,000 in 1993 to 1,224,000 in 2002.  From 2000 to 2002, the number of visits that included antipsychotic treatment was significantly higher for male youth (1913 visits per 100 000 population) than for female youth (739 visits per 100,000 population), and for white non-Hispanic youth (1,515 visits per 100,000 population) than for youth of other racial or ethnic groups (426 visits per 100,000 population). Overall, 9.2% of mental health visits and 18.3% of visits to psychiatrists included antipsychotic treatment.  From 2000 to 2002, 92.3% of visits with prescription of an antipsychotic included a second-generation medication. Mental health visits with prescription of an antipsychotic included patients with diagnoses of disruptive behavior disorders (37.8%), mood disorders (31.8%), pervasive developmental disorders 17.3%), and psychotic disorders (14.2%) (Olfson, Blanco, Liu, Moreno, & Laje, 2006).

The trends in prescriptions of antipsychotics within the Texas Medicaid Program demonstrated that the prevalence of atypical antipsychotic use increased by almost 500% over 5 years, with an increase of 609% in children 5 to 9 years old (Patel, Sanchez, Johnsrud & Crismon, 2002).  Nearly 25% of youth on antipsychotic medication in one study were aged nine years or younger and nearly 80% of these were boys (Curtis, Masselink, Ostbye, Hutchinson, Dans, Wright, et al., 2005).  Further, prominent differences in psychotropic medication treatment patterns exist between youth in the US and Western Europe with 1.5-2.2 greater use in the U.S.(Zito, et al., 2008).

Other treatment options for disruptive mood and excessive anger in youth, such as forgiveness therapy, need to be considered in view of the recent reports of serious side effects from the use of atypical antipsychotics. Specifially, a 2013 retrospective cohort study of youth in the Tennessee Medicaid program with 28,858 recent initiators of antipsychotic drugs and 14,429 matched controls showed that the users of antipsychotics had a 3-fold increased risk for type 2 diabetes that increased with cumulative dose (Bobo, et al., 2013).

Alternative Placement

Some parents find that if numerous attempts to resolve their child’s disruptive, defiant, disrespectful and angry behaviors fail that it may be necessary to consider removing their child from the home. This is particularly the case when the angry behaviors begin to have a negative effect upon the physical and emotional health of a parent or other siblings. Successful alternative placements have been with other relatives, friends and even in boarding schools. A guiding principle in these cases is to protect the spouses and children from the harmful effects of a child’s excessively angry and defiant behaviors and to not enable it. Too often parents err by not taking stronger steps to protect their family from the harmful effects of ODD anger in a their child.

Faith and Anger

In year four of a 12 year study of excessive anger in children in Belfast and in Milwaukee Dr. Robert Enright, U. W., Madison) reported that more robust research findings are found for forgiveness use in angry children when the option of spiritual forgiveness is offered, (Enright, R., et al. 2007. Reducing anger through forgiveness education: Teacher-led curricula for primary grade children in impoverished and violent communities. J. Research in Education, Fall, pp. 63-78.)

We have found that in Catholic families the regular reception of the sacrament of reconciliation is very effective in diminishing intense irritability.

Reasons for Hope

Fortunately, some ODD behaviors resolve in children as they grow in maturity.  Also, both clinical experience and the research findings on angry children by my colleague, Dr. Bob Enright at the University of Wisconsin – Madison demonstrate the remarkable benefits of teaching children how to master and resolve their excessive anger and subsequent defiant behaviors through growth in the use of the virtue of forgiveness and in other virtues such as generosity, patience and self-denial.  As parents learn to master their own anger by the use of immediate and past forgiveness exercises, they will be more helpful and effective role models for their children.  Also, we hope that in the future research studies will done in angry, defiant children which compare the use of medication with the psychotherapeutic use of forgiveness.

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