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A New Approach for Handling "Explosive Children"
One of the most frequent questions I receive from parents concerns how they should deal with their child's temper outbursts and "explosions". Although such characteristics are not part of the core symptoms of ADHD (click here for complete diagnostic criteria), and can certainly occur for a variety of reasons besides ADHD, such explosiveness does seem to be more common among children with ADHD and is often a major source of concern.
I just finished an excellent book called The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, "Chronically Inflexible" Children. The book is authored by Dr. Ross Greene, a clinical psychologist on the faculty at Harvard Medical School. I purchased this book hoping for some helpful insights for dealing more effectively with my own charming but difficult 3-year-old. The approach described by Dr. Greene impresses me as a very thoughtful and useful approach that may be helpful to many parents, and I wanted to share his ideas with you.
What Are The Common Characteristics Of Inflexible-explosive Children?
It is important to begin by noting that the label "inflexible- explosive" is certainly not a diagnostic term recognized in DSM-IV - the official diagnostic guide for psychiatric disorders. Instead, it is used by Dr. Greene to capture the key features of children who can be extremely difficult for parents to manage. According to Dr. Greene, the key features of such children are the following:
1. A Remarkably Limited Capacity For Flexibility And Adaptability And A Tendency To Become "incoherent" In The Midst Of Severe Frustration.
These children are much less flexible and adaptable than their peers, become easily overwhelmed by frustration, and are often unable to behave in a logical and rational manner when frustrated. During periods of incoherence, they are often not responsive to efforts to reason with them, which can actually make things worse.
Dr. Greene refers to these episodes as "meltdowns", which strikes me as a very apt description. Because a child's ability to think clearly during a meltdown is essentially nil, their behavior can appear exceedingly wild and irrational. Cursing, screaming, breaking things, and physical aggression are quite common during these episodes, which can last from several minutes to several hours. Dr. Greene believes that the child has little or no control over his/her behavior when in the midst of a meltdown.
2. An Extremely Low Frustration Tolerance Threshold.
These children often become overwhelmingly frustrated by what seem like relatively trivial events. Because their capacity to tolerate frustration does not develop at the same rate as their peers, the child often experiences the world as an extremely frustrating place filled with people who do not seem to understand what they are experiencing.
3. The Tendency To Think In A Concrete, Rigid, Black- And-white Manner.
These children fail to develop the flexibility in their thinking at the same rate as peers, and tend to regard many situation in an either-or, all-or-none, manner. This greatly impairs their ability to negotiate and compromise.
4. The Persistence Of Inflexibility And Poor Response To Frustration Despite A High Level Of Intrinsic Or Extrinsic Motivation.
In other words, even very salient and important consequences do not necessarily diminish the child's frequent, intense, and lengthy "meltdowns". This means that typical approaches of consistently rewarding a child for desired behavior and punishing negative behavior may not make a dent in the child's tendency to "fall apart". According to Dr. Greene, traditional behavioral therapy approaches for such children often don't work at all and can actually make things worse.
In addition to these key features, Dr. Greene notes that a child's "meltdowns" often have an "out-of-the-blue" quality, occurring in response to an apparently trivial frustration even when the child has been in a good mood. As a result, parents never know what to expect - i.e. all hell can break loose at seemingly any moment. These children may have a specific issue about which they are especially inflexible (e.g. the food they will eat, the order in which certain things need to be done), or can be this way about multiple issues.
What "causes" A Child To Be This Way?
According to Dr. Greene, there are a variety of "pathways" that a child may move along towards developing these "inflexible and explosive" characteristics. For the most part, he seems to believe that all of these pathways are predominantly biological in nature, and that most children who become extremely inflexible and explosive do not do so in response to "poor parenting". How parents respond to these biologically- based vulnerabilities in their child, however, can have important implications for how well their child is able to master his or her problems over time.
Below is a brief description of the different characteristics that are identified as predisposing a child to become highly inflexible and explosive. Bear in mind that this is probably not an exhaustive list (some would suggest that allergies - espcially food allergies - should be on this list) that not every child with any of these characteristics will display the kinds of problems that Dr.Greene describes, and that some children will possess more than one of these "predisposing" attributes.
Difficult Temperament - By nature, some infants come in to the world being more finicky, emotionally reactive, and more difficult to soothe than others. For example, with my younger daughter, almost anytime she was awake during her first 6 months she was crying. Calming her down and soothing her was all but impossible with anything other than letting her nurse. As she grew older, she continued to get upset easily, to be virtually impossible to distract when she got her mind on something (which is a real problem when it is something she can't have or do), and to display her negative emotions in intense and persistent ways. Undoubtedly, we've made mistakes in how we have tried to deal with these difficulties, and these have probably contributed to their ongoing nature. The bottom line, however, is that this was essentially how she came into the world. These "innate" aspects of personality are what psychologists refer to as temperament. (Note: It is important to recognize that even very difficult temperaments can be modified over time and this in no way "dooms" a child to a life of ongoing difficulty and struggle.)
ADHD And Executive Function Deficits
Many children with difficult temperaments also wind up being diagnosed with ADHD at some point. As discussed in a prior issue of ADHD RESEARCH UPDATE, current conceptualizations of the core difficulties associated with ADHD focus on deficits in a crucial set of thinking skills called "executive functions". Although there is no universal agreement on the specific skills that constitute executive functions, the typical list of such skills would include such things as: organization and planning skills, establishing goals and being able to use these goals to guide one's behavior, holding information in memory, selecting strategies to accomplish these goals and monitoring the effectiveness of these strategies, being able to keep emotions from overpowering one's ability to think rationally, and being able to shift efficiently from one cognitive activity to the next.
Deficiencies in these skills are believed to help explain not only the core symptoms of ADHD (i.e. inattention and hyperactivity/impulsivity), but also to the poor tolerance for frustration, inflexibility, and explosive outbursts that are seen in "inflexible-explosive" children. For example, if a child has difficulty shifting readily from one activity to the next because of an inherent cognitive inflexibility, it may explain why he or she becomes so frustrated when parents request that he/she stop playing and come in for dinner. Such a child may not be intentionally trying to be non-compliant, but their non- compliance may instead reflect trouble with shifting flexibly and efficiently from one mind-set to another.
Language Processing Problems
Language skills set the stage for many critical forms of thinking including problem solving, goal setting, and regulating/managing emotions. Thus, it is not surprising that children with less well- developed language abilities - either in receptive language (i.e. taking in and understanding what is said) and/or expressive language (i.e. communicating their thoughts and ideas clearly to others) would be at risk for dealing effectively and adaptively with frustration. Dr. Greene believes that such language difficulties often contribute to the problems displayed by children he describes as "explosive".
Mood Difficulties
Some children are born predisposed to perpetually sunny and cheerful moods; others, unfortunately, tend to experience sustained periods of irritability and crankiness. Clearly, our moods are effected by what actually happens to us in the world. Green notes, however, that there is an important biological component to one's general mood state. This is not just true for children who experience full-blown mood disorders such as depression or bipolar disorder, but can apply to "sub-clinical" mood difficulties as well.
Imagine for a moment how you tend to handle things when feeling cranky and irritable. If you're like most people, you probably become frustrated more easily and lose your temper more readily as well. So, for children who are prone to these kinds of moods, more chronic difficulties with frustration and temper are likely to be evident.
What Can Parents Do?
How does a parent go about helping their "explosive" child become less explosive, and thereby create a better quality of life for everyone in the family?
Dr. Greene begins by describing common recommendations from the mental health field that often fail to bring the desired relief. First, of course, is the use of medication. Dr.Greene does not appear to be anti-medication, and we certainly know that for children with ADHD, properly prescribed medication often helps, not just with the core symptoms of ADHD, but also with the associated behavior problems such as the explosive outbursts that are the focus of this book. For a number of children with ADHD, however, and certainly for children who are prone to explosions for a variety of the other possible reasons outlined above, medication may often fail to provide a significant benefit. In the book, Dr. Greene describes a number of children he worked with who had been tried on a variety of different meds with limited or no success.
Another common approach - and one that is especially likely to be recommended by child psychologists - would involve behavioral intervention. The basic idea is that by consistently rewarding a child for good behavior, and consistently "punishing" them when they "explode" (e.g get angry, throw stuff, curse, etc.) the child will eventually learn that their tantrums fail to produce any desired consequences for them and these tantrums would then diminish. Essentially, through this approach, children learn that they need to obey parents when commands are given because things go better for them when they do then when they don't.
Certainly, behavioral approaches can be enormously helpful for many children and parents. The literature on the benefits of well executed behavioral treatment is voluminous, and this is one of the best-validated psychosocial interventions that exists. For children whose explosiveness stems from one or more of the reasons that Dr. Greene identifies, however, behavioral interventions may not be effective. In fact, he thinks that they can actually make things worse in many cases - increasing rather than decreasing the frequency with which a child loses control.
Here's why. According to Dr. Greene, a child who is developmentally compromised in the skills of flexibility and frustration tolerance may have difficulty switching from their agenda to their parents' agenda (i.e. responding to a parental command) regardless of how enticing the reward or how aversive the punishment is. So, if I'm a child who currently lacks the capacity to behave logically and coherently when frustrated, then punishing me for telling you to "shut up" when I've become frustrated may make you feel better because you "didn't let me get away with it", but it won't make me any less likely to do the same thing next time. Why? Because the threat of consequences simply can't have an effect on a child who is in a state of mind where they are so upset that the liklihood that they will consider the consequences of their actions is nil. The analogy is that punishing a child with a reading disability for doing poorly on a reading test won't result in better performance on the next test.
It is important to note that this notion runs counter to what many parents and professionals instinctively believe to be true. The widely held belief is that if a child misbehaves, then he or she needs to be punished. If the child is not punished, they will simply not be deterred from continuing to misbehave, and even to get worse. Thus, Dr. Greene's thesis here is a controversial one. I am certainly not suggesting that these ideas are "correct", but do think this is a very useful perspective to consider. From my own experience, I can honestly say that no matter how consistently I might "punish" my younger daughter for getting angry and telling me to "shut up", the impact this has had on helping her to stay in better control - or at least to refrain from telling me to "shut up" when she loses control - has been a BIG FAT ZERO. Perhaps this is not an unfamiliar situation for some of you as well.
If These Options Don't Work, Than What?
Developing an effective approach to dealing with explosive children is the heart and soul of Dr. Greene's book, and I can not really do justice to it in this brief review. I will, however, try to convey the basics of his approach to provide you with a general understanding of the framework that he recommends. Specific strategies about what to do are provided in abundant detail in his excellent book.
The first step is to develop a clear understanding of the reasons for your child's explosiveness.
This is the key first step. To the extent that parents - and others - regard a child's explosiveness as reflecting deliberate and willful attempts to "get what they want", the overwhelming tendency will be to respond in punitive ways. As noted above, however, punishments will not be successful with a child who lacks the skills to handle frustration more adaptively and, who, when frustrated, can not possibly use the anticipation of punishment to alter their behavior.
When one's mindset changes from "my child is acting like a spoiled brat" to "my child needs help in learning to deal with frustration in a more flexible and adaptive manner", one can move from a punishment-oriented approach to a skills-building approach.
Dr. Greene talks about how parents can create a "user- friendly" environment for their child that can dramatically reduce the number of explosive outbursts. Doing so involves a combination of steps including:
Making Sure That All Adults Who Deal With The Child Have An Accurate Understanding Of The Child's Unique Difficulties, Especially Those That Contribute To The Child's Explosiveness. (note: Consultation With A Mental Health Professional To Get An Accurate Understanding Of These Difficulties Can Be Absolutely Essential.)
Parenting Goals Are Judiciously Prioritized Such That The Demands For Flexibility And Frustration Tolerance That Are Placed On The Child Are Reduced.
In other words, parents have to make a concerted effort to make life easier and less frustrating for their child. Just like a child with a reading disability requires accommodations in what they are expected to do academically, a child with a "disability" in tolerating frustration requires analogous accommodations. This can be difficult for parents - and teachers - to do, particularly as long as the child's behavior continues to be regarded as deliberate and willful. Specific recommendations that Dr. Greene provides to accomplish this task are presented below.
Efforts Are Made To Identify In Advance The Specific Situations That Tend To Trigger Inflexible- Explosive Episodes.
Although not all explosions can be predicted, parents can often get a very clear picture of the situations that tend to be consistently difficult for their child to handle (e.g. going shopping, having to do homework, getting ready for bed.) Once these triggering situations are identified, parents can decide whether they can be avoided altogether to reduce the child's frustration, which can be altered in ways that make it easier for the child to deal with, and which are, unfortunately, unavoidable. For example, for a child who has meltdowns in a store when he/she can't get what she wants, simply not taking them with you as infrequently as possible can be quite helpful until they develop the skills to handle their frustration better. With homework, accomodations can often be made in terms of the amount of work the teacher requires the child to do.
Parents Recognize That A Child's Behavior During Meltdowns For What They Really Are: Incoherent Behaviors.
When a child has begun to lose control - or has already lost control - and starts screaming and cursing at a parent, it can be excruciatingly difficult not be become angry and hurt. As a result, it is all too easy for parents to get drawn into making a punitive response, or a demand on their child ("You apologize now!") that only serve to add fuel to the fire.
As tempting as such responses are, Dr. Greene suggests that parents carefully consider whether they really accomplish anything positive. For example, he talks about asking many parents whether their history of punishing their child for such behavior has had any effect at all in reducing the likelihood of such behavior occurring the next time the child becomes frustrated. When many parents consider this question, they realize that it has not. So, if the primary reason for punishing a child is to change the child's behavior, and this is clearly not working, one can legitimately question the utility of punishment.
When behavior that occurs in the midst of a meltdown is seen instead as incoherent behavior that the child can not currently control, a different mind set is possible. One can focus instead on how to help the child regain control, which will inevitably lead to the end of the behavior that parents find so upsetting and offensive.
A critical belief that underlies this approach is that the vast majority of explosive children really do want to behave better and feel badly about their outbursts. Thus, they are already motivated to change their behavior but just lack the skills to do it. Therefore, they don't need more motivation to behave better (increasing motivation is what rewards and punishments are supposed to do). Instead, they need to acquire the skills that will help them to achieve something they are already motivated to accomplish.
The "basket" Approach
When a child is experiencing frequent meltdowns, the toll on the child, parents, and siblings can be enormous. Unfortunately, I speak from some experience on this topic, as my younger daughter is prone to the types of episodes that Dr. Greene describes.
Because such explosions are so difficult for everyone in the family to endure, the primary objective in working with such children is to first reduce the frequency of such episodes. For example, just reducing the number of meltdowns from several per day to one per day, and eventually to just a handful per week, can make an enormous difference in the quality of family life. Initially, this is accomplished largely by reducing the demands to tolerate frustration that are made on the child. Dr. Greene refers to this as the "basket" approach.
Basket A
Some behaviors are clearly so important that they have to remain non-negotiable, even if enforcing them will result in setting off a meltdown. Initially, Dr. Greene suggests that the only behaviors to be placed in Basket A are those that are clear safety issues (e.g. wearing a seat belt in the car; not engaging in dangerous or harmful behaviors such as hitting others). These core behaviors that have clear safety implications are where parents must continue to stand firm and require compliance on.
As important as these Basket A behaviors are, it is also important to note the kinds of things that may not initially be placed in Basket A. Dr. Greene suggests that these can include such things as homework, not yelling at parents, brushing one's teeth, etc. To make it into Basket A, 3 criteria must be met:
- 1. The behavior must be so important that it is really worth enduring a meltdown to enforce:
- 2. The child must be capable of exhibiting the behavior on a fairly consistent basis.
- 3. It must be something that you are actually able to enforce.
For example, Dr. Greene would argue that there is no point insisting that completing assigned homework be placed in Basket A when there is little chance that he or she has the skills and frustration tolerance to do this consistently.
There are many things we wish our child would do that we are simply in no position to control. For example, you may want to insist that your child not hang out with certain peers during the school day, and there may be some very legitimate reasons for this. This, however, is not something that most parents are in any position to be able to enforce. As a result, you can wind up triggering meltdowns for no real reason and wind up undermining your credibility to boot.
Simply by greatly reducing the number of behaviors for which compliance is non-negotiable to those that are really essential, that the child is capable of performing, and that the parent is capable of enforcing, the number of exchanges that are likely to set off explosive episodes is drastically reduced.
Basket B
Basket B - the most important basket according to Dr. Greene - contains behaviors that really are high priorities but are ones that you are not willing to endure a meltdown over. These can include such items as completing school- work, talking to parents with respect, complying with reasonable expectations, etc.
It is around Basket B behaviors that Dr. Greene believes that critical compromise and negotiation skills can be taught to your child. For example, suppose your child is watching tv and you know it is time to stop and get started on homework. You tell your child to turn off the tv and get started, and he refuses.
The temptation here would be to insist on immediate compliance and to threaten punishment (e.g. no tv for the rest of the week) if your child does not comply. But, in Dr. Greene's framework, this is not a safety issue, and thus should not be placed in Basket A. He would ask what is likely to happen if you make such a response? One likely consequence is that your child's frustration will increase, he or she will lose control, and a full-fledged meltdown will ensue.
Is this worth it? Now, if standing firm and tolerating this meltdown really made it more likely that your child would readily comply the next time you made such a demand, the answer might be yes. If, however, standing firm and triggering the meltdown in no way increases the likelihood of future compliance or decreases the likelihood of future meltdowns, Dr. Greene would suggest it was definitely not worth it. Unfortunately, this can often be the case.
What to do instead? Dr. Greene argues that these Basket B behaviors provide wonderful opportunities to try and engage your child in a compromise and negotiation process. In the scenario above, the parent could say something like, "I know that it is important to you to keep watching tv. I would like for you to be able to do this, but I also know that you have homework that needs to get done. Let's try to come up with a compromise where you'll get some of what you want, and I'll get some of what I want."
The goal here is not just to get the child to give in and do what you want, but to begin to help your child learn the compromise and negotiation skills that will contribute to his or her gradually becoming more flexible over time. Dr. Greene points out how this process can be extremely difficult for inflexible-explosive children, and that it is not unusual for them to become increasingly agitated when trying to negotiate a solution.
As a parent, if you observe this starting to occur, and sense your child is getting closer to a meltdown, the goal becomes trying to diffuse the tension so that a meltdown does not take place. This can mean offering compromise solutions for the child in an effort to help things calm down. When this does not work, Dr. Greene suggests just letting things go so that the meltdown is avoided. In the example above, should the efforts to negotiate fail and lead the child to the verge of a meltdown the parent might say, "Well, I can see you are getting really upset about this. I appreciate that you tried to work out a compromise with me but we have not been able to come up with a good one yet. So, why don't you just watch a bit more tv for now and we can try again in a little while to work out a good compromise."
This can be very difficult to do. Certainly, many parents - and mental health professionals - would be concerned that such actions would result in teaching the child that he or she can get what she wants simply by refusing to give in and becoming upset. This is certainly what a traditional behavioral therapist would argue. From Dr. Greene's perspective, however, insisting that the child turn off the tv when a compromise was not reached would accomplish little more than triggering a meltdown that would also prevent homework from getting started on and be much more upsetting for everyone. So, instead, you do your best to help your child develop some much needed negotiation skills, but drop things when it is clear that an explosion is imminent. Later, when the child has settled back down, you can resume your efforts to negotiate. (By the way, this can also be quite beneficial in helping parents to keep their composure as well - it has certainly been that way for me.)
Developing these skills to compromise and tolerate frustration don't happen right away. Dr. Greene points out that progress in these areas can be painstakingly slow, but that over time, the approach he recommends can lead to substantial gains for explosive children.
Basket C
Basket C contains those behaviors that once seemed like a high priority but have since been downgraded considerably. These are behaviors that you simply don't mention anymore let alone endure meltdowns over. By placing a number of previously important behaviors in Basket C, the opportunity for conflict producing meltdowns between parents and their child is greatly diminished.
What kinds of things belong in Basket C? This depends on the specifics of each situation but may include such things as what a child will and will not eat, what clothes they wear, how they keep their room, etc. The question to ask in determining whether a particular behavior falls into Basket C is "Is this so important that it is really worth risking a meltdown over?" If not, and you've already identified a number of behaviors that seem more important and worth negotiating over (i.e. those in Basket B), then into Basket C it goes.
Isn't This Just Giving In To A Tyrannical Child?
Not necessarily. Dr. Greene points out that there is an important difference between giving in and deciding what behaviors are important enough to stand firm on. It remains the responsibility and prerogative of parents to be clear about what is non-negotiable, when compromise is a reasonable way to go, and what things to let slide for the time being. As the child becomes better able to tolerate frustration and learn much-needed compromise and negotiation skills, more and more behaviors can be moved from Basket C into Basket B, thus providing your child with increasing opportunities to practice learning to compromise.
Does This Approach Work?
It is important to emphasize that although Dr. Greene is a well- regarded researcher in child psychology, the approach described in this book is based primarily on his own clinical experience. He does not cite any studies in which the approach he recommends has been rigorously evaluated. So, the data to support this system is not yet available to the best of my knowledge.
That being said, I will say that I found many of his ideas to be quite sensible and compelling. For children who are prone to frequent explosions, the goal of reducing the frustration in their lives to decrease the frequency of their outbursts is critical. Also, recognizing that these explosions often reflect a real lack of ability to handle themselves more adaptively rather than being willful and intentional certainly applies to many children with these difficulties. If you buy this premise, then it is reasonable to argue that punishments won't be effective in altering this behavior. Instead, such children need to learn the skills that can help them maintain better control.
I have been trying this approach for the past several weeks with my own child and have been encouraged with the change in her behavior that has occurred so far. Things are a little better. The number of explosions has diminished and this has seemed like a major blessing. Hopefully, this progress will continue.
If you have a child who shows the characteristics that Dr. Greene describes, I would strongly recommend that you go out and purchase his book. It is thoughtful, well-written, and offers a set of ideas for helping your child that may be quite different from what you have considered. I think that it is certainly worth a careful look.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.