When observing and diagnosing behavior in children, it is very important to differentiate between aggression and hyperactivity. Hyperactivity is not synonymous with being oppositional or aggressive. Whereas hyperactivity is a defining feature of ADHD, aggression is not. Similarly, a child with Oppositional Defiant Disorder (ODD) is oppositional with rules at home and/or in school, but they are not physically aggressive. There are disorders where aggression is a defining feature or an inherent part of how we conceptualize the disorder.
For example, one way to understand depression is that it is the result of aggression being directed toward the self. Sometimes aggression is not buried deep beneath the surface as in depression, but percolates just below the surface and erupts periodically. This is the case with the Impulse Control Disorders where the person cannot resist the urge to express an aggressive impulse that is harmful to himself and/or others. The DSM lists five Impulse Control Disorders: Kleptomania, Trichotillomania, Pyromania, Compulsive Gambling, and Intermittent Explosive Disorder.
Intermittent Explosive Disorder is a disorder where a child will react to a stimulus with an explosive, aggressive act that is completely out of proportion to the stimulus. For example, a child may be told that they cannot have a toy, and as a result they have severe tantrums that include: kicking, biting, yelling, turning over desks, throwing chairs, and destruction of property. During these episodes, some children will run out of school and off school property, in any direction, so they can burn off the energy they are experiencing. After these intense discharges of energy, some children become exhausted and fall asleep. These explosions are not intentional and many children do not remember what they did while in this state, so they have difficulty expressing remorse. Other children will remember what they did and may or may not express remorse. Children with this disorder are usually described by their parents as sweet and considerate and they often have many friends. These children cannot predict or control the explosions of anger and aggression that they experience.
If left untreated, Impulse Control Disorders usually get worse as the child matures, especially with boys who get older and stronger and can become more destructive. Once children become adults, the law will not accept the explanation that they could not control their urges. Consequently, these disorders must be treated as soon as they are recognized.
A family history often reveals that other people in the family have impulse control issues. These traits are described as familial, because it is unclear how much of the behavior is genetically determined and how much is learned. Like many personality traits, parents often notice these aggressive traits in their children at a very young age, even as toddlers. They may report that, when angry, their toddler banged their head against the wall or floor. Parents may have been uncomfortable leaving their more aggressive child with their other children. Sometimes relatives of the child have a mood disorder where extreme shifts in energy levels can lead to irritability, anger, and displays of aggression.
Impulse Control Disorders can be treated with psychotherapy and medications, such as antidepressants and anti-anxiety medications. Medications that are usually prescribed for mood disorders or psychotic disorders may be prescribed in low doses for Impulse Control Disorders because of their effectiveness in stabilizing mood and aggression – not because the child actually has a mood disorder or is psychotic.
It is important to notice if a child becomes more aggressive during certain times of the year. Stressful periods of time, such as finals or exams times, can make a child more likely to have aggressive explosions. The onset of sunlight in the spring has been known to contribute to manic episodes in people with bipolar disorder and aggressive behavior in individuals who have Impulse Control Disorders. One ten-year-old child I had treated had explosive tantrums every year since age four, but the tantrums started in April or May and ended with the onset of summer.
Many children with Impulse Control Disorders are angry for a variety of reasons – abuse, neglect, trauma, loss, economic and family stress can all be contributing factors. Some children are not angry because of life events, but rather because of a personality style. In some cases their limited vocabularies cannot express their anger or they may be discouraged from expressing anger by adults. If a child can learn how to express their anger verbally, they will be less likely to explode because they will use words to constantly relieve the tension we all experience from an accumulation of small annoyances. A combination of play and talk therapy can be tailored to the needs of the child, which will change as the therapy and their relationship with the therapist develops.
The therapist must be able to tolerate and encourage the expression of anger, aggression and other “negative” emotions in order for the child to learn how to express their impulses in socially acceptable ways, through language, art, music, sports or any of the other ways that healthy people channel their natural aggression.
Jonathan Bellin, LCSW is a child, adolescent, and adult psychotherapist in private practice in Riverdale. He received his Master in Social Work from Yeshiva University and is a Supervisor and Field Instructor at the Northside Center for Childhood Development in Manhattan. Visit his website, www.jonathanbellin.com or email jonathanbellin7@gmail.com.