Opinion

Strategies for Managing Impairing Emotional Outbursts

VIEWPOINT

Jon M. McClellan, MD Impairing emotional outbursts, defined by explosive responses from parents, caregivers, and others in envi-
Department of bouts of anger or distress, are common in youth receiv- ronments where the behavior occurs.
Psychiatry and ing services in primary care and mental health clinics, Understanding the function of the behaviors is key.
Behavioral Sciences,
emergency departments, schools, juvenile justice Common goals include attention, emotional relief, avoid-
University of
Washington, Seattle. programs, and social welfare agencies.1,2 Outbursts are ance, and power and control over the environment. Al-
associated with multiple psychiatric conditions, includ- though these goals are understandable, the methods for
Lucy Berliner, MSW ing attention-deficit/hyperactivity disorder (ADHD), achieving them are often self-defeating, disruptive, or
Department of disruptive mood dysregulation disorder, disruptive be- harmful.Thetreatmentteammustidentifymodifiablefac-
Psychiatry and
havioral disorders, depression, anxiety, mania, autism tors that trigger, reinforce, and/or excuse the behaviors.
Behavioral Sciences,
University of spectrum and other neurodevelopmental disorders, psy- Then, based on the functional analysis, the treatment
Washington, Seattle; chotic illness, borderline personality traits, and trauma- team designs a behavior intervention plan to promote al-
and School of Social related syndromes. Risk factors include those specific to ternative prosocial strategies while not inadvertently re-
Work, University of
Washington, Seattle. the child (eg, temperament, sensory overload, and cog- inforcing maladaptive behaviors (eg, allowing children to
nitive and developmental lags) and to the environment escape ordinary situations or expectations, providing one-
Gabrielle A. Carlson, (eg, family conflicts, parental psychopathology and sub- on-one adult attention). Short-term worsening is likely to
MD stance misuse, maltreatment, domestic violence, pov- occur because it takes time to change entrenched pat-
Renaissance School of
erty, and racism).1 Only a few disorders specifically in- terns of behaviors.
Medicine at Stony
Brook University, clude outbursts as part of their diagnostic criteria (eg,
New York. disruptive mood dysregulation disorder, intermittent ex-
Teach and Reinforce Adaptive Coping Skills
plosive disorder), and many children and adolescents
Adaptive coping is the ability to handle conflict and frus-
presenting with severe outbursts do not meet criteria for
tration in order to function in the world. Collaboratively
these conditions.1 Although outbursts are common rea-
identifying coping strategies that children and care-
sons for clinical referrals, the lack of a single diagnostic
givers are most likely to adopt and maintain is impera-
“home” for them challenges efforts to track their fre-
tive. Practice is needed in actual stressful settings, with
quency and clinical effect on systems of care. Neverthe-
supportive coaching and reinforcement. Most impor-
less, pediatricians play an important role in assess-
tant, there must be positive outcomes or results that chil-
ment, prevention, and early intervention through parent
dren can obtain or achieve. Too often, parent-child
education and guidance.
interactions are predominantly negative, and families
find it difficult to reset the balance to reinforce positive
Context Matters
opportunities.
Emotional and behavioral dysregulation is best concep-
Basic elements of cognitive and behavioral inter-
tualized as maladaptive coping skills, including deficits
ventions, including psychoeducation, positive reinforce-
in self-calming, problem-solving, and interpersonal ne-
ment, selective attention, self-regulation, and problem-
gotiation strategies.1 Outbursts typically occur when the
solving skills, are the basis of short- and long-term
child feels overwhelmed in response to conflict and frus-
intervention and prevention.1 Therapeutic strategies for
tration over unmet needs and demands. Patterns of mal-
self-regulation include mindfulness, distraction, con-
adaptive behaviors evolve over time and, in some cases,
trolled breathing, relaxation, radical acceptance, and dis-
are the natural outcomes of neglectful or traumatic ex-
tress tolerance. 3 Interventions can be mixed and
periences. Disruptive and/or unsafe behaviors can pro-
matched, tailored to fit the developmental and psycho-
vide an escape from unwanted circumstances or de-
social needs of the child and family.
mands, and/or ensure proximity with a desired person,
need, or outcome. Children and caregivers are often un-
aware of these dynamics. Once established, maladap- Diagnosis Matters (Sort of)
tive coping strategies often persist unless caregivers Accurate diagnosis and treatment of underlying psychi-
change patterns of reinforcement, and the child is taught atric conditions that contribute to outbursts is impor-
new skills. The model of care is rehabilitative rather than tant, especially when evidence-based effective treat-
Corresponding a quick fix. ments (eg, cognitive-behavioral therapy [CBT] for
Author: Jon M. depression or anxiety, parent training for disruptive be-
McClellan, MD, Behavior Matters havior, trauma-focused CBT for posttraumatic stress dis-
Department of
Psychiatry and
Outbursts by children are remarkably effective for en- order, and medication therapies for ADHD) exist.1 For
Behavioral Sciences, gaging adults. Prevention and treatment strategies build some diagnoses (eg, psychotic illnesses), the treat-
University of on basic principles of behavioral modification and ment of the primary condition takes priority. However,
Washington, Box
contingency management.1 The goal is to teach and for most children, the initial focus should be on outburst-
356560, Seattle, WA
98195 (drjack@ reinforce more adaptive coping and problem-solving specific strategies, deferring other aspects of treat-
uw.edu). skills in the child, in part by instilling more effective ment until the behaviors are under better control.

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 Opinion Viewpoint

Psychopharmacology sary, seclusion is more developmentally appropriate, and the least

Medication therapies can be helpful for treating underlying condi-
tions that contribute to outbursts. For example, youth with ADHD
and explosive anger outbursts showed a significant reduction in
aggression when they were treated with the combination of opti-
mized stimulants and family-based behavioral therapy/parent
training.4 Antipsychotic agents (risperidone, in particular) are help-
ful for treating aggression in the context of psychosis, pediatric ma-
nia, ADHD/disruptive behavior disorders, and irritability associ-
ated with autism spectrum disorders. 1 Although health care
professionals in emergency departments and inpatient settings fre-
quently use oral as-needed medications, evidence supporting their
effectiveness is lacking.5
Inpatient and Residential Treatment
Outbursts are common reasons for referral to inpatient and resi-
dential care. Recognizing patterns of behavioral reinforcement is criti-
cally important in these settings.1 As nurturing safe havens, inpa-
tient units and emergency departments typically focus on keeping
the child safe in the moment, which may inadvertently reinforce mal-
adaptive behaviors (eg, one-on-one time with a preferred staff mem-
ber for threats of self-harm). While keeping a child and others safe
is obviously a priority, the most important goal is for these children
to maintain safe behaviors when they return home.
Seclusion and restraint should only be used for severe out-
bursts after less restrictive interventions have failed. Severe aggres-
sive or dangerous behavior cannot be ignored. Allowing a child to
destroy a unit or terrorize their peers reinforces the use of aggres-
sion as a negotiation tactic and increases the long-term risk for fu-
ture violence. In general, if physical intervention becomes neces-
reinforcing of maladaptive behaviors since staff can safely with-
draw attention until the child is calm.
Brief hospitalizations are often inadequate to treat severe out-
bursts, thus resulting in high rates of emergency department visits
and readmissions.2,6 If hospitalization is needed, the model of care
should be based on the length of time and types of treatments nec-
essary to effectively intervene, rather than an arbitrary number of
days based on funding or administrative priorities. Across the en-
tire system of care, a continuum of programs and resources can pro-
vide sustained evidence-based behavioral and cognitive-
behavioral strategies, both inpatient and outpatient (including
intensive outpatient, partial hospitalization, therapeutic school pro-
grams, and mobile response teams).7
Summary
Impairing emotional outbursts in youth significantly affect child and
family functioning and confer enormous costs and burden on sys-
tems of care. Outbursts arise in the context of different disorders
and psychosocial risk factors and often represent maladaptive or de-
ficient coping strategies. Identifying modifiable factors that trigger
and reinforce outbursts is key to preventing their recurrence. The
goal is to generalize adaptive coping across environments, using evi-
dence-based treatments that include parent management training
and interventions based on CBT, to teach the child and family more
effective observational, coping, and negotiation strategies. A shared
approach and the strategic use of well-established interventions
among health care professionals and across service systems would
go a long way toward better addressing the needs of the most chal-
lenging children and families.

ARTICLE INFORMATION
Published Online: May 1, 2023.
doi:10.1001/jamapediatrics.2023.0787
Conflict of Interest Disclosures: Drs McClellan and
Carlson reported receiving grant support from the
National Institute of Mental Health. Dr Carlson
reported receiving honoraria from the American
Academy of Child and Adolescent Psychiatry; she
also stated that her spouse sits on the Data and
Safety Monitoring Boards for Pfizer and Lundbeck.
No other disclosures were reported.
REFERENCES
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2. Cushing AM, Liberman DB, Pham PK, et al.
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doi:10.1001/jamapediatrics.2022.4885
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J Am Acad Child Adolesc Psychiatry. 2021;60(9):
1105-1115.e4. doi:10.1016/j.jaac.2021.01.016
4. Blader JC, Pliszka SR, Kafantaris V, et al. Stepped
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place: it is time to create a system of care that
works. Child Adolesc Ment Health. 2021;26(2):174-
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