One of the most challenging problems is parents to deal
with is explosive outbursts in their child. Such outbursts occur with
distressing regularity in some children - regardless of whether the child
also has ADHD - and can contribute to an extremely difficult home environment.
A number of years ago I cam across a book called 'The Explosive Child: A
New Approach for Understanding and Parenting Easily Frustrated, "Chronically
Inflexible" Children' that I found to provide some very useful ideas for addressing
these issues. The book is authored by Dr. Ross Greene, a clinical psychologist
from Harvard Medical School. Dr. Greene's approach impressed me as a thoughtful
and respectful way to deal with the behavioral volatility and emotional outbursts
that often add to the challenges faced my many parents of children with ADHD.
** WHAT ARE THE COMMON CHARACTERISTICS OF
The label "inflexible-explosive" child is 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 are extremely difficult for parents to manage. According to Dr.
Greene, the key features of such children are the following:
1. A very limited capacity for flexibility and adaptability and a tendency
to become "incoherent" in the midst of severe
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 not responsive to efforts to reason with them, which may actually
make things worse. Dr. Greene refers to these episodes as "meltdowns" and
argues that the child has little or no control over his/her behavior during
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
develop more slowly than their peers, they often experiences the world as
a frustrating place filled with people who do not understand what they are
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 situations 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.
Even very salient and important consequences do not necessarily diminish
the child's frequent, intense, and lengthy "meltdowns". As a result,
typical approaches of rewarding a child for desired behavior and punishing
negative behavior do not diminish 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 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 and things can seem to fall apart
at any moment.
** WHAT CAUSES A CHILD TO BE THIS WAY?
According to Dr. Greene, most children who become extremely inflexible and
explosive do so because of biologically-based vulnerabilities and not because
of "poor parenting". The list of biological vulnerabilities that may predispose
children to develop these characteristics include the following:
- Difficult Temperament
By nature, some infants come in to the world being more finicky, emotionally
reactive, and more difficult to soothe than others. 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 are eventually diagnosed with
ADHD. As discussed in prior issues of Attention Research Update, current
theorizing about the core deficits associated with ADHD focus on problems
in a crucial set of thinking skills referred to as "executive functions".
Although there is not universal agreement on the specific skills that constitute
executive functions, most lists would include such things as: organization
and planning skills, establishing goals and being able to use these goals
to guide one's behavior, working memory, 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
the poor frustration tolerance, inflexibility, and explosive outbursts that
are seen in the "inflexible-explosive" children described by Dr. Greene.
For example, if a child has difficulty shifting readily from one activity
to the next because of an inherent cognitive inflexibility, this child may
feel overwhelmingly frustrated when parents say it is time to stop playing
and come in for dinner. The child may not intend to be disobedient,
but may have trouble complying with parents' demands because of trouble shifting
flexibly and efficiently from one mind-set to another. In fact, Dr. Greene
argues that most "explosive children" want to behave better and feel badly
about their outbursts. He believes they are motivated to change their
behavior but lack the skills to do it.
- 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 poorly developed language abilities,
as is often true in children with ADHD, would have greater difficulty managing
- Mood difficulties
Some children are born predisposed to perpetually sunny and cheerful moods.
Others, unfortunately, tend to experience sustained periods of irritability
and crankiness for reasons that are rooted largely in biology. 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
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. For children who are
prone to these negative mood states, more chronic difficulties with frustration
and temper are thus likely to be evident.
** WHAT CAN PARENTS DO?
How can a parent help their "explosive" child become less explosive, develop
greater self-control, and thereby create a better quality of life for everyone
in the family?
According to Dr. Greene, the first step is to develop a clear understanding
of the reasons for the child's explosiveness. 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. Dr. Greene argues convincingly, however,
that punishments will not work for a child who lacks the skills to handle
frustration more adaptively. That is because when these children are frustrated
they are not able to 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", it becomes easier to move from a punishment-oriented
approach to a skills-building approach. At the heart of this effort
is what Dr. Greene refers to as the "Basket Approach".
** THE "BASKET" APPROACH
Because "meltdowns" can be so difficult for everyone in the family to endure,
the primary objective in working with "explosive children" is to first reduce
the frequency of such episodes. 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 and to children developing
a sense of being able to control their behavior. Initially, this is accomplished
largely by reducing the demands to tolerate frustration that are made on the
child by sorting the types of behaviors the create problems into 3 baskets
according to how critical it is to change the behaviors or to curtail them
when they occur.
- Basket A
Some behaviors are so problematic that they must remain off-limits even
if enforcing the rule against them will result in 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). This is where
parents must continue to stand firm and insist on compliance. Dr. Greene's
specific criteria for what goes in Basket A are as follows:
1. The behavior must be so important that it is worth enduring a meltdown
2. The child must be capable of behaving in the way that is expected.
For example, Dr. Greene would argue that there is no point insisting that
completing assigned homework be placed in Basket A when the child lacks the
skills and frustration tolerance to do this consistently.
By reducing the number of behaviors for which compliance is non-negotiable
to those that are really and truly essential and that the child is capable
of performing, the number of exchanges that are likely to set off explosive
episodes can be 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
schoolwork, talking to parents with respect, complying with reasonable expectations,
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
Is this worth it? If standing firm and tolerating this meltdown made
it more likely that your child would comply the next time you made such a
demand, the answer would be yes. If, however, standing firm and triggering
the meltdown does not increase the likelihood of compliance in the future,
or reduce the probability of future meltdowns, Dr. Greene would suggest it
was definitely not worth it.
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 only to get the child to give in and do what you want,
but to begin teaching your child the compromise and negotiation skills that
will contribute to his or her 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 and many parents along with mental health
professionals would be concerned that such actions would result in teaching
the child that he or she can get what she wants by refusing to give in and
becoming upset. This is 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. Because of this,
he advocates doing your best to help your child develop some much needed negotiation
skills, but dropping things when it is clear that an explosion is imminent.
Later, when the child has settled back down, you can resume your efforts
Developing skills to compromise and tolerate frustration does not 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 are simply not worth enduring a meltdown
over, even though they may have previously seemed like a high priority. By
placing a number of previously important behaviors in Basket C, the opportunity
for conflict producing meltdowns between parents and their child is greatly
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. Dr.
Greene suggests that 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.
- How does this compare to traditional parenting
Dr. Greene's approach to dealing with explosive children runs counter to
what many parents and professionals believe, i.e. that if a child is not punished,
for behaving inappropriately they will never develop the necessary self-control
nor be deterred from continuing to misbehave. Thus, Dr. Greene's thesis here
is a controversial one and is at odds with traditional behavior therapy approaches
that have substantial research support. Dr. Greene suggests, however,
that for children whose explosiveness stems from a basic and biologically
based inability to manage frustration, Dr. Greene suggests that behavioral
interventions may not be effective can actually make things worse by increasing,
rather than decreasing, the frequency with which a child loses control.
- Isn't this just giving in to a misbehaving
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? RESULTS FROM A
Dr. Greene's approach will resonate with some people and be sharply criticized
by others. However, the hallmark of a scientist is a willingness and
desire to test one's theories through empirical research and I was thus quite
pleased to recently come across a study published several years ago by Dr.
Greene in which he tested the approach described above against more traditional
behavioral parent training therapy with a sample of oppositional defiant children
who also had symptoms of a mood disorder (Greene et al. . Effectiveness
of collaborative problem solving in affectively dysregulated children with
oppositional-defiant disorder: Initial findings. Journal of Consulting
and Clinical Psychology
, 2004, 72, 1157-1164).
Participants in this study were parents of 50 children with ODD - for a
description of diagnostic criteria for ODD see http://www.helpforadd.com/oddcd.htm
- who also had at least sub threshold features of either childhood bipolar
disorder or major depression. In addition, about two-thirds of the children
were diagnosed with ADHD and many were being treated with medication.
The parents of these children were randomly assigned to 1 of 2 interventions
designed to help them bring their child's behavior under better control: the
collaborative problem solving model developed by Dr. Greene or a more traditional
behavioral parent training program developed by Dr. Russell Barkley, one
of the world's leading authorities on ADHD.
Dr. Barkley's parent training program is a highly structured behavior management
program that lasted for 10-weeks. The focus is on teaching parents more
effective discipline and behavior management strategies and sessions were
attended primarily by parents, although children participated occasionally
Families assigned to the Collaborative Problem Solving (CPS) treatment were
educated about the biological factors contributing to their child's aggressive
outbursts, the "baskets" framework described above, and about the use of collaborative
problem solving as a means for resolving disagreements and defusing potentially
conflictual situations so as to reduce the likelihood of aggressive outbursts.
As with Barkley's parent training program, sessions were attended primarily
by parents. The number of sessions attended by parents ranged from
7-16 and the average length of treatment was 11 weeks.
At the conclusion of treatment, parents in both groups reported a significant
decline in their child's level of oppositional behavior. At 4-months post-treatment,
however, the gains reported by families who received traditional parent training
were beginning to erode while those who received Greene's Collaborative Problem
Solving therapy reported that gains were fully sustained. Specifically,
80% of children in the CPS condition were reported to be either very much
improved or much improved by their parents compared to only 44% in the traditional
parent training program.
Parents in the CPS condition also reported that they were experiencing significantly
less stress, that their children were more adaptable, and that hyperactive-impulsive
symptoms were reduced. They also felt more effective at setting limits
for their children and that communication with their child had improved.
Significant improvements on these dimensions were not evident.
- SUMMARY and IMPLICATIONS
The approach developed by Dr. Greene for developing self-control in children
prone to emotional outbursts and melt-downs represents an important shift
from traditional behavioral treatment methods. It is based on the premise
that when this behavior has a strong biological underpinning, as he feels
is true for many children, the use of punishments and rewards are not likely
to be effective. Instead, he advocates that parents work to remove sources
of frustration from their child's life, become clear about what behaviors
they truly need to take a stand on, and focus on helping their child develop
the ability to negotiate, compromise, and manage their affect. Because
melt-downs can be so painful for everyone to endure, parents are taught to
avoid making demands on their child that would be likely to trigger a melt-down
unless it is absolutely necessary.
This will be regarded by many as a controversial approach, but results from
a preliminary test suggest that these ideas may have real value for children
and families. Because this is only an initial study, however, it is
clear that more work needs to be done, and there is currently a larger trial
underway. When these results become available, I will make sure to report
them in Attention Research Update.
For those of you who would like to learn more about these interesting ideas,
there is an excellent web site at http://www.livesinthebalance.org/
where you can find a wide range of additional information on this approach.
Another excellent site to visit developed by Dr. Greene is at http://cpsconnection.com/
you will find these sites to be worth visiting.