Managing anger in adolescents

At first sight you might not think that a young person with anger issues is not part of your remit as a general practice nurse (albeit it may well be for those of us who are also parents). But in some instances, this is very much a medical problem, where a well-informed and empathic nurse can make a significant contribution

It can feel very difficult to be a teenager. Adolescence is a time of flux, of movement between childhood and adulthood, and of huge physical, emotional, and psychological changes. It’s also a time of starting to understand and accept yourself, and also to understand and get to grips with the important moral issues and dilemmas of the world, and this can be disturbing and challenging.

Some teenagers seem to coast through all this, but others find themselves in significant difficulty. Half of all lifetime mental health disorders start by the mid teens, including psychotic disorders, depression, personality disorder and substance misuse and its consequences. People handle frustration and stress in different ways because of specific situations, outside issues and personalities. Some get depressed, some become more resilient and some get angry.

Many teenagers feel angry, and develop problems managing their anger.

In this article we discuss the particular problems of anger management in adolescent patients, although many of the suggested resources will offer help with many areas of teenage life.

IS TEENAGE ANGER A MEDICAL PROBLEM?

Anger can cause distress and family dysfunction, and can lead onto other more serious issues. The practice nurse is well placed to spot teenagers asking for help. Adolescent patients consult frequently, and often see the practice nurse. Many will attempt to raise issues that disturb or concern them – many more will look for an opportunity to do so but won’t see one. It is important for practice nurses to think about adolescent patients they see on their practice list, be open and listen for the signs that the apparent presenting complain is not the only one.

Of course NHS does not have the manpower or the resources to nurture all teenagers through normal adolescence. However, it is very important that we offer a listening ear to those who seek us out and point them in the direction of resources that CAN help them.

At the same time we need to spot those who really need medical help. We must use focused history and examination to detect those adolescents – and families – who display early signs of significant mental health issues or who may be at risk of the consequences of more severe dysfunction and distress such as family breakdown, truancy, mental health problems, drug misuse, teenaged pregnancy, suicide, isolation, extremism and violence.

RANGE OF ISSUES

Anger in adolescence may present in the surgery in many ways. The person consulting may be the parent, the child or another concerned individual.

It may present openly as an anger management problem, or through associated problems such as:

• Family dysfunction
• Violence
• Aggression
• Isolation
• Rejection
• Depression
• Criminality
• Eating disorder
• Loneliness
• Educational deterioration
• Self-harm
• Running away
• Suicide attempts

OPENING PANDORA’S BOX: BARRIERS TO DIAGNOSIS

It should be easy to spot the angry teenager – but it isn’t always so, there are multiple barriers – doctor and nurse barriers, patient barriers and family factors.

Health professional barriers include:

• Surgery process designed to persuade patients to raise one issue only
• Worsened by expecting patient to tell the receptionist, first, what the issue is
• Emphasis on need to be only ten minutes
• Difficulty making accessible and confidential consultations
• Fear of discovering multiple difficulties in a ten-minute consultation which was supposed to be about a sore toe
• Fear of having nothing to offer

Patient factors include:

• Confidentiality concerns
• Not knowing how to ‘open’ the conversation
• Not expecting anything useful to happen
• Not being able to frame the problem

WHAT IS ANGER?

Anger is a normal human emotion, a way of releasing mental and emotional pressure. It can be seen as

• A defence mechanism
• A coping mechanism
• A means of displacing other difficult emotions.
• A reasonable response in some circumstances

Getting angry is normal, but letting anger get the best of you is not.

Anger is not present alone. It is often triggered by other difficult feelings such as hurt, frustration or sadness, and can be a means of deflecting or avoiding these emotions. Sometimes getting to the root cause of the anger can defuse it, by analysing the real problem and learning to deal with it rationally.

WHAT’S THE PROBLEM WITH ANGER?

Anger can be overwhelming, and it can be difficult to know what to do with it.

Although anger can produce physical and emotional discomfort, it is the manner of expressing it that can cause the problems. Anger leads to acting rather than thinking, and therein lies the difficulty.

A teenager who can’t cope with angry feelings may feel a strong desire to act directly on the feelings, even when it puts them or others at risk or leads them to actions which, when not angry they would consider reprehensible.

Dealing with the consequences is then as much a problem as the anger itself.

Anger produces moves outward, usually towards another person. It tends to discharge onto other people or objects. This can involve punching inanimate objects, getting into fights and upsetting much-needed friendships. People can make poor decisions when they are angry.

Managing anger involves helping the teenager understand that anger is a normal feeling, but the way they choose to deal with it is a choice. They need help to find different strategies that won’t cause harm or destroy their life-relationships.

ASSESSING ANGRY TEENAGERS: INTERVENTIONS FOR HEALTH PROFESSIONALS

When a teenager wants to talk about anger issues then, as in any consultation, you need to focus on the problem, find out what’s been happening and try to help find solutions. Building rapport is very important, but beware of promising absolute confidentiality – you may hear something that you cannot keep confidential.

Listen to them

• Use active listening. Let them talk
• Understand their life situation
• Make time: make it clear you have time
• Acknowledge their feelings. Put the problem on the table and look at it together
• Find out what they feel and do when they’re angry
• Ask what negative consequences have there been
• Find out what the young person feels about their family. It helps gain confidence and make a plan
• Find out who they talk to (ask about online influences).

Check sensitively

Be alert to worrying features, such as:

• Self harm
• Interest in suicide
• Cruelty to animals
• Disordered thoughts and ideas
• Suggestions of internet grooming
• Isolation from peers and family
• Use of drugs, alcohol
• Risky sexual behaviour

Talk to them about anger

Draw them a diagram of feelings leading to actions and the alternatives of thought and time out.

Tell them that anger is an altered physical state.

Discuss how this feels. Explain how anger is an emotion not an act.

Discuss the difference between anger and aggression. Try to find common ground around the fact that some actions are harmful and should be avoided.

Make it clear that you would like to help.

Box 1 offers pointers to help them recognise that their anger may be a problem.

Box 2 shows them how to recognise the signs of anger build-up.

Get them to list the problems in their lives

Can they see where the anger is coming from?

Work out with them which problems to look at first – choose one.

List all possible solutions – advantages and disadvantages.

Offer solutions

Make a printout for your practice of the kinds of solutions suggested in articles like this one.

Discuss with the teenager strategies such as those in Box 3

Offer review – take ownership of the problem, be interested.

Explain how the teenager can return to see you if they wish to do so.

RESOURCES FOR ADULTS AND TEENAGERS

Working out where to send angry teenagers and their families for further help is not always easy. Local resources may be restricted to the most severe cases, and there may be long waiting times.

Local resources

Compile a list of the resources available to teenagers in your area. This may include youth clubs and youth workers as well as the local Connexions service.

Schools

Find out which school they are at. Schools have access to psychology services and will be able to offer support if the problem can be shared with them.

Local psychiatry and psychology services

Find out whether local psychologists and child psychiatrists will see angry teens – and which ones they will see (most adolescent psychiatry services restrict new referrals tightly). There may also be private psychologists and family therapists for those who want to pay for help. Family therapy, where available, can address the problems through involving the whole family. This takes a lot of co-operation, and in families in which there are breaks and remarriages this may not always be possible.

Websites

Choose websites you feel are helpful. Direct the teenager to them but support this with a printout and an explanation as to why you feel the site is good. Avoid letting them feel fobbed off.

CONSULTING WITH PARENTS

Your consultation may be with or may include the parents too. Even if they’re not there, offering them strategies will also be helpful. It will also help the teenager to know that they are not the only person who has to change something in order to solve the problem. Box 4 includes anger management strategies for families.

Teenagers often don’t want to talk to their parents. This lack of conversation leaves many parents feeling shut out from their adolescent’s world. There are some strategies parents can use to encourage teenagers to talk:

Listen and reflect

When your teenager talks to you, don’t jump in and automatically share your opinion. Instead, reflect what you hear to show that you’re really listening.

Show respect and good manners

We are less tolerant with our families than with strangers. Avoid using harsh words that you wouldn’t say to a stranger. Don’t respond to disrespect from your teen with equally disrespectful behaviour. You’re the adult.

Acknowledge how they feel

This doesn’t mean you have to agree. For example, ‘I can hear how frustrated you are.’

Try to change the way you talk to them

If your current attempts to talk to your teen don’t seem to be working, break the pattern and try something new to see if it encourages him or her to talk.

Listen more than you talk

Listening will get you much further than talking. Be willing to hear what your teen has to say. Use active listening skills to show that you really want to understand. This means things like repeating words back, prompting them to continue, mirroring their posture and concentrating on them.

Ask questions that help them find the answer

Open questions are better than closed questions, generally. Be curious and interested, not nosy or prying.

Put the problem on the table

Teens need to start learning how to solve problems but you can help. Don’t give the problem straight back to them but don’t keep it either. Put it on an imaginary table between you and look at it together.

Try to be credible

One common barrier is that teens think their parents can’t possibly relate to what they’re going through. Saying ‘I was a teenager once’ won’t help. Instead of telling them that you understand, show them you are trying to understand.

SUMMARY

It is important to be alert to the possible presence of an unhappy teenager with an apparently trivial problem, and to be prepared to ask open questions. If you are busy and in a short triage appointment then take ownership of the issue, spend a little time now with the teenager but make them an appointment they can keep later and have the surgery phone or text them to remind them to come.

There are a great many strategies and ideas the practice nurse can offer to teenagers and their families where anger is an issue. If you are interested in helping teenagers you can easily develop the skills to help with anger management. If you are interested and empathic word will spread.