Aggressive 10 year old endangers others

Hi there.  I live in Canada and apparently psychiatrists here don’t believe in diagnosing bipolar or any mood disorder for that matter in children.  My 10-year-old son has been diagnosed with ADHD and ODD and is on some pretty heavy meds.  He spent one year in a residential treatment school for his highly aggressive nature in order to learn warning signs and coping, however, he returned to his community school in January of this year and it has been a disaster.  

My son does not like competition and has been suspended for assaulting children he feels are not playing fairly.  My son felt one child in his class was asking too many questions, so took scissors and cut up the kids sweatshirt.  He has threatened to kill kids in his class.  He has delivered severe upper cuts to the face of his female educational assistant, has kicked the principal, consistently swears, and has thrown large rocks at three of his teachers earning  him not only another suspension, but a call to the Police.  When the Police arrived, my son swore at them and also threw rocks at them which resulted in him being handcuffed (for shock effect), which didn’t work.  He has run away from school on a number of occasions.  

He has angry and very physically aggressive outbursts almost on a daily basis and then becomes extremely exhausted and needs to sleep afterwards.  When he wakes up, he doesn’t want to talk about what happened, and presents as a very calm and loving child.  It’s almost as if he is possessed when he enters these episodes and then he snaps out of it.  Aside from diagnosis (which I am curious for your feedback), what therapies would you recommend?  The schools have pinpointed, for the most part, his triggers, but it has also been decided that often there is no indicator.  He has hit me, his father, his sister, his grandmother.  Thankfully, he is extremely gentle caring and compassionate with animals and is a very smart kid academically.

Any thoughts?

Hi, It sounds like your son is extremely impulsive and aggressive toward his family, teachers, and peers.  In situations where the aggressive behavior can seriously harm other people, I would recommend a residential school.  I assume the behaviors you describe have occurred since he came back home from residential treatment.  If so, it sounds like he was released too soon.  There ought to be continual supervision and a very structured environment that only a residential placement can provide.  Was there improvement while he was in that setting previously?

The change in moods sounds dramatic.  He can go from gentle and caring to extremely aggressive and dangerous toward others.  I would not rule out pediatric bipolar disorder, but I cannot make a diagnosis without being there to evaluate your son.  I describe some of the criteria for pediatric bipolar disorder in my earlier books:  "Your defiant child:  Why is nothing working?"  and "Why is my child's ADHD not better yet?"   If bipolar disorder is present, appropriate medication should be considered.

Also you would want to rule out post traumatic stress disorder (PTSD) and fetal alcohol syndrome (FAS).  The former can be caused by being exposed to violence or sexual abuse, and the latter is caused by being exposed to large amounts of alcohol in utero.   FAS children can have extremely poor self-control, and it can take years to make small gains.  For PTSD children, there is a range of functioning, depending on the abuse and on the child's make-up, but intensive therapy can often help. 

In terms of behavioral treatment for your child, adults would need to intervene as quickly as possible when he gets angry, and be prepared to use physical restraints if people's safety is threatened.  Usually ignoring outbursts is indicated, but not when someone could be seriously hurt.  If some triggers are known, adults should try to avoid them or prepare your child in advance each time a known trigger might occur.    Some other ideas are to establish distractions that are highly engaging for your child,  and to go over "catch phrases" every morning before school  like "Sometimes I'm not going to like the way other kids ask questions or play games.  No one is perfect. Turn away if I don't like something."  These possible cues are in response to the triggers you mentioned in the first paragraph of your e-mail.  These and other approaches are outlined in my workbook on anger overload.  Keep in mind that any of these behavioral approaches will not yield immediate results, especially if there is a mood disorder or other serious underlying diagnosis. 

I would also recommend having your son evaluated at a major teaching hospital mental that is known to work with severe behavior problems and is aware of the kinds of mood disorders that can occur in children.  Best, Dr. Dave Gottlieb