8 yr old with anger and anxiety: therapy or medicine?

Dr. Gottlieb,

I came across your website while searching for a way to help my 8 yr old son.  My son is very intelligent and does very well in school.  About 7 months ago his 2nd grade teacher suggested to us he may have ADD, and suggested we talk with our pediatrician.  We all filled out surveys on my son, and the pediatrician put him on Quillivant XR - which I understand is a liquid, long acting form of Ritalin.  We started at 20mg in the morning before school.  The teacher, who we like and respect, said she noticed a difference at school even though we did not see a difference in behavior at home. The pediatrician recommended raising he dosage to 40mg per day.  We tried 40mg for a couple of days, and he really seemed out of it.  We lowered his dose to 30mg per day, and he has been taking this dose for a couple of months.

Now that he is home most of the day for summer vacation we can observe his behavior all day.  Not only do we think the medication is not helping, it may be making his behavior worse.  I believe he has above normal anxiety, like me.  I believe his angry outbursts are because of fear and anxiety and lack of self control.  Your article on anger overload describe him very well.

I have two questions.  How do we find a therapist who is familiar with your concepts of anger overload in children?  Also, is there a medication we should consider to help him with anxiety?

I appreciate your time an advice.

Hi, To find a therapist in your area who is familiar with anger problems, I would first ask your pediatrician or school social worker.  You would want a therapist who works with children and with the parents, since many of the anger overload strategies are practiced at home with the parents.   Another possibility is to check with the mental health department of a teaching hospital in your area.  Ask the mental health professional if he has worked with anger issues, and maybe show him my blog or parent's manual to see if he/she could help your son develop self control strategies.   If anxiety is a related problem, you would want the therapist to address this issue as well.  

Regarding the ADHD medication, sometimes ADHD is misdiagnosed in young children, but sometimes the medication is helpful in school, and not so much at home.  In school, the demands to sit quietly and listen are greater than in the home where children can move around and switch activities more freely.  Also, some children do better on a lower dose of medication.  You will see next school year if your son does well in school without the ADHD medication.  Furthermore if he responds to treatment for anxiety and anger overload, then he may be more focused in school.  See what happens in the year to come.

As for medication for anxiety for children, doctors will often consider a small does of an SSRI medication (serotonin reuptake inhibitor) if psychotherapy is not helping.  With an eight year old, though, I would recommend first trying psychotherapy, as medication may not be needed.  If your son can learn how to lower his anxiety, he will have tools to use his entire life.  Many SSRIs have been approved by the FDA for children, but there are possible side effects, so many doctors suggest psychotherapy first.

All the best, Dr. Dave Gottlieb