Sunday, December 1, 2013

9 yr old: Anger Overload or Explosive Disorder?

We have a nine year old boy who struggles with anger. He's always been a challenging child, requiring more consistency, consequences (both positive and negative), and supervision than his older two siblings. Until second grade, he did not act up in school. Now, however, he's had a number of incidents where he's become so angry that he's hit a classmate. Often it is because of perceived "fairness" - a foul at recess.  We've tested him for ADHD and he shows impulsivity but doesn't fit that diagnosis completely. We did start him on ADHD medications in the fall (Concerta/Intuniv) and that seemed to work for a couple of months, in conjunction with therapy.

We've had some good success, but not enough - this week, he completely lost his temper at school, tried to hit the classmate and then tried to run away from the teacher and refused to listen. Therapy alone isn't enough. Do you know of another class of medication which we should consider? And would you consider "Anger overload", as you describe it in one of your articles, a classification of intermittent anger disorder as described in the DSM V?

Hi, Anger overload is an intense reaction to frustration that can sometimes be physical, but often is verbal.  By contrast, to be diagnosed with intermittent explosive disorder, there must be physical violence:  there are serious physical assaults and often destruction of property, which you usually do not see with anger overload.  Anger overload is more common in children in my experience.   

Children with ADHD can have a) hyperactive and impulsive behaviors, or b) distractability, or c) both.  So your son may meet criteria for the hyperactive-impulsive type. 

You mention the issue of "fairness" as a concern of your son.  I have seen this issue for other children with anger overload.  What I would recommend is "priming" your son before he goes to school.  Explain that children often "foul" at recess and it is not called because there is no referee.  If he wants to play a competitive game at recess, this will happen often.  Is it worth it to him to play?  What are his alternatives?  Try to discuss these issues when he is calm in the mornings, or if there is not time then, try to do it at bedtime.  Empathize that there is unfairness when fouls are not called, but explain that it probably will keep happening.

Another strategy is to talk with him about how people can have different points of view.  There is a section in my parent's manual that explains a way to do this.  As a last resort, I would consider talking with the school about taking away the privilege of playing a competitive game at recess for a day or two and then try again.  If there are repeated problems, then see if the school can have an adult nearby to intervene early.  Once your child gets real upset, it would not be advisable to talk with him until he calms down.  If possible, there could be a space away from the action where he can settle himself.

As for medications, there are anti-agitation medications, but they can make children tired and/or gain weight, among other possible side effects.  Sometimes low doses can help with minimal side effects.  However, some of these medications are not FDA approved for pre-teens.  Talk it over with your child's psychiatrist or medical doctor to see if he or she thinks another medication is indicated.

All the best, Dr. Dave Gottlieb

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