Tuesday, June 3, 2014

Bipolar disorder? 6 yr.old outbursts since age 2

Hi Dr. Dave,

My son is 6 years old and trying to complete his first year of kindergarten. He was diagnosed with ADHD and ODD in September 2014 after a series of issues he was having in the classroom.

Some history: He was asked to leave several preschools since the age of 2. Many discussions were about his inability to control his impulses, and was simply too much to handle. He started becoming more violent over the last 2 years, picking up chairs and throwing them across the room, turning over book cases, throwing anything he could get his hands on in the heat of the moment. It does not seem that he is trying to hurt anyone, he just looses it.

Recently, he has been suspended from school because of an angry outburst. His outbursts at school range from yelling, ripping up his classwork, throwing chairs, throwing his shoes, etc. Teachers have struggled trying to figure out what triggers him. He does express this behavior occasionally at home, but we have only seen him triggered by something that gets him angry; his little brother getting something that he wanted, loosing at a board game, getting privileges taken away if he had a bad day at school, etc. We have also seen him triggered by being embarrassed or asked to go into a large and loud crowd of people (i.e. school plays). We as well as multiple teachers have seen him get a glazed over look, like he isn't there when he is going through a rage. The rage will last less than an hour. Typically after it seems like he looks around at a destroyed room and doesn't know what happened; that he did it. He can't express why, even when asked to draw a picture of what upset him; his answers are always "I don't know". He will start to trigger again if we press the issue, as if he is getting increasingly upset that he did the things we are telling him.

We tried Ritalin and Concerta, but he would be extremely tired and over emotional (crying for no reason). We stopped the meds and have been to multiple physiologists/psychiatrists and behavior therapy and have found little help. The school seems to be loosing their patience and it feels like they are giving up on him. We don't know where to go from here.

Any advice would be more than helpful.

Hi, I can see you have been working on this issue for several years with little success.  It does sound like anger overload, and I can suggest some strategies, but you would also want to rule out additional diagnoses:  a mood disorder, high functioning autism, and fetal alcohol syndrome.  The latter two are unlikely, but make sure the doctors have ruled them out.  It is possible that your son has a mood disorder, namely pediatric bipolar disorder, and while this is not a very common disorder, it can occur along with anger overload.  With bipolar disorder, the changes in affect (such as angry outbursts) alternate throughout the day with periods of calm or periods of dysphoria ("down" mood).  The bipolar child is impulsive and wants his needs met immediately.  Often these children are "revved up" and on the go.  So it is not unusual for doctors to first consider ADHD, because it is a more common diagnosis and is also marked by impulsivity and hyperactivity.  Since your child did not respond to ADHD medications, it is possible that there is a different underlying biological pathway, such as what can occur with bipolar disorder.  Some studies of bipolar children have found weaker connections between the amygdala (one of the emotional centers of the brain) and the frontal cortex (that helps to control emotional responses).  Several major medical centers in the country have pediatric mood disorder centers investigating this diagnosis and its biological underpinnings.  The University of Illinois in Chicago is one such center. 

Whether or not your child has pediatric bipolar disorder, there are strategies that I outline in my parent's manual and in this blog that can help.  But if there is the additional bipolar diagnosis, medication may be helpful too.  You have observed some triggers at home, and it would help if the teachers could record what is going on before an outburst happens in school.  The idea is not to try to interpret what is going on at school right away, but just record what is going on in the classroom before an outburst occurs.  Then look back over several weeks, and try to notice patterns.  The reason is that if you can avoid some triggers, or at least see early signs, interventions will be more effective.  As you have noticed, once a child is in the overload phase, it is extremely difficult to reach them, and then it is usually best to say or do as little as possible, as long as the child is safe and not hurting anyone else. 

For young children, in my manual I write about a) changing the sequence to avoid a trigger, b) lowering expectations (as high expectations can lead to frustration and then to an outburst), c) emotional distraction, and d) developing a calming station.  You can read more about how to implement these strategies in my parent's manual and in other posts on this blog. 

All the best, Dr. Dave Gottlieb

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