Tuesday, October 20, 2015

Medication versus behavioral strategies

Our "small for his age" and academically gifted 7 year son suffers from frequent anger outbursts and a co-worker recommended your Anger Overload manual to us. The 8-year-old you describe in the book could be our son. He can be a delightful boy when everything is going his way, but he cannot cope with even minor frustrations and disappointments without flying off the handle and turning verbally and physically abusive. It is severely impacting our family life and, though he generally keeps it together in school, has started to bleed into his social life.

In addition to seeing a CBT therapist, we have been diligently applying the strategies you recommend. Our son has great self-awareness and insights into his own behavior so he has been good at the worksheets, but when he's in anger mode he cannot stop and think rationally. Also, while we have learned to recognize his triggers and head off a lot of problematic situations at home, we can't protect him from every frustration and disappointment in life. 

This brings me to my question. Our son has a NOS diagnosis because he does not meet the full criteria for ADHD, ODD, or any mood disorder. Do you ever recommend medications like Intuniv for children like this? Our therapist is pushing for it, but we are reluctant. Do we just need to give these strategies more time, or will the medication help him leap forward?   Do you find, in your practice, that children tend to outgrow anger overload as their brains mature?

To my knowledge Intuniv is sometimes used for ADHD and has a "slowing down" effect on hyperactive behavior. I would check with a psychiatrist if you are considering it. The strategies in my manuals take time, often several months to begin to see changes, and may not work as well when his anger rises real quickly. If you can catch the frustration early sometimes, the cognitive strategies in the second half of the manual will be easier for your son to use. Otherwise you will need to rearrange the sequence, or lower the expectations, or use emotional distraction, or use mantras and imaginary stories (described in volume 2) ahead of time. The work you do with your son before an outburst, or when you review the day at night, is key for teaching children to have better self control.  I haven't had a child with anger overload take Intuniv so I'm not sure how it would work, but I suppose if it lessens his quick anger response it could be helpful. But this is new territory and I'd check with an M.D. who is familiar with these medications and who works with children.

Regarding changes in self control as a child matures, it is hard to say for sure how much is maturity and how much is due to practice because there are no controlled longitudinal (long term) studies of anger overload. Short term studies of anger indicate that cognitive behavioral strategies like I outline in my manuals are effective. Keep using strategies like labeling levels of anger and discussing options when he is calm, and developing mantras (sayings) that you can use before he gets upset to remind him to lower his expectations or to look at an issue in a different way, It may not help prevent overload immediately but it keeps the importance of self control in his mind and helps him begin to think about a frustrating situation in a different way. Let him know this is important, and you and he will keep working on it with him. Empathize that it's not easy but "seed" the idea that as he matures he will be able to do it, You want to communicate repeatedly that you are going to work as a team, and praise him (when he is calm) if he tries to use the strategies.  When he goes into anger overload, say as little as possible and wait until later, and then calmly review the trigger and how else he could think about that situation in the future.

Best, Dr. Dave Gottlieb

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