Possible bipolar, anger overload, and ADHD in 8 yr old

Dr. Dave,

Our son struggles with what I believe may be “anger overload”. His struggles are very much like what you and your readers have described in your blog. He gets angry when he doesn’t like what he is hearing, is sometimes told what to do, another child is annoying him and he can’t ignore the other bad behavior, makes a simple mistake doing his school work, or other similar situations described in your blog. Our son is incredibly smart, fast paced, and driven when he wants to do well at things. He sleeps well at night. He is currently in an ISE program at school and has his biggest and most often outburst there. They include hitting his teacher, spitting, throwing things, and tearing things up around the classroom. He sometimes finishes with crying saying he can’t help it. He has been suspended 5 times this school year so far.

We have been to more than one psychologist, and more than one psychiatrist. Mostly due to insurance reasons or others such as one doctor needing more information from another doctor first, etc. Blood work has been done. Our most recent psychiatrist  suggests our son has a mood disorder and has just recently put him on 150mg of Trileptal and plans to go to 300mg and then combine it with an ADHD medication (unknown at this point). When we question him he is very insulted by our questions being we have come to him for help.  But our pediatrician  suggests the psychiatrist has been doing this for a while and as desperate as we are we should listen and just watch our son carefully. As you probably know this med is usually prescribed for children with epilepsy and similar disorders. So it concerned us. Medicines were always going to be the last resort for our son. It’s just not what we want for him. But the school is becoming impatient.

Our un-trained thoughts are son doesn’t have ADD or ADHD. When he wants to do something he doesn’t show signs of attention problems. He is very easy to teach when he is interested. He is an honor roll student at school most quarters (but again he is only in 2^nd grade). Most of his meltdowns are at school or with his mother when I am not home. Usually for the same reasons mentioned above. He goes to a friend's for after school care and he is PERFECT there. Zero incidents.

My questions to all of this is when should we decide a medication is or is not working? Our son will be on the 150mg of Trileptal for 2 weeks this week than we go to 300mg. At what point do you say this is not working and then we have to slowly wean him off the drug and begin another? Or are we still trying drugs too soon?  We have heard many say it’s the parents that need the teaching but no one seems to really offer this in our area and I don’t think the school will continue to wait before sending our son to an Academy for troubled youth.  

I am also interested in which book you recommend for us. 

Hi, 

It can be difficult to differentiate between anger overload and pediatric bipolar disorder.  For bipolar disorder there are usually frequent changes in mood (often daily) with some manic episodes.  The question is what constitutes a manic episode in children.  In chapter six of my book "Your child is defiant:   Why is nothing working?" I discuss the criteria for manic episodes and also discuss the criteria for ADHD.  Bipolar children are often pleasure seeking and take risks in order to seek out exciting or stimulating events.  When their desires are blocked by adults (because their wishes are dangerous or inappropriate) these children can react with rage.  The question then becomes is the anger overload you are observing with your son a symptom of bipolar disorder or just anger overload.  Many children experience anger overload, but only a small portion exhibit bipolar symptoms.  What your doctor tries to determine is whether your child has frequent changes in mood in addition to anger overload.   Since the diagnosis of bipolar disorder in children is continuing to be re-evaluated by mental health professionals (and will be re-defined in the upcoming diagnostic manual put out by the American Psychiatric Association), different doctors use slightly different criteria for this disorder.

Your son's psychiatrist feels your son meets the criteria, and Trileptal is one of the medications doctors use to treat bipolar disorder.  I am Ph.D. clinical psychologist, not an M.D. psychiatrist, so if you are unsure if the medication is working, discuss your observations with the doctor, or if he will not discuss it with you, maybe you could get a second opinion (although I see you have been to a number of doctors already). 

Regarding your observations about ADHD, it is not uncommon for children with this diagnosis to pay good attention when they are interested in a subject or activity.  The problem occurs when they are bored or when they are emotional.  Their attention ( and sometimes impulsivity) becomes an issue then.  So the words "attention disorder" is really a poor choice of words.  The problem is really "fluctuating attention," such that the ADHD child's attention drops off significantly (much more than for the average child) when the child becomes bored.

Regarding which book would help you, I'd recommend my workbook for parents dealing with anger overload so that you can try some of the strategies with your child.  The other book that would be helpful if you want to learn more about bipolar disorder and ADHD is one of my earlier books, the one on defiance (that I mentioned at the beginning of my response above) or our book "Why is my child's ADHD not better yet?:  Recognizing the undiagnosed secondary conditions that may be affecting your child's treatment."  In the latter book there is a chapter about children who have ADHD and bipolar disorder.  You can find my books by clicking on the photo of the child on this blog or by going to an online book site like Amazon or Barnes and Noble.

Hope you see some changes soon.  It sounds like you have been though a lot of trying situations with your son.  Hang in there, Dr. Gottlieb