ADHD, Aggression, & Medications
A "Focus" on ADHD and Aggression
Aggression is usually not a disorder in and of itself, but rather a symptom of many disorders.
One of the most common causes of aggression is ADHD, especially when it is untreated or undertreated, or their medication has worn off!
ADHD is much more than having difficulty focusing in school and being "hyper." It is very often minimalized, and therefore not adequately treated with medication, but ADHD is actually quite powerful, causing severe, disruptive and disabling symptoms that most people don't recognize as being part of ADHD!
Consider this scenario--a kindergarten student is quietly redirected by the teacher to focus on the worksheet in front of him/her, when suddenly the student jumps out of the chair, grabs the worksheet and rips it up, then throws the pieces at the teacher. The student then grabs his/her chair and thrusts it towards the teacher. The student then screams and runs out of the room when the teacher tries to take the chair away and asks the student to go sit in the "Quiet Corner" until he/she is feeling calmer.
Sound familiar? Is this your child, a classmate of your child, a relative's or friend's child? Likely you know or are aware of a child that fits this scenario. So, is that child just a "spoiled brat", getting no discipline at home from the parents? This could be, and certainly a lack of adequate rules and structure in the home inhibits a young child from feeling safe in their environment and from learning the moral "rules" of normal society in order to be able to have healthy interactions with others in all scenarios throughout their life.
However, the child may also have abnormal functioning in the part of their brain that inhibits behaviors that are "not acceptable" and that is able to filter out distractions while trying to complete a task requiring a lot of focus. Like any other biological disorder (or chemical imbalance) in the body, such as Diabetes, ADHD is a real medical disorder, not something "made up" to explain away "bad behavior" or lack of focus! ADHD is also very highly genetic (about an 80% contribution from a parent with ADHD, which is similar to the contribution from a parent's height on the child's final height).
What is it about ADHD that would make a child or teen aggressive? The best answer to that is Irritability!! Anyone with ADHD tends to have a lot of irritability and low frustration tolerance, either occasionally with certain triggers (such as being hungry or tired), but others have it as frequently as daily or several times a day! This irritability is often described by parents that their child/teen "Goes from 0-100 in the blink of an eye!" In fact, this sudden explosion of anger or rage is so remarkable that it is often thought to be due to Bipolar Disorder (BPD), due to this "rapidly changing mood!" If this irritability from ADHD has such a huge impact to be mislabeled (more on BPD below), it is hard to consider it as "just a problem with focusing or sitting still!"
The fact is, this aggression is considered in screening questionnaires for ADHD, such as the Vanderbilt Scale completed by parents and teachers. One component of this scale includes many questions about troublesome behaviors, ranging from blaming others for things and lying to get out of trouble, to physical aggression. Given this range, I like to think of this
Aggression as a Spectrum of Severity, which may range from occasionally "snapping" at a parent who reminds their child to do a chore when that child is playing video games, to full-blown rage with physical aggression towards others, including hitting, kicking, biting, throwing things, or punching holes in walls. In adults (and sadly, some teens or younger children), these sudden episodes of rage can lead to road rage or physical assault on another person. Sometimes, the
extreme combination of impulsivity and rage can result in using a deadly weapon, such as a knife or a gun, in response to even the slightest provocation, escalating the level of violence to committing murder (whether intended or not)!! It is no wonder why there are so many violent criminals in prison with ADHD (either already diagnosed or having all of the symptoms to meet the official criteria for a diagnosis)!!
When the Irritability and anger/rage/aggression are more prominent, they are given a separate diagnoses, in addition to ADHD. The "mildest" of these "Disruptive-Impulse Control Disorders," as defined by the DSM V (the "official" guide to diagnostic criteria) is Oppositional Defiant Disorder (ODD). This is characterized by any child/teen who is frequently argumentative with authority figures or deliberately defiant. They often blame others for their own mistakes or misbehaviors, and they often deliberately annoy others or do things out of spite towards another person.
Next along this spectrum of severity is Intermittent Explosive Disorder. This diagnosis only applies to kids 6 years old and older, and includes outbursts of verbal aggression with "temper tantrums" or verbal tirades, and/or physical aggression towards property or animals/people, with or without significant injury or damage. The magnitude of this aggressive response is out of proportion to the precipitating trigger. The most severe disorder in the DSM-V under the category of "Impulse Control Disorders" is Conduct Disorder. This includes characteristics that are normally associate with violent actions against others (physical and/or sexual assault--either with or without a weapon, armed robbery, etc) or deliberate damage to physical property, whether by setting fires or other means. These symptoms are "child-onset" if they occur before age 10 yrs, or "adolescent-onset" if they start after 10 yrs old.
One other diagnosis that the DSM-V lists under the category of "Depressive Disorders" is
Disruptive Mood Dysregulation Disorder (DMDD). This diagnosis shares the same types of sudden verbal or physical outbursts as ODD and Intermittent Explosive Disorder. However,
the defining difference between them and DMDD is that, between these outbursts, the child or teen remains persistently irritable or angry most of the time. This is likely the rationale for its different classification in the DSM-V. This disorder, fitting with being on the severe end of the "Aggression Spectrum",
cannot co-exist with ODD or Intermittent Explosive Disorder--If a child of
at least 6 years old, but less than 18 years old, meets the
criteria for the diagnosis of DMDD and one of these other "less severe" disorders, that other disorder is removed, and
the child/teen is only diagnosed with DMDD! This diagnosis also cannot co-exist with Bipolar Disorder (in this case, the diagnosis of BPD would become the only diagnosis).
Facts About Medication for ADHD & Aggression
Whenever a child or teen has frequent rage, anger, or just becoming easily annoyed by small things, the initial treatment for aggression is the same recommendation as for treating ADHD...Stimulants!
As discussed in the "Focus" section above, ADHD is very often associated with the varying degrees of irritability and aggression, so it makes sense to treat these as symptoms of ADHD, whether the child/teen was "officially diagnosed" with ADHD or not!.
Stimulant medications consist of two classes of drugs--Methylphenidates (MPH) and Amphetamines. In each of these classes, the medications are either "Immediate Release" (IR) or "Extended Release" (XR). With IR forms of stimulants, the entire amount of the drug is released all at one time, and is absorbed in the intestines to become immediately active in the body. Regardless of the class of stimulant, the IR forms are all very short-acting, with effects usually lasting 4 hours or less. While this short duration can be ideal in certain situations, it is most often a general nuisance, since it means multiple doses in a single day (including the hassle of sending the child to the school nurse for a dose at school)!
The XR forms of both of these stimulant classes are a bit more complicated, made that way by the tricks of the pharmaceutical companies to make their version different from all of the others on the market, so that they can get their product FDA-Approved (thereby making them a lot of money!). XR forms of stimulants (and other types of drugs in general) are designed in some way so that only some of the drug is released immediately, while the rest of the drug is released at 1 or 2 different later intervals, thereby providing 2 or more surges of medication, with the effects lasting over a longer period of time. The types of mechanisms to produce these varying drug releases are a major way that a drug company uses to gain a patent (the proprietary rights) on a drug, whether the drug itself is new or not. Drug companies also have used the trick of controlling what percentage of a drug is released at each interval! For instance, there may be more drug released in the immediate phase, and smaller amounts released later, or vice versa. While sometimes these variabilities may be important for the occasional child or teen, for the majority of kids, they are irrelevant! (But don't let the drug companies hear that!). Ultimately, for the overwhelming majority of kids and teens (and likely many adults, too), the XR forms are much more convenient, avoiding bringing controlled substances to school, and trying to remember to give the next dose after only 4 hours!
The "Art" of prescribing stimulant medications comes down to individualizing the best treatment for each child or teen. Both Stimulant classes are considered essentially equivalent, so a child/teen can start with either one of these! Studies evaluating the treatment of ADHD have shown that stimulants by far have the greatest success rate-->80-85% of kids will have very effective control of their symptoms with the first or second drug tried!!
So what about the Non-Stimulant Medications?
These include medications that can lower blood pressure, such as clonidine (XR=Kapvay) and guanfacine (XR=Intuniv), as well as medications classified as NRIs (Selective Norepinephrine Reuptake Inhibitors), such as Atomoxetine (Strattera) and the newest one, Viloxazine (Qelbree).
Studies* have shown that the Non-Stimulant medications used in ADHD only have an approximately 30 % success rate for controlling the symptoms! Not only that, but these medications are also much less effective for improving concentration. Given this huge difference in success rates, the belief in trying to "spare the child or teen from using stimulants" can unfortunately cause significant delays in achieving good control over their symptoms. Why is this so important? Because, once again, ADHD has a much more powerful influence on a child's/teen's self-esteem and self-acceptance than many parents, teachers, and even medical providers, give it credit for. For instance, a child with impulsivity in school may frequently get in trouble for not following directions, so they start to think of themselves as the "bad kid." This is worsened by the fact that they lack good social skills (with ADHD), and therefore the other kids avoid them, reinforcing these negative self-thoughts. Another example is the intelligent child or teen who finds that they cannot finish their classwork in the same time as other students, and they often get lower grades than they are academically capable of achieving, often due to "stupid mistakes." They might start to question, "I thought I was smarter than that other kid, so why is he getting better grades than I am? I must be really stupid!!"
These non-stimulants do have a purpose, however. For medical reasons (heart abnormalities, etc), the child or teen may not be able to take stimulants without the risk of serious complications. In other cases, a child/teen with isolated motor or vocal tics, or both combined (Tourette's Syndrome) is treated primarily with clonidine or guanfacine. In some kids, the addition of either clonidine or guanfacine may have additive effects on decreasing impulsivity, hyperactivity, or occasionally, aggression.
In severe cases of physical aggression, especially towards people or animals, a child or teen may need to be treated with an additional medication from the class known as "Atypical Antipsychotics." Though these medications were initially used to treat psychosis and schizophrenia, they are probably used more often now as "Mood Stabilizers" for not only the aggression from ADHD/ODD/DMDD/Intermittent Explosive Disorder, but also in kids with autism spectrum disorder and in cases of severe depression and bipolar disorder. (See box below).
*Qelbree, being the newest non-stimulant, has not had as many studies as the others, but it is also most likely to have similar success rates.
Does Treatment with Stimulants Lead to Addiction?
Some parents are very concerned that if they treat their young child or teen with stimulant medications for the ADHD, their child will become "addicted" to stimulants and continue to abuse other substances.
However, research has shown that treating ADHD with stimulant medications actually LOWERS that child/teen's risk of substance abuse!
This is likely due to several factors: many teens or adults experiment with drugs or alcohol to "self-medicate" their mental health symptoms, perhaps because they are in denial or they are afraid of the "stigma" associated with a mental health diagnosis. The temporary benefits they might notice from drugs and/or alcohol leads to increasing use, until physical dependence or addiction can occur. Teens may also experiment with drugs due to the impulsivity and risk-taking behavior from their ADHD causing them to give in to peer pressure.
When stimulants are taken as prescribed by a medical provider, they are very safe and extremely effective for all of the components of ADHD: difficulty concentrating, impulsivity, irritability, and aggression!
Atypical Antipsychotics to Treat Aggression...Cautiously!
In many cases, when aggression is severe, and/or when it occurs in a child/teen with autism spectrum disorder, medications in the class of Atypical Antipsychotics (APs) are used for better control of these symptoms. While these medications do work to decrease aggression, they also carry a high risk of potentially serious side effects, especially with long-term use.
Sometimes these medications are used as the first line of treatment for children and teens with physical aggression, instead of the recommended first-line treatment with stimulants. This may be for many legitmate medical reasons, but often it is more of a reaction to the level of aggression. However, as discussed in the section above, most aggression is successfully treated with stimulants alone.
So, what is the problem with just starting with APs? Unlike stimulants, APs all have varying degrees of risk for several potentially severe side effects effecting several different organ systems. Each AP has a different risk of each category of side effects and, unfortunately, there is no AP that has a low risk of causing every category of symptoms!
The 3 major categories of side effects from Atypical Antipsychotics are:
=metabolic effects, most commonly weight gain, but also elevated cholesterol and elevated glucose and A1C (potentially resulting in the development of diabetes in those with a strong family history). Blood tests are required to monitor for any of these changes.
=Neurological effects, which consist of abnormal, involuntary movements that often begin very subtly, and are often overlooked. Over time, however, they become more pronounced to observers or the patient themselves. In some other APs, the type of abnormal movement may involve an overall sense of extreme physical restlessness and the need to constantly move (this is different than the hyperactivity of ADHD). Any of these abnormal movements may become permanent, in which case they are then referred to as "Tardive Dyskinesia."
At times, APs may cause the sudden onset of an involuntary posturing (dystonic reaction), such as the head remaining turned to one side or an unusual facial grimace. These sudden abnormal postures cause significant distress for the patient, and often great pain from the spasm of the involved muscles. While this is type of reaction is not hard to miss, fortunately it is also not very hard to treat. During follow-up appts in these patients, the provider conducts a specific visual exam of movements to look for any signs of abnormal movement.
=Cardiac effects, include a specific type of new or worsening arrythmia (abnormal electrical signal). Certain APs may also cause a prolongation of part of the electrical signal of each heart beat, which if severe enough, can result in a sudden critical heart rhythm which results in the ventricles being unable to pump any blood. This causes sudden collapse and death if not treated immediately with defibrillation and cardiac medications. For most people, unless they are taking many different drugs that all can have this same effect on the heart, it is most significant in those with a genetic family history of this "Prolonged QT". These APs are therefore monitored with EKGs to measure the "QT" duration.
Despite these risks, these medications are very effective in controlling severe aggression, stabilizing mood (from ADHD irritibility and severe depression). They are also extremely effective in decreasing tics in kids with Tourette's syndrome or chronic motor or vocal tics. And of course, as their name implies, they are used to effectively treat psychosis, bipolar disorder manic episodes, and schizophrenia.
More ADHD/Aggression FAQs
