One of the frequent issues I help parents deal with is a child who is profoundly angry . . . the “too mad too fast over dumb stuff” syndrome. It is a frequent accompaniment to both ADHD-spectrum issues and mood disorders, and is typically more difficult to deal with than the other presenting aspects of the illness. A child with this pattern of difficulty will typically become profoundly angry and oppositional with little provocation, and will often earn them the “Oppositional Defiant Disorder” diagnosis in addition to the primary ADHD or mood disorder diagnosis. For these kids, basic expectations such as coming to the dinner table or getting ready for bed can precipitate profound tantrums that involve aggression and use of nasty language. Parents often end up walking on eggshells . . . and sometimes tailoring their expectations of the child . . . so that they can skip the drama of a 30-minute temper tantrum in the middle of their busy lives. This is, of course, evidence of a parent well trained! But make no mistake about it, the explosive nature and the unpleasant way it impacts a household and other children in the household makes it a very, very difficult situation for everyone.
When I talk to the children who have this pattern of irritability, they are generally quite unhappy about it. Some have little insight into the anger and feel justified. As kids get older, however, they are more likely to have some insight . . . even if they don’t admit it. Along with that insight comes a heightened sense of sadness and isolation. They can get so mad so frequently that they end up alienated from their parents and siblings. They can feel on the outside looking in at everyone else getting along and having a good time. Left unchecked over time, these kids have a greater tendency for severe mood disorders and severe behavior disorders that lead to a lower level of achievement.
In addition to opportunities to talk about these issues and do some problem solving in therapy, medication can be profoundly beneficial in altering the behavior and promoting a positive change in the dynamic of the family/social system. Behavior modification that includes family therapy is a must. A careful assessment of dietary habits and use of supplements can be helpful. By the time most kids/families get to my office, however, they are in crisis mode and ‘need fixing’ quickly. So what do I usually recommend?
Tenex (typically the generic guanfacine or the extended release brand Intuniv) is my first choice of medicine for kids with this pattern of difficulties. First marketed as a blood pressure agent for adults, it was found to be profoundly beneficial for many kids with ADHD-spectrum irritability. So beneficial, in fact, that Intuniv . . . the magical once-a-day version of Tenex . . . was developed. I typically have good results with the generic Tenex, so prescribe Intuniv infrequently. It is very well tolerated by most children who take it. Headaches and stomachaches are infrequent. Younger children are more prone to becoming ‘bland’ on it. A reduction in dose will typically allow for control of irritability without alteration of personality.
How young will I go with it? I have found it effective and safe for children as young as four. These kids are too young for insight and can be resistant to behavior modification. It is clearly “off-label” for this age group, but really low doses can be profoundly effective. It can help a child who is about to be kicked out of daycare or kindergarden (and, yes, I have had children who have been expelled from kindergarden . . . sometimes more than one . . .) settle down and do well. Typically a 0.5 mg dose once or twice a day will help a very young child. As kids get bigger, the dose will need to go up. Children of school age typically benefit from 2-3 mg daily.
It is a scary leap for parents to medicate a very young child. It is important, however, to get control of this as quickly as possible. Angry and negative behavior patterns can take on a life of their own. Relationships, once damaged, can be difficult to mend. It is important that these kids be given every opportunity to establish and maintain healthy and positive relationships with peers and siblings. Sometimes, use of a medication such as Tenex can make all the difference.
–Dan Hartman, MD
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