I recently took care of an adolescent boy in the hospital who had severe anger control problems and had become suicidal. He was hurting himself as he hit things and broke things instead of hitting people. He also was very impulsive and driving recklessly. He would become stuck on one thing and not be able to stop thinking about it and would then get very agitated. He did fairly well in school [A and B student] but in talking to him he related that he had to work hard to stay focused in school and was often exhausted after school. In addition, he always completed school work at the last minute. He was irritable every day and would become angry even over small things, especially after he had been in school. His daily irritability and anger outbursts alerted me to the possiblility that his irritability was due to the stress of his ADHD symptoms vs being caused by mood swings where the irritability and anger would be episodic. His anger was so intense that his primary care physician was treating him with two atypical antipsychotic medications and lorazepam. He would be calmer for a couple of hours and then the anger would return. I was sure that a lot of this adolescent's anger was related to his untreated ADHD. His anger would have made his primary care physician afraid to treat his ADHD if he had recognized that he had that diagnosis. Even though the adolescent did well in school, he struggled every day to concentrate and he procrastinated. As I have mentioned before, everyone I have evaluated who procrastinates has ADHD or ADD. Other people without concentration problems may try to procrastinate but the deadline pressure makes it hard for them to complete the work.
I decided to treat this adolescent's ADHD even with his severe anger problems. He responded rapidly with improved concentration and significantly improved anger control. He said that he felt "calmer" and more "even" without the irritable reaction to minor stresses. He still was reacting to some stresses that had been very intense for him. Because of the degree of anger that was still occuring, I decided to treat him with Depakote ER [vs Lamictal] as he needed more rapid help with the anger. His improved concentration abilities and lowered irritability helped him to learn DBT coping skills that are taught as part of the treatment program on the Copestone Adolescent Inpatient Program.
I have previously blogged about the importance of diagnosing and then treating ADHD in adolescents [or children or adults] who are irritable every day as this will significantly lower their irritability. I wanted to write about the above adolescent because even with severe anger control problems, treating the ADHD is critical to helping the adolescent gain control of their anger.