UNTREATED ADHD AND SEVERE ANGER CONTROL PROBLEMS

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. 

PLACEBO EFFECTS AND TREATMENT RESPONSES

There has been a lot written recently about the placebo effect and how it shows that medications are ineffective because they are not more effective than placebo.  In these studies, the placebo response is often in the 30-50% range as is the response to the active treatment being studied. Placebo controlled studies are ones where if we were in the study, we would not know whether we were getting the actual treatment or are receiving everything but the active component of the treatment. Thus, we would think we were getting the treatment but we would not be.  Thus, the placebo response is the response to the belief that we are getting the treatment.  In medication studies, the treatment would be the medication.  It is quite amazing to me that believing that we are getting medication can lead to a benefit as if we wer getting the treatment. This response only occurs if we believe that we are getting the medication.

I have often heard people say that if there is a placebo response close to the response to the actual treatment [medication in this case] that the treatment is not effective.  Studies have repeatedly shown that responses to treatment are improved considerably if medication is combined with different forms of therapy and I wonder if this would also help the placebo responders to improve their outcomes. Another important fact to be aware of is the limitations of studies that involve larger numbers of people as the statistical analyses show correlations but not causations.  Also, the studies are short duration and often do not generalize to real life experience with the medications.  In fact, the placebo controlled randomized studies identify potentially useful medications that then are prescribed by your doctor and you then become part of the larger study determining the effectiveness of the medication.  This is very important as it requires more time and dosing adjustments to fine tune the use of medications to determine how effective they are.  There are two problems that prevent this from occuring.  First, it takes time with each person to assess their response to medication and to help them to determine how they are responding.  Unfortunately, it is not common for physicians to take the time that is needed. Second, there is no mechanism to feedback information about how you responded or are responding to the medication in order to update the research.  Thus, there is no way to update research with your experiences and then decisions about treatment remain limited to the initial, time limited studies.  This is another reason that treatments [like medications] are considered to be ineffective.

LISTENING...REALLY LISTENING

Over the past several weeks the topic of listening has come up in my work.  Often, the importance of listening or being listened to is not recognized.  Frequently, people are upset because they don't know what to do to help people who are distressed.  They want to do something to help these people who are suffering, but they don't know what they can do.  This inevitably leads to a reflection on what is missing for these people who are distressed and experiencing a crisis. From their own experiences [and from my own] we wonder if feeling alone and isolated and disconnected is what people in crisis are experiencing.  So, that might mean that they are missing feeling the support and encouragement of another person, the feeling of being cared about.  This then led to recognizing that "just" listening might be helpful, even without  "dong anything" except listening.  As we discussed listening and how that can be experienced as being with the person that you are listening to, the importance of listening became clearer.  We then concluded that just listening can be and likely is a powerful way of being with someone in their time of need.  I then thought about the importance of listening without adding our two cents as this can interfere with the support that we are trying to provide the other person.  So, to actually listen and not give advice, etc. is important and one practice that can help us to do this is called "active listening."

You can check the internet regarding active listening. My understanding of this is that we focus our attention on the person who we are listening to.  We then repeat what we have heard to be sure that we have been listening and understanding what is being said.  We can ask a question clarifying what had been said but are not to add comments, advice, side-comments, moans or groans, or distracting behaviors like rolling our eyes or body postures that are in effect the same as making comments.  When the other person is finished.  You might ask if there is anything else they would like to share.  Then you might thank them for sharing with you and then look for another topic or share something yourself that might be stimulated by what  you have heard but is not a commentary on what you have heard.  This can be more difficult than you think.  

Actually listening to someone, and not commenting or correcting or giving advice, is a powerful way to support and encourage others....even if we mistakenly feel like we aren't doing anything.  Try it!

TF-CBT [TRAUMA FOCUSED COGNITIVE BEHAVIORAL THERAPY] FOR CHILDREN WHO HAVE BEEN AFFECTED BY SEXUAL ABUSE OR OTHER TRAUMATIC EXPERIENCES

It has become very clear how damaging chronic stress is for our bodies and our minds.  It is also becoming clearer how many children are traumatized by different types of events and suffer from chronic stress.  TF-CBT was developed to specifically treat symptoms of chronic stress [Post Traumatic Stress Disorder (PTSD)].  This has been adapted for use with children and recent studies have demonstrated it's effectiveness.  To review some of these studies you can go to: The California Evidence-Based Clearinghouse For Child Welfare (2011) at http-//www.cebc4cw.org; or SAMHSA Model Programs: National Registry of Evidence-Based Programs and Practices at http://ncrepp.samhsa.gov. There have also been studies showing benefit for children who have witnessed violence, see Cohen, Mannarin, & Lyengar, 2011 and also benefiting parents. Children who have experienced abuse often experience: feelings of guilt for what they see as their role in the abuse; anger toward their parents for not knowing about the abuse and for not protecting them; feelings of being powerless; feeling that they are "damaged goods"; and fears that they will be treated differently because of the abuse. They also may demonstrate negative behaviors, have other mental health problems such as depression and have PTSD symptoms that include: intrusive and traumatic thoughts of the abuse; avoidance of reminders of the abuse; emotional numbing; irritability; trouble with sleep and concentration; and physical and emotional hyperarousal with sudden and more extreme emotional reactions than is indicated for different situations. 

Benefits of TF-CBT for abused children include: reduced symptoms of PTSD and depression and also reduced behavioral problems while providing support and positive coping skills for non-offending parents.  TF-CBT components are described using the word PRACTICE.  P = psychoeducation and parenting skills. R = relaxation techniques. A= affective expression and regulation.  C= cognitive coping and processing.  T= trauma narrative and processing.  I= in vivo exposure.  C= conjoint parent and child sessions.  E= enhancing personal safety and future growth.   The therapy involves individual and parent and child sessions.  In our hospital based treatment program at the Copestone Child and Adolescent Inpatient Programs at Mission Hospital, we have found that a group therapy focus can more rapidly help children and adolescents to feel less stressed about their problems and to learn positive coping skills as they support each other in talking about their problems and learning better coping skills. 

Hopefully, more children who have been abused will be identified and referred to therapists who have been trained in TF-CBT.  It is important to note that some children or adolescents who have been running away, cutting themselves or are actively suicidal should be stabilized first using DBT [dialectical behavioral therapy] before TF-CBT is used.  For more information on TF-CBT you can go to the Child Welfare Information Gateway at http://www.childwelfare.gov/pubs/trauma.

WHY MUST TREATMENT BE INDIVIDUALIZED?

I have previously written about the fact that we are not statistics and that any one individual may not fit where most people [statistically about 68%] can be grouped when making diagnostic and treatment decisions.  It is clear that 32% of people fall outside one standard deviation from the mean and may not fit diagnoses or treatments based on studies that use statistical analyses [they almost all do].  In addition, the accuracy of these studies depends on the diagnostic symptoms or treatment responses being causally related to the results.  Statistics show that things are correlated and the studies need to not have other factors that are not part of the study influencing the outcome.  The other factors are often called factors and they are either controlled for or not.  Studies can control for age, sex, socioeconmic status, etc. and yet there are many other factors in humans that are hard to identify and very hard to control for.  So, studies might show statistical evidence that the treatment works but it might be only correlated and not causally connected to the outcome.  

Wow, that's confusing. However, it does seem to lend support to the idea that we must make the diagnosis or treatment fit each of us specifically.  This is obviously harder than lumping all people into one group and diagnosing or treating them the same way until it doesn't seem to work or doesn't work as well as we [you or me] had hoped.  Unfortunately, even trying to do things this way is a problem as it requires knowing each person and their specific responses to determine if the treatment is working.  It takes time and skill to listen and support someone so that they participate in figuring out if something is working or not.  

I have found that I must not only listen and clarify a person's response to a  treatment, but must also help that person identify other factors that influence their response.  Some of these factors can then be treated so they do not interfere or confuse the response to the treatment being evaluated.  Also, each of us must be willing to give the treatment a try and willing to work with their physician, psychologist, therapist, etc. in order for the treatment to have a chance to be helpful.  Part of this involves identifying the way the person experiences their symptoms and also how they experience improvements.  All of this is unique to the person.  

We are all unique and we must be helped with this in mind.