Can PDD and ADHD cause aggressiveness?
Patient: My child is very violent and abusive towards me. He is nine and has ADHD and PDD. He threatens me by saying he is going to kill me one day with a knife and punches, kicks and verbally abuses me. What is wrong and what can I do? He already sees a psychiatrist and a therapist and takes Adderral, Paxil and Trazadone. Something is wrong with him and it is getting worse as he gets older. What could it be and what can I do? Doctor: YYour son may have bipolar disorder.  The things to consider are: Is there a family history of severe mood disorders? Does your child seem to have dramatic changes in his personality, mode of expressing himself, behavior, facial expression, demeanor during his aggressive rages and then after an episode is over does he seem to feel sorry but not really appreciate the details of what he has done? Does his personality return to normal briefly after a rage? Can you tell just by the look on his face or the way he is speaking that he is going to go into a rage and is it impossible to reason  with him when he is in a rage? Does he become extraordinarily strong during a rage episode? Does he appear to be menacing, threatening, frightening, unwilling to back down and unusually cruel in what he says and does?  Does he seem, after a rage attack, to be at peace, more normal, kind, apologetic?  Does he truly not remember the detail of what he has said or done or does he seem to disregard the seriousness as if he does not believe what he is told he did?  Does he have difficulty going to sleep? Does her seem unhappy and discouraged a lot, as though he is unable to help himself feel good?  Does he have a lot of anxiety? Are these symptoms more common at home or when he is trying to “shut down his brain” after playing games or otherwise occupying his mind.  If these seem to relate to your child, he needs to stop the Adderall, wean the Paxil and start a mood stabilizing medication like Tegretol.  Once he has been stabilized on the Tegretol and the episodes have stopped, remaining ADHD symptoms can be safely treated with a stimulant medication.  These episodes are seizure like events arising from the amygdala and the use of a stimulant medication makes them more frequent and more severe.  So does the use of Paxil.  When he starts Tegretol, you will immediately notice a few things.  He will be happier, will be able to sleep well, will not have such severe rages.  As the body builds a tolerance to Tegretol until the maximal metabolism of it is in place, you may notice backsliding and need to raise the dose repeatedly over a period of a week or two until he saturates the ability of his liver to metabolize it after which this level will remain steady and he will stop having rages.  When this happens, you will notice what I call the Tigger stage, where he will be happy and very hyperactive, impulsive.  This is the time to start the stimulant medication to fuel the parts of the brain in the frontal area that have not been well fueled because the rage activity has been such a great consumer of fuel. Make sure his doctor is taking all of this seriously as interruption of this process will eventually extinguish it and prevent  long term psychiatric disability.  Allowing these episodes to continue will cause the development of permanent neutral pathways of responding to life in the manner he does when in a rage and therein lies chronic psychiatric disability.  He is young and with proper treatment you can have your child back and assure his good future. Best of luck to you an feel free to contact me again should you run into difficulty or have further questions.  Remember, he is the child you love.  His symptoms are not him and he is not in control of what he does during episodes of rage.