Seeing red with ADHD?

By Dr Frans A Korb, Clinical Psychologist

ADHD is characterised by three categories of symptoms: inattention, hyperactivity and impulsivity (DSM-5 and ICD-10). Unfortunately, these criteria don’t clearly define aggression, which, in reality, can exist within these symptoms. Aggression can also be difficult to pick up as it overlaps with common ADHD co-morbidities such as oppositional defiant disorder (ODD) and conduct disorder (CD) in children and personality disorders in adults.

Why you get aggressive
Aggressive behaviour is a broad concept with many definitions. It’s worthwhile to look at what causes aggressive behaviour. Numerous influences can shape a person’s behaviour. For instance, physical and mental health (depression, bipolar disorder, anxiety, PTSD, schizophrenia, ADHD). Other influences might be substance abuse, family structure and relationships. The working environment for adults and school for children can have a major impact, as do societal and socioeconomic factors, individual traits and life experiences.

Adults might act aggressively in response to negative experiences they encounter. For example, if you have ADHD, you may become aggressive when you feel frustrated. Mental health problems associated with aggression in children may include: autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), conduct disorder and intermittent explosive disorder.

Aggression in children may also be a result of poor relationship skills, underlying health conditions, poor stress or frustration, tolerance and inability to cope with their emotions. Puberty can also be a stressful time for many teens, when aggression might be encountered more often.

Physical causes may also limit a person’s ability to control aggression. For example, brain damage as the result of stroke, traumatic head injury, certain infections (including HIV) and other illnesses.

Two types of aggression
Aggression usually falls into one of two categories: externally directed or self-directed. Clinically, aggression has been reported as a common behaviour seen with ADHD in adults and children. Some rating scales, like the Wender Utah Rating Scale for Attention Deficit Hyperactivity Disorder in Adults, include childhood symptoms like hot tempers, short-lived outbursts, rapid calming down, and temporary loss of control.

Risk-taking and the research
In ADHD, risky behaviours may also be seen as a variation of aggressive behaviour. The known symptoms of risky behaviour include starting fights or arguing, speeding and dangerous driving, risky sexual behaviours (unprotected sex) and substance abuse.

Few studies had examined aggression in individuals with ADHD until a recent study published by Dowson and Blackwell (2010) examined aggression in 73 adult men with ADHD. Patients had verbal IQ scores of at least 90 and no histories of neurological disorders, bipolar disorder, or schizophrenia.

The results showed that 11 of the participants experienced impulsive, externally-directed aggression* (losing control, hitting or throwing things when angry), while 16 participants said they experienced impulsive auto-aggression** (trying to hurt or kill yourself or threatening to do so). Both types of aggression were experience by 18 of the participants.

Following from the results of this study, the authors commented that impulsive aggression in adults with ADHD carries significant impact for treatment. This is because ADHD is often associated with difficulties in adulthood (e.g. borderline personality disorder and bipolar spectrum disorders) and with childhood disorders (e.g. ODD and CD) which can evolve into adult antisocial personality disorder. Impulsive aggression is often a feature of these conditions.

Dealing with aggression
If you’re experiencing aggression alongside ADHD, the first step in managing aggressive behaviour is to identify its underlying causes. This can be done with a medical practitioner, psychiatrist or psychologist. Talk to a psychologist about the causes and experiences that makes a person feel aggressive.

Learn how to avoid frustrating situations by making changes to your lifestyle or career. Psychologists can also help to develop strategies for coping with frustrating situations, e.g. learning how to communicate more openly and honestly without becoming aggressive. The best evidence for psychotherapy for aggressive behaviour will be to find a psychologist who practices cognitive behavioural therapy (CBT). CBT can also help a person understand the consequences of their actions and change negative feelings to positive feelings.

Cognitive behaviour therapy (CBT) may also help with self-esteem. It can include relaxation training and stress management. Life coaching can help a person with setting goals and learn new ways to stay organised at home and work. A further purpose of CBT can help a person with job coaching or mentoring e.g. to help a person to have better working relationships and improve on-the-job performance. Finally CBT can help with family education and therapy. This can help a person and their loved ones understand ADHD better and deal with the consequences ADHD has had on a person’s life.

Managing aggression with medication
In some cases, medication may be prescribed to treat aggressive behaviour. For the management of ADHD, the psychostimulant group of drugs (methylphenidate) are the most commonly used. Patients may benefit from psychostimulants to help with the control of their impulsive aggression, however some patients may become more irritable and anxious.

Other groups of medications that might help to control aggression may be antiepileptic drugs (e.g. lamotrigine, sodium valproate and carbamazepine). Antidepressants can help stabilise mood and reduce aggressive behaviour. Benzodiazepines are normally prescribed to treat anxiety and can be useful in conjunction with stimulants to treat patients with ADHD and aggression (e.g. clonazepam and diazepam). Benzodiazepines are unfortunately highly addictive and should not be used in the long term.

*External aggression was predicted by ratings on all three ADHD diagnostic criteria (inattention, hyperactivity, and impulsivity), past oppositional defiant disorder (ODD), past conduct disorder (CD), lower IQ score, high emotional overreaction and global severity scores, and personality disorder features. Impulsive auto-aggression was predicted only by ratings of inattention, high emotional overreaction, high global severity, dysfunctional interpersonal relationships, childhood clumsiness, and poor school performance.