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Integrated treatment of aggression in the context of ADHD in children refractory to stimulant monotherapy: a window into the future of child psychopharmacology.
Am J Psychiatry. 2009 Dec;166(12):1315-7
Authors: Steiner H, Karnik NS
PMID: 19952080 [PubMed – indexed for MEDLINE]
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(Via Am J Psychiatry – Medline.)
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The article discusses the use of Divalproex in the treatment of aggression in children with ADHD.
The problem I have is that aggression is not part of ADHD.
I suggest teasing it apart from ADHD and considering it as part of a mood disorder. Thus the child would have ADHD + Mood Disorder.
This would clarify the issues and would help more easily determine pathophysiology and the course of treatment.
One of the causes of aggression in ADHD is high dose stimulant treatment. This is more easily seen with the amphetamine-based medications. One way to predict this is to measure the child’s total cortisol level. Generally, when it is low, the child may not be able to tolerate stimulant treatment since low cortisol response to stress results in mood instability. And stimulants destabilize mood.
Since Depakote, itself, can impair attention, as anticonvulsants can frequently do, I suggest examining the child for the pathophysiology of the mood disorder to help determine what would be the best course of treatment that doesn’t exacerbate the primary problem itself (ADHD). For example, if the child is iron-deficient, both attention and mood may be disrupted. Addressing this deficiency may address both problems.