Case Study #2: An 8-year old exhibits rage outbursts followed by feelings of guilt.
The parents of eight-year-old Michael explained “He’s very polite and well-behaved 90% of the time, but several times a day, like when we have to tell him to do a simple thing like to turn off a video game he’s playing so he can start getting ready for bed, he often, but not always, will fly into a rage, swear at us, and head-butt us, and then keep kicking against a door. This goes on for about 10 or 20 minutes and then he starts crying and says “I can’t move, I’m stuck, come help me.” He wants one of us to come hold him quietly for a minute or two, then he tells us he’s very sorry for being so bad and then it’s over and he’s all good again until the next time.” Michael’s mother shook her head and said “We’ve tried systems to reward him for any day without these meltdowns, but that didn’t help at all.” His father said, “When he does that stuff, it makes me so mad that I start screaming at him, even though I know that does no good at all and probably makes it worse.” Michael’s parents also reported, “He’s had a few episodes at school where he had meltdowns and hit other kids; he got suspended twice, but those are rare. Mostly, this just happens at home.”
Two years prior to my seeing him, Michael had been diagnosed by another doctor as having ADHD; she prescribed some stimulant medication for him, but that had to be stopped because it intensified the meltdowns and anger outbursts. I arranged for Michael to begin a trial of a non-stimulant medication to help him control his intense episodes of anger; I also met individually with Michael, with his parents, and with the three of them together
This was not just a problem with Michael; it was a problem for the whole family and was fueled by multiple factors. Michael clearly had a very short-fuse when he was frustrated; yet his impulsive angry outbursts were quickly followed by strong feelings of guilt and fear. His father reported that his own father, his father’s father and his brother all had struggled with brief, but intense outbursts of rage similar to what Michael experienced. This suggested that genetic factors were probably involved. Michael’s dad also reported that he himself felt overwhelmed with anger and screamed at Michael with intensity anytime Michael acted angry. This intensified Michael’s anger and his fear of his own temper and of his father.
Michael’s father also acknowledged that he, himself had been diagnosed with ADHD and was taking medication for it. Unfortunately, his medication dosing was helping some, but not much. I suggested that he discuss the possibility of a change of medication or dosage change with his prescriber.
The parents also explained that they were struggling with financial pressures. The husband had been laid off and had been unable to find a new job for more than a year. This was frustrating and embarrassing to him as his wife was working long hours to support the family while he was staying home taking care of the house and Michael. Meanwhile, Michael’s mother was clinically depressed and also frustrated that her husband often seemed not to be pulling his weight at home. Both parents were often in conflict, unable to provide much emotional support for one another or for Michael. Both clearly loved their son intensely and were committed to one another, but they were feeling increasingly frustrated with him, embarrassed that they could not control his outbursts or their own, and hopeless about how to help him and one another.
There is no single profile of emotions common to all individuals with ADHD. There is much diversity due to differences in age, temperament, personality style, family life, cultural background, and many other variables. Yet there are some ADHD characteristics and some situations often experienced by many with ADHD (and those involved with them) that cause particular patterns of emotional dynamics to emerge more frequently among these people. These case studies describe some emotional dynamics often reported by children, adolescents or adults with ADHD and those who interact with them.
The palette of human emotions is rich and variegated. It includes happiness, enthusiasm, interest, disinterest, boredom, delight, worry, fearfulness, panic, terror, frustration, annoyance, anger, rage, pride, envy, embarrassment, shame, guilt, jealousy, disappointment, discouragement, grief, hopelessness, sadness, depression, longing, trust, optimism, expectancy, determination, affection, passion, love, hope, and many others.
Emotions are dynamic in that they often change and interact, sometimes in an instant, sometimes over hours, weeks or years. Often they change in response to specific circumstances of a situation, what someone else says or does and how individuals perceive and react to one another in given moments and over time. Sometimes emotions are quite transient, a flash of anger or a moment of jealousy, pride or affection that may quickly be modified or replaced by other emotions which may be quite contradictory. Emotions also may be persistent over much of a lifetime, absorbed into the fabric of one’s personality across differing settings.
Emotions vary not only in type, but also in intensity. Sometimes emotions arise with fierce or crushing intensity; at other times that same emotion may be scarcely noticeable. Emotions also vary in level of consciousness. Sometimes a person is fully aware of a particular emotion in a given moment, yet at another time that person may be totally unaware of an emotion that others readily recognize and respond to.
In all persons, emotions tend to arise in multiple mixes and blends. Sometimes the blend is subtle and convergent—affection and longing, pride and hope. In other instances, emotions strongly conflict with one another— interest and fear, pleasure and guilt, pride and resentment, love and hate. Sometimes the conflict is immediate; in other instances, one emotion may be followed quickly or gradually with another, or a person may experience rapid alternation between one emotion and another. Examples described in this case study may be experienced by various individuals in many different ways, only some of which are included here.
Brown, T. E. (2017). Emotional Dynamics in Individuals, Couples, and Families Coping with ADHD. In Outside the Box; Rethinking ADD/ADHD in Children and Adults (pp. 151–170). Arlington, VA: American Psychiatric Association Publishing.