Severe Aggresive(aggressive) Behavior

This is about a 2 year old boy who has had aggressive behavior for about 8 months. He was born with transposition of great vessels. He only has a 4-word vocabulary. He goes into tantrums several times a day, gets angry and bangs his head on the wall and has made holes in the wall. His sisters who are 3 and 4 years old are terrified of him and he gets into frequent fights with daycare children.  He took a 19-inch television and pushed it off the stand with enough force to make a hole in the wall. He frequently bites himself on his arms and hands, leaving his teeth marks and bruising the skin. He will climb on any table or surface and let himself drop on the floor without expressing any pain, just laughing afterwards.  He used to scream and thrash things all over the room until he'd get tired and sometimes would not be able to sleep for 3 days in a row and when it looked like he might start to fall asleep he'd jerk out of sleep and get up again.  He tried to poke his sister's eyes with his fingers.  His psychologist stated "boys will be boys". He was started on Ritalin 5 mg at age 18 months and was able to sleep and behavior improved; he is now on ritalin 5mg twice daily but he still has tantrums daily and is aggressive with everyone. Strattera was tried but it did not work and ritalin was resumed.  Any suggestions?

[Kevin Kennedy, Ph.D.]

The cardiac defect per se would not be indicative of any other problem. What is of concern is whether your son displays some variant of Pervasive Developmental Disorder, or other developmental disorder. This appears to be the major diagnostic question, and its answer might lead in the direction of a different pharmacological treatment plan. At the very least, it's worth considering a change in the stimulant medication, perhaps switching from a methyphenidate product to an amphetamine product (e.g., Adderall (adderrall)). While both hyperactivity and impulsivity are part of the symptom profile (thus the plan to treat with stimulant med), the aggressive component of your son's behavior is of equal (and perhaps even greater) concern. You might arrange for an evaluation by a developmental team, including developmental pediatrician, developmental psychologust, child psychiatris, and speech/language therapist. Your son's delay in language development (most two-year-olds have more of a vocabulary and may piece together a couple of words to form simple 'sentences').