Ryan S. Sultan, MD

→ Clinical Presentation

Ryan S. Sultan, MD
Assistant Professor of Clinical Psychiatry
Child and Adolescent Psychiatry Consult Service
Weill Cornell Medicine & Columbia University

Originally Presented: May 2019 - Pediatrics Grand Rounds

⚠ Important Clinical Principle

Aggression and temper tantrums are not diagnoses—they are symptoms. They generally indicate an underlying condition that needs to be identified and treated.

Treating only the tantrum behavior without addressing the underlying cause will lead to continued dysregulation.

Presentation: Alex, a 7-year-old boy, was sent to the pediatric emergency room after standing on a desk at school screaming and throwing computer keyboards. He was admitted to the child psychiatry unit at Westchester. He had two previous psychiatric admissions and was currently on Risperdal (having been tried on several antipsychotics).

Key History:

• Chronic worries that his chronically ill mother will die and leave him without care
• Severe separation anxiety - difficulty separating from parents
• Continues to sleep in parents' bed
• Poor sleep, worries about break-ins
• Never been tried on an SSRI
• Tantrums occur primarily around separation or social situations
• Between tantrums: well-related, appropriate child

The Missed Diagnosis: Separation Anxiety Disorder

Treatment: Discontinued Risperdal, started on Prozac (SSRI) → Significant improvement in behavioral issues

Clinical Lesson: This child's aggressive tantrums were manifestations of untreated anxiety. He was being treated with antipsychotics for aggression when the underlying anxiety disorder had never been addressed. Once the anxiety was treated with appropriate first-line medication (SSRI), the "behavioral issues" resolved. See research on off-label antipsychotic prescribing for evidence-based alternatives.

Presentation: Samuel, a 6-year-old boy, was sent to the pediatric emergency room after an aggressive outburst at school resulting in threatening peers and staff. He had a chronic history of behavioral issues but no previous psychiatric evaluation or care.

Examination Findings:

• In ED: easily playing with Xbox, engaging with toys
• Moves around constantly, unable to sit still
• Difficulty staying on topic during interview
• Asked for a "brain scan" to help see "all the thoughts and feelings stuck in his head"
• School reports: difficulty participating in class, reactive toward staff/peers, low frustration tolerance
• Between tantrums: well-related child

The Missed Diagnosis: ADHD (Attention-Deficit/Hyperactivity Disorder)

Treatment: Admitted to Child Psychiatry unit, started on stimulant → Improved behavioral control

Clinical Lesson: This child's "aggression" was actually impulsivity and frustration intolerance from untreated ADHD. The hyperactivity, distractibility, and difficulty with emotional regulation are core ADHD symptoms. Once the ADHD was treated, the behavioral dysregulation improved dramatically.

Presentation: Danny, a 10-year-old boy, was brought from home after becoming aggressive in the car toward his mother. He had one previous psychiatric hospitalization and was on no medications.

Key History from Mother:

• "I have never been able to manage him"
• Physically aggressive toward mother and older brother
• Daily outbursts - verbally and physically threatening
• Has damaged many items in the house
• Demanding and argumentative
• Child does not respond to any limit-setting attempts
• "I'm walking on eggshells with him—he is chronically irritable"

The Key Feature: Chronic irritability - not just episodic tantrums

Likely Diagnoses: Disruptive Mood Dysregulation Disorder (DMDD) and/or Oppositional Defiant Disorder (ODD), plus probable Parent-Child Mismatch

Treatment Approach:

• Consider SSRI for underlying mood dysregulation
• Parent Management Training (PMT) - Critical component
• Possible addition of antipsychotic if severe aggression persists
• Family therapy to address dynamics and establish consistent structure

Clinical Lesson: Unlike Alex and Samuel, Danny does NOT have a "euthymic baseline." He is chronically irritable, which suggests a mood spectrum disorder (DMDD) rather than triggered dysregulation from anxiety or ADHD. Additionally, the parent-child relationship has become severely disrupted, requiring behavioral interventions.

Step 1: Is the child's baseline mood euthymic (normal/happy) or irritable?

Euthymic Baseline:

• Look for triggers (separation, social situations, demands, transitions)
• Consider: ADHD or Anxiety Disorders
• Treatment: Stimulant (ADHD) or SSRI (Anxiety) + PMT

Chronically Irritable Baseline:

• Tantrums on top of baseline negative mood
• Consider: DMDD or Depression
• Treatment: SSRI + PMT, consider antipsychotic for severe aggression

Step 2: Evaluate parent-child interactions

• Are parents consistent? Reinforcing tantrums? Using effective strategies?
• Always include Parent Management Training

Step 3: Treat the underlying condition, not just the symptom

• Medication targets the neurobiological underpinnings
• Behavioral interventions teach skills and change patterns
• Parent training ensures consistency and effective management

1. Tantrums are symptoms, not diagnoses - Always look for the underlying cause
2. Distinguish between triggered dysregulation and chronic irritability - This guides diagnosis and treatment
3. Three common mistakes:
   • Treating aggression with antipsychotics when it's actually untreated anxiety (Case 1: Alex)
   • Missing ADHD because you only see the "bad behavior" (Case 2: Samuel)
   • Not addressing parent-child dynamics (Case 3: Danny)
4. Parent Management Training is essential - Not optional, especially for ODD and DMDD
5. Match treatment to underlying condition:
   • ADHD → Stimulant + PMT
   • Anxiety → SSRI + CBT + PMT
   • DMDD/ODD → SSRI + PMT, consider antipsychotic if severe
   • Parent-Child Mismatch → PMT is first-line
6. Don't reach for antipsychotics first - Treat the underlying condition appropriately