IASO: “immature adrenaline systems over-reactivity” is a term used to describe aggressive or violent scenarios/behaviors among children by Dr. Ralph Ankenman. As a psychiatrist who has been consultant to nearly a dozen residential and mental health facilities, Dr. Ralph Ankenman has observed and cared for developmentally disabled children with impulsive, violent behaviors for decades. Ankenman believes that aggression is not part of most mental illnesses, but rather mental illness can set the stage for aggression to occur more often and more unpredictably as a secondary symptom to immature adrenaline systems over-activity. He asserts that Autism and other developmental disabilities hinder normal maturing of the adrenaline arousal system (an instinctual, physical response to crisis or danger), and an immature or dysfunctional adrenaline arousal system more easily triggers aggressive rage and violence, sometimes in unexpected situations. Normally, when a person faces extreme situations, his/her adrenaline (“fight or flight hormone”) will cause the person to behave in extremes. However for those who have not fully developed mature control of their senses, a seemingly minor situation can cause their adrenaline systems to over-activate leading to uncontrollable, extreme impulsivity or aggressive/violent behaviours. Through years of observation, Dr. Ankenman has found that out-of-control children had abnormally high blood pressures and pulse rates, even while resting, indicating their bodies were overloaded with adrenaline. By controlling their adrenaline levels, troubled children can be freed from their outbursts and given the chance to learn more mature responses to frustration and threats, Ankenman says.
Instead of using psychotropic agents to manage those impulsive and troubled children’s behaviors, Ankenman has developed an unorthodox approach – IASO treatment in his practice, which is endorsed by Columbus pediatrician Dr. Ed Cutler & Dr. Elisha Injeti, the director of research and development at Cedarville University’s school of pharmacy. IASO treatment uses adrenaline blockers ( alpha-blocker such as doxazosin and beta-blocker such as Bystolic or propranolol) to protect nerve cells from excess adrenaline that triggers rage. There are two types of adrenaline driving the child’s aggression — alpha or beta, which corresponding with two clusters of symptoms of IASO, and there are physical and behavioral symptoms that help identify each of them.
Beta Type [flight/remorse]
Beta adrenaline leads to the “flight” response, where anxious children lash out when they feel threatened. Once they calm down, the children often express remorse for their behavior.
Behaviors 1–12 = symptoms of adrenaline over-reactivity (beta/ flight type)
- The child has explosions of sudden anger when frustrated.
- During episodes, the child has mostly random, unfocused hitting out at whatever is nearby (others, objects, or himself/herself).
- During episodes, the child becomes flushed (face or body reddens).
- Afterwards, the child says that he/she tried to stop but could not.
- Afterwards, the child apologizes.
- Certain adults can calm the child quickly (either by talking to or holding the child).
- The child complains that his or her heart was beating fast or hurting during the episode.
- During episodes or when excited, the child has hand or finger tremor (fingers or hands shake slightly).
- The child has a habit of biting or picking at fingernails or skin.
- During episodes, the child is unusually strong.
- The child is very physically active as part of his or her normal personality (i.e., rarely sits still even while watching television).
- The child tends to run a high resting heart rate (90 beats per minute or above).
Alpha Type [fight/no remorse]
Alpha adrenaline is tied to the “fight” response — the predator rage of, say, a lion attacking its prey. Children whose wild-eyed violence is triggered by alpha adrenaline seldom show any remorse. Instead, they’ll blame their victim for provoking the attack. Sometimes, too, the rush of alpha adrenaline erases any memory of their blinding rage.
Behaviors 13–21 = symptoms of adrenaline over-reactivity (alpha/fight type)
- 13. During episodes, the child has “crazy” or “evil” looking eyes. Eyes may appear dilated, unfocused, or non-responsive.
- 14. During episodes, the child’s personality seems changed, for example, becoming hateful with swearing and threatening.
- 15. During episodes, the child threatens to kill or harm others or claims to hate people who he or she loves
- 16. After episodes, the child does not apologize or seem remorseful.
- 17. After episodes, the child denies certain behaviors that happened.
- 18. After episodes, the child seems not to remember the whole event.
- 19. During episodes, the child becomes more violent if there is any attempt to hold or restrain him or her.
- 20. The child’s aggression seems focused and deliberate toward particular people or targets.
- 21. The child has anger episodes that move from being anxious and upset to getting wild-eyed and “going crazy.”
Bipolar Type Behaviors 22–27
- 22. The child will suddenly have an extreme increase in energy and activity that lasts for several days or weeks in a row.
- 23. During times of extreme energy and activity, the child will sleep fewer hours without acting tired (several days or weeks in a row).
- 24. The child’s changes in mood happen for no apparent reason, not in response to events or people around him or her.
- 25. The child has times of intense and unrealistic feelings that everyone is against him or her.
- 26. The child’s mood changes suddenly from several days of extreme activity to several days in a row of completely normal personality.
- 27. During periods of extreme activity or a mood change, the child has wild and unrealistic ideas about his or her own abilities.
Write down the numbers of the following behaviors applicable to your child or patient which are observable during an aggressive episode:
Behaviors 1–12 = symptoms of adrenaline over-reactivity (beta type)
Behaviors 13–21 = symptoms of adrenaline over-reactivity (alpha type)
Behaviors 22–27 = bipolar disorder symptoms
As this adrenaline-blocking therapy hasn’t been proven safe and effective in double-blind randomized clinical trials — the gold standard for evidence-based medicine, Ankenman, Cutler and Injeti feel a book is needed to get their message out to the public. In their book “Hope for the Violently Aggressive Child”, Dr. Ankenman, Cutler & Injeti, assert that these states are not necessarily signs of mental illness—they are signs of immaturity in the child’s adrenaline reactivity. Children have natural, primitive “emergency” adrenaline reflexes that they learn to control as they grow up. In some children these reflexes remain immature, and they are not able to prevent the adrenaline surge from escalating into a state of violent aggression. The book explains what happens in a child’s body when excessive adrenaline is released, and how those changes can lead to episodes of violent aggression. It also explains how to identify the different behavioral and physical symptoms of “beta” versus “alpha” adrenergic over-arousal. Behaviors 22-27 specifically relate to classic bipolar disorder. If none of the last six behaviors are relevant to a child’s situation, the diagnosis of bipolar disorder is not highly likely. However, there is ongoing research and debate about bipolar symptoms in children. A brief overview of bipolar disease and the controversies surrounding its diagnosis in children is discussed in the book.
This unorthodox approach has its critics who warn of risks. Dr. Floyd Sallee, a professor of psychiatry and neurology at the University of Cincinnati College of Medicine who has studied adrenaline’s role in ADHD, said putting drugs to a new use — a practice known as “off-label” prescribing — poses risks for patients, especially children, “Any time you have an off-label use for a medication in a population for which a drug was not intended, you run the risk of unintended consequences.” Bob Kowatch, director of psychiatric research at Children’s Hospital Medical Center in Cincinnati, said he, too, needs more than anecdotal evidence to be persuaded. “Thirty to 40 percent of kids will respond to placebo” — that is, any pill that they and their parents think might make them better, Kowatch said. “All kinds of doctors work up little concoctions of some kind and everybody thinks it works well — at least for a while.”
For more details of adrenaline-blocking therapy, please see the following links:
Or buy the book:
Hope for the Violently Aggressive Child (ISBN 978-0-57809458-8)