A 10 year-old male is brought by his mother for consultation. He has been treated with Focalin, Concerta, Adderall, methylphenidate, and Dexedrine. He also has received aripiprazole and olanzapine, added to the above agents. His main problems involved not being able to pay attention in school, and being aggressive and agitated toward other children. In two years of treatment, he had not improved, and was forced to change schools multiple times. At one point, while at a restaurant with his parents, he bolted out the door and tried to run down the street. On other occasions, he tried to open the car door on the highway. His parents were concerned about these impulsive behaviors, which had not improved with multiple amphetamines.
He was markedly anxious and had marked insomnia, but his family denied increased or a high level of energy. They also denied any observable depressive symptoms such as suicidality or noticeable sadness or anhedonia. He was adopted and biological family history was unknown. He lived in an intact and loving family with two parents and an older adopted sister, who had no psychiatric problems and was very successful in school and social life.
He was observed to be very short for his age, and very thin.
On mental status examination, he was polite but played mostly with a video game, answering questions briefly. He was frustrated about his poor social and academic skills and how it harmed his friendships with his peers. He expressed this frustration appropriately and rationally during the interview. He said he wanted to come off his current medications of methylphenidate 60 mg/d and aripiprazole 5 mg/d.
The PL diagnosis was that anxiety symptoms were present, which could explain all of his attentional impairment, which could further explain his school-related agitation. The worsened impulsivity was attributed to the harmful manic-like effects of amphetamines. The recommendation made was to stop both methylphenidate and aripiprazole. Since the latter has some dopamine agonist effects, it could be contributing to the worsening impulsivity. Two treatment options were given for symptomatic purposes: very low dose SRI for anxiety, or low dose risperidone for pure anti-dopamine effects to target impulsivity. The diagnosis was unknown since family history was unknown and because of his young age. It is typical for anxiety symptoms to be the earliest manifestation of other psychopathology, such as later depressive or bipolar illness.
The PL approach in children is to use medications minimally for symptoms, provide as many behavioral interventions as possible at school and home to improve function, and then to observe the evolution of the illness until a more definitive diagnosis could be made.
Within weeks of stopping methylphenidate, his parents reported that he was much calmer, less anxious, and less agitated. He began to eat more and was putting on needed weight. A few months later, he became somewhat anxious, and the family chose to start SRI treatment. The PL recommendation was 10 mg fluoxetine given twice weekly. This is because fluoxetine has a very long half life of one week and thus it can be dosed weekly. This approach would give the lowest amount of SRI feasible, and also the child would not see himself as being medicated daily. Within weeks, his anxiety resolved and his behavior improved notably.
At one year follow-up, taking only fluoxetine 10 mg 1-2 times weekly and no other medications, he had grown a number of inches and was closer in stature to his peers, which markedly improved his self-esteem. He had gained weight and was normal in his body mass index. He was doing very well in a private school with sufficient attention to providing behavioral assistance for executive dysfunction. His peer and family relationships had improved markedly.