Conclusion: Navigating Setbacks to School—A Complex Pediatric Case Study

Vladimir Maletic MD, MS, discusses how he would treat the patient from his case presentation "Navigating Setbacks to School: A Complex Pediatric Case Study," including the treatment goals of pediatric attention-deficit/hyperactivity disorder (ADHD) when patients are heading back to school.

Transcript:

Hello, my name is Dr Vladimir Maletic. I am an adult and child adolescent psychiatrist. I'm clinical professor of psychiatry at USC School of Medicine in Greenville, South Carolina. In front of you, you have a challenging case, yet a case that you may likely encounter in your clinical practice.

Why is it challenging? It is challenging because we don't have diagnostic clarity. If we are hasty, this child can end up being diagnosed with half a dozen different conditions. One can make a case that this child has ADHD. What would be some of the elements of diagnosis? Well, he is fidgety, hyperactive in his class. He's impulsive. He's getting out of his seat quite often. He's inattentive, daydreaming. He has difficulty sustaining focus in the school setting, has a hard time completing his work, and at home has a hard time completing his homework. There are some elements of emotional dysregulation and often neglected symptom domain in the context of ADHD.

So due to impairment in several different spheres of functioning due to its duration, it's clearly over 6 months, we can easily entertain a diagnosis of ADHD. What might be another condition where we see that this child has issues with social communication, he has very few peer relationships. We also see that this child has a hard time with change. Think about when symptoms emerged.

After the school year has started, he has been into it six, seven weeks, but wait a minute, he's 12. This is sixth grade! This is transition to middle school. So any change in routine. We have also seen that if his place at table is shifted, he has intense emotional responses.

So, adhering to routines, liking predictability, and stability can be something that is an aspect of autistic spectrum disorders. Because, again, he has problems with social communication. He has problems maintaining reciprocal relationships and now we see these challenges with changes and disruption of routine.

We can make a pretty good case for autistic spectrum disorder. He is anxious during the night, waking up, can't sleep without lights, and comes to his parents' room. He reports feeling anxious from time to time.

Is there an anxiety disorder? We see that at times, both in school and with parents, he can be oppositional and defiant. Does he have oppositional defiant disorder? There are elements of depressive disorder symptomatology. At times he feels hopeless; he feels sad. We are not to forget that sometimes anger can be a manifestation of depression in children and adolescents. Is there a depressive disorder? We can just keep on going on, but I think before we start attaching all these diagnoses, it's important that we have clarity.

So let us go through some of the potential options.

One is, well, he doesn't seem to be doing so well with his current methylphenidate extended-release formulation. Might amphetamine be more helpful? Well, possibly so, but we need to keep a few things in mind.

I would say that the strongest case is that this child has ADHD and autistic spectrum disorder. Stimulants in this constellation of diagnosis can sometimes worsen anxiety, cause more problems with irritability and aggression, can enhance sleep disturbance, all of which are already there. I would advise caution. In addition to that, stimulant medications in individuals who have both ADHD and autistic spectrum disorder, ASD, don't work as well. So pluses and minuses. Adjunctive alpha 2 agonists can definitely be an option because it may help with sleep, it may help with hyperactivity and impulsivity and it may add to symptom control if it is combined with the stimulant. So definitely something that can be helpful. On the other hand, when it comes to autistic spectrum disorder, there is some data but not very robust control data supporting their usage.

So where would I start? Psychological evaluation for autistic spectrum disorder would be where I would start. Clinicians may be comfortable utilizing interviews that are designed for autistic spectrum disorder or utilizing scales. Where I like to start is the strength and difficulties questionnaire. It is useful both for certain emotional manifestations of ADHD as well as autistic spectrum disorder. Why? When you approach the child from the perspective of assessing their strengths, they have a much better response, and you build a much better relationship than when you're pointing out deficits. In terms of an SSRI, yes, SSRI may help with depressive symptoms. It may help with irritability, may help with anxiety.

On the other hand, SSRIs, when it comes to attention deficit disorder, sometimes can be a plus-minus scenario. There is some evidence that they may help enhance social skills in individuals who have autistic spectrum disorder. It definitely would be a possibility. I would not be a big fan, although some literature suggests that replacing stimulant with bupropion, it may address at the same time depressive symptomatology. I think depressive symptomatology is more a manifestation of the circumstance rather than depressive disorder per se. Bupropion does not seem to have as robust evidence suggesting its efficacy in ADHD, so I'm not sure that this would be a step in the right direction and in addition to that, may actually exacerbate some of the sleep problems that this child has.

Another alternative, which has not been listed here, but I would entertain, is utilizing viloxazine extended-release. Why? It is approved for the treatment of ADHD. We have no evidence that it can help in autistic spectrum disorder aside from empirical. I have used it on a few occasions with pretty good outcomes. What may be an aspect of this medicine that may be appealing? This is medication, which based on preclinical studies, including preclinical studies in primates, which are soon to be published, tends to increase serotonin. We may cover more than one base. It may help with ADHD symptomatology, an increase in serotonin, but these are a lot of "maybes." We lack good controlled evidence. It may help with anxiety, may help with depressive symptomatology, and may help with some of the social symptomatology associated with autistic spectrum disorder.

So again, if we were to choose just one option, I would say let us first gain diagnostic clarity, let us see if autistic spectrum disorder, as we suspect, is really there and then let us emphasize psychosocial treatments. I think helping this child develop a better communication and language skills, helping this child develop better relationships, very often in autistic spectrum disorder and ADHD, there's social misattribution where some neutral social cues are interpreted as challenges, as hostile expressions. Correcting that may really make social education much easier.

Psychosocial intervention would include working with parents and with school authorities. Psycho-education would be very important in this context.

These are just some of the things to think about. I would suggest that you maybe spend a little bit more time formulating in your own mind what the best diagnostic impression would be and what kind of treatment course would you design in this scenario. I want to thank you for your attention and for joining us today. I hope that this discussion will help you and your patients in the future. Thank you.