“Alan” is an 11-year-old boy who was first seen in our clinic 3 years ago. His parents’ chief complaint at admission was Alan’s physically aggressive behavior at home, in particular toward his mother, as well as fights with children and teachers at school.
Alan reportedly met his early developmental motor and cognitive milestones, but he showed difficulties with temper control and frustration tolerance as a toddler, having “significant fits” and biting other children. In preschool, Alan’s behavior was generally without significant aggression except when his mother was there to volunteer. In kindergarten, his parents reported, his behavior was managed with the help of a teacher who was very consistent with discipline and structure, but the following year, his first-grade teacher provided much less structure, and Alan started getting into fights again with other children. His behavior also worsened at home; for instance, he would fight a neighbor boy and “the kids would scratch each other bloody.” The parents started family counseling at that time, which did not reduce the problem behaviors.
In second grade, at the end of the first trimester, Alan reportedly “lost it.” After a family session, he “cleared the entire desk of the therapist” and “threatened to hurt the therapist.” At home, he would take knives from kitchen drawers and threaten family members. He would “shut down” and not talk about his feelings or thoughts. He was referred by the outpatient psychotherapist to the emergency department and was subsequently treated in a day hospital program, which did reduce his outbursts. He was not put on medication. Discharge diagnoses were mood disorder not otherwise specified, rule out depressive disorder, and rule out anxiety disorder.
After discharge, Alan was referred to our clinic. He continued to struggle with aggressive outbursts. When he was told to do minor chores or homework, he “would never do it.” Sometimes he would be “good” in the morning, but his mood was usually irritable, and little things would set off explosive outbursts, with yelling, throwing things, and punching people around him, resulting in bruises; his parents had some concern about the safety of Alan’s sibling, as well as their own safety. He had such outbursts approximately four times per week, each lasting 30 to 45 minutes. His parents also reported an apparent “female authority problem”; Alan responded much better to male authority figures than to women.
During a review of Alan’s developmental history, his parents reported that their son had poor eye contact since early age and that he would “suppress” emotions and had a flat affect. They also noted that Alan did well approaching adults but did not attach emotionally to other children and struggled with making same-age friends. His own perception, however, was that he had many friends. Alan was always very much interested in science and was an expert in dinosaurs and rocks. “While other kids look at things in museums and move on,” he would read all the information he could get. Alan excelled in memorizing other people’s names and faces and after years would recognize someone he had seen only once. He was also noted to struggle with change in routines and to fidget with his hands. There was no history of abuse, contact with drugs or alcohol, mania, anxiety, or major medical illness. The family environment was reported as stable. Alan has one sibling, and no psychiatric family history was reported. Alan had never been hospitalized; he had been seen by three outpatient family therapists in the past, and, as noted, he had been in day hospital treatment.
Alan himself reported that at times he did “not feel good,” but he denied depression or anxiety. He acknowledged having fights with other children but did not elaborate on circumstances. He reported hearing “animal voices” from under his bed or from the closet, but he could not really make them out. He felt there were ghosts and monsters in his room, and he was afraid of somebody pulling him down under his bed. When he looked, he reported seeing a lot of “stuff under his bed,” but denied seeing monsters. On further questioning, Alan said he thought those voices could be from the wind or his parents, but he was not certain about the absence of monsters. He had these experiences mostly in the darkness, at night. He denied paranoia or ideas of reference.
Alan was assigned to a regular classroom in the third grade. He performed very well academically, and the school provided accommodation for him to seek out a quiet room when he got upset.
On examination, Alan was dressed appropriately for his age, showed moderate eye contact, and had a significantly restricted affect with little reactivity. His speech was characterized by a monotonous tone but normal volume and rate. Overall, his thought process was linear and goal directed. He reported his mood as “okay” and denied low or elevated mood but acknowledged irritability throughout the day. He denied current suicidal or homicidal ideation but described the potential hallucinatory experiences mentioned above. He appeared somewhat hyperactive, fidgeting in his chair. His cognition was grossly intact, oriented to time, place, and person. His insight and judgment were rated as fair in this interview, with deterioration during violent outbursts. The Vanderbilt ADHD Diagnostic Parent Rating Scale indicated subthreshold hyperactivity and no attention difficulties.
At the time of the visit, Alan was diagnosed with Asperger’s disorder, intermittent explosive disorder, rule out psychotic disorder, and rule out high-functioning autism. After normal results were obtained on screening laboratory tests, including glucose level and a lipid panel, risperidone, 0.25 mg at bedtime, was prescribed to target baseline irritability and violent outbursts.
On follow-up, Alan’s parents reported improvement but still significant mood instability. The risperidone dosage was increased to 0.5 mg at bedtime. About 2 weeks later, the parents reported that Alan’s tantrums were down to 10–15 minutes and that Alan was able to “catch himself better,” was less physical with and doing better interpersonally with peers, and was smiling more, and that he reported feeling happier. At school, adjustments were made to provide emotional support and structure for Alan when needed, including a focus on social skills development.
Alan returned to clinic regularly and progressed well over the next 8 months, but he did not return for another 7 months, well into the fourth grade. After a good second half of third grade, Alan reportedly had trouble readjusting to the next school year, a typical high-stress situation for him. After several altercations at school, he was moved to a school that specialized in behavioral problems.
His parents had continued Alan’s medication through third grade, but with some hesitancy. Reportedly, the medication was skipped at times during the summer, but the parents did not provide any detailed information as to how often. They reported that Alan’s aggressive behaviors had returned gradually. Since the last visit, Alan had grown significantly, and his parents hoped that he would “grow out” of needing medication.
During the visit, Alan presented as emotionally very labile, and at one point he ran out of the room and had to be brought back by his parents. Alan reported feeling stress at home; he initially did not want to describe it, but eventually he endorsed seeing a frightening tall man-animal figure at home. He was not open to discussing this experience further. He expressed some death wish but denied suicidal plans or acts.
Over the following 2 months, his risperidone dosage was adjusted to 0.5 mg twice daily, which he tolerated well, and his behavior greatly improved. The school provided specific treatment for pervasive developmental disorder, including a highly structured environment as well as social skills training to ensure that Alan would understand cues and instructions.
During the next 6 months, Alan was “Student of the Month” several times, and he transitioned well into a new school year. His parents requested that his medication be reduced. In the treatment sessions, he made an effort to show good eye contact, and he expressed how therapists or other children make him feel. He denied any psychotic experiences, but his affect continued to be restricted.
After repeated requests from the parents, Alan’s risperidone dosage was decreased to 0.5 mg at bedtime. Over the following 8 weeks, which coincided with the transition back to the regular school environment, Alan started to deteriorate again, becoming physical with other students, and he was referred to the emergency department. His risperidone dosage was brought back to 0.5 mg b.i.d., and he stabilized within 2 weeks, having less irritability and no significant behavior problems.
Asperger’s disorder, a pervasive developmental or autism spectrum disorder, is characterized by 1) impairments in nonverbal communication, ability to develop normal peer relationships, and ability to enjoy and share experiences with others; and 2) restricted or stereotyped behaviors or activities such as preoccupation with special interests, being inflexible about change of routines, and stereotypic motor behaviors. Anger and irritability are common in Asperger’s disorder (1); in one large study, up to 44% had a behavior disorder, 42% an anxiety disorder, 26% a tic disorder, and 6% a mood disorder (2). Individuals with Asperger’s disorder struggle to identify social cues (3), leaving them in a state of “not understanding” the world around them (4).
The average age at which Asperger’s disorder is identified is around 11 years (5), and Alan’s diagnosis was therefore relatively early. Still, he had been seen by three therapists and had been treated in a day treatment program without having been diagnosed with the disorder, although the presentation was consistent with diagnostic criteria (6).
The primary approach to behavior problems in children with Asperger’s disorder is to teach them to control emotions, teach them problem-solving skills, and teach the parents to manage those behaviors (7). The Asperger’s diagnosis made an important difference in Alan’s treatment, since the frequently occurring irritability can be targeted with medication to enable behavioral gains. Parents rightfully question the need for medication for their children, and providers also may avoid pharmacologic treatment because of the risk of side effects. However, careful use of medication (“start low and go slow”) can make a remarkable difference, and treatment with an atypical antipsychotic such as risperidone in combination with parent training and specialized patient interventions has been shown to be superior to medication alone (8). Providers should discuss with the patient and parents a time frame for trying to discontinue medication, and having this discussion early on is usually very much appreciated by the family (9).
Accepting the diagnosis of a pervasive developmental disorder is difficult for parents, and it may be associated with both perceived positives and negatives (10). For Alan’s parents, the Asperger’s diagnosis “all of a sudden made sense” of their son’s problems, they said. Nevertheless, hearing the diagnosis was difficult, and accepting it took some time; additionally, it took courage for them to accept that certain problems cannot be handled within the family alone and that the family had to adjust their expectations for their child. Stigma around mental health and mental illness is still widespread (11), and assessments and support through the school psychologist are important in reducing barriers to care (12).
Complicating this case were Alan’s intermittent psychotic symptoms. The potential for violent behaviors in pervasive developmental disorders, including Asperger’s disorder, is greater in the context of co-occurring psychosis (13). Hallucinations are not pathognomonic for schizophrenia in children, though (14), and the differentiation of a primary psychotic disorder and a pervasive developmental disorder is not always straightforward. Notably, the presence of psychotic symptoms seems highly related to anxiety in children (15). In Alan’s case, it seemed that the psychotic symptoms were stress induced. Alan did not report any psychotic symptoms for several months during a low-stress period when he participated on a football team and felt more socially competent. However, with increased stress during the last school transition, his symptoms reemerged and he needed an increase in his medication dosage once again. This case indicates the important interaction between illness and environment, and time will tell whether anxiety or psychosis will emerge as primary exacerbating factors in Alan’s pervasive developmental disorder (16).
Violence in the context of Asperger’s disorder poses significant challenges for diagnosis and treatment. Here we presented the case of a child who was identified relatively early and made great improvements with the help of specialized school interventions, psychotherapy, and medication. However, environmental stress repeatedly triggered the reoccurrence of symptoms, limiting reductions in his medication dosage.