Challenges in psychopharmacological management of a young child with multiple comorbid disorders, history of trauma, and early-onset mood disorder: the role of lithium.

[Author Affiliation]Deepmala. 1 Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas.Barbara Coffey. 2 Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, New York 10029, E-mail: Barbara.coffey@mssm.eduChief Complaint and Presenting ProblemH. was an 8-year-old adopted Caucasian girl who was initially referred for outpatient psychiatric evaluation at age 6 years for multiple problems in the context of developmental delays and complex trauma symptoms secondary to neglect and physical abuse.History of Present IllnessH. 's early history was notable for neglect, physical abuse, and possible sexual abuse, experienced from age 1 to 2 years, before H. 's adoptive family obtained permanent custody. H. first entered the mental health system for severe behavioral problems at age 3 years; her problems at that time included yelling, screaming, throwing things, hitting, biting, and destroying property. H. was reported to have a very low frustration tolerance, and demonstrated hyperactivity, impulsivity, and inattentiveness. H. 's disruptive behaviors were almost always precipitated by limit setting. H. also demonstrated overfamiliarity with strangers. She became instantly affectionate to any stranger, hugging them and sitting in their lap within a few minutes of interaction. Parents denied any nightmares or flashbacks related to trauma, but had observed H. mumbling under her breath on occasion, talking to someone else when upset. H. avoided talking about emotional subjects related to her birth mother. Initial psychiatric evaluation yielded diagnoses of attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorder, mood disorder not otherwise specified (NOS), and reactive attachment disorder (RAD), all in the context of early speech and fine motor delays.Parents reported that a significant stressor in H. 's life was the sudden death of their 23-year-old son in a motor vehicle accident when H. was 4 years old. H. was reported to be very close to this adoptive brother, who had long-term plans of adopting her. Around this time, H. reportedly slept only 1-2 hours for 2-3 consecutive nights, and exhibited significant irritability. H. was treated with trazodone at night, which was quickly increased to 150 mg, and was reportedly partially helpful. However, even while on trazodone, H. reportedly only slept 4-5 hours per night, and experienced problems with sleep maintenance and early morning waking. H. mentioned on several occasions missing her deceased adoptive brother; parents denied H. had experienced depressed mood or loss of interest or pleasure. H. 's mood fluctuated daily between happiness and irritability, although she had no history of cyclical mood or sleep changes. Parents reported that H. had always exhibited high energy levels, impulsivity, and inattention without cyclical variation. H. always wanted things her way, but had experienced no distinct period of grandiosity.When H. was age 6, her adoptive mother left town for three weeks for a funeral and H. stayed with her adoptive sister. Father visited intermittently during this time. H. was described as extremely emotional during this period; she stated multiple times that her mother "will never come back. " Her behavior gradually deteriorated to severe emotional outbursts; she banged her head when upset, and became very clingy to mother once she returned. This behavior ultimately culminated in daily school refusal and emotional outbursts in school resulting in dismissal within the first two hours. As a result, her outpatient team sought urgent consultation and referred her to the emergency department at a state tertiary care center. At that time H. was on risperidone 1 mg in the morning and 2 mg at bedtime; divalproex ER 250 mg in the morning and 375 mg at bedtime; and trazodone 150 mg at bedtime, with very limited response. …