An 11-year-old boy with Asperger's disorder presenting with aggression.

“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 exceptwhen hismother 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 followingyear,hisfirst-grade teacher providedmuch 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 emergencydepartment 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 themorning, but hismoodwasusually irritable, and little things would set off explosive outbursts, with yelling, throwing things, and punching people around him, resulting inbruises;his parentshad someconcern 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, ormajormedical illness. The family environmentwas 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” fromunder 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 experiencesmostly in thedarkness, atnight.Hedenied paranoia or ideas of reference.