Emotional dysregulation in a child with attention-deficit/hyperactivity disorder and anxiety: psychopharmacological stategies.

[Author Affiliation]Anupriya Srivastava. 1 Mount Sinai Hospital System, Division of Child and Adolescent Psychiatry, Department of Psychiatry, New York, New York.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 ProblemD. is an 11-year-old boy in a fifth grade special education program with an individualized education plan (IEP). He lives with his mother and older sister. D. was referred to Child and Adolescent Psychiatry Family Services for declining academic performance, impulsive and oppositional behavior, anxiety, and poor sleep.History of Present IllnessMother reports that D. has had problems with his behavior, specifically trouble managing frustration and anger, since the age of two. Mother reported that D. had no history of developmental delays, and had not received early intervention. He received speech therapy in school until age seven.D. was initially evaluated at the age of seven for concerns regarding his poor academic performance, lack of response to limit setting, impulsive and aggressive behavior, anxiety, and trouble sleeping. D. was subsequently diagnosed with impulse control disorder-not otherwise specified (NOS), anxiety disorder-NOS, and learning disorder-NOS.D. received individual and family therapy, tutoring services, and pharmacotherapy. D. was treated with several medications including aripiprazole, clonidine, ziprasidone, olanzapine, diphenhydramine, and OROS methylphenidate. D. remained on OROS methylphenidate for his impulsive behavior, olanzapine for his aggression, and diphenhydramine for sleep initiation. D.'s behavior and impulsivity was reported to improve on the OROS methylphenidate and olanzapine, but his sleep remained problematic on diphenhydramine.Unfortunately, D.'s mother experienced an exacerbation of her own mental health problems this past year when D. was age 10, and for three months was unable to bring him to his appointments. D. attended a few appointments independently, but was not consistent with his therapy or tutoring services, or adherent with his medications. As a result, D.'s services were terminated at the clinic last year, and D. was without consistent psychiatric care for a prolonged period.About six months later, D. was referred to an academic center for child and adolescent psychiatry services. At that time, mother reported that he had " low frustration tolerance, anger, aggressive behavior, poor academic performance characterized by declining grades, anxiety, and trouble sleeping." Mother complained that when he does "not get what he wants," he becomes "aggressive, self-injurious and displays oppositional behavior at home." For example, if he does not get the "right kind of snack" he "bangs his head, punches walls" and "raises his fists" as if he was "about to punch someone." D. was also having trouble with his peers and teachers at school. Mother noted that he appeared to be anxious "all the time" and had trouble initiating sleep at night. As a result of going to bed late, he had difficulty waking up in the morning. Because mother reported difficulty with sleep initiation herself as well, D. missed school at times.D. was diagnosed with attention-deficit/hyperactivity disorder (ADHD) combined presentation, oppositional defiant disorder, and learning disorder. The recommendation was for a multimodal treatment plan to target his disruptive behavior, anxiety, and sleep initiation difficulties. D. began individual weekly therapy, and monthly or bimonthly medication management, but declined to participate in group therapy. Parent-child relational therapy was recommended, but mother was not able to consistently attend appointments, so this treatment was discontinued. …