Increasing anger and emotional outbursts

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The child’s parents were concerned for his safety after therapy for ADHD and depression failed to stabilize his mood.

Jimmy, 10 years old, was brought by his mother to the primary-care nurse practitioner’s office for evaluation of worsening anger and mood disorders. According to his mother, Jimmy had been exhibiting increasingly rebellious behavior, defiance, and angry outbursts on a daily basis. She also noted that during the day, he had been withdrawn, quiet, and sullen. Jimmy ishomeschooled, and his mother said that the daily lesson routine has turned into a major battle.

In the past, Jimmy would simply leave the house for hours at a time. When his parents attempted to talk with him about his feelings, he would hold his head and scream “my head is broken.” When he proclaimed that “it was all his fault, and everything would be fine if [he] was gone,” his parents sought professional psychiatric help. Recently, Jimmy experienced an episode while lying in bed. He claimed that his idle ceiling fan began to “move on its own and play music.” At that point, he left his room and refused to return.

History

Jimmy was a full-term baby, born following a normal pregnancy, with no trauma or medical difficulties. He was the second of five children. Although Jimmy had no developmental abnormalities, his parents described him as “an angry child” who was difficult to discipline, even when he was a toddler.

Jimmy’s parents had tried many different approaches to help him with his behavior problems. Psychiatric treatment resulted in a diagnosis of attention-deficit hyperactivity disorder (ADHD). Jimmy was given atomoxetine (Strattera) and methylphenidate (Concerta), but these medications seemed to make him even more difficult to control at home. Recently, Jimmy’s doctor suggested that the boy partake in an extensive allergy-testing program. Jimmy’s daily mood seemed to improve significantly after he was placed on a gluten- and casein-free diet, but his parents were concerned following his most recent episode.

Jimmy’s family history was positive for ADHD and distant (third- and fourth-generation) psychosis and depression. There was no history of domestic violence or other pathologies. All Jimmy’s childhood vaccinations were up to date.

Examination

On evaluation, Jimmy was normally developed for a child his age. Vital signs were unremarkable. His recent allergy workup included a chemistry profile and complete blood count, results of which were normal.

During the entire examination, Jimmy remained quiet and would rarely make eye contact. He was very reluctant to respond to questions. His speech, hearing, and vision, however, were normal. Although he had difficulties with school, he could read at an age-appropriate level.

Based on the history obtained from his parents, Jimmy was referred to an adolescent mental-health specialist. Several test panels were performed. The NP at the mental-health clinic explained to Jimmy’s parents that a diagnosis might be difficult to define because many of the boy’s symptoms overlapped. At this time, the differential diagnosis included ADHD, depression, and bipolar disorder.

The NP and Jimmy’s parents were reluctant to explore bipolar disorder because of a perception that the diagnosis carries a potentially damaging stigma. Jimmy was started on a selective serotonin reuptake inhibitor (SSRI) for his current symptoms of depression. He was scheduled for ongoing psychological counseling.

Within 36 hours after Jimmy took the SSRI, his parents called the mental-health clinic and reported an alarming worsening of the boy’s symptoms of depression. Jimmy couldn’t sleep and had stopped eating. His siblings had even expressed a fear of him.

Diagnosis

At that point, the clinician reconsidered bipolar disorder as the cause of Jimmy’s symptoms. Jimmy was begun on a gradually increasing dose of risperidone (Risperdal) as a mood stabilizer. Within one week, the boy’s parents began to note significant improvement in his mood. He was more conversant, his appetite returned, and his sleep patterns began to return to normal. His outbursts became less frequent and less severe, and the general level of tension in the household began to decline.

Although the risperidone seemed to control Jimmy’s outbursts and depression, he gained a significant amount of weight. So he was switched to aripiprazole (Abilify). His mood stabilized, and he could once again sleep in his room and play with his siblings without any problems. After three months on aripiprazole, atomoxetine was added to Jimmy’s regimen to help control his ADHD. He was able to enroll in a public school and is functioning normally.

Analysis

Contrary to popular opinion, bipolar disorder is a common pediatric and adolescent problem. Studies have indicated that up to 16% of pediatric and adolescent patients seen in psychiatric clinics may have bipolar disorder.1 Of those diagnosed with the condition, 28% began exhibiting symptoms before age 13; 65% began showing signs by age 18.

In addition to the difficulties of pinpointing mental disorders in such young patients, a diagnosis of bipolar disorder can be particularly challenging because it often presents with an atypical clinical picture and frequent comorbidities. ADHD occurs concurrently in 40%-90% of children diagnosed with bipolar disorder. Conduct or oppositional defiant disorder occurs in 30%-76% of these patients. Substance abuse occurs in 30%-40% of adolescent bipolar patients.

Children with bipolar disorder are most commonly seen in primary care for evaluation of behavior difficulties, poor school performance, or discipline problems. Parents may report that although the child appears sad or depressed, he is prone to angry outbursts and defiant behavior. Changes in mood and behavior may cycle very rapidly, or the patient may remain consistently angry and depressed.

If bipolar disorder is suspected, the patient should be referred to a mental-health specialist because diagnosis is challenging even for experienced clinicians. Treatment is usually successful, but as younger children approach puberty, the types of medication used and dosages must be followed more closely. The use of SSRIs for symptoms of depression often escalates the mood swings and anger, so mood stabilizers, including lithium, are often the drugs of choice. Atypical antipsychotics (e.g., risperidone and aripiprazole) are promising and becoming widely used, but they lack large studies in pediatric populations.

Ms. Sego is a primary-care nurse practitioner at the Department of Veterans Affairs Medical Center in Kansas City, Mo., and a contributing editor to The Clinical Advisor.

Reference

1. Wozniak J, Biederman J, Kiely K, et al. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry. 1995;34:867-876.

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