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Son’s Complex Case

Question. Our 14-year-old son has been treated with stimulants since he was 4. In June, 1996, we ended a Tofranil trial early because he had screaming rages and he began gouging walls and his bedding with a Boy Scout knife. He has also had problems with hair-pulling and mania. We have tried Prozac, Tegretol and lithium, but none of the medications seem to completely resolve my son’s problems. He is extremely hyperactive, is very grandiose, talks incessantly, is extremely irritable, has alienated almost all his former friends and has periods of insomnia. Most alarmingly, in his impulsive state, he has almost surely inhaled quite a number of substances, including moth balls, paint, cleaning compounds and other household items. This behavior combined with other symptoms (including his ongoing social problems) have caused his doctor to give a provisional diagnosis of Asperger’s Syndrome. Can Asperger’s and bipolar disorder coexist? Can ADHD coexist with these two, or could his lifelong hyperactivity be part of the Asperger’s? What treatment is appropriate for this child? What medications could help control the behavior? What should we be doing that we’re not doing?

Tofranil

Answer. I sympathize with your (and your son’s) plight and commend you for seeking new approaches to this difficult situation. Your son’s condition sounds quite complicated, perhaps involving multiple, interacting disorders or causes. Some studies have shown a higher-than-expected cooccurrence of ADHD (Attention-Deficit Hyperactivity Disorder) with bipolar disorder in adolescents, while other studies have not confirmed this. Certainly, bipolar disorder in children or adolescents is often misdiagnosed as ADHD, since the bipolar child is (intermittently) hyperactive. But, unlike the ADHD child, the bipolar child is only intermittently hyperactive; i.e., during the hypomanic or manic phases.

I am not aware of studies showing that Asperger’s Syndrome is associated with bipolar disorder more frequently than chance alone would predict, but the latter is certainly a possibility. Having one disorder does not protect the individual from having the other. Complicating your son’s picture, however, is the solvent and substance abuse, which may have permanently affected his brain and muddied the diagnostic waters. However, I don’t think pessimism is in order. Regardless of the specific diagnoses, there are many pharmacologic approaches that could be helpful. Some agents that might be helpful for the manic and impulsive behaviors include Depakote, Lamictal and Neurontin. A beta blocker, such as propranolol, could also help with aggressive behaviors. Clonidine or guanfacine could also be helpful (these are sometimes used for aggressive ADHD kids). It may be necessary to combine several mood stabilizers, such as lithium plus valproate, plus or minus Neurontin. Low doses of an antipsychotic agent, such as risperidone or olanzapine, may also be useful, though not without long-term risks.

The bottom line is that your son needs to be managed by a very sophisticated child and adolescent psychiatrist, with a good deal of experience in bipolar disorders. I would suggest getting a second opinion at a medical school-based department of child and adolescent psychiatry. I certainly would consider an inpatient stay to stabilize your son on a new medication regimen. Perhaps you need to emphasize the destructive and potentially violent aspects of your son’s case to a new clinician. Regarding residential treatment, I don’t know where you live, but you might contact the Rockwood Center/Brattleboro Retreat in Vermont at (802) 257-7785 and ask if they can recommend a similar long-term facility near you.

A partial hospitalization/day treatment program in a highly structured setting might also be appropriate for your son. You might want to try calling the National Clearinghouse for Family Support and Children’s Mental Health at (800) 628-1696. Finally, you may want to look into one of several nationwide Parent Training programs for conduct-disordered children; e.g, try calling the one at Yale (203-432-9993) or Philadelphia (215-707-8495) for referrals in your area. Good luck!

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