49. Mystery Case - 9 yo with anxiety and sudden behavioral problems

Welcome to our new segment called Mystery Case Files where we walk through a clinical case that presents a bit of mystery. Using the latest research and evidence, we discuss practical approaches to help YOU care for your patients effectively.

This episode features the case of a nine-year-old boy with anxiety who develops new onset of behavior problems. 

00:00 Introduction to Mystery Case Files

00:27 Today's Mystery case

00:27 Presenting the Case: A 9-Year-Old with Anxiety

00:54 Initial Thoughts and Differential Diagnosis

01:32 Reviewing the Patient's History

02:04 Choosing the Right Medication for Anxiety

02:10 What is the best medication for anxiety?

03:34 Four Weeks Later: Follow-Up Visit

03:58 Analyzing New Symptoms and Possible Causes

05:01 Is the anxiety medication making him worse?

05:26 Exploring ADHD and Medication Side Effects

07:09 Understanding Activation Syndrome

08:45 Pharmacokinetics and Genetic Factors

10:25 Solving the Mystery and Next Steps

11:02 Conclusion and Call to Action

Visit us on our website or message us with YOUR MYSTERY CASE that we can discuss!

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Transcript

Dr. Elise Fallucco: 0:21

Welcome back to Psyched for Peds. I'm your host, Dr. Elise Fallucco, child psychiatrist and mom. So we're starting a new segment today called Mystery Case Files, where we're going to walk through a clinical case. That is a little bit of a mystery and as usual, we're going to apply the latest science research and evidence in a practical way to help the patients that you're taking care of in your office. So let's begin. Today's mystery case is a nine year old boy with anxiety who's typically well behaved and a pretty good student, but his parents brought him to your office today because they're concerned that recently he's been having behavior problems in school, as well as some hyperactivity, insomnia, and impulsivity. Your job is to figure out what is causing these new symptoms. and how you can help. So just based on this information, my mind wonders, is this worsening anxiety? Because we know kids with anxiety can manifest with behavior problems. The other thing that I would be thinking about is, is there some major stressor that's been going on? Could this possibly be some traumatic reaction or change in behaviors related to a stressor? Of course, anytime you hear the words hyperactivity and impulsivity, you can't help but think about ADHD. So that's also something to consider. Or, could it be something else? So, let's back up. You had most recently seen this nine year old boy in your office about four weeks ago. And at that time, he had been in therapy for his anxiety for months, but parents were concerned that it was not helping. His SCARED score was in the high 30s, which is well above the clinical cutoff of 25. He had no other medical diagnoses and was not on any meds. And you had considered starting a medication for anxiety. And you were wondering to yourself, what is the best medication for anxiety? I have to tell you this is one of the questions I get asked the most often. And so we're going to talk about it. What we know is that really we have good evidence for use of fluoxetine. Sertraline and escitalopram for anxiety. So any of the three of those medications could be a great option for treating kids and teens for anxiety. And really it just comes down to looking at the side effect profile and what the patient needs. So fluoxetine tends to be more activating, so this is good for kids who kind of need a little bit more energy. It also has a really long half life, so it's good if you don't remember to take the med every single day. Sertraline, tends to be a favorite choice for anxiety because it can be a little bit sedating, can be dosed at night and be good for kids like this guy who have trouble falling asleep. And the medicine that's probably the relatively new player on the field is escitalopram, which has the FDA approval for treatment of anxiety. So in other words, I don't want to say you can't go wrong, but all three could be really reasonable choices. So for this kid, you talk to the family about all three of those options of SSRI medications. So while parents are somewhat hesitant to start a medication, one of the parents says that she has a friend who is on escitalopram or Lexapro and has heard good things about that and so would prefer to start that one over sertraline or fluoxetine. So you start this child on escitalopram 10 mg and have him follow up in about 4 weeks in your office. So now this brings us to today, where he presents for his four week follow up visit. What happens next? This is where it gets interesting. So the family is saying he's having fewer outbursts. And he actually seems to be more relaxed before his soccer games, before big exams at school. And he feels calmer on the inside, but here's the problem. His mom wonders if maybe the medicine is making him worse and why is that? So he's becoming a little bit more impulsive and definitely more fidgety, restless and hyper, so he seems happier and calmer, but he's getting in trouble at school for blurting out answers for sort of saying silly things in the middle of class and even acting out. Now, this was a pretty easygoing kid for the most part, and so it's unusual to see these new behavior problems at school. And since this represents a pretty abrupt change in behavior of course you're wondering have there been any stressors or bullying or is there something going on recently that's associated with these behavior problems. But when you talk to him neither he nor his parents can identify any major stressors at home or at school. And furthermore there's this disconnect where his outside behavior of being kind of hyper and impulsive It seems to be unrelated to anything he's feeling on the inside because he's saying he's feeling happier and calmer. What do you think could be going on? Could it be A, that we miss some underlying diagnosis of ADHD that is somehow unmasked in treating his anxiety? Could it be B, some side effect from his four weeks of treatment with escitalopram 10 milligrams? Or C none of the above. Okay, let's go through each of these options. So is it A, that we've unmasked ADHD, or that ADHD has been around the whole time and we just haven't been paying attention? Okay, so he's more hyper and he's impulsive, which are definitely symptoms of ADHD. So what you'd want to ask about is, is he having trouble paying attention or any concentration issues, either now or in the past? has there been any difference in his academic performance? And what you find out is he's actually a pretty great student. He always has been, with B pluses and A's consistently. His teacher has not noticed any problems during the actual exam or any tests, it really seems to be more behavioral than having anything to do with concentration. So that would make ADHD less likely, given that there's no clear signs of inattention at all. Also, given the fact that he's nine years old. It would be unlikely that ADHD would all of a sudden show up at that time. We would expect that he would have had years of problems with inattention and hyperactivity and or impulsivity predating this. So the time course doesn't match for A, ADHD. So how about B? Is there something about this medication that is giving him side effects or making him worse? The time course. Given that the symptoms all began after he started treatment with the medication would suggest that the escitalopram has something to do with it. And let's look at his constellation of symptoms. So he's more impulsive, he's restless, fidgety, getting in trouble for blurting things out, which again can be a symptom of verbal impulsivity. And he's having more trouble falling asleep at night. So this constellation of symptoms of initial insomnia, restlessness, hyperactivity, and some impulsivity is part of an activation syndrome, which you can see in kids and adolescents treated with SSRI medications like fluoxetine, sertraline, citalopram, and escitalopram. And we know that the kids who are at greatest risk of developing activation with SSRIs are those pre pubertal kids. So our nine year old boy, boom. He is going to be at the risk for it. But here's what doesn't make activation seem as likely. He's being treated with escitalopram. Is that one of the medications that we think of as being highly activating? Not really. It is an SSRI, and all of them can have activation associated with them. But, the medication that we typically think of as causing activation is Fluoxetine. Hmm, so what's our other question? What dose is he on? We see activation at really high doses and he is on 10 milligrams. Well, that's a little bit more than I typically start a prepubertal kid on. I'd usually start with 5 milligrams, honestly, or sometimes 2. 5 if I want to be conservative for a week before going up to 5. So. it's not the lowest dose, but it's certainly not the highest dose of escitalopram, which would seem to make it, again, less likely. So here is where it's a great chance to consult your colleagues and or the literature to try to explain what can possibly explain activation on 10 milligrams of escitalopram in a nine year old boy. So here is where it's really helpful if you manage to stay awake in your pharmacokinetics class. I promise you this will have a fun point. So basically, if you remember, citalopram and s citalopram are the two SSRIs that are metabolized by this one particular cytochrome, Cytochrome 2C19.. And why do we care about that? Well, what's really important about that one is that about a third of the population has some sort of genetic polymorphism that makes them either really poor metabolizers or really super speedy metabolizers through this cytochrome, which is to say that there's a lot of variability in terms of. How quickly or how slowly people metabolize these particular drugs just because of their own genetic idiosyncrasies. And before going too deep down this rabbit hole, what you need to know is that kids of Asian ancestry, about a third of them are really poor metabolizers of 2C19, which means that when you give them a normal dose of 2C19, S citalopram or Lexapro, it's going to feel like a much larger dose, and so they're going to be developing side effects on really low doses. And kids who are Caucasian or African American, about 12 to 15 percent of them are also really slow metabolizers. So again, when you start to see in practice something that seems a little off, like why are these kids developing side effects that we wouldn't typically expect on this dose, It's a great reminder that all of our bodies are different and we process medications in different ways. And without even having to do elaborate testing, we suspect that this is what could be going on with this kid. Mystery solved! So at this point, because he's developed activation, we have really two options. We could try to decrease the dose a little bit and see if we can still get control over anxiety at a lower dose without the side effect, which is probably what I'll do. Assuming that the family is not too scared off or too concerned about the medication. And then another option would be to think about switching to a different medication. But since his anxiety seems to be well controlled, And we suspect that he's a poor metabolizer, it would just make sense to put him on 5 milligrams instead of 10 milligrams of the escitalopram and see how he does and then take it from there. Well, please let me know what you think of this mystery case format Feel free to reach out, message us, and send us your questions or any interesting clinical conundrums or cases that you want us to discuss on the pod. As always, you can find us on our website, psyched4peds. com, also on Instagram at psyched4peds Thanks so much for listening and please tune in next week as we're going to continue the mystery case series.