Callous-Unemotional Traits in a Child with Attention-Deficit/Hyperactivity Disorder and Oppositional Defiant Disorder: Managing Medication and Expectations

Chief Complaint and Presenting Problem

F. is a 12-year-old boy who carries a diagnosis of attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and communication disorder referred by another clinic for oppositional and destructive behaviors.

History of Present Illness

Mother first became concerned about F.'s behavior beginning in early childhood. She reports that although he began to walk at 11 months, his speech was delayed. Mother reports that F. had always been a very “hyper” child, and his behavior worsened around 2 to 2 ½ years old. She correlates a worsening of his behavior with his father's return home following an eight-month parental separation.

Mother sought a pediatric neurodevelopmental evaluation when F. was 3 years and 10 months old for several behavioral concerns. F. reportedly did not listen to her, broke objects and hit his sister when he didn't get what he wanted, and would often jump on mother. She expressed concern about his lying and his telling exaggerated, worrisome stories about his family to others. She noted that he would also cry in response to limit-setting, and on a few occasions had banged his head. F. was subsequently diagnosed with ADHD, parent-child relational problem, and language impairment; ODD was a rule out. Recommendations were made for speech and language therapy and referral to the special preschool committee, and F. was enrolled in a special education setting.

By age 5 years, F. began to engage in fire-setting on several occasions, causing destruction of some property. Also, F. reportedly killed the family goldfish. Throughout early childhood and elementary school, F. was described as having trouble following directions both at home and at school and was intrusive, disrespectful, and hyperactive. F. reportedly generally preferred to spend time alone, often playing video games or watching television, demonstrating little interest in peer relationships.

The family moved out of state following father's relocation when F. was 6 years old, and mother sought psychiatric services shortly thereafter. F. participated intermittently in supportive and individual psychotherapy, some with mother, over the years. Mother reports that F. seemed to derive minimal benefit from therapy. Mother was unclear on the timeline but believes a medication, likely a stimulant, was initiated when F. was 6, with some improvement in hyperactivity, focus and completion of tasks. However, his impulsivity and intermittent aggression continued, often without discernible precipitants.

By age 7, F. had begun to experience initial and middle insomnia; his stimulant was maintained and clonidine was added for initial insomnia and augmentation for ADHD symptoms. Additionally, F. was reported to be stealing on multiple occasions, and was reportedly subsequently beaten by his father. Around this time, it is likely that F. witnessed multiple episodes of domestic violence between his parents, although details could not be obtained. Mother moved with her children back to New York when F. was 8 years old. F. reportedly resumed contact with mental health providers about a year later, and methylphenidate extended release and clonidine were reinitiated for symptoms of hyperactivity and impulsivity.

At 10 years of age, F. pushed a classmate down the stairs at school, injuring the peer, and he was subsequently admitted to an inpatient psychiatric unit for about one month to manage his aggression. Mother was unsure about his treatment course, although it seems he may have been prescribed risperidone at that time. From the age of 10 to 12 years, F. was treated in a psychiatric outpatient clinic with risperidone up to 4 mg daily, extended release methylphenidate 54 mg daily, and clonidine 0.1 mg three times a day. and 0.3 mg at bedtime. F. reportedly developed gynecomastia, and risperidone was slowly decreased. Treatment at the clinic was terminated due to appointment nonadherence; F. was off of all medications for two weeks prior to his current evaluation.

Mother's primary concern at the current evaluation was F.'s disregard for following rules and his aggression, as he was punching walls and destroying objects such as the television and video game controllers. F. was reported to be stealing objects and eating his siblings' food. He was reportedly purchasing items on mother's credit card without permission, and throwing away items in the homes of others. He had reportedly pushed mother and his 21- and 6-year-old sisters on multiple occasions, often without provocation. F. had been involved in several physical fights with peers, resulting in several suspensions from school. On one occasion, a peer required medical attention when F. pushed a classmate down a staircase in school. Most concerning, F. had reportedly not expressed guilt or concern about the safety of others.

In school, F. was described as disorganized, requiring frequent redirection to stay on task, although responsive to positive reinforcement. Teachers reported that F. struggled with peer relationships and initiated conflicts.

In review of other symptoms, F. had no reported history of suicidal thoughts or intentional self-harm. F. had no history of using weapons, gang involvement, or any legal involvement.

Past Psychiatric History

There was no past psychiatric history other than described above. At age 3 years and 10 months, psychoeducational testing revealed low average IQ and a mixed receptive-expressive language disorder. Repeat testing at 12 years confirmed the low average IQ.

From the age of 10 to 12 years, F. was treated with medication by a psychiatrist in outpatient treatment.

Developmental History

F. was the product of an uncomplicated pregnancy, and delivered at full term via a normal spontaneous vaginal birth. He was reported to be easy to soothe as an infant. Motor milestones were achieved within normal limits, but F. had delays in language acquisition; he did not speak his first word until age 2 years, and spoke in two to three word sentences until 3 years.

Educational History

F. was enrolled in special education programs from preschool onward in which he received speech and language therapy. Throughout elementary school, F. alternated between a school setting with 12 children, one teacher, and one assistant teacher in the classroom (12:1:1) and an integrated co-teaching service.

This year, in sixth grade, F. received home instruction for one hour a day for three months for a medical condition; he required a specialized boot following surgery on his right foot. Within one month of his return to regular classroom, F. was moved to a 12:1:1 setting given the high level of supervision and instruction he required.

Social History

F. had witnessed domestic violence between his parents, although details remain unknown. F. was reportedly verbally and physically abused by his father around age 6 and 7 years for stealing. While mother had been a consistent support for F., she had struggled with her own mental health issues and had limited ability to cope with F.'s behaviors.

F. had problems with social relatedness and reciprocity, and the development of peer relationships appropriate to his developmental level. F. and his family had been isolated from extended family at times, given F.'s problematic behaviors. The family had been living in shelter housing for the past two years; F. shared a room with his sisters. The family had limited resources and some financial stress, amplifying the hardship of food scarcity and damaged objects and property.

Pertinent Family History

Mother had reportedly been diagnosed with major depressive disorder, panic disorder, and possibly posttraumatic stress disorder (PTSD). It was suspected that father may have antisocial personality disorder traits and history of conduct disorder. F. had two paternal cousins with ADHD.

Medical History

F. underwent surgery to correct fallen arches on his right foot at age 12 years. There was no history of major childhood illnesses, serious medical problems, hospitalizations, or other surgery. He had received all his appropriate vaccinations. F. had no allergies to food or medication.

Medication History

F. had been treated with risperidone up to 4 mg daily during his previous outpatient treatment. Risperidone was tapered and discontinued after he developed gynecomastia. At the time of his discharge from his previous treatment, F. was receiving a tapering dose of risperidone with a plan for discontinuation; extended release methylphenidate 54 mg daily, and clonidine 0.1 mg three times a day. with 0.3 mg at bedtime.

Rating Scales

Quantitative assessment of ADHD symptoms was significant on the parent Vanderbilt Scale for symptoms of hyperactivity, impulsivity, distraction, and externalization consistent with a diagnosis of ADHD. The teacher (tutor) Vanderbilt screen was also positive. A parent Screen for Child Anxiety Related Disorders (SCARED) was essentially negative, and self-reports on the Epidemiological Studies Depression Scale for Children (CES-DC) and SCARED were essentially unremarkable.

Mental Status Exam

Mental status examination revealed a superficially cooperative child with no dysmorphic features or abnormal movements. His responses to questions about everyday life seemed reliable but brief. F. was alert, and oriented to time, place, and person. He tended to avert eye contact and focused on building with Lego pieces during most of the encounter. F.'s speech was largely non-spontaneous, fluent, and with mild response latency. He appeared euthymic, though possibly apathetic, and affect revealed a narrowed range with some reactivity. Thought process was coherent and linear with limited abstraction; thought content was generally relevant but only marginally meaningful. When asked directly, F. spoke of feeling angry at times, and acknowledged several episodes of having not followed household rules, recently breaking the video game controller, and at times, intentionally hurting others. He was limited in describing a context for these episodes, and was not able to delineate antecedents for his anger or aggressive behavior. He was also unable to appreciate the consequences of his actions for himself or others. F. denied perceptual disturbances such as hallucinations or thoughts of harming himself or others. He demonstrated limited insight into his mood states and difficulties.

Treatment Course

F. had not been taking medications for about two weeks prior to evaluation. Mother had agreed with the previous discontinuation of risperidone due to gynecomastia, but was insistent upon resuming prior doses of extended release methylphenidate and high doses of clonidine. During the first month of treatment, F. was receiving home instruction and not attending school. F. had begun was outpatient weekly psychotherapy that was generally supportive and focused on family dynamics.

After confirming F.'s diagnosis of ADHD and ODD, and given the history of at least partial response to his previous regimen, extended release methylphenidate was reinitiated at 36 mg daily and clonidine 0.05 mg at bedtime. Mother reported that F.'s behavior was unchanged in the home after resuming medications, and there were recognizable limitations in assessing his academic progress while he received home instruction. Mother was most concerned with his poor sleep, with marked sleep-onset latency of several hours, which she attributed to low clonidine dosing. Notably, F. shared a room with his sisters, and was insistent on repeatedly turning the television on after his bedtime. Mother acknowledged that she was unable to provide adequate supervision at night, believing F. slept for only a few minutes at a time and for a total of an hour overnight. Sleep hygiene was recommended.

Mother also expressed concern that stress caused by F.'s behaviors exacerbated her own psychiatric conditions, and feared that inadequate treatment for F. would result in inability to care for him appropriately and compromise her own treatment. F. continued to have episodes of lying, breaking objects, and disregarding household rules.

After he returned to school, F. continued to have difficulties at home, and oppositional behavior was most challenging. F. was reportedly still sleeping minimally; sleep hygiene was again recommended. During this time, mother became open to home-based services. Over the course of several weeks, clonidine was increased from 0.05 mg at bedtime to 0.1 mg at bedtime and ultimately 0.1 mg twice daily to address breakthrough ADHD symptoms, specifically intrusiveness and impulsivity, and for sleep initiation, which was a priority for mother. Extended release methylphenidate was maintained at 36 mg daily with good tolerance.

Over the course of several weeks, the family underwent an unplanned move to a larger shelter, since mother was reportedly being threatened by some neighbors. The older sister was charged with assault in a related dispute with a court case pending.

F. continued to have considerable difficulty after returning to school. He was quickly transitioned to a 12:1:1 setting where he was able to maintain better behavioral control. He was described as being more respectful toward his teacher, but maintaining minimal motivation to participate in school or complete homework. Although hyperactivity and inattention had improved, impulsivity and intermittent aggressive behavior remained a concern.

Brief Formulation

In summary, F. is a 12-year-old boy who meets diagnostic criteria for ADHD, ODD, and communication disorder referred for oppositional and destructive behaviors. Conduct disorder symptoms such as lying, stealing, and harming others have been present since early childhood. His aggression toward peers and family, notable for a lack of discernible precipitants and resulting in physical injury, is a significant concern, particularly since F. has appeared to be devoid of empathetic response.

From a biopsychosocial perspective, F. appears to have a diathesis for affective illness, disruptive behavior, and possibly antisocial personality disorder, given major depressive disorder, panic disorder, and possibly PTSD on the maternal pedigree, and antisocial personality disorder traits, conduct disorder and ADHD on the paternal pedigree. There appear to be no significant other biological or medical contributions.

From a psychosocial perspective, F. has experienced significant stressors over the course of his young life, having witnessed domestic violence, experienced possible physical abuse by his father, and social hardship including living in a shelter. From a psychological and developmental perspective, his lack of interest and involvement in reciprocal peer relationships and apparent lack of empathy, guilt, and remorse are worrisome, and may predict future antisocial problems. His symptoms and course are suggestive of the callous-unemotional conduct disorder.

Multi-Axial Diagnoses

Discussion

This case represents a very commonly encountered challenge in child and adolescent psychiatry practice: how to manage conduct disordered behavior in the context of ADHD. A second issue is to identify any potential predictors of poor long-term outcome, such as substance abuse, legal problems, and/or antisocial personality disorder. Of particular concern in this case are F.'s callous-unemotional traits. What evidence-based interventions are most likely to reduce bad outcomes, and in particular, what are the best psychopharmacological approaches?

Risperidone has been shown to have efficacy for disruptive behavior disorders in randomized, controlled acute trials and long-term open label trials (Findling et al. 2000). In a study of children age 5–17 who had responded to risperidone in a 12-week controlled trial, Reyes and colleagues (2006) reported that of 335 who were randomly assigned to six months double-blind maintenance for disruptive disorders, time to recurrence was significantly longer in patients who continued on risperidone as compared to those on placebo. (Reyes et al. 2006). Weight increased in the risperidone group over the initial 12 weeks, but stabilized during maintenance. A more recent six-week, open label study of another neuroleptic, aripiprazole, demonstrated significant reduction of both physical and verbal aggressive behavior in adolescent boys with conduct disorder (Kuperman et al. 2011). At a mean dose of about 10 mg, aripiprazole was generally well tolerated and adverse effects were mild.

F.'s aggressive behavior improved on risperidone, but unfortunately treatment was limited by gynecomastia and perhaps other metabolic adverse effects. To date, F. appears to have received significant therapeutic benefit from a combination of extended release methylphenidate and clonidine. F.'s conduct problems developed in the context of early onset ADHD, complicated by difficult psychosocial circumstances, including parental separation, witnessing domestic violence, possible physical abuse, shelter living, and an older sister's legal problems. Any pharmacological intervention must take place as a component of a multimodal treatment program including psychosocial treatment and educational intervention. F. was receiving individual and family oriented therapy, as well as special educational services in school, which were at least somewhat helpful.

From the psychopharmacological perspective, F.'s ADHD symptoms appeared to be responsive to extended release methylphenidate and modest doses of an alpha agonist, which may have had its most important impact on sleep initiation. However, F.'s aggressive behavior and callous-unemotional traits remained problematic.

Clinicians and investigators have often been concerned that callous-unemotional traits in youth with conduct disorder are less or unresponsive to pharmacological treatment (Connor et al. 2006). Conduct disorder often develops in the context of ADHD; heightened impulsivity appears to be the common substrate from which both conduct disorder and aggressive behavior develops. (Blader et al 2013). Aggressive behavior can be further classified into reactive (defensive in response to threat) or proactive (harmful volitional behavior); lack of empathy and response to others' suffering is described as callous-unemotional behavior, and often contributes to proactive aggression. (Frick and Morris 2004)

A recent randomized controlled trial of optimized stimulant therapy in 160 children ages 6–13 with ADHD, ODD or conduct disorder and significant aggressive behavior evaluated the impact of treatment on proactive aggression. Results indicated that 51% experienced remission of aggressive behavior, but neither callous-unemotional traits nor proactive aggression predicted remission (Blader et al 2013). Given F.'s moderate doses of extended release methylphenidate, it is not clear whether this dose is optimized currently. Further titration upward is indicated to explore whether a higher dose would reduce his aggression more effectively.

It is interesting that F.'s previous clinician used 0.6 of clonidine, higher than typical dosing recommendations, primarily to induce sleep, by report. At least currently, it appears that environmental and psychosocial factors contributed heavily to F.'s initial insomnia, as evidenced by shelter living and mother's concern that F.'s night time disruptive behavior would precipitate a setback in her own mental health. It does appear that adherence to sleep hygiene guidance has been at least somewhat beneficial, allowing for more modest clonidine dosing. This targeted combined pharmacotherapy may indeed be an optimal intervention, but may require additional dose titration.

A recent review suggests a promising approach can be developed in the future to better understand the developmental psychopathology of conduct disorder and callous-unemotional traits. The authors report that three neurocognitive dysfunctions have been linked to clinical conduct disorder symptoms, highlighting the callous-unemotional subgroup. The first, deficient empathy, appears to be a common characteristic of these youth, in contrast to the second, heightened threat sensitivity, which is more often observed in conduct disorder without callous-unemotional traits. Deficient decision-making, the third characteristic, appears to occur in both groups, and is thought not to be unique to youth with conduct disorders. (Blair et al. 2014) The authors highlight that these characteristics map on to several different brain circuits, which, when more fully elucidated, may provide neurophysiological/neurochemical targets for more specific therapeutic interventions.

At this time and in the past, clinicians have been limited to treatment of conduct disorder by targeting symptoms and not underlying brain mechanisms. Aggression and impulsivity, for example, are non-specific symptoms and often final common pathways deriving from many different underlying disorders, and ultimately, brain systems. Whether these particular neurocognitive dysfunctional systems, or others, will lead us to more precise and effective treatments remains to be seen, but more studies are clearly needed.