Posttraumatic Stress Disorder in a Child with Autism Spectrum Disorder: Challenges in Management

Chief Complaint

M. was a nine-year-old Mexican-American boy, bilingual (English dominant language) and recently promoted to the third grade in a special education setting (12:1:1) in a regular public school. M. lived with his 28-year-old mother and six-year-old sister. He had been diagnosed with autism spectrum disorder (ASD), borderline intellectual functioning, and attention-deficit/hyperactivity disorder (ADHD). M. was referred for worsening aggressive and self-injurious behavior, as well as multiple behavioral problems at home and school, following physical and emotional abuse and exposure to domestic violence 15 months prior.

History of Present Illness

M. was initially referred after he presented to the emergency department with suicidal thoughts in the context of bullying at school. He also presented with self-harm behaviors consisting of picking his hand with a pencil repeatedly and expressing no pain. M. had expressed feeling sad on various occasions. His mother had noticed a lack of interest in activities he once enjoyed, and he appeared to be more withdrawn from the family. His performance at school had also progressively worsened over the past six months.

Mother reported a history of multiple developmental delays. M. didn't babble until approximately 10 or 11 months and made little eye contact. He was diagnosed with pervasive developmental disorder, not otherwise specified at 18 months, and was immediately referred for early intervention. He was placed in an applied behavioral analysis (ABA) program with intensive in-home speech therapy, occupational therapy, behavioral therapy, and parent education and support from 18 months to three years of age. He was subsequently referred to a specialized center for children with developmental disabilities, where he attended school from pre-kindergarten to first grade. He was in a classroom with eight students, one teacher, and one para-professional with daily speech therapy, twice a week occupational therapy, and daily behavioral treatment. He did not speak his first words until age two. M. began speaking in phrases around age four, and spoke in full sentences at age five. M.'s speech improved significantly with early intervention; however prosody and pragmatic use of language had remained a problem. Mother also reports a history of echolalia that resolved approximately three years ago.

Despite treatment, M. continued to show little interest in others and made fleeting eye contact unless prompted. In his early years, M. engaged in neither functional nor symbolic play. He was now able to follow play if invited, but only marginally, and did not participate in imaginative play. There was little shared enjoyment in activities. M. had a history of unusual sensitivities (he could not tolerate washing his hair, certain clothing materials, and some food textures) and high pain threshold. During play he showed unusual sensory interests such as feeling textures repetitively and prolonged visual examination of toys. He had a low frustration tolerance and difficulty with transitions. M. demonstrated stereotyped movements in early childhood, such as hand flapping and rocking, which had resolved.

Mother reported that M. had a long history of aggressive behavior towards others (family members, teachers, and peers), self-injurious behavior, and low frustration tolerance. Mother also noted hyperactivity from infancy. M. had difficulties with change in routine and transitions. Inattention, distractibility, and worsened hyperactivity were evident in kindergarten, where he struggled with following instructions in school, often left his seat, and required constant reminders and redirection from teachers. M. was diagnosed with ADHD, combined presentation, at age five years by his school psychologist; however, no pharmacological treatment was recommended at that time. Behavioral interventions in a specialized education setting significantly improved symptoms of hyperactivity, distractibility, and aggressive behavior.

Fifteen months prior to his referral, M. was the victim of physical abuse by mother's boyfriend, who stayed with the children while mother was working. Per M.'s report, mother's boyfriend would cover him with a blanket in order to avoid leaving marks, and hit him repeatedly on the face, mouth, and extremities to “discipline” him. M. also witnessed domestic violence during this time. M. disclosed abuse to school counselor after about three months, and child protective services were involved. Mother received assistance; she was not found guilty of abuse and therefore did not lose custody.

Three months following this abuse, M. was promoted to the second grade, during which time frequency of speech, counseling, and occupational therapy were reduced. He was also switched to a regular public school in a special education class with 12 students to 1 teacher and 1 paraprofessional. Around this time, mother noticed that M. began to present frequent and severe temper tantrums lasting more than an hour and requiring multiple emergency department visits. During these episodes M. had thrown chairs and bit and kicked peers, teachers, and family members. He also had begun to demonstrate self-injurious behaviors like “choking himself,” hitting his head against the wall, and picking/stabbing his hand with a pen.

For the past year, M. also started exhibiting sadness and appearing withdrawn from family members. He became easily frustrated and oppositional with mother, refusing to follow most of her directions. Similar behaviors were evident in the school setting, where teachers noticed declining academic performance and marked hyperactivity and impulsivity. M. refused to complete school work or participate in any school activities.

M. also started reporting nightmares; he would wake multiple times during the night and not go back to sleep unless he was with his mother. M. made multiple comments to his mother indicating fear of a strange man coming into his room and harming the family. M. refused to discuss abuse after initial disclosure and became emotionally dysregulated when it was mentioned in front of him. M. also started wetting his bed about once a month after being fully trained.

M. was initially treated with guanfacine (0.5 mg orally twice a day, titrated over one month to 1 mg orally twice a day) to target anxiety, hyperactivity, aggressiveness, and disrupted sleep. He responded well, but with some initial daytime sedation that promptly resolved. M.'s aggressive behavior in school and home improved, as did his hyperactivity, impulsivity, and sleep. He was waking up less often at night, and although he continued to come into mother's bed, his sleep was no longer disturbed by nightmares. He was also referred to individual therapy, and efforts were made to increase level of services at school and educate mother regarding his symptoms. M. was assigned a paraprofessional to assist him during school, which reduced the frequency of tantrums and aggressive behavior.

Despite interventions, M. remained sad and irritable, and began to verbalize death wishes, feeling that he was a “bad boy,” and nobody loved him. Sertraline 10 mg orally daily was added. M. returned two weeks later, exhibiting euphoria, grandiosity, worsening of irritability, and decreased need for sleep. Sertraline was discontinued immediately and the symptoms remitted within one week. Aripiprazole 1 mg orally daily was started two weeks later, and increased to 2 mg orally daily after three weeks. Irritability and anger improved markedly within first few weeks. Aripiprazole was increased to 3 mg orally daily with worsening of irritability and deterioration of sleep. The dose was decreased to 2 mg orally daily, which resolved the adverse effects.

Two months later, M. again complained of sadness and sleep disturbance, along with anxiety relating to his and family's safety. He began to wake up multiple times during the night. Guanfacine was increased to 1.5 mg orally at bedtime with improvement of his sleep pattern; however, anxiety and sadness remained unchanged. A cytochrome P450 (CYP) genotyping profile was ordered (GeneSight®) with the aim to select another antidepressant (Table 1). M. showed impaired metabolism for most antidepressants commonly used in childhood, including all selective serotonin reuptake inhibitors (SSRIs). Given M.'s history of poor response to sertraline, after discussion with mother, it was decided to monitor symptoms, and mood and anxiety symptoms improved after four weeks.

Past Psychiatric History

M. had no previous psychiatric history. Bilingual psychological testing at age 28 months revealed an IQ of 79. M. also showed poor adaptive skills and delayed socio-emotional development. M. had not been previously treated with psychotropic medications.

Developmental History

M. was the product of an uncomplicated, full-term pregnancy and delivery. He was of average size and weight on birth. Mother received prenatal care without complications, but was victim of domestic violence while pregnant. She denied in-utero exposure to nicotine, alcohol, illicit substances, psychotropic medications, or opioid medications.

Milestones were reported to be delayed. Mother reports that M. was difficult to soothe. M. walked after 18 months, and exhibited poor grasping and delayed motor development. M. did not speak or show interest in communicating with others until about 18 months when he started receiving services. His first words reportedly occurred at about 24 months, and phrases by 48 months. M. did not speak in full sentences until he was five years of age. He continues to struggle with prosody and pragmatic use of language. M. was fully toilet trained at 48 months. M. exhibited unusual sensitivities and a high pain threshold.

Educational History

M. received early intervention services in the home, as described in history of present illness, from ages 18 months to three years. He was then transferred to a specialized education setting with eight students, one teacher and one to two paraprofessionals until the end of first grade. Services were reduced in the second grade due to apparent improvement in deficits; however, this was detrimental for M.'s progress.

Social History

M. lived with mother and six-year-old sister. There was an extensive history of domestic violence of father against mother, although this was not witnessed by M., per mother's report. M. was later exposed to domestic violence. Biological father had not lived with mother since M. was an infant, although he was the father of M.'s sister. Father had no contact with the children and was incarcerated for aggravated assault.

Paternal grandmother and paternal aunt live nearby and are a source of support for the family. Mother had a fifth-grade level of education and spoke only Spanish.

M. exhibited aggressive behavior towards peers, poor interest in others, and limited eye contact.

Family Medical and Psychiatric History

Mother was reported to have posttraumatic stress disorder (PTSD) symptoms and was currently in individual therapy and receiving pharmacological treatment with good response of symptoms. Biological father was reported to be aggressive, with a history of alcohol abuse and incarceration for aggravated assault. There was a history of ASD and intellectual disability in M.'s paternal first cousin.

Medical History

Growth and development have been within normal limits. M.'s weight is currently at 45th and height at 25th percentiles. Mother denies problems with sleep until recently. M. had no history of chronic medical illness or known allergies. There was no history of traumatic brain injury, seizures, or thyroid disease. He has never been evaluated by neurologist.

Mental Status Examination on Intake

M. was an age apparent eight-year old boy of average size, who was well groomed and wearing age appropriate attire. There were no dysmorphic features. The interview was conducted in both Spanish and English. He was able to understand both, but replied only in English. M.'s speech, nasal at times, was oddly intonated and difficult to understand. Sentences were underdeveloped but he was able to communicate his needs. No abnormal movements or tics were observed, although he appeared to be hyperactive and showed a limited attention span.

M. was poorly related, in that he showed fleeting eye contact; he responded to cues but did not initiate any interaction with examiner. M. demonstrated neither functional play nor use of imagination. His responses were brief and consisted of one or two words. M. described his mood as “angry” (using mood chart); his affect was restricted with limited or no smiling. Impulse control was poor.

M. was fully oriented to person, place, and time. His thoughts were logical and goal directed; there were no delusions, ideas of reference, or obsessions noted. No perceptual disturbances or restrictive patterns of interest were noted. There was no evidence of suicidal or homicidal ideation, intent, or plans. His insight and judgment were poor.

Autism Mental Status Examination (Grodberg et al. 2012): Score 9 (A cutoff of ≥5 predicts ASD classification on the Autism Diagnostic Observation Schedule with a sensitivity of 94% and a specificity of 81% in an unstratified high risk population.)

Biopsychosocial Formulation

M. was a nine-year-old boy with borderline intellectual functioning, ASD referred for intrusive symptoms associated with trauma, avoidance, negative alterations in cognition and mood, and increased arousal consistent with PTSD following significant physical and emotional abuse. Biological factors include a difficult temperament, a family history significant for anxiety disorders, aggressive behavior, intellectual disability and ASD, and maternal domestic abuse during pregnancy. There was no known medical illness. Psychological factors are significant including trauma characterized by physical and emotional abuse and neglect. Father had been in prison and largely absent from M.'s life. Maternal PTSD was a significant factor in early neglect. Social contributions to M.'s decline included reduction in services and educational supports, and cultural issues in an immigrant parent.

Multi-Axial Diagnosis

Discussion

M.'s case illustrates a complex interface between ASD and traumatic life events. Children with ASD and other developmental disabilities are 1.5 to 3 times more likely to be victimized than their peers (Kerns et al. 2015). There is evidence that autistic traits increase the risk of exposure to perilous situations, given diminished social awareness and deficits in emotional and social cognition (Roberts et al. 2015).

Poorer outcomes following traumatic stress are associated with premorbid anxiety disorders, repetitive exposure to trauma, parental psychopathology, limited social support, and lower intellectual functioning (Cohen et al. 2010, Kerns et al. 2015, Roberts et al. 2015). Children with ASD present with many risk factors that may perpetuate the impact of traumatic life events. These children are significantly more likely to manifest anxiety and depressive disorders (Roberts et al. 2015, Volkmar et al 2014). They have difficulties in social communications and tend to isolate. Further, poor emotion regulation and communication skills affect their ability to navigate traumatic sequelae. M.'s experience of a significant traumatic life experience was accompanied by decrease in social support in the school setting and mother's psychopathology (PTSD), both which likely precipitated his referral and aggravated severity of symptoms.

Treatment of children with ASD alone can be challenging. In addition to the core symptoms of the disorder, children may present with aggressive behavior, hyperactivity, impulsivity, self-injury, and other comorbid psychiatric conditions (Young et al. 2015). They tend to respond less favorably to psychotropic medications and are more likely to experience adverse events (Stigler 2014; Young et al. 2015).

Guanfacine, an alpha agonist, was initially selected to treat M's symptoms of hyperarousal, aggressive behavior, irritability, and poor sleep. He responded well and in a short period of time. In addition, alpha agonists such as clonidine often reduce re-experiencing symptoms in adults with PTSD (Cohen et al. 2010). SSRIs, paired with trauma-focused psychotherapeutic interventions, are the initial treatment of choice in PTSD. However, M. developed manic symptoms on a very low dose of sertraline, which fortunately remitted within a week after stopping the medication.

Second generation antipsychotics, particularly aripiprazole and risperidone, have been shown to be effective for the treatment of irritability and aggression in ASD. Studies indicate that aripiprazole is an ideal choice for treatment of aggression and irritability in children with intellectual disabilities. Aripiprazole has been shown to be efficacious in reducing irritability, aggression, self-injury, hyperactivity, and stereotypic behaviors (Stigler 2014; Young et al. 2015). M.'s response to aripiprazole was notable for worsening of mood symptoms at a dosage above 2 mg. Low-dose aripiprazole was maintained for its antidepressant properties, which appeared to stabilize over time.

The usefulness of CYP genotyping in psychiatry to individualize treatment is controversial. From a pharmacological perspective, response to a drug results from the interplay between genetic factors, other personal influences such as age, sex and disease state, and environmental factors. Genetic factors can influence adverse reactions and therapeutic response or failure (Spina et al. 2015). It is accepted that genotyping can be helpful when selecting medications for either poor metabolizers or ultra-rapid metabolizers. M.'s adverse effects which resulted from sertraline, an SSRI mostly well tolerated, and later with a small increase in the dosage of aripiprazole, prompted clinicians to order CYP genotyping to aid in selection of future treatment. M.'s profile suggested that he is an intermediate metabolizer for CYP2D6, ultra-rapid metabolizer for CYP1A2 and had reduced activity for HTR2A. Risperidone and aripiprazole should be prescribed cautiously in CYP2D6 poor metabolizers (Spina et al. 2015). As an intermediate metabolizer, M had an adverse reaction to small increases in aripiprazole which cautioned clinicians against a switch to risperidone.

Psychopharmacological interventions played an important component in treatment of M's symptoms. However, psychotherapeutic interventions, in combination with parental education, parental support and treatment of psychopathology, and increased frequency of services in the school setting were also important components in M.'s treatment. Children with complex clinical pictures and comorbidity often do best in multi-modal treatment, as M. illustrates here.