Abstract
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Although A had significant behavior problems before the disclosure of her trauma, information regarding the chronicity of abuse, stress from the trial, the penalty associated with the conviction, and risk of ongoing exposure to the abuser would have provided a more robust understanding of the potential contribution of abuse to A's behavior problems. On careful read, A meets all criteria for posttraumatic stress disorder except for avoidance. If her behavioral dysregulation occurred, in part, in an attempt to avoid trauma reminders, as often occurs in patients with a history of abuse, she would meet full criteria (Sege et al. 2017).
Regarding treatment, of significant concern was the cross-taper of decreasing aripiprazole while starting and increasing oxcarbazepine. Oxcarbazepine is a CYP 3A4 inducer and aripiprazole is a CYP 3A4 substrate. Modeled exposure studies show oxcarbazepine associated with induction of aripiprazole metabolism resulting in an estimated 68% decrease in aripiprazole serum concentration (McGrane et al. 2018). Atypical antipsychotic discontinuation syndrome precipitated by the decrease in aripiprazole and concurrent increase in induction of its metabolism by oxcarbazepine could explain A's “pronounced behavioral dysregulation” after the cross-taper initiation.
The authors state they chose to trial oxcarbazepine “in an effort to sufficiently lower her suicide and violence risk.” There is no evidence that oxcarbazepine reduces either suicide or violence risk in children or adolescents. A cohort study of anticonvulsants showed oxcarbazepine associated with an increased risk of suicidal acts when compared with topiramate (Patorno et al. 2010).
An alternative evidence-based and guideline-recommended treatment approach would have involved deprescribing as well as potential retrial of medications with stronger empiric support in children, such as selective serotonin reuptake inhibitors (SSRIs). Although A had side effects with two SSRIs, side effects do not indicate a failed trial. Indeed, in the case of polypharmacy, side effects of one medication may be misattributed to another. Furthermore, as children develop, their responses to various medications often evolve (van den Anker et al. 2018). Although A had multiple listed therapies, it is unclear whether she received trauma-focused cognitive behavioral therapy (TF-CBT). If trauma is conceptualized as part of the etiology of A's behavioral difficulties, then TF-CBT would be an appropriate, evidence-based psychotherapy.
We share in the frustration of the inadequate evidence base for pharmacotherapy in children with trauma and complex psychiatric histories. These vulnerable patients deserve a thorough trauma-informed assessment, safe consideration of medication deprescription, optimization and retrials of empirically supported medications in children, and ongoing comprehensive evidence-based therapy. Although amantadine may be a helpful agent in children with a history of chronic stress who display symptoms of disruptive mood dysregulation disorder, multiple confounding factors within this case report limit its support of that conclusion.