Executive Function Deficits, Attention-Deficit/Hyperactivity Disorder, Tics, and Obsessive-Compulsive Disorder in an Adolescent

Abstract

., a 13-year-old boy, was referred by his home school dis-trict for a diagnostic evaluation. R. had been suspended fromschool for the last half of eighth grade due to aggressive behavior.History of Present IllnessR.’s parents noted behavioral difficulties when R. was as youngas 18 months of age. Mother reported she had a feeling that‘‘something was not quite right’’ due to R.’s physical aggressive-ness. One example of this was when R. threw a shoe at his motherwhile sitting in his car seat. Mother also reported that R. had severalsubsequent episodes of loss of behavioral control that includedthrowing a plant at her and biting his brother. During preschool R.was also difficult to manage.R. began to develop repetitive behaviors at age 3 years such aslining up his cars and toys. He was initially evaluated by a psychol-ogist who questioned a possible diagnosis of autism. By age 3 1=2years, R. had developed motor tics such as eye blinking, squinting,eye rolling, nose twitching, nostril flaring, and more complex ticssuch as kicking. At age 5 years, R. was evaluated by a neurologistwho diagnosed Tourette’s disorder (TD) and attention-deficit=hyperactivity disorder (ADHD). Some obsessive-compulsive fea-tures were also noted. R. was subsequently referred to a specialtyclinic, where a workup including MRI and EEG were within normallimits.R.’s problems with aggressive behavior continued to escalateinto his middle-school years. Loss of control was precipitated by avariety of innocuous things such as being asked to stop playing avideo game. The school’s decision to place R. out of school wasreportedly made after several incidents of escalating aggressivebehavior. R. reportedly hit a boy with a baseball during recess, gotinto fights with several classmates, and hit a teacher in the arm afterhearing a remark that upset him.Father describes R.’s aggressive outbursts as ‘‘like a seizure’’;the outbursts occur approximately 2–5 times per day and last15 minutes on average, with the longest episode lasting 45 minutes.Most often, the episodes resolve on their own if R. is left to calmdown. R. is described as very remorseful after these episodes.Parents say that they are afraid to bring R. anywhere right now dueto these rages. The outbursts have occurred in school, at home, andwhen R. plays sports but have not happened while with friends.In terms of ADHD symptoms, the parents describe R. over theyears as quite fidgety, restless, and very impulsive. The parentsworried that R. would run out into traffic when he was younger. Hecontinues to be restless and hyperactive. Although he is able tofocus on topics that he likes, he has walked out of the classroomwhen he decides that a topic is ‘‘boring.’’ He has not been able to sitthrough classes and has been permitted to leave as needed ac-companied by a paraprofessional.With regard to obsessive-compulsive symptoms, R. continues tolineup hisanimals aroundhisbed.He has ahistory ofworries aboutbad things happening to his brother, and he asks if he will die if hetouches something and puts it in his mouth. He has requested thatthe family have a home security system at night so he can feel lessworried about invaders. He is anxious and tense as well as generallyconcerned about contamination.R. has talked about killing himself at times, not necessarily as-sociated temporally with the explosive episodes. He feels he is a‘‘burden to his parents’’ and says, ‘‘I don’t like to live this way.’’ R.tried to choke himself last year and has had episodes of trying tohold his breath long enough to pass out. However, R. has not de-scribed periods of depressed mood or loss of interest lasting morethan a few minutes up to a few hours. He has had no vegetativesigns such as loss of appetite or change in sleeping habits.Past Psychiatric Treatment HistoryR. has been evaluated in the past by several clinicians includingpsychiatrists and psychologists. One of the first interventions was aparent management program when R. was approximately six yearsof age. His parents also worked with a social worker and a psy-chologist at the therapeutic school program where R. was enrolled.R. had a therapist at school but, since returning to public school inGrade 6, is currently not in therapy. Parents report that no inter-ventions thus far have been helpful in addressing R.’s aggressivebehaviors.Developmental HistoryR. was the product of an uncomplicated 40-week pregnancy,labor, and delivery. Apgar scores were described as excellent.There were no neonatal problems except that it was difficult forR. to sleep through the night. Developmental milestones wereachieved within normal limits. Parents reported that although R.