When There is no Available Evidence-Targeted Management of Comorbid Anxiety to Address Aggression in a Child With...

Jake is a 13-year-old boy with autism spectrum disorder with an accompanying language impairment and intellectual disability of unknown cause (despite a comprehensive medical workup), who is nonverbal. He was referred by his pediatrician, and after 3 months on a wait list, he was evaluated as an outpatient by a child psychiatrist for a 6-month history of having multiple daily episodes of aggression and self-injury. These episodes often lasted upward of an hour and were usually triggered by transitions or delayed gratification. Prior trials of risperidone, aripiprazole, and guanfacine yielded minimal benefit. Despite enrollment in a self-contained special education program, he was removed from school because of severe aggression.Jake's aggression has persisted despite trials of clonazepam (up to 2 mg daily), clonidine (up to 0.2 mg daily), and a retrial of aripiprazole (up to 20 mg) in various combinations. The family described significant property destruction at home, frequent injuries to others, and persistent self-injury. During this time, Jake presented to the Emergency Room (ER) 6 times, often requiring physical restraints and 2:1 observation. Treatment with chlorpromazine (titrated up to 300 mg daily) and valproate (titrated up to 1500 mg daily) were initiated in the ER. He was denied admission to multiple acute inpatient units and residential centers because of his aggression. Attempts at in-home behavioral services failed when therapists refused to return. Services through a state office for individuals with developmental disabilities were pursued for over 2 years and are yet to be established.Jake was followed weekly by his child psychiatrist. His treatments with valproate and aripiprazole were both discontinued for lack of efficacy, and his treatment with chlorpromazine was consolidated to 100 mg nightly given its benefit for sleep. His treatments with clonidine and clonazepam were maintained, with minor dose adjustment, offering partial symptom relief in the setting of otherwise refractory behavioral dysregulation. Trazodone was trialed briefly for sleep but discontinued because of lack of benefit. Although these regimens occasionally blunted the outbursts, they were limited by sedation, often prompting the parents to self-adjust doses.Most recently, Jake's parents described certain anxious behaviors, such as insistence on sleeping in their room and intense aggression episodes whenever his father would attempt to leave the house. Suspected comorbid anxiety prompted initiation of sertraline at a dose of 12.5 mg/day with reported reduction in aggression within 1 week. With titration to 100 mg/day, Jake's outbursts became less frequent, shorter, and easier to de-escalate, and his sleep schedule normalized. Because of these improvements in association with his initiation of treatment with sertraline, Jake was successfully weaned off his treatment with clonazepam and clonidine. His current psychotropic medication regimen includes sertraline at a dose of 100 mg daily and chlorpromazine at a dose of 100 mg nightly. Jake has continued to show improved aggressive and self-injurious behavior over the course of 6 months of this treatment regimen.In a combined Child Psychiatry/Developmental-Behavioral Pediatrics case conference, what teaching points are raised by this case?