Pharmacotherapeutic Challenges in Treatment of a Child with "The Triad" of Obsessive Compulsive Disorder, Attention-Deficit/Hyperactivity Disorder and Tourette's Disorder

By Rice, Timothy; Coffey, Barbara | Journal of Child and Adolescent Psychopharmacology, March 2015 | Go to article overview

Pharmacotherapeutic Challenges in Treatment of a Child with "The Triad" of Obsessive Compulsive Disorder, Attention-Deficit/Hyperactivity Disorder and Tourette's Disorder


Rice, Timothy, Coffey, Barbara, Journal of Child and Adolescent Psychopharmacology


[Author Affiliation]

Timothy Rice. Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.

Barbara Coffey. Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.

Chief Complaint and Presenting Problem

J. is a 9-year-old boy with attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), and Tourette's disorder (TD) who was referred for medication management following group cognitive behavioral therapy (CBT) for OCD, which had resulted in dramatically changed symptomatology.

History of Present Illness

Mother reported that J. was a difficult to soothe baby who by age 2 years was significantly hyperactive. As a preschool child, J. developed additional behavioral and emotional difficulties that impacted his functioning both at home and at day care. Problematic behavior included low frustration tolerance and aggression; for example, J. had a history of cruelty to animals. Emotional problems included tantrums, crying episodes, outbursts, and demanding behavior; as a result, J. was reported to have poor peer relationships. J. was referred at age 5 and a half years to a community clinic affiliated with an academic teaching hospital for threatening to kill his older sister during an argument.

J. was subsequently diagnosed with a disruptive behavior disorder, not otherwise specified. His initial treatment plan included weekly group therapy with an emphasis on social skills training, parent management training (PMT) and dyadic work with J. and his mother. A psycho-educational evaluation revealed findings including a learning disorder, not otherwise specified, and a mixed receptive-expressive language disorder. J.'s mother was often non-adherent to the PMT program.

In addition, J. began to frequently smell his fingers and to check to see if they were clean; difficulties around separation with mother and frequent crying were also observed. A subsequent re-evaluation resulted in a diagnosis of an anxiety disorder, not otherwise specified; a formal diagnosis of OCD was not given. At that time, the other symptoms suggestive of an anxiety disorder were separation difficulties from mother, easy tearfulness, and an increase in disruptive behaviors around anxiety-provoking content, both in group therapy and in dyadic work with J.

In this context J.'s parents, who had been having significant conflicts, made plans to divorce just prior to J.'s sixth birthday. J. subsequently began to express suicidal ideation and guilt-laden thought content that he was a "bad child" and would "burn in the fire." His finger smelling increased in frequency and he began washing his hands frequently, expressing anxiety if he was interrupted.

J.'s clinicians viewed his diagnosis as an anxiety disorder not otherwise specified, with a co-occurring learning disorder. By six years and nine months his separation anxiety was noted to have increased significantly; he began to refuse to shower or play in a room alone as a result of fear that his mother would abandon him.

On J.'s seventh birthday a diagnosis of ADHD was confirmed. After J.'s finger smelling began to increase significantly, referral was made to a pediatric neurologist for diagnostic clarification. The neurologist reportedly felt that the finger smelling was a tic, and diagnosed a tic disorder (based on this single tic). Upon retrospective review, multiple other simple tics, including shoulder shrugging, grunting, nasal flaring, jaw thrusting, biting, and eye rolling, appeared to be present at this time, but had not been brought to clinical attention. Given these additional motor and vocal tics that had been present for more than one year, J. would also have met diagnostic criteria for Tourette's Disorder (TD)

By the time J. was age seven and a half, the full diagnostic picture of ADHD, OCD, and TD was established. At age nine J. was referred for group exposure-response prevention (ERP) therapy for his obsessive-compulsive symptoms. …

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