Treating a child with Asperger's Disorder and Comorbid Bipolar Disorder

J Frazier, R. Doyle, S. Chiu, J. Coyle, The American Journal of Psychiatry; January 2002; 159, 1, Pages 13 - 21.

This report summarises a clinical case conference presented at McLean Hospital in Belmont, Mass. The presentation was used to inform clinicians about the occurrence of psychiatric disorders among developmentally disabled children, with an emphasis on those with Pervasive Developmental Disorder. It also serves as an illustration of how aggressive and self-injury can be symptoms of comorbid psychiatric disorders and underscores the necessity of proper diagnostic formulation in these children. For this child, the proper diagnosis was not recognised for years. Once he was diagnosed with comorbid bipolar disorder, appropriate treatment led to a decrease in problematic behaviours, an improvement in quality of life for the child, and a decrease in family burden. Bipolar disorder should be entertained as a possible diagnosis when there is deterioration in cognition, language, behaviour, or activity; when there is a clear pattern of fluctuation or cyclicity in activity, behaviour, and interests (with 'good times' and 'bad times'); and when observed behaviour indicates a mood problem. (As examples of the latter, an increase in crying, self-injury, sleep disturbances, and social withdrawal, a decrease in activity, and a loss of interest of in activities of daily living may indicate depression; an increase in silliness, distractibility, poor judgement, intrusiveness, laughing, aggression, pressured speech, non-compliance and agitation may represent symptoms of mania. It is important to emphasise that there are a limited number of controlled trials regarding the use of psychopharmacological interventions in this population. Therefore, pharmacological intervention should be chosen judiciously, and patients should be closely monitored for symptom improvement and side effects. Given that these patients are often treated with psychotropic medications, there is a crucial need for systematic controlled trials to establish both the safety and efficacy of pharmacological agents in children with Asperger's Disorder and with developmental disabilities in general.

Abraham had symptoms of an active illness beginning at an early age. For him, delayed diagnosis and treatment led to 5.5 years of progressive dysfunction and a worsening of symptoms. His affective disorder exacerbated the underlying symptoms of Asperger's Disorder. For example, when he was manic, Abraham became more intrusive and engaged in more socially inappropriate behaviours; his pedantic speech became more pressured, he engaged in lengthy monologues, and his obsessionality became intense. Once comorbid bipolar disorder was diagnosed and appropriate treatment occurred, Abraham gradually began to recover and his self-injury, aggression, and intense pressured obsessiveness disappeared.