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CPAN Case of the Month – April2025

Each month, PCPs call CPAN with a wide variety of mental health questions. Find out how CPAN helped a PCP during this consultation.

Psychiatrist: Muruga Loganathan, MD  

Consult: 

A 9-year-old male with ASD, ADHD, Insomnia, and Unspecified Learning Disorder currently on Abilify and Clonidine with questionable visual hallucinations and sporadic irritability and aggression. The question posed was, “Is the Abilify worsening the challenging symptoms?” 

An earlier treatment that was efficacious and well tolerated was Focalin XR 20 mg until their aggression became more problematic. This necessitated the transition to Abilify.  

The consultation conversation focused on having a clear timeline related to the various symptoms: psychosis, irritability, aggression, anxiety, and impulsivity, as these symptoms can relate to environmental stressors, be part of a discrete diagnostic category, or be a side effect to a treatment.  An additional discussion related to how rare a psychotic disorder in youth < 12 years old is, and that the greater likelihood is that the hallucinations were a part of the current diagnosis(es) and/or side effect.  

The conversations focused first on stimulant medications, especially in people with autism, as they can worsen anxiety, irritability, and occasionally cause psychotic symptoms. Additionally, Abilify specifically has serotonergic effects, which may also cause anxiety, akathisia. Given that the symptoms have been sporadic, it was important to do a psychosocial review to understand if there are triggers that are worsening behaviors. After the review, the decision was that Abilify had improved aggression, but impulsivity remained problematic. Given that the child was already utilizing Clonidine and that stimulants did appear to worsen aggression, an increase in Clonidine or a change to a longer-acting alpha agonist, Intuniv might be of benefit. The PCP felt more comfortable with a switch to Intuniv. We reminded the PCP that they can call again as the care progresses if additional questions arise.