CPAN Case of the Month – January 2025

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

Patient: 14-year-old female

Reason for CPAN Consultation: Support with clarity of diagnosis and treatment

Explanation of the Case and Outcome of the Call:

14-year-old with concerns for autism spectrum disorder (ASD) and recent worsening of tics, anxiety and emotional dysregulation is brought to the PCP for help. The parents prefer non-pharmacological options. Socially the young person has experienced bullying and a new school with significant academic demands. This stress has been compounded by the twin sibling who excels socially and academically. Her vocal tics have worsened as the stress has increased. She is avoiding all interactions with her siblings, struggling with daily tasks and is academically declining.    

Recommendations 

While previous assessments had ruled out ASD, the continuing challenges socially and academically suggest that new psychoeducational assessment for both mental health diagnoses and learning differences may be warranted. The symptoms of emotional dysregulation were poorly quantified, such that the recommendation was for the PCP to consider utilizing some age-appropriate screening tools to better quantify. (e.g. Patient Health Questionnaire PHQ-9 A, SCARED, Suicide Screening using the Columbia Suicide Severity Rating Scale Revised). Given the concern for her daily level of functioning and age it is a best practice to screen for both depression and suicide.  The young person would certainly benefit from an Individualized Education Plan meeting within the school to determine if new accommodations are warranted. Finally, in regard to a pharmacological intervention, her tics have persisted for > one year. Alpha agonists have shown evidence for improving tics. The family could be provided the option of Clonidine 0.1 mg (starting at 0.05 to avoid problematic side effects most commonly sedation).  Slow titration over the course of several weeks to a maximum of 0.3 mg in divided dosages may be of benefit.  It would not be advisable at this juncture to recommend other types of pharmacological interventions as a DSM-V diagnosis beyond Simple Motor Tics has not yet been confirmed.