February 25, 2025 • 12 mins
Welcome to our new segment called Mystery Case Files where we walk through a clinical case that presents a bit of mystery. Using the latest research and evidence, we discuss practical approaches to help YOU care for your patients effectively.
This episode features the case of a nine-year-old boy with anxiety who develops new onset of behavior problems.
00:00 Introduction to Mystery Case Files
00:27 Today's Mystery case
00:27 Presenting the Case: A 9-Year-Old with Anxiety
00:54 Initial Thoughts and Differential Diagnosis
01:32 Reviewing the Patient's History
02:04 Choosing the Right Medication for Anxiety
02:10 What is the best medication for anxiety?
03:34 Four Weeks Later: Follow-Up Visit
03:58 Analyzing New Symptoms and Possible Causes
05:01 Is the anxiety medication making him worse?
05:26 Exploring ADHD and Medication Side Effects
07:09 Understanding Activation Syndrome
08:45 Pharmacokinetics and Genetic Factors
10:25 Solving the Mystery and Next Steps
11:02 Conclusion and Call to Action
Visit us on our website or message us with YOUR MYSTERY CASE that we can discuss!
Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Elise Fallucco (00:00):
Welcome back to Psyched for Peds.
(00:01):
I'm your host, Dr.
Elise Fallucco, childpsychiatrist and mom.
So we're starting a new segmenttoday called Mystery Case Files,
where we're going to walkthrough a clinical case.
That is a little bit of amystery and as usual, we're
going to apply the latestscience research and evidence in
(00:21):
a practical way to help thepatients that you're taking care
of in your office.
So let's begin.
Today's mystery case is a nineyear old boy with anxiety who's
typically well behaved and apretty good student, but his
parents brought him to youroffice today because they're
concerned that recently he'sbeen having behavior problems in
(00:42):
school, as well as somehyperactivity, insomnia, and
impulsivity.
Your job is to figure out whatis causing these new symptoms.
and how you can help.
So just based on thisinformation, my mind wonders, is
this worsening anxiety?
Because we know kids withanxiety can manifest with
(01:02):
behavior problems.
The other thing that I would bethinking about is, is there some
major stressor that's been goingon?
Could this possibly be sometraumatic reaction or change in
behaviors related to a stressor?
Of course, anytime you hear thewords hyperactivity and
impulsivity, you can't help butthink about ADHD.
(01:23):
So that's also something toconsider.
Or, could it be something else?
So, let's back up.
You had most recently seen thisnine year old boy in your office
about four weeks ago.
And at that time, he had been intherapy for his anxiety for
months, but parents wereconcerned that it was not
helping.
(01:44):
His SCARED score was in the high30s, which is well above the
clinical cutoff of 25.
He had no other medicaldiagnoses and was not on any
meds.
And you had considered startinga medication for anxiety.
And you were wondering toyourself, what is the best
medication for anxiety?
(02:04):
I have to tell you this is oneof the questions I get asked the
most often.
And so we're going to talk aboutit.
What we know is that really wehave good evidence for use of
fluoxetine.
Sertraline and escitalopram foranxiety.
So any of the three of thosemedications could be a great
option for treating kids andteens for anxiety.
(02:25):
And really it just comes down tolooking at the side effect
profile and what the patientneeds.
So fluoxetine tends to be moreactivating, so this is good for
kids who kind of need a littlebit more energy.
It also has a really long halflife, so it's good if you don't
remember to take the med everysingle day.
Sertraline, tends to be afavorite choice for anxiety
because it can be a little bitsedating, can be dosed at night
(02:48):
and be good for kids like thisguy who have trouble falling
asleep.
And the medicine that's probablythe relatively new player on the
field is escitalopram, which hasthe FDA approval for treatment
of anxiety.
So in other words, I don't wantto say you can't go wrong, but
all three could be reallyreasonable choices.
So for this kid, you talk to thefamily about all three of those
(03:09):
options of SSRI medications.
So while parents are somewhathesitant to start a medication,
one of the parents says that shehas a friend who is on
escitalopram or Lexapro and hasheard good things about that and
so would prefer to start thatone over sertraline or
fluoxetine.
So you start this child onescitalopram 10 mg and have him
(03:31):
follow up in about 4 weeks inyour office.
So now this brings us to today,where he presents for his four
week follow up visit.
What happens next?
This is where it getsinteresting.
So the family is saying he'shaving fewer outbursts.
And he actually seems to be morerelaxed before his soccer games,
before big exams at school.
(03:53):
And he feels calmer on theinside, but here's the problem.
His mom wonders if maybe themedicine is making him worse and
why is that?
So he's becoming a little bitmore impulsive and definitely
more fidgety, restless andhyper, so he seems happier and
calmer, but he's getting introuble at school for blurting
(04:14):
out answers for sort of sayingsilly things in the middle of
class and even acting out.
Now, this was a pretty easygoingkid for the most part, and so
it's unusual to see these newbehavior problems at school.
And since this represents apretty abrupt change in behavior
of course you're wondering havethere been any stressors or
bullying or is there somethinggoing on recently that's
(04:37):
associated with these behaviorproblems.
But when you talk to him neitherhe nor his parents can identify
any major stressors at home orat school.
And furthermore there's thisdisconnect where his outside
behavior of being kind of hyperand impulsive It seems to be
unrelated to anything he'sfeeling on the inside because
he's saying he's feeling happierand calmer.
(05:01):
What do you think could be goingon?
Could it be A, that we miss someunderlying diagnosis of ADHD
that is somehow unmasked intreating his anxiety?
Could it be B, some side effectfrom his four weeks of treatment
with escitalopram 10 milligrams?
Or C none of the above.
(05:23):
Okay, let's go through each ofthese options.
So is it A, that we've unmaskedADHD, or that ADHD has been
around the whole time and wejust haven't been paying
attention?
Okay, so he's more hyper andhe's impulsive, which are
definitely symptoms of ADHD.
So what you'd want to ask aboutis, is he having trouble paying
attention or any concentrationissues, either now or in the
(05:47):
past?
has there been any difference inhis academic performance?
And what you find out is he'sactually a pretty great student.
He always has been, with Bpluses and A's consistently.
His teacher has not noticed anyproblems during the actual exam
or any tests, it really seems tobe more behavioral than having
anything to do withconcentration.
(06:08):
So that would make ADHD lesslikely, given that there's no
clear signs of inattention atall.
Also, given the fact that he'snine years old.
It would be unlikely that ADHDwould all of a sudden show up at
that time.
We would expect that he wouldhave had years of problems with
inattention and hyperactivityand or impulsivity predating
(06:33):
this.
So the time course doesn't matchfor A, ADHD.
So how about B?
Is there something about thismedication that is giving him
side effects or making himworse?
The time course.
Given that the symptoms allbegan after he started treatment
with the medication wouldsuggest that the escitalopram
has something to do with it.
And let's look at hisconstellation of symptoms.
(06:55):
So he's more impulsive, he'srestless, fidgety, getting in
trouble for blurting things out,which again can be a symptom of
verbal impulsivity.
And he's having more troublefalling asleep at night.
So this constellation ofsymptoms of initial insomnia,
restlessness, hyperactivity, andsome impulsivity is part of an
(07:16):
activation syndrome, which youcan see in kids and adolescents
treated with SSRI medicationslike fluoxetine, sertraline,
citalopram, and escitalopram.
And we know that the kids whoare at greatest risk of
developing activation with SSRIsare those pre pubertal kids.
So our nine year old boy, boom.
(07:38):
He is going to be at the riskfor it.
But here's what doesn't makeactivation seem as likely.
He's being treated withescitalopram.
Is that one of the medicationsthat we think of as being highly
activating?
Not really.
It is an SSRI, and all of themcan have activation associated
with them.
But, the medication that wetypically think of as causing
(08:01):
activation is Fluoxetine.
Hmm, so what's our otherquestion?
What dose is he on?
We see activation at really highdoses and he is on 10
milligrams.
Well, that's a little bit morethan I typically start a
prepubertal kid on.
I'd usually start with 5milligrams, honestly, or
(08:21):
sometimes 2.
5 if I want to be conservativefor a week before going up to 5.
So.
it's not the lowest dose, butit's certainly not the highest
dose of escitalopram, whichwould seem to make it, again,
less likely.
So here is where it's a greatchance to consult your
colleagues and or the literatureto try to explain what can
possibly explain activation on10 milligrams of escitalopram in
(08:43):
a nine year old boy.
So here is where it's reallyhelpful if you manage to stay
awake in your pharmacokineticsclass.
I promise you this will have afun point.
So basically, if you remember,citalopram and s citalopram are
the two SSRIs that aremetabolized by this one
particular cytochrome,Cytochrome 2C19..
(09:03):
And why do we care about that?
Well, what's really importantabout that one is that about a
third of the population has somesort of genetic polymorphism
that makes them either reallypoor metabolizers or really
super speedy metabolizersthrough this cytochrome, which
is to say that there's a lot ofvariability in terms of.
(09:25):
How quickly or how slowly peoplemetabolize these particular
drugs just because of their owngenetic idiosyncrasies.
And before going too deep downthis rabbit hole, what you need
to know is that kids of Asianancestry, about a third of them
are really poor metabolizers of2C19, which means that when you
(09:46):
give them a normal dose of 2C19,S citalopram or Lexapro, it's
going to feel like a much largerdose, and so they're going to be
developing side effects onreally low doses.
And kids who are Caucasian orAfrican American, about 12 to 15
percent of them are also reallyslow metabolizers.
So again, when you start to seein practice something that seems
(10:08):
a little off, like why are thesekids developing side effects
that we wouldn't typicallyexpect on this dose, It's a
great reminder that all of ourbodies are different and we
process medications in differentways.
And without even having to doelaborate testing, we suspect
that this is what could be goingon with this kid.
Mystery solved! So at thispoint, because he's developed
(10:29):
activation, we have really twooptions.
We could try to decrease thedose a little bit and see if we
can still get control overanxiety at a lower dose without
the side effect, which isprobably what I'll do.
Assuming that the family is nottoo scared off or too concerned
about the medication.
And then another option would beto think about switching to a
different medication.
(10:50):
But since his anxiety seems tobe well controlled, And we
suspect that he's a poormetabolizer, it would just make
sense to put him on 5 milligramsinstead of 10 milligrams of the
escitalopram and see how he doesand then take it from there.
Well, please let me know whatyou think of this mystery case
format Feel free to reach out,message us, and send us your
questions or any interestingclinical conundrums or cases
(11:13):
that you want us to discuss onthe pod.
As always, you can find us onour website, psyched4peds.
com, also on Instagram atpsyched4peds Thanks so much for
listening and please tune innext week as we're going to
continue the mystery caseseries.
Welcome back to Psyched for Peds.
(00:01):
I'm your host, Dr.
Elise Fallucco, childpsychiatrist and mom.
So we're starting a new segmenttoday called Mystery Case Files,
where we're going to walkthrough a clinical case.
That is a little bit of amystery and as usual, we're
going to apply the latestscience research and evidence in
(00:21):
a practical way to help thepatients that you're taking care
of in your office.
So let's begin.
Today's mystery case is a nineyear old boy with anxiety who's
typically well behaved and apretty good student, but his
parents brought him to youroffice today because they're
concerned that recently he'sbeen having behavior problems in
(00:42):
school, as well as somehyperactivity, insomnia, and
impulsivity.
Your job is to figure out whatis causing these new symptoms.
and how you can help.
So just based on thisinformation, my mind wonders, is
this worsening anxiety?
Because we know kids withanxiety can manifest with
(01:02):
behavior problems.
The other thing that I would bethinking about is, is there some
major stressor that's been goingon?
Could this possibly be sometraumatic reaction or change in
behaviors related to a stressor?
Of course, anytime you hear thewords hyperactivity and
impulsivity, you can't help butthink about ADHD.
(01:23):
So that's also something toconsider.
Or, could it be something else?
So, let's back up.
You had most recently seen thisnine year old boy in your office
about four weeks ago.
And at that time, he had been intherapy for his anxiety for
months, but parents wereconcerned that it was not
helping.
(01:44):
His SCARED score was in the high30s, which is well above the
clinical cutoff of 25.
He had no other medicaldiagnoses and was not on any
meds.
And you had considered startinga medication for anxiety.
And you were wondering toyourself, what is the best
medication for anxiety?
(02:04):
I have to tell you this is oneof the questions I get asked the
most often.
And so we're going to talk aboutit.
What we know is that really wehave good evidence for use of
fluoxetine.
Sertraline and escitalopram foranxiety.
So any of the three of thosemedications could be a great
option for treating kids andteens for anxiety.
(02:25):
And really it just comes down tolooking at the side effect
profile and what the patientneeds.
So fluoxetine tends to be moreactivating, so this is good for
kids who kind of need a littlebit more energy.
It also has a really long halflife, so it's good if you don't
remember to take the med everysingle day.
Sertraline, tends to be afavorite choice for anxiety
because it can be a little bitsedating, can be dosed at night
(02:48):
and be good for kids like thisguy who have trouble falling
asleep.
And the medicine that's probablythe relatively new player on the
field is escitalopram, which hasthe FDA approval for treatment
of anxiety.
So in other words, I don't wantto say you can't go wrong, but
all three could be reallyreasonable choices.
So for this kid, you talk to thefamily about all three of those
(03:09):
options of SSRI medications.
So while parents are somewhathesitant to start a medication,
one of the parents says that shehas a friend who is on
escitalopram or Lexapro and hasheard good things about that and
so would prefer to start thatone over sertraline or
fluoxetine.
So you start this child onescitalopram 10 mg and have him
(03:31):
follow up in about 4 weeks inyour office.
So now this brings us to today,where he presents for his four
week follow up visit.
What happens next?
This is where it getsinteresting.
So the family is saying he'shaving fewer outbursts.
And he actually seems to be morerelaxed before his soccer games,
before big exams at school.
(03:53):
And he feels calmer on theinside, but here's the problem.
His mom wonders if maybe themedicine is making him worse and
why is that?
So he's becoming a little bitmore impulsive and definitely
more fidgety, restless andhyper, so he seems happier and
calmer, but he's getting introuble at school for blurting
(04:14):
out answers for sort of sayingsilly things in the middle of
class and even acting out.
Now, this was a pretty easygoingkid for the most part, and so
it's unusual to see these newbehavior problems at school.
And since this represents apretty abrupt change in behavior
of course you're wondering havethere been any stressors or
bullying or is there somethinggoing on recently that's
(04:37):
associated with these behaviorproblems.
But when you talk to him neitherhe nor his parents can identify
any major stressors at home orat school.
And furthermore there's thisdisconnect where his outside
behavior of being kind of hyperand impulsive It seems to be
unrelated to anything he'sfeeling on the inside because
he's saying he's feeling happierand calmer.
(05:01):
What do you think could be goingon?
Could it be A, that we miss someunderlying diagnosis of ADHD
that is somehow unmasked intreating his anxiety?
Could it be B, some side effectfrom his four weeks of treatment
with escitalopram 10 milligrams?
Or C none of the above.
(05:23):
Okay, let's go through each ofthese options.
So is it A, that we've unmaskedADHD, or that ADHD has been
around the whole time and wejust haven't been paying
attention?
Okay, so he's more hyper andhe's impulsive, which are
definitely symptoms of ADHD.
So what you'd want to ask aboutis, is he having trouble paying
attention or any concentrationissues, either now or in the
(05:47):
past?
has there been any difference inhis academic performance?
And what you find out is he'sactually a pretty great student.
He always has been, with Bpluses and A's consistently.
His teacher has not noticed anyproblems during the actual exam
or any tests, it really seems tobe more behavioral than having
anything to do withconcentration.
(06:08):
So that would make ADHD lesslikely, given that there's no
clear signs of inattention atall.
Also, given the fact that he'snine years old.
It would be unlikely that ADHDwould all of a sudden show up at
that time.
We would expect that he wouldhave had years of problems with
inattention and hyperactivityand or impulsivity predating
(06:33):
this.
So the time course doesn't matchfor A, ADHD.
So how about B?
Is there something about thismedication that is giving him
side effects or making himworse?
The time course.
Given that the symptoms allbegan after he started treatment
with the medication wouldsuggest that the escitalopram
has something to do with it.
And let's look at hisconstellation of symptoms.
(06:55):
So he's more impulsive, he'srestless, fidgety, getting in
trouble for blurting things out,which again can be a symptom of
verbal impulsivity.
And he's having more troublefalling asleep at night.
So this constellation ofsymptoms of initial insomnia,
restlessness, hyperactivity, andsome impulsivity is part of an
(07:16):
activation syndrome, which youcan see in kids and adolescents
treated with SSRI medicationslike fluoxetine, sertraline,
citalopram, and escitalopram.
And we know that the kids whoare at greatest risk of
developing activation with SSRIsare those pre pubertal kids.
So our nine year old boy, boom.
(07:38):
He is going to be at the riskfor it.
But here's what doesn't makeactivation seem as likely.
He's being treated withescitalopram.
Is that one of the medicationsthat we think of as being highly
activating?
Not really.
It is an SSRI, and all of themcan have activation associated
with them.
But, the medication that wetypically think of as causing
(08:01):
activation is Fluoxetine.
Hmm, so what's our otherquestion?
What dose is he on?
We see activation at really highdoses and he is on 10
milligrams.
Well, that's a little bit morethan I typically start a
prepubertal kid on.
I'd usually start with 5milligrams, honestly, or
(08:21):
sometimes 2.
5 if I want to be conservativefor a week before going up to 5.
So.
it's not the lowest dose, butit's certainly not the highest
dose of escitalopram, whichwould seem to make it, again,
less likely.
So here is where it's a greatchance to consult your
colleagues and or the literatureto try to explain what can
possibly explain activation on10 milligrams of escitalopram in
(08:43):
a nine year old boy.
So here is where it's reallyhelpful if you manage to stay
awake in your pharmacokineticsclass.
I promise you this will have afun point.
So basically, if you remember,citalopram and s citalopram are
the two SSRIs that aremetabolized by this one
particular cytochrome,Cytochrome 2C19..
(09:03):
And why do we care about that?
Well, what's really importantabout that one is that about a
third of the population has somesort of genetic polymorphism
that makes them either reallypoor metabolizers or really
super speedy metabolizersthrough this cytochrome, which
is to say that there's a lot ofvariability in terms of.
(09:25):
How quickly or how slowly peoplemetabolize these particular
drugs just because of their owngenetic idiosyncrasies.
And before going too deep downthis rabbit hole, what you need
to know is that kids of Asianancestry, about a third of them
are really poor metabolizers of2C19, which means that when you
(09:46):
give them a normal dose of 2C19,S citalopram or Lexapro, it's
going to feel like a much largerdose, and so they're going to be
developing side effects onreally low doses.
And kids who are Caucasian orAfrican American, about 12 to 15
percent of them are also reallyslow metabolizers.
So again, when you start to seein practice something that seems
(10:08):
a little off, like why are thesekids developing side effects
that we wouldn't typicallyexpect on this dose, It's a
great reminder that all of ourbodies are different and we
process medications in differentways.
And without even having to doelaborate testing, we suspect
that this is what could be goingon with this kid.
Mystery solved! So at thispoint, because he's developed
(10:29):
activation, we have really twooptions.
We could try to decrease thedose a little bit and see if we
can still get control overanxiety at a lower dose without
the side effect, which isprobably what I'll do.
Assuming that the family is nottoo scared off or too concerned
about the medication.
And then another option would beto think about switching to a
different medication.
(10:50):
But since his anxiety seems tobe well controlled, And we
suspect that he's a poormetabolizer, it would just make
sense to put him on 5 milligramsinstead of 10 milligrams of the
escitalopram and see how he doesand then take it from there.
Well, please let me know whatyou think of this mystery case
format Feel free to reach out,message us, and send us your
questions or any interestingclinical conundrums or cases
(11:13):
that you want us to discuss onthe pod.
As always, you can find us onour website, psyched4peds.
com, also on Instagram atpsyched4peds Thanks so much for
listening and please tune innext week as we're going to
continue the mystery caseseries.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!