Treatment of Aggressive Behavior and Agitation in an 11-Year-Old Boy with Co-Occurring Autism and ADHD: A Case Report and Literature Review on the Use of Intravenous Valproate in Emergency Psychiatry

Abstract

Background: Autism spectrum disorder (ASD) is a persistent neurodevelopmental disorder frequently co-occurring with attention-deficit/hyperactivity disorder (ADHD) and behavior-related disorders. While behavioral therapy is the first-line option to manage the core symptoms of ASD, pharmacological therapy is sometimes needed to treat acute problems, such as agitation and aggressive behaviors. Recent guidelines recommend the use of neuroleptics to reduce psychomotor agitation in patients with ASD. However, as children with ASD are often drug-resistant, alternative treatments are often justified. Reports from the literature have indicated that intravenous valproate (IV-VPA) can be effective in reducing agitation in psychiatric patients, with a lower frequency of adverse events compared to conventional treatments. However, as the related findings are occasionally inconsistent, IV-VPA is not yet an approved option in the context of clinical psychiatry. We aim to improve knowledge of the IV-VPA treatment option for emergency psychiatric treatment in pediatric patients. Methods: We report the case of an 11-year-old boy suffering from a complex neurodevelopmental condition who experienced a psychotic episode with severe aggressive and disruptive behaviors and was successfully treated with IV-VPA. Furthermore, we provide an updated literature review on this topic. Conclusion: In our case, first-line therapies proved to be ineffective. To the contrary, IV-VPA led to safe and prompt clinical success, which is in line with other reports. Based on our literature review, IV-VPA can be highly effective and reduces the risk of adverse events that frequently occur with the use of high-dose standard medications in emergency psychiatry.

Keywords: ADHD; agitation; autism; intravenous valproate.

Figure 1

Study selection flowchart. PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases [39]. This figure shows a flowchart detailing the selection criteria for the collected articles.

Figure 2

Pharmacological treatment history of the clinical case, showing the timeline of the treatments. In red the IV-VPA administrations. It is important to note a concomitant reduction in the use of other medications after the IV-VPA injection was started. The timeline can also be compared to the MOAS scores presented in Figure 3 below. It is also important to note that, when the IV-VPA treatment started, the other treatments decreased.

Figure 3

MOAS aggressive behaviors scale. It can be seen, according to the color scale, that there was a rapid reduction in the MOAS scores. The MOAS aggressive behaviors scores showed a reduction on the third day of the hospitalization (on 4 March 2023), immediately after the IV-VPA administration started (compare with Figure 2, showing the pharmacological treatment history of the clinical case, above).