Impulse Control Disorder in a 4-Year-Old Child

Case summary An atypical case of impulse control disorder in a 4-year-old boy was diagnosed and successfully managed with a Second Generation antipsychotic in this case report.


Case Report
A 4-year-old pre-school boy was referred to the Child and adolescent Psychiatry clinic, Teaching Hospital, Anuradhapura by the Consultant Dermatologist.The referred child presented with multiple abrasions and lacerations over his face and both upper limbs.His face was severely deformed due to multiple scratch marks.His mother had difficulty in managing the child's repetitive scratching and skin picking, especially over the face and upper limbs.Child screamed with pain due to infected wounds.He was not cooperative for the interview.Collateral history was taken from his mother and siblings.There was no history to suggest ADHD, Autistic Spectrum Disorder, Intellectual Disability or Munchausen by proxy.
There was a clear history of recurrent extreme urges to pick the skin and scratch his face for 6 months duration.He could not resist the impulse to damage his skin.This child failed to avoid the act despite painful injuries to him.There was evidence of increasing anxiety prior to the act.He felt tension and arousal before skin picking and scratching.He experienced a sense of gratification and relief following the act.There was no evidence of provocation before the urges and impulses.He did not have any feeling of regret, remorse or guilt about the behaviour.Episodes of such acts were pervasive and persistent.It took place during the clinical examination as well.

Figure 01: Injured skin due to scratching
His family members were severely distressed by the condition.The child's mother showed signs of depression due to her only son's behaviour.There were recurrent infections due to repetitive scratching and skin picking over infected wounds.Dermis was exposed in multiple areas on his face and upper limbs.There were more injuries on his left upper limb and left side of the face as he mainly used his right hand for scratching and skin picking.

Abstract
An atypical case of impulse control disorder in a 4-year-old boy was diagnosed and successfully managed with a Second Generation antipsychotic in this case report It was difficult to treat the child with behavioural strategies due to his age, limited rapport and parents' level of education.A trial of Risperidone 0.5 mg was started in the child and adolescent outpatient clinic.Review in two weeks showed a marked improvement of his condition.A significant proportion of his facial and upper limb injuries were healed.There were no infected wounds.The frequency of scratching and picking behaviour had gone down.The child was not crying or screaming anymore.His family members showed happiness and a sense of hope for the child's future.

Discussion
Individuals with impulse control disorders cannot behaviours that might bring harm to themselves or others.There's increasing anxiety before the action and feeling relief or happiness following the action.The disorder is characterized by an inability to control one's actions, and results in a negative impact on the person.
The DSM-IV recognizes pathological gambling, kleptomania, trichotillomania, intermittent explosive disorder, and pyromania as impulse control disorders(1).Diagnostic criteria have been proposed for pathological skin picking, compulsive sexual behaviour and compulsive buying, which are classified under impulse control disorders not otherwise specified (NOS) (1).
A study in 2005 concluded that impulse control disorders are common among psychiatric inpatients (2).In this study 30.9% of adult psychiatric inpatients were diagnosed with at least one impulse control disorder 1 .The most common impulse control disorders were compulsive buying [9.3%], kleptomania [7.8%], and pathological gambling [6.9%](2).The Disorder is relatively common among adolescents and adults, and can often be effectively treated with behavioural and pharmacological therapies (3).A study of 791 college students demonstrated the common nature of these disorders in general population (10.4%) (Odlaug and Grant, 2010).Dopamine receptor agonist drugs are found to associate with serious impulse control disorders(4).
Pharmacological treatment for impulse control disorders have been relatively understudied (3).There are no FDAapproved medication for any impulse control disorder(3).Antidepressants, mood stabilizers and antipsychotics have been studied with mixed results(3).Large-scale, placebocontrolled, comparative pharmacological treatment studies need to be completed to find the most effective treatments for impulse control disorders(3).
The child with an impulse control disorder in this case report improved with treatment with second-generation antipsychotic medication.