Fetishism in ADHD: an impulsive behaviour or a paraphilic disorder?

Abstract

A boy with attention deficit and hyperactivity disorder (ADHD) presented with a fetish for and the subsequent stealing of female undergarments. He was predominantly inattentive and had been a slow learner. Psychological tests showed that he had significant cognitive and inattention problems without significant hyperactivity, and was at risk of dyslexia as well as conduct disorder.

Background

Fetishism is a variant of paraphilia but it may become a paraphilic disorder depending on its extent. There are limited research on paraphilias or paraphilic disorders in children or adolescents as compared with adults. Nevertheless, it has been shown that many individuals with paraphilic disorders actually had underlying attention deficit and hyperactivity disorder (ADHD) and other comorbid psychiatric conditions. Contrariwise, ADHD may itself manifest as risk-taking and impulsive behaviours, predisposing the subjects to paraphilic acts.

Case presentation

A 16-year-old boy was diagnosed to have ADHD when he was 8 years old, after having difficulties in paying attention and frequently noted to be ‘day dreaming’. It was difficult for him to complete his school work without guidance and he seemed not to listen when teachers or parents talked to him. There was tendency to fidget with stationeries whenever he tried to complete his school assignments. As a result, he underperformed at school, failed most subjects and had only started reading when he was 8 years old. Nevertheless, his social function was reported to be good as he could mingle well with others and was able to start friendships. However, his mother’s concern was that he began to be teased by his more intelligent friends. Soon, encouraged by his school teachers, his mother brought him over to the child and adolescent psychiatry clinic for mental health evaluation and treatment.

His condition seemed to improve to a certain extent following the commencement of stimulant treatment; his focus in the classroom and at home improved although his examination scores did not. However, after 2 years of treatment, his mother was astonished when she found a female underwear hidden under his bedroom mattress. When confronted, he told her he did not have any idea how it ended up in his room. Not convinced with his explanation, she began checking his room from time and time. He was finally caught red-handed when she found him asleep, with another female undergarment worn inside his pants. He finally relented and admitted that he had been stealing undergarments he spotted on their neighbours’ cloth hanger. He also admitted to have taken his mother’s and his living-in aunt’s undergarments too. By this time, he got so mortified that he promised not to repeat it.

His mother subsequently informed his treating psychiatrist and he was scheduled for further assessment for paraphilia. During his separate sessions with psychologist and psychiatrist, he confessed that he felt ‘excited’ when he could hold the female underwear. However, he denied experiencing any pleasure on wearing the underwear or that he had ever dressed as the opposite sex. He went further to describe hat he had first became sexually aroused with the material when he saw women wearing underwear on a television programme around the time when he turned 11. Even though he realised that the act of stealing was wrong, he did not have the faintest idea about the implication of his fetish. He had found himself unable to control the excitement with undergarments but discovered later that smoking helped him to curb this. That was when he began smoking cigarettes with increasing frequency.

His prenatal, postnatal and medical history was unremarkable. There was no sexual abuse or exposure. A maternal aunt had postpartum depression but otherwise there was no history of paraphilia, ADHD, mood disorder or psychosis in the family. He lives with his army father, mother, three younger brothers and a maternal aunt.

Investigations

His blood counts were within normal range. Thyroid, liver and renal functions were normal. His urine toxicology showed no evidence use of illicit substances.

There were neither brain imaging nor electroencephalographic test carried out.

Wechsler Intelligence Scale for Children-Fourth Edition showed full-scale IQ of 86 indicating low average range.

• Verbal comprehension index was low average.

• Perceptual reasoning index was average.

• Working memory index was low average.

• Processing speed index was low average.

Conner’s Parent and Teachers’ Rating Scale showed significant cognitive/inattention problems while hyperactivity was not significant. The results suggested the presence of ADHD, predominantly inattentive presentation, moderate.

Dyslexia Screening Test-Secondary suggested that he was at risk for dyslexia.

Learning Disabilities Diagnostic Inventory showed consistent pattern of low scores in listening, speaking, reading, writing, mathematics and reasoning.

Child Behaviour Checklist (CBCL 6–18) showed clinically significant withdrawn/depressed symptoms. Internalising problem: within the borderline clinical range. At risk of affective problems, anxiety problems, attention deficit/hyperactivity problems and conduct problems.

Differential diagnosis

He was diagnosed and treated as ADHD, predominantly attention deficit, with comorbid fetishism and mild intellectual disability.

Treatment

He was treated using bio-psychosocial approach. First and foremost, methylphenidate 10 mg per day was started but was later changed to atomoxetine 18 mg after he lost appetite and significant amount of weight with the former. However, he developed bilateral hand tremor when atomoxetine was increased to 25 mg, so he was just maintained with 18 mg.

Subsequently, both parents received psychoeducation about ADHD, including academic and social complications that entail. After understanding and co-operation from them had been garnered, a further treatment plan using occupational therapy and social skill therapy were started. Later, education on issues related to puberty and sex were delivered to him, an approach which he appreciated much.

Social skills training was conducted via video demonstration and role play. He was also assisted to quit smoking and his stealing behaviour.

Outcome and follow-up

During series of psychiatric interviews, he openly admitted having sexual desire with the undergarments. After stealing them, he usually handled, smelled and sometimes wore them. He occasionally masturbated while performing these acts. He remembered having this interest since a year before but he only started stealing for a few months before his mother caught him. It started off as admiration over photos of women with undergarments on television. He felt shameful about stealing and having the interest for female underwear but did not know that the fetish was unacceptable. He himself had tried to control the desire but failed.

As the first approach, his therapists negotiated with him not so steal. Subsequently, they went on to start educating him the rights and wrongs related to sexual behaviours. Soon therapists continue to discuss with him regarding puberty and physical changes that he was experiencing. His father was also encouraged to discuss matters of puberty and sexual development with him, possibly with his other siblings.

With the initiation of methylphenidate, his stealing behaviour stopped over the next 2 months and he felt less excited on seeing female undergarments. However, mother reported that his focus remained to be impaired and his appetite reduced. Similarly, assessment using Conner’s parent rating scale failed to show improvement. When his weight seemed to be affected too, the treating psychiatrist took methylphenidate off and started him on atomoxetine 18 mg/day.

Despite experiencing nausea initially, he could focus longer and was learning better in the classroom, as reported by his teacher. However, his mother noticed that he would be sometimes inattentive when she was helping him out with his schoolwork. Due to this observation, the dose of atomoxetine was increased to 25 mg OM. Unfortunately, he developed bilateral fine tremors soon after the initiation of the new dose and hence he returned to the previous dose.

At 1-year follow-up, the patient admitted that he still had the urge to touch female underwear but he was able to restrain himself from giving into the craving by persuading himself that it is not the ‘normal’ way.

His current follow-ups with a child psychiatrist is generally done every 3 or 4 months, intermittent with occupational therapy, which gradually ceased as his attention and behaviour improved over time.

Discussion

Individuals with fetishism have persistent sexual arousal in association with non-living objects or body parts,¹ as detailed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.² This condition should be present over a period of at least 6 months and usually occurs mostly in men while having its beginning in adolescence. Fetishism is not considered a disorder unless it causes personal distress and functional disruption. In relation to this condition, ADHD was the only axis I disorder which is significantly associated with paraphilias in children and adolescent population.³ Although paraphilias and paraphilic disorders in adults are well documented, there are limited work done in children or adolescents. Nevertheless, a review of literature revealed that there are several case reports of paraphilia and sexual fetishism in adolescent subjects with ADHD. Female undergarments and shoes are among the most frequently preferred fetish objects.^{4 5} While the impact of ADHD on the development of paraphilias in adolescents should warrant further research, it can be speculated that ADHD itself may contribute in fetishism and other risky sexual behaviours⁶ in these subjects. Compared with their peers, children and adolescents with ADHD experience more motor vehicle accidents, hospitalisations, and significantly higher school failure and delinquency. They are also at risk of antisocial activities, teen pregnancy and sexually transmitted diseases.⁷ It would be expected that ADHD subjects with predominant hyperactive–impulsive presentation would represent the majority of those associated with risky and impulsive behaviours like fetishism, but in reality, the vast proportion of the hypersexual patients diagnosed with ADHD was of the inattentive subtype.⁸ However, this finding was seen among adults ADHD so it must be applied with caution as adult ADHD is associated with less predominant symptoms of hyperactivity or impulsivity and more inattentive symptoms.

Medications such as gonadotropin-releasing hormone agonists and selective serotonin reuptake inhibitors (SSRI) have been used for paraphilic disorders.⁹ In our case, the child was mainly treated for his ADHD with stimulant medication. It was hoped that his attention would improve, which will lead to better self-confidence and self-image. The addition of an SSRI was also considered, but the suggestion was quickly disapproved by his mother, who saw improvement in his stealing behaviour since the commencement of the stimulant agent. SSRI has been shown to be effective for paraphilias,¹⁰ and methylphenidate–SSRI combination was equally effective in adults,¹¹ particularly when there is comorbid ADHD. Dealing with this child’s inattention symptoms might have helped reduce a number of symptoms associated with his fetishism. On top of that, he should also receive a psychological management in the form of rational emotive therapy.⁹

A child presenting with both sexual fetishism and ADHD is definitely a rare bird. Nevertheless, any young person manifesting these conditions should go through a thorough clinical assessment, including developmental and medical history, sexual development, history of abuse, family history, academic and social functioning, and criminal history if relevant.¹² Just like this case, treatment of comorbid disorders like ADHD may lead to improvement in fetishism. Combined psychosocial and psychopharmacological interventions have been shown to be more effective than either intervention alone. Despite the absence of a structured cognitive and behavioural intervention in this case, this case report may contribute further in the understanding and management of fetishism/fetishistic disorder in adolescents. More systematic research are needed on the impact of ADHD on the development of paraphilia or paraphilic disorder in children and adolescents.

Patient’s perspective.

From his mother: ‘He does not do it (stealing undergarments) anymore so I am relieved but now I am worried about his future as he still has a lot to catch up academically’.

Learning points.

• It is common for individuals with attention deficit and hyperactivity disorder (ADHD) to have paraphilia or paraphilic disorder, just as common as individuals with paraphilia to have features suggestive of ADHD.

• Individuals with either predominantly hyperactive–impulsive or predominantly inattentive ADHD are at similar risk of paraphilic disorder.

• Optimising medications for ADHD might just be the approach needed to help overcome fetishism in ADHD.