Pediatric Bipolar / ADHD / ODD

[ajs67]

Over the past several weeks since Brandon’s medications have been lowered he has become much more difficult to deal with at home, school, and with peers.  He refuses to do homework, schoolwork, will only eat specific foods, will not stop annoying habits, does rude things, says things to his brother like I will cut you with this pocket knife when he his mad at him but has never acted on it, and has no respect for authority just laughs at authority figures when being asked to behave or do something.  We are not sure what to do?

My son Brandon has learning disabilities, behavioral difficulties that we noticed when he was starting kindergarten which we had him repeat twice, and then it became very apparent that something was different.  He is now eight years old, and for the past years he has been through a lot with his previous pre-school and kindergarten teachers setting him aside because he was just not the norm and required one on one attention and extra help, which damaged his self-esteem, his nature, and I believe adding to his separation-anxiety and depression.  He has had two positive years in the Folsom Carl Sundahl School system with great teachers, and a special additional for two years in a row for an hour after school each day for one on one reading and math assistance and they have brought him a long way in the past couple of years, yet he is still is just approaching grade level which is very frustrating for him, and his school comes very easy for his younger brother who is only 13 months younger then him.

Background:
Diagnosis:  ADHD/ODD, Anxiety, Depression, Bipolar II, Learning Disability
 Separation Anxiety, Deep depression – up and down (swings), eyelash pulling and pulling out hair without anti-depressant, it took 150mg of Zoloft to finally stop the habits and put a smile on his face.
 Does not feel pain like other children – can run across rock beach with no shoes and feels nothing - no pain.  Loves animals can get stung by bees and does not care.
 Cannot focus in school, difficult for Brandon to concentrate or for teachers to get quality time with him
 Tries to manipulate teachers by telling them stories and get them off the subject so that he can get out of doing the work he does not like
 Rude to others, more disrespectful than normal, blurts out rude comments to people – does not think before speaking
 Refuses to perform at Bright Futures Learning Classes and sits idle during his one on one session for private tutor lessons
 Does crazy things like swallows objects that are dangerous – things that he has never done before…. When on ADHD medications
 Abnormal climbing walls, and furniture, abnormal walks away from home to ponds to find animals and lizards without telling us where he is going… not normal behavior… when on ADHD medications – this is why pediatrician – Dr. Arab referred Brandon to Dr. Clopton
 Outbursts rude statements to adult authorities –
 teachers, neighbors, parents, waiters, etc. without any concern
 for their feelings
 Does not respect authority – he says the only ones with authority are police because they have guns
 He talks about death with high interest and enthusiasm and wants to know details of stories on the news etc.
 When he finds a dead animal he wants to examine it but we have tried to teach him that the best thing for the animal is to bury it
 Very particular about foods and will not eat unless he gets what he has programmed his mind to eat….. for the given meal very stubborn

Interests:
 Lizards, animals, and always trying to get another animal as a reward in exchange for doing something.
 Fishing, Wandering in open country free of inhabitance
 Religion – Jewish, Hebrew School
 Keeping thin…
 His little brother and baby sister – he does love them very much – even if he beats the pulp out of his little brother from time to time!

His medications were as follows as of 1/18/08 and prior for at least 6-months:
DEPAKOTE ER 500MG TAB TWO TIMES DAILY
ZOLOFT / SERTRALINE 100MG (1 ½ TABS) EACH MORNING CLONIDINE HCL 0.2MG (1 TABLET 30 MINUTES PRIOR TO BEDTIME)

His Psychiatrist had him on  the following and added Abilify, Then, on 1/19/08, his Doctor changed the medication as follows which caused a problem Dystonic Reaction and he ended up in the Pediatric ICU two days later from the Abilify.
DEPAKOTE ER 1000MG (BEDTIME)
ZOLOFT / SERTRALINE 100MG (1 ½ TABS) EACH MORNING CLONIDINE HCL 0.2MG (1 TABLET 30 MINUTES PRIOR TO BEDTIME) ABILIFY 10MG (1 TABLET EACH MORNING)


Discharge instructions from Sutter Memorial from Dr. Chretien and during his first appointment with Dr. Chretien on Feb. 7, 2008, medication dosages were kept same for now:
DEPAKOTE ER 500MG (Bedtime)
ZOLOFT / SERTRALINE 100MG (Morning)
CLONIDINE HCL 0.2MG (1 TABLET 30 MINUTES PRIOR TO BEDTIME)

On appointment Thursday, February 14, 2008, during Brandon’s first appointment with his new Psychiatrist, Dr. Ted Hoffman, after discussing background and my personal diagnosis as a parent from the reading that I have done (Bipolar Disorder Type Two, Attention Deficit Hyperactivity Disorder, Learning Disabled, Anxiety, and Oppositional Defiant Disorder).  Dr. Hoffman said that it was unfortunate that Brandon responded poorly to Abilify because the dopamine is what he needs for his condition, but since this caused a Dystonic Reaction he will have to work around this with different medications.  Dr. Hoffman decided to change medications as follows and to see Brandon back in three weeks:
DEPAKOTE ER 250MG (Morning and Afternoon)
ZOLOFT / SERTRALINE 50MG (Morning and Afternoon)
CLONIDINE HCL 0.1MG (1 Tablet in Afternoon), and (2 TABLET 30 MINUTES PRIOR TO BEDTIME)
Results:  Drowsy - no focus, motivation, attention benefits, and he is beginning to pick his finger nails now.

[psychdoc551]

My heart goes out to you.  I am a child psychologist, with expertise in differential diagnosis.  If it were my son, or if you were my patient, I would absolutely recommend that you do the following:

1) Start your son in weekly or twice weekly psychotherapy with a well-known licensed clinical psychologist right away, and plan to meet with the psychologist weekly on your own, to discuss your son's progress and treatment, and to obtain assistance with parenting him. It's unhelpful to treat emotional/behavioral problems, even those with a neurobiological basis, with medication only.  Combined medication and intensive psychotherapy is strongly advised.  If your doctor tells you that psychotherapy is not necessary, run for the hills and find another physician fast; someone who supports the combined approach. Check out the PBS Frontline presentation The Medicated Child.  If nothing else, it will be eye opening.
2) I would be extremely cautious in giving your son antipsychotic medication (i.e. seroquel, Abilify, Risperdal, Geodon), even though it has become quite common to prescribe these medications to young children. The FDA has not approved most antipsychotics for the treatment of Bipolar Disorder in children.  Find out which meds have been approved for the treatment of specific disorders, and get a second opinion. Also, please be advised that there is only clinical support for the diagnosis of early onset Bipolar Disorder.  The American Psychological and Psychiatric Associations have not yet formally recognized Bipolar Disorder as a childhood disorder. Know that the experts disagree as to whether childhood onset Bipolar Disorder even exists.
3) Does your child have an Individualized Education Plan?  Either way, go to wrightslaw.com and find out your rights as a parent of a child with special needs.  He needs you to advocate for him in the school setting.
4) Get an independent educational evaluation. Go to the state board of education website in your state and you'll be able to find a list of approved evaluators who can test your child, and accurately diagnose the nature of his learning disabilities.
5) Has your son had a 24 or 48 hour EEG?  What about an MRI? You should take him to see a pediatric neurologist to rule out a possible seizure disorder or structural abnormality.
6) Get an Occupational Therapy evaluation done, privately. It sounds like he has sensory integration problems (heightened tolerance to pain, movement seeking, and general dysregulation).
7) The mother of one of my patients with ADHD began following the Feinstein diet, and she is reporting some positive results. It might be worth checking into it.
8) Please do not admit any of these steps.  Do them all.  You won't regret it.  

I hope this was helpful.  

[psychdoc551]

I meant to say omit, not admit, in #8.  It's late and I'm tired.  Best of luck to you.