another newbie---day tx now reccommended

Discussion in 'General Parenting' started by helppls, Nov 8, 2011.

  1. helppls

    helppls New Member

    I posted last week as a complete newbie, and was so grateful for your responses. This week has continued the downward spiral, and we’re now looking at a day treatment program for anxiety/school refusal, with a potential opening by week’s end. I’m wondering how many of you have been down this road, and I’m guessing many of you will have had this or similar experiences.

    Yesterday husband and I met with a child psychiatrist, who said that day tx was the way to go, because difficult child had another day of school refusal yesterday, and also refused his rehearsal for his upcoming recital. He was struck that the ODD symptoms which are present are, almost overnight, in a whole new category than anything we’ve seen before. He said this meant that the ODD we’re seeing now was physiological in nature. He requested a complete metabolic blood panel with lipids, blood count, etc, and would like difficult child to start on Seroquel, although he also indicated that if the day tx program will open by week’s end, we may want to delay Seroquel and let the psychiatrists there make the calls on medications.

    My lingering questions…..always in the future…….what happens next? Do kids typically return to the former school environ? Do they switch schools upon discharge? How much improvement might there be? Has anyone heard of physiologically induced ODD?

    I’m attaching below the history a number of you asked for last week, in case this is helpful still.

    difficult child’s History:

    1. #2 (let’s call him Ben) was induced at 41 weeks for social support reasons. Induction was started with Cytotec/Misoprostal. We later learned that this drug can be disastrous, but we didn’t know that then. After the second (of 2) administrations of Cytotec, I went to sleep, and woke up maybe 3 hours later in transition (but didn’t realize that’s what it was). “Ben” was almost immediately in acute distress on the monitor and NICU was called. I was told that the rapidity of the birth process was potentially causing Ben to go into shock, and that he needed to be delivered NOW---push 100% of the time, full force, contraction or no. When he was being delivered, the cord was revealed to be so tightly around his neck, strangling him, that it needed to be cut off. Initial APGAR of 5, oxygen treatment boosted 2[SUP]nd[/SUP] APGAR to 8. He was taken to NICU for more oxygen and observation, and returned to maternity 3 hours later. Able to nurse shortly thereafter.
    2. Normal developmental milestones for talking, walking, turning, crawling, etc.
    3. I learned early that it was best to be home between 2-8 pm, as this could be a very fussy time for Ben, and he would sometimes have “marathon” nursing sessions lasting over an hour. Other than this, he was happy, content, very cuddly and affectionate.
    4. Multiple ear infections, probably somewhere between 5-9.
    5. Repeated bouts of croup, the most recent coming only last year, when he was 10 years old.
    6. At 2 years, Ben fell and bit entirely through his tongue. He received Versed and Ketamine in the E.R. as an anesthetic during suturing of his tongue. He required very large doses to even slightly calm him and staff expected him to be sedated over three hours. He awoke fully within 30 minutes. The following day his pediatrician described the amount of medication administered as “enough to provide general anesthetic properties for an adult male”
    7. Ben attended preschool, as had big brother “Abe”, and as does little brother “Cal” Of the three, he has shown the most separation anxiety, but it’s in line with what I’ve seen in these kinds of situations. He was the worst at his preschool for his year, but not worse than the worst on Abe’s or Cal’s years, let’s say. However, Ben did have a season when all he wanted to do was to stay home. He went from having separation anxiety at drop off and then enjoying the day to talking at the end of preschool about how he still wished he’d been at home. That year I gave Ben two weeks of Spring Break, his from preschool, and Abe’s from Kinder, which was the next week. He successfully returned to school after the two weeks off. When it was time for Ben to attend preschool, I remember telling friends that I thought Ben would be happiest as a home-schooled child, but that I didn’t think I could manage the power struggles that would come with the territory of being both teacher and mom.
    8. When Ben was four, he saw an Occupational Therapist (OT) once weekly for about six months for general fine and gross motor skill development, as Abe had when he was that age.
    9. Ben begins Kinder at a small, fairly elite, private school, similar to the one he now attends.
    10. In 1[SUP]st[/SUP] grade, Ben’s teacher suggested that we have him evaluated for possible attentional or reading issues. We had a general psychiatric and educ. assessment at a local university. Ben was diagnosed with ADHD and dyslexia. Many ODD characteristics were noted on evaluation, but the diagnosis wasn’t made, as it was hoped that these behaviors were in response to feeling unable to focus and not doing as well in school as he wanted to. General Intelligence measured nearly two Standard Deviations above the mean, Processing Speed measured at the mean, Working Memory measured about one standard deviation below the mean.
    11. Dyslexia remediated through private tutoring, twice weekly through 1[SUP]st[/SUP] grade and that summer, once weekly through most of 2[SUP]nd[/SUP] grade. Ben reads prolifically and well above grade level.
    12. ADHD treated with medication: initial trial of Daytrana was failed due to negative, existential, perseverative thoughts on rebound. Adderall XR trial well tolerated, titrated up to 15 mg. This works well from the end of first through the start of third grade. Sleep issues did occur, Melatonin 1 mg used.
    13. In 3[SUP]rd[/SUP] grade, Ben’s school announces that they will close due to financial problems at year’s end. Ben is devastated.
    14. In late fall of 3[SUP]rd[/SUP] grade, Ben said that he needed more “concentration medicine” Adderall XR increased to 20 mg, a week later Ben said this wasn’t adequate support. Dosage increased to 25 mg, and within a week Ben has suicidal ideation, was really irritable---generally looks a lot like he does now. Stimulants discontinued, medication care transferred from pediatrician doctor to psychiatric doctor for evaluation of suicidal ideation, etc. psychiatric doctor. determined that SI was result of stimulant side effects. Guanfecine trial produced no helpful results. Strattera on own also not helpful, seemed to be potentially agitating, especially at higher doses. Finally, after about 4 months of being stimulant free, psychiatric doctor re-introduced Adderall with Strattera, transferred care back to Peds doctor.
    15. Ben applies to a number of similar schools during the time he is stimulant free. He is rejected by all except for the school big brother Abe transferred to the year previously (we saw the writing on the wall). This school, his current, will not take him this year, but agrees to reconsider the application on another year.
    16. Ben spends 4[SUP]th[/SUP] grade at a nearby religious school, complains of boredom, learning nothing, hating homework.
    17. Strattera replaced with Intuniv, for weight gain reasons, well tolerated change. Good growth pattern following.
    18. Ben transfers to his current school for 5[SUP]th[/SUP] grade. Although he still wishes he could return to his first school (now closed), he is glad to go to this new school.
    19. Ben complains of allergic like symptoms and is feverish in the spring of 5[SUP]th[/SUP] grade (last year). Peds refers him to the ER because of throat constriction. ER does a CAT scan, says the glottis is infected, and they suggest overnight hospitalization because of the swelling in Ben’s airway. Dechadron steroids are ordered to reduce inflammation. Ben becomes very agitated, Ativan is given. He develops visual hallucinations which persist for 24 hours, he does not “feel himself” for another three days.
    20. Ben moves from the elementary to the middle school division of the school. First couple of weeks go well, the Ben begins to complain that there’s too much homework. And that he needs more medications for ADHD symptoms during the day.
    21. Intuniv increased to max. dosage, from 3 to 4 mg. Ben still felt he needed more support, so Adderall increased to 25 mg. Ben became more irritable, so we backed down again to 20 mg. Ben later confessed to Suicidal Ideation while on the 25 of Adderall. pediatrician doctor feels Ben is “tachyphalactic” (not responding) on Adderall, titrates off, initiates short-acting Ritalin trial. 5 and 7.5 mg trials are tolerated, but not therapeutic. 10 mg dose produces feelings of racing heart, Ritalin discontinued.
    22. Ben is evaluated in the psychiatric ER on Day 2 of school refusal, acute anxiety and possible depression suggested. He is discharged to home, with recommendation for group tx of anxiety
    23. Ben returns to school, but has now had 3 more days of school refusal over the past 6 days of school. He's pulled out a patch of his hair. He refuses to go to his violin rehearsal for his recital, and tells his teacher he does not feel able to attend the recital

    Family History:

    1. husband has mild depression, finds life easier with medications than without. husband’s dad likely had Obsessive Compulsive Disorder (OCD).
    2. My father has undiagnosed dyslexia, minimally dysthymia, very limited social life and social skills. A binge alcoholic while I was growing up, he quit when MD said it would kill him.
  2. SomewhereOutThere

    SomewhereOutThere Well-Known Member

    The very first thing that jumps out at me is that if it were my child, I would take Ben to see a neuropsychologist to see if the psychiatrists haven't missed the boat. It sounds like something other than <acronym title="Attention Deficit Hyperactivity Disorder">ADHD</acronym> to me. Or at least co-morbid. A <acronym title="Neuropsychologist">neuropsychologist</acronym> would be better able to evaluate than a <acronym title="Psychiatrist">psychiatrist</acronym> or therapist.

    As for therapeutic day school, I have no experience with it but a close friend had two of her children in one. The little girl did tremendously and has been better ever since, however a lot of her issues were adoption related. Her little boy gained nothing from it and is on the verge of psychosis still. The police are often called to the house because he is uncontrollable and nothing seems to work. For her it was a mixed bag. Both kids were returned to regular school. Son is floundering. Son has so many diagnosis., Friend doesn't really care anymore...she just wants things to get better.
  3. InsaneCdn

    InsaneCdn Well-Known Member

    This just screams "comprehensive evaluation" at me, too. neuropsychologist, or childrens' hospital. evaluation team, or equivalent.
    This is not ONE diagnosis. Expect several. Some of which may work against each other.

    And yes, physical/medical stuff can generate psychosis... among them: sleep deprivation (insufficient and/or lack of quality sleep), or brain tumor, or thyroid problems, for starters... so yes, rule out any possible medical problem first.

    This doesn't mean that therapeutic day school is the wrong thing right now - it may be a safe place for him while you work through the issues. Really depends on the school in particular and the specific skills of the staff involved.
  4. soapbox

    soapbox Member

    The issues you are dealing with may not be the same as ours, but I can tell you that hidden, un-diagnosed problems CAN generate significant secondary issues... from anxiety to depression to psychosis.

    Dealing with these as secondary dxes is very different than if they are primary dxes... in that, you will NOT solve the problem, until you get to the bottom of the real primary dxes.

    Middle school is a classic time for problems to really hit the fan. The child who has been scraping by, suddenly gets snowed under, doesn't have the base skills to do the work - but refusal is seen as "attitude" rather than "lack of ability"... and they sink FAST.

    For us, it was a combination of Developmental Coordination Disorder (Developmental Coordination Disorder (DCD)) and Auditory Processing Disorder (Auditory Processing Disorders (APD)). Yours may be other things.
  5. buddy

    buddy New Member

    No, but I can guess..... I think it sounds like something physical/neurological has happened that has changed his way of behaving. That is what happened to my son with the medication reaction he recently had. He turned into a different child. Several others here have had similar experiences. There could be so many reasons for it... I wonder if puberty would be considered a reason??? Anyway, it would seem to me that the point of it is that this is not who he probably truly is (there are kids who are just ODD types from the get go) and he just wants to make sure that they are treating the right things to help him improve.

    Any other guesses? anyone know for sure???