Whats the right diagnosis and order of treatment?

[ducky8888]

I am in a relationship with the mother of a 10 year old, male difficult child diagnosed with ADHD and ODD (diagnosed long before I came around). He is on multiple medications (don't know which ones by name, I know a stimulant, a meth, and a couple others). The issue I have is that he displays symptoms that seem outside the realms of the typical adhd/odd diagnosis. I come from a family riddled with mental disease (bi-polar, borderline, manic, etc.) so I am familiar with many aspects of mental health. What I want to know, and from my research I cant determine, is, are these symptoms that are regularly seen with ADHD/ODD or should these symptoms be treated as in addition to his other issues?

He will get something in his mind and is relentless until he gets his way (usually causing an episode of ODD and fighting, tantrum, etc.). What I mean is if he gets it in his head that he is hungry (even though he just got done eating 2 plates of food) he will not give up until he gets more food (usually cereal or some treat like ice cream). He found out I have a handheld gaming device and at my house and when ever they visit he asks to play it, even though I have told him over and over it doesn't work, doesn't have a charger, etc. After I told him there was no charger he began search through my house, garage, shed, closets, trying to find the charger. Every visit he asks to play it, trys to enter my bedroom to retrieve it, searches more for the charger, and every time I tell him the same thing, that he will never have a chance to use the device. In his own home he goes on searches when he thinks of something, tears through the house ripping open drawers, emptying them on the floor, dumping storage tubs in the garage, etc. until he finds what he is looking for. When he cant find what he is searching for he gets frustrated and begins destroying and throwing things. I call this behavior "obsessive" but he doesn't display any "compulsive" behavior. he is not clean or neat, at all, in fact quite the opposite. Does not organize anything. does not worry about dirt or disease, to a fault (i.e. eating food off a dirty driveway).

At all times he is very selfish, self-centered, narcissistic, etc. For example, he and his brother were given a broken down bike. I spent an afternoon with them driving them around sourcing parts and assembling the bike and getting tubes patched, etc. As soon as the bike was up and running he got on it and started riding. Both his brother and I asked to have a ride, and eventually this turned into a huge tantrum. We all spent time, money and effort to get the bike ride able and in the end he staked claim and wasn't giving it up no matter what kind of reasoning we tried.

In the months I have been around I have seen how his behavior effects the rest of the family (older sister moved out so as not to be around, younger brothers learning his bad behavior, i.e. punching walls, slamming doors, cursing, throwing fits) and it doesn't seem the medications are doing anything to curb his behavior. he has several tantrums a day, ranging in severity. I have read that some of the other symptoms should be treated with medication before treating the ADHD/ODD. For example the stimulant he is taking may exasperate his obsessive behavior, creating anxiety and nullifying the effect and causing tantrums. I have suggested his mother talk to his doctor about this, see about dropping the other medications and putting him on an SSRI to address the anxiety and obsessions before putting him back on stimulants, but his Dr doesn't address these issues, only the ADHD and ODD

Does anyone out there have similar issues with their child? What has worked for you? She has talked about finding another Dr, but is hesitant.

 

[BusynMember]

Hi there and welcome to the board.
Sounds to me like this difficult child needs a more intensive evaluation, like a neuropsychologist evaluation. Having said that, this is likely how the child will be for the foreseeable future. He sounds autistic spectrumish to me. But it could be anything. Either way, you have to ask yourself if you want to sign up for this. He is part of the deal, and if you don't want to deal with his odd behaviors, the relationship likely won't work out. He is her child, after all. Even with help, he will continue to be difficult and normal parenting methods tend not to work with our differently wired children.

If you want to stick it out, I'd encourage you to ask girlfriend to take him to a neuropsychologist because I think it's obvious that more is going on than ADHD/ODD. As he gets older, chances are it will only get worse. Does he have a relationship with his father? Was his very early life chaotic? Do you know anything about his milestones? Does he have any friends? How does he do in school?

Good luck with your difficult decisions!

 

[buddy]

I agree with mwm, making an appointment with a neuropsychologist would be very helpful. Obsessions are the thinking part.....compulsions are the behaviors. Some people do the cleaning orderly type but sounds like this boy gets ideas in his head ( obsessions).then is compelled to act (compulsions).

This is quite common in many conditions and yes autism spectrum is one of the options. Does he have a social life? Does he or has he ever been able to pretend play in a creative way (as opposed to imitating shows or people and playing chase or other non imagination games). Does he act overly sensitive to taste sound textures etc? Does he seek out touching things or other sensory input?

If he is on the spectrum it would explain the "selfish " behaviors because many people with autism need specialized direct teaching to learn how to take the perspective of another person especially if that conflicts with what the person with Autism Spectrum Disorders (ASD) wants.
Of course there are many other issues this could be and we.can't diagnose here, I think you just hit some red flags for those of us who live and work with that particular issue. 1) he obsesses about his interests 2) unable to take perspective of another 3) meltdowns when things don't happen as he pictured it in his mind 4) the.first diagnosis. Before the underlying one is adhd + ODD + anxiety very often.

I hope his mother is willing to have a complete evaluation done. A typical psychiatrist or psychologist does not do the in depth testing that looks at both mental health and neuro developmental issues. A neuropsychologist evaluation is quite long and usually very helpful. Regretting not having explored all options when behavior is so compromised is a terrible feeling and the older a child gets without appropriate therapy the harder to undo patterns.
My best to her!

 

[busywend]

Yes, I think there is more going on here. It would be a good idea to contact the local Children's Hospital for a complete evaluation. The best thing you can do is support the mom (if you choose to stick around) and make sure she gets breaks away from him at least once a week. Us warrior moms need the break to decompress and be able to handle the next meltdown. It really drains us.

 

[ducky8888]

Thanks everyone for the information. A little history, I have known the mother for a very long time (18 years) and have no intentions on going anywhere. About difficult child: mom and dad had a rocky relationship. even when they were married (divorce was when difficult child was around 3yo) father was distant, if not absent. Behavior started around 3yo (around the same time father left). Father is bi-polar, narcissistic, and pathological liar (in and out of jail for fraud). Father has been absent for the majority of their lives, recently takes the kids every other weekend for a day and a half. Reports from the father are that difficult child does not have the severe obessions and tantrums that he has when with his mother. He also spends a night a week with his paternal grandmother. I also frequently send her off for time away. Its still not enough as he has tantrums 2-3 mornings a week, mild tantrums daily after school and at least one tantrum (food related) at some point throughout the evening. For school, he attends a special school for children like him because he has been expelled from all public schools. Even in his current school he is often kicked from the transportation van, has broken windows during weekly meetings, and is frequently restrained for aggressive behavior towards teachers and students. His education is significantly sub-par. His reading and math skills are very, very low. He has had a psychiatric evaluation, in which he was tested for intelligence, temper and behavior. The report states he is very low intelligence, bordering on retardation, but that the tests were not completed because of the difficult child's frustration while testing and inability to complete the tests. He does not have any friends to speak of. Most children in the neighborhood wont befriend him (they are all friends with his younger brother). He doesnt talk much about school, so I assume he doesnt have any close friends there. difficult child has excellent gross motor skills (riding a bike at a young age, coordinated dance moves, all siblings are the same), but very very poor fine motor skills (hand writing and using tools makes him frustrated quickly). He really enjoys music (the louder the better), but so far I have not seen or heard of any sensory issues.

 

[InsaneCdn]

There is more going on.
A comprehensive evaluation is the only way you will know.
And that needs to include testing both motor skills and sensory challenges.
And hearing. And APDs. Absolutely every thing.

Part of the challenge is that you DON'T know.
But the behaviors are typical of many "complex" kids.

Small example - if he has a hearing problem, he may come across as uncooperative, as "slow", etc. - when really, he just isn't "getting the message".
Or he could be wired differently.
Plus... obviously, with a family history of MI, there may be some of that in the picture too.

JMO - it's likely to be either something pervasive, OR it's several things ... OR both.

 

[flutterby]

We can't diagnose here, obviously, but he does sound more spectrumish to me, too. Although, you should look into executive function deficits and ADHD. There is a thread in the archives to get you started. http://www.conductdisorders.com/for...yperactivity-disorder-executive-function-763/

I agree that he should be evaluated at a Children's Hospital. The sooner that process is started the better, as there is going to be a wait. It's likely that his IQ test isn't an accurate reflection if he was that frustrated and unable to complete it. My daughter tested average IQ and the neurpysch thinks she is actually higher, but anxiety kept her from being able to really do the tests.

 

[BusynMember]

I'd definitely do the neuropsychologist evaluation. Something isn't right. Again, I think he sounds spectrumish, but let the neuropsychologist figure that out. Neuropsychs do intensive testing up to ten hours in every area of function and find things that other professionals don't. Doing nothing will only make things worse. I do not believe, more than ever now, that this is a "bad" boy who disobeyes on purpose. I think you have a frustrated kid who can't fit in to society and you and girlfriend need to find out why and to help him. Discipline likely won't help because his issues are deeper than just not doing what he's supposed to do. He is basically failing at every aspect of life...again, reminding me of high functioning autism, untreated. This poor kid has nothing going for him at all and I personally don't think he can help it. He needs a diagnosis so he can get interventions and so you can understand him and parent him appropriately for his needs. He may be around a while and not able to go out on his own at eighteen, like most kids. I have a boy on the spectrum. Please take him to a neuropsychologist.

Impending bipolar can't be ruled out either. He may never see his birthfather, but he shares 50% of his DNA. Aspergers and bipolar often co-exist. You may have two disorders going on, but this young boy needs help. If he, perchance, does have bipolar, stimulants are TERRIBLE for him...they make bipolar worse. His obsessive thinking screams "autism spectrum" to me (they have many Obsessive Compulsive Disorder (OCD) traits), but again you really need to take him for a total evaluation. Neuropsychs can be found both at children's hospitals and university hospitals. If you're going to be one of his parents, you should encourage Mom to do this important step.

Good luck and keep posting!

 

[buddy]

Is he in the USA? If so he can't be expelled from a school if he is identified as a child with special needs. maybe you are using that term to mean they decided to move him which the Individual Education Plan (IEP) team can decide to do but unless he did something with drugs or had a weapon at school he could not be expelled. If that really happened I am not sure what is going on....

Is he in the public schools or private? In the public schools he would have had an evaluation and a plan designed tohelp him reach appropriate educational and behavioral and social goals would be developed. For children with behaviors, there is an additional behavioral evaluation that must be done to look at the specific behaviors in question (called an FBA, functional behavior analysis) and a plan called a positive behavior intervention plan (PBIP) or similar term must be developed. The plan must use positive methods (not punishment and restraint) to help him develop skills to do things that are an alternate to the negative behaviors. If he is being restrained it must be a specialized plan (unless done on an emergency basis and rarely) and even then if it has to be used frequently it must be documented well and it means the pbis is inadequate and must be redone to look at what is causing the upsets. This is federal and state law across the entire country (called IDEA). It is not optional for schools. Even if he is in private school he may go to the public school in his area for an evaluation to classify him as educationally disabled and he can receive services through the public schools while at the private school (he would have to be brought to the public site for that, sometimes half day during the week or after school hours). BY THE WAY...transportation is part of the IEP accommodations and if there is behavior on the bus it must also be addressed through a plan. My son has his own bus with specially a specially trained aide and driver. He has had zero incidents since that. They can not kick him off the bus as a method of behavior management just like they can't suspend more than ten times per year. Its the law.

In addition to the neuropsychologists evaluation (make sure you do not go to a neuropschiatrist, different professional both sometimes called neuropsychologist) I'd suggest from what you said that you encourage the mother to get him to a therapy clinic for children where they have occupational therapists and speech/language therapists. The Occupational Therapist (OT) (occupational therapist) looks at fine motor and sensory integration skills. (sensory integration issues cause a child to sometimes look very defensive or on the other end can seem very adhd because they either avoid sensory input or they seek it out excessively) and you already mentioned the fine motor issues. THe schools should have tested for these but therapy for these things in the schools will only address what DIRECTLY affects current work and sadly rarely even then....despite the fact that over and over in the courts it has been made clear that there is to be no difference between school and private therapies. (recently a mother here of a child who had an accidental brain injury won a big case for that). But knowing of these issues results in many accommodations in schools like sensory breaks, offering of items like weighted blankets to help kids calm etc. It is very very important to help figure this out. Therapy for fine motor skills is extremely helpful for most who use it.
The speech language therapist (Speech Language Pathologist (SLP) formally called a speech language pathologist) not only looks at how a child says sounds (what most people associate speech therapy as being) but also looks at how well a person can express themselves and understand communication and can investigate the root cause(s) of that. For example some kids may hear fine but their brains do not interpret sound, sometimes all sound sometimes only language sometimes a mix.....and it is important to see what is going on. Can you imagine if no one found that out...that would make a child look like they were delayed cognitively! They also work on non verbal social communication skills. THese skills are the biggest determiner of social communication success. For many kids with disabilities their ability to read faces and body language is off. So is their ability to use appropriate tone of voice, and use of body and facial expressions. If he has not had a complete evaluation for these issues, it could be very very informative and for him if they find something, could be life changing.

Getting in to see these professionals can often happen sooner than a neuropsychologist and they do much more indepth testing in their areas than the neuropsychologist can do. So, if you get it done first and then bring those results to the neuropsychologist they can use that information to help you receive a more appropriate diagnosis.

His genetic background is important and mental health is a big risk for him. That does not explain the developmental issues you describe though. However, sadly many of our kids are hit with more than one thing. If you only see a mental health professional, they often just flat out deny other reasons for behavior. so, even if we love and trust a doctor, our loyalty is to our kids to look under every rock to make sure we are not missing some critical piece of info. And I am not talking about off the wall evaluations.....endless searches....etc. The things we discussed here are very mainstream things and very comprehensive. Unfortunately many people are not guided by their health professionals to get these things done. They often do not understand the true overwhelming nature of what is going on at home. Our kids can hold it together for short periods of time and can seem different out of their home environment, sometimes for the worse and sometimes for the better so when we discuss what is going on with professionals, it is not a time to brag on the strengths (which as parents we want to do to make our kids not sound so negative as well as it is natural to want to look for the good...but when looking for services and diagnosis, this is the time to really let them know how it is).....not saying to exaggerate but do not forgo the negative issues and negate them with buts......but he is good at ....nope, not the time to do that. The forms you fill out will give a chance to say what he can do and what he cant. If borderline go for the cant side of the options. Skills need to be solid before they are considered accomplished.

Neuropsychs are good at taking information from several sources and putting the big picture together. Their training is specifically to figure out how behavior is connected to how our brains work.

I hope for difficult child's sake if these things have not been done, that his family is open to it. I know it is not easy. Trust me, most of us know. He is getting older and as I have had to adjust to in the last year, when they hit that adolescent growth spurt, life takes a dramatic turn. People everywhere have fears and are less willing to be accommodating so it is important to know school laws and have a paper trail of evidence regarding his disability challenge areas. Therapy to help him regulate his behavior will likely need to be on several fronts because all of these pieces pile up on eachother and make our kids look just plain oppositional and defiant. This is why many here do not look at ODD as a stand alone diagnosis. It simply describes behavior and can allow insurance to pay for services, but it does not help with why this is going on which is the ticket. Sometimes that is not doable, but from what you are describing, seems like some things will be pretty clear on evaluations and can lead to some level of therapies both private and in schools.

I'm anxious to hear if you are in the USA and if he has a special education plan.

If he does not, many here can help his mom to get that ball rolling. I imagine he has one, but just curious when you said he had been expelled and that he is restrained.

You sound like a stand up guy, the family is lucky to have you.