I started writing this post while sitting in Alex's (not his real name) bedroom, waiting for him to finally fall asleep. He would have been happy to go to be alone, since I later found my smartphone once again hidden under clothes in his closet. But in the last week, he has broken one of his bedroom windows, gouged several holes in the drywall throughout the house, thrown eggs in our living room, and jumped the backyard fence to "unplant" the neighbor's vegetable garden. This is the more serious behavior. I've come to expect the daily organizational chaos that includes scattering Legos around the house, taking kitchen utensils in the backyard to dig holes and then smear dirt on the house. When I look at what I've described, he sounds like an unsupervised monster, but all this happened when my wife and I, and our other three kids were home. It's gotten to where, today, I literally wouldn't let him out of my sight, other than to use the bathroom, and even there I watched the clock to make sure he was coming right back. And yet, he can be delightful at times--for a moment here and there. We first fostered him at 6 weeks and then adopted him at 1.5. He was neglected by his birth mom, who drank and used drugs while pregnant. He came to us withdrawn and resistant to affection. Through a lot of TLC and Occupational Therapist (OT), he came out of his shell considerably, but has always had a hard time socially, combination of withdrawn behavior and sensory-seeking behavior: he's either by himself or trying to jump on someone to get them to play with him. At 3, he aged out of early intervention services and began receiving school-based services in pre-school, then kindergarten. He had an IEP, but he is so smart and met his goals so well that he started 1st grade this past year without an IEP--big mistake. He had behavior issues almost from the outset and wouldn't sit to focus on any academic work. The fall was a total loss. In January, we got an IEP back in place, which helped tremendously, but still had significant social/behavioral issues throughout the year. If we didn't have such a great elementary school who was really committed to work with him and us, he would have been out on his ear. He's also been on medications for the last two years. We have a psychiatrist who first worked with our older son, who has mild ADHD and is impulsve. Vyvanse worked great for "Sam"--giving him the mental room to focus and consider his actions before committing to them, and we were hopeful we'd find a similar experience with Alex. Because the doctor believed some of Alex's aggressive behavior was anxiety-related, he started him on Zoloft first. We later added Concerta to help with the ADHD symptoms. Since then, we've gone back and forth, tweaking the dosages on those two medications when things seemed to be getting worse again. This past January, we switched from Concerta to Vyvanse and saw some improvement on the academic front, but not much change on the behavioral front. Things seemed to get worse after school ended, and we briefly tried upping the Zoloft, which didn't help at all. At the checkup where we considered increasing the Zoloft, the doctor also mentioned that we might need to consider another approach, perhaps either Guanfacine or Abilify. The Guanfacine would be an addition to what he's currently on; the Abilify would be a replacement. A week ago, he started a 1 mg dose of Abilify, although the doctor decided to at first keep him on the Vyvanse and Zoloft. I thought I saw a big difference the first 24 hours--calmer, more social, easier to reason with--but since then he's continued to exhibit the same negative behaviors, with little to no impulse control (which is the aspect of his behavior we are most concerned about right now). When he does something he knows is wrong and is caught and disciplined (time outs, loss of play privileges), he is first mad, then contrite, and then he goes and does the same thing later the same day. He even says that his brain is just not in his head--it's gone somewhere else. So I don't know what to do, but I know we've got to get a handle on this over the summer, or second grade is going to be another disaster. I don't know if Abilify is the right path but we haven't found the right dose yet, or if we should stop everything and then see what to add back in. With his prenatal and developmental history, I know he needs medications as part of a multilayered approach, but with him it's hard to pin down a diagnosis and course of action. Officially, he's ADHD, but many of his symptoms are consistent with Fetal Alcohol Syndrome (FAS) and Asperger's. It's not that we haven't tried environmental interventions as well as medications. All four of our kids are adopted, three of which we fostered, and three of the four are special needs, so we're well-versed with the world of therapists of different stripes (SLPs, OTs, PTs), and I'd like to think I know what I'm doing, but with Alex I've hit a wall (not literally, at least not yet). I'm writing both to get this off my chest and to ask for help. If there's someone who's been where we are and has some wisdom, I'd love to hear it. P.S. even though I know the alphabet soup of therapy acronyms, I guess I'm a newbie here and don't know what difficult child or easy child means in the context of these discussions.