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Thomas, a 6-year-old boy from an intact nuclear family, had been diagnosed with ADHD 6 months prior to his initial appointment with me. The initial evaluation was at the urging of his kindergarten teachers. Although they found him very endearing and exceptionally bright, they expressed concern about his over-activity, impulsivity, seeming lack of attention for dangerous situations or actions, and his episodic anger outbursts. His classmates found him overwhelming and avoided him. Thomas was referred for a second diagnostic opinion regarding his behavioral and uncontrolled moods. His parents, both of whom looked tense and tired, accompanied Thomas, a smiling little boy who appeared to be all knees and elbows, to the interview. Since his initial diagnosis of ADHD Thomas had been tried on two stimulant medications. His parents were ambivalent about the medication's effectiveness and occasionally skipped doses saying, "He can be hyper with or without it and he can be mellow with or without it." They had been in weekly play therapy with Thomas for the past four months. Instead of improving with intervention, Thomas's behaviors and moods worsened.
Over the past few months Thomas's tantrums had become severe and prolonged, lasting up to 3 hours. His parents said that during the tantrums, "He doesn't even hear you." Thomas would smash his toys, kick holes in doors or walls, rip his clothing, scratch his face or punch himself in the head. When the tantrum was over, he would be remorseful, seek multiple hugs and reassurances, and rapidly return to his usual sweet and sunny self. Thomas's moods were increasingly random and unpredictable. Though usually a sweet child, "with a fantastic sense of humor," he could, "turn on a dime." During a recent and particularly severe tantrum, he screamed, "I wish I were dead! Why don't you just kill me! Get a big knife, cut out my heart, and splatter my blood all over the walls!" Thomas was having increasing difficulty sleeping, although his sleep had never been what his mother considered to be, "normal." His bedtime was 9 p.m. He was routinely up and awake in his room until 1:00 a.m. or 2:00 a.m. He was ready for the day by 7 a.m. Approximately once weekly Thomas would, "finally collapse from exhaustion," and sleep for 16 uninterrupted hours.
Thomas was being terrorized by the, "shadow monster," and the "spider king". For the past few weeks they had been appearing to him multiple times daily and telling him to do "bad things." They were also present in his amazingly gross and gory nightmares, which he openly described to others. Thomas had experienced a sudden onset of excessive sexual curiosity and frequent masturbation, even in public places. The parents reported a "creepy and constant" attempt by Thomas to see his younger sister naked.
Family psychiatric history
During one of Thomas's periods of dysphoria and rage, he expressed the desire to die and had a spectacular plan. Suicide in childhood often looks like an accident because of their limited repertoire and access. Suicidal behavior in pediatric BPD is as high as 25% (Pavuluri, et al.). The incidence of completed suicide in BPD is estimated to have a 19% lifetime occurrence (Goodwin and Jamison). This is an unacceptably high rate of fatality for any illness. Thomas's auditory and visual hallucinations could be explained away as childish imagination or as lying. However, Thomas did not find them at all fun and he did not seem to bring them up only when it suited his purposes. Thomas was still young enough not to realize how bizarre it was to have these apparitions. Older children do and they often keep hallucinations to themselves to avoid alarming others or being indelibly stamped with the label of "crazy".
A healthy child is usually a good sleeper. The development of chronic sleep problems is cause for concern. Thomas demonstrated difficulty sleeping regularly since infancy. His sleep now had fallen into a common pattern seen in pediatric BPD. He needed very little sleep to leave him refreshed and bursting with energy. Episodically he had periods of hypersomnolence. The spider king and the shadow monster carried over into Thomas's dreams. Not atypically, children with BPD have gory, gruesome, extreme dreams that leave one wondering to what deviant experiences these children have been exposed to. Often no history of such exposure is found or exists. Hypersexuality is a symptom of BPD in all ages. When it occurs in a child, sexual abuse is often suspected, and rightly so. The possibility of sexual abuse should be investigated. Regardless of whether the child has been abused or the hypersexuality is solely a symptom of the illness, the child needs to be protected from compromising situations and predators who might seek to capitalize on the child's disinhibition.
BPD is a heritable condition and it is important to get a complete family psychiatric history. Family pedigrees of patients with BPD generally include first or second degree members with affective disorders. While bipolarity is generally over-represented, other affective disorders, including anxiety disorders, are present as well. Members with uncontrolled anger and issues of alcohol or substance abuse also seem to be over-represented (Popolos and Popolos).
Thomas's treatment started with prompt discontinuance of the stimulant medication. As expected, Thomas's symptoms had broadened and worsened within weeks of its initiation. Depakote sprinkles were started for mood stabilization. Baseline and monitoring laboratory tests were done. Thomas achieved adequate mood swing control with a Depakote level maintained at a high therapeutic level. At the same time, Risperidone was added and slowly titrated to a final dose of 1.0 mg at bedtime. The Risperidone was briefly increased to 1.5 mg. but at this dose, Thomas developed some uncomfortable extrapyramidal side effects. The dose was dropped back to 1.0 mg and 25 mg of Benadryl was added. The side effects rapidly resolved. Risperidone was effective in helping Thomas settle and sleep through the night without nightmares. The daytime visits from the spider king and shadow monster also stopped.
- Duval, Sarah J; Six-year old Thomas Diagnosed with Pediatric Onset Bipolar Disorder: A Case Study; Journal of Child & Adolescent Psychiatric Nursing; Jan-Mar2005; Vol 18 Issue 1; p38
Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these Personal Reflection Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a work in progress. You will not be required to provide us with these Journaling Activities.
Reflection Exercise #1