David Steele Out of Control and In

David Steele Out of Control and In Control Since David’s mother left when he was only 1 year old, Tom has struggled continually to meet his son’s escalating needs. Being a single father was a very difficult task, especially with all of David’s problems. In fact, Tom couldn’t believe that David would be celebrating his ninth birthday soon. For Tom, David’s childhood was just a blur, like watching a roller coaster speed down the track at 100 miles an hour. The highs and the lows were beginning to run into each other more and more. There were days when David seemed to be able to handle things, and then he would just fall apart, crying and saying he hated himself. DEVELOPMENTAL HISTORY/FAMILY BACKGROUND David had always been difficult, even as a baby. As an infant, he seemed to spit up more food than went down, and then he would wake up crying in the middle of the night because he was hungry. Then he would overeat and cry again, his little stomach distended with gas. David’s mother would have had problems handling the best of babies; with David, she didn’t have a chance. Tom worked nights and would often arrive early in the morning after the night shift to hear David screaming in the crib and his wife sleeping through it on the couch. Eventually, she left, saying that she just wasn’t cut out for motherhood. In the first three years, Tom struggled with David’s mother going in and out of his life. David would wait patiently for her visits, and then she would either not show up or come over in one of her “moods.” Her erratic behavior and mood swings were what caused the marriage breakup in the first place. Ultimately, she stopped coming for visits altogether, and it had now been four years since David had seen his mother. In the beginning, David talked about his mother incessantly, asking why she would not see him. Often, he would cry himself to sleep at night. Although David finally seemed to accept the fact that his mother would not return, Tom felt that David never really understood why. David did not get along with his stepsister, Emily. Emily was 14 years old and Tom’s daughter from his first marriage. David and Emily were like night and day. While David was extremely temperamental and hard to get along with, Emily was sweet, soft-spoken, and eager to please. Emily did well in school and had many friends. Often, David would deliberately set out to annoy Emily, as if he were angry that she seemed so happy. When Tom started dating again, David went ballistic. One night when Emily was babysitting, David went totally out of control. He started smashing things in Tom’s room. Emily called her father on his cell phone and he came home immediately, but not before David had made a complete mess of his room. Drawers were dumped on the floor and the lamp was smashed against the wall. Tom tried to restrain David, who was flailing his arms and behaving like a human tornado. After this frenzied burst of activity, David collapsed on the floor and began sobbing. He told his father he was sorry and felt very bad about the damage he had done. The pattern repeated itself again and again: Angry outbursts would be followed by remorse and guilt. David seemed to have little control over his emotions in either direction. On days when he was having a good time, his exuberance would also spiral out of control. Tom remembered the day David got his new bike. He went right out into the traffic and was almost hit by a truck. David also had few friends, because he always seemed to overreact and either get in fights with other kids or blame them if things were not going well. His behavior was unpredictable and bossy. He would often come home from the playground in tears. Although David’s behaviors made it difficult for Tom to have a social life, Tom eventually met Eileen, and despite David’s efforts to come between them, Eileen moved in. The next two years were horrible for everyone in the house. David was very easily upset and seemed to have a continual chip on his shoulder. Eileen initially thought that David would warm up to her in time; however, any time she attempted to get close to him, David would do something to draw the line. David’s irritable disposition also made it difficult for anyone to get close to him. Discipline was very problematic, because David was unable to handle criticism at any level. Any time Eileen would reprimand David, he would break into tears, yelling at her that she was not his mother and had no right to act as if she were. In time, David’s behavior became the focal point for arguments between Tom and Eileen. David was also spending an inordinate amount of time in the garage working on his go-cart. On several nights in succession, Eileen found David in the garage painting and putting decals on the cart well after bedtime. He was getting up at all hours of the night, seemingly obsessed with these late-night activities as well as not needing to sleep. Eileen and Tom incessantly argued about how to deal with the problem and could not agree on a resolution, so nothing was done. Homework assignments were not handed in, and homework became another battleground for David and Eileen. Finally, Eileen refused to get involved with David’s schoolwork and the job fell to Tom, who was often very tired after working a long day at the trucking firm. David began to complain of headaches and stomachaches and wanted to stay home from school. While doing his homework, David would make self-deprecating comments, calling himself stupid and a dummy. He complained frequently of feeling ill, and he was not eating or sleeping very well. Eileen eventually left, saying that she could no longer tolerate the family situation. She said that David was spoiled and that Tom did nothing to control his behavior. Their constant fights about David had finally taken their toll. David said that he was happy the “witch” was gone. Tom wondered, however, if David felt that he had just lost another mother or, worse yet, that he had caused another mother to leave. David was also beginning to get into more trouble at school. His teacher had called Tom twice in the past week, and Tom was asked to come in for a parent-teacher conference. At the school’s suggestion, Tom agreed to have the school psychologist observe David in the classroom and conduct a full assessment to determine whether David might also be having learning problems that were adding to his difficulties. When the school psychologist observed David in the classroom, it was readily apparent which child she was there to observe. David was sitting at his desk, slouched down, with his arms folded around himself in one enormous pout. Apparently, his teacher had reprimanded David on the way back from lunch because he was running in the hall. David continued to glare at the teacher, with his eyes bearing down on her and his lips pursed tightly. The teacher asked the class to break into small groups of six for the next activity, which was a math game. David quickly got out of the chair and gleefully joined his group, hopping and bouncing up and down. In the groups, children rotated the leadership role by selecting the next child to take the math lead. For a brief time, David seemed to be doing well and getting along with the others in his group, until it was his time to pick another child to be the group leader. Instead of picking another child, David began teasing the others in the group, pretending to pick someone and then changing his mind, pointing at them with his chalk and then retracting it. Finally, David’s group began to ignore him and selected another leader. At this point, David threw the chalk on the floor, sulked, stomped his feet, and returned to his chair and resumed his position of master pouter. David’s teacher intervened, once again, and directed David back to his group. At this point, David returned to the group but threw himself down on the floor in the middle of the group, which was ignoring him. He managed to get the chalk away from the leader and would not give it back. At this point, the group was becoming very upset with David and asked the teacher to intervene. This time, the teacher walked David back to his seat, and David sat quietly while the other children returned to their seats as well. When the teacher asked for volunteers to write their group’s response on the board, David’s hand shot up and he started yelling, “Me, pick me!” When he was not picked, David threw his book on the floor and resumed the pout position. Prior to the outburst that landed David in the alternate school placement, David started repeatedly asking if he could see his mother again. He was very disturbed that no one seemed to know where she was. David was obsessed with finding her and would spend long hours at night searching for her on the Internet. At school, David was getting into trouble on a regular basis. He was not sleeping well and was now irritable most of the time. He was having problems concentrating on schoolwork, and he seemed unable to cope with other children or school demands. David would frequently burst into tears and had to be removed from the classroom on several occasions. Socially, other children would either tease him or ignore him. David’s responses were very unpredictable: volatile and aggressive at one moment; at another time, crying and saying that he wished he was dead. Tom attended another school conference, and the school psychologist shared concerns regarding her observations of David in class and around the school on her regular visits. After discussing David’s family history, the psychologist asked if David’s mother had ever had a psychiatric assessment or if anyone in the family had a psychiatric disorder. Tom mentioned that his ex-wife had been diagnosed with bipolar disorder but would not take the prescribed medication, saying it made her feel lousy. He added that her extreme mood swings made their marriage very difficult. The school psychologist said she wondered if David might also have bipolar disorder. Tom scheduled a psychiatric appointment for David; however, the earliest date he could get was in two months’ time. In the interim, Tom agreed to take David to his family physician for his medical opinion. REASON FOR REFERRAL On Friday morning, Tom took David to his family physician. Tom did not tell the physician that the school psychologist mentioned the possibility of bipolar disorder, since he wanted the doctor to have an unbiased opinion. The physician said that given David’s problems with concentration, attention, and hyperactivity/impulsivity, David was likely demonstrating symptoms of attention-deficit/hyperactivity disorder (ADHD), which could explain why he tended to be so impulsive and demonstrate such poor behavioral controls. The physician prescribed a trial of Ritalin and asked Tom to have the teacher rate his behavior on the rating scale when he dropped David off at school and then again on Monday when the Ritalin would be started. The physician was hopeful that the Ritalin would reduce David’s impulsivity and attention problems. Two days after he began taking the Ritalin, when a peer started teasing him, David ran out in front of the school bus and narrowly avoided being struck by the bus. When the teachers retrieved him and tried to get him back into the classroom, he began kicking and screaming. David grabbed a chair and threw it at one of the teachers. David was removed from the school and placed in an alternative school placement for the next 45 days. While in the alternative setting, the Ritalin was discontinued, since there were major concerns that the medication might have escalated his behaviors. While in the alternate setting, his behavior was charted on an hourly basis to see what patterns, if any, might be evident in his moods and also to determine if certain triggers were likely to set him off. Tom was also asked to keep a similar record of David’s behaviors in the home. A pattern began to emerge, which seemed to repeat every 24 hours. Results of the observations revealed mixed hypomania evident in ultradian cycling (brief manic episodes lasting from minutes to hours and occurring on a daily basis) that became evident in the late afternoon and progressed onward until about 2:00 to 3:00 in the morning. David would come to school in a very irritable mood, tired, sleepy, and very grumpy, since he had been up until very late the night before. This irritable mood, during which he was very “touchy,” distractible, easily upset, and difficult to communicate with, began to wear off in the late afternoon, gradually being replaced by increased physical movement, agitation, and the excessive need to talk about anything and everything. At home, shortly after dinner, around 7 o’clock in the evening, David’s behaviors would begin to escalate in a more rapid and consuming fashion; this was evident in giddy and silly behaviors (laughing, dancing, singing), with increased energy and insomnia until the early hours of the morning (around 2:00 to 3:00 a.m.), when he would literally crash into a deep sleep. It was nearly impossible to get him up for school in the morning, and David would begin each day irritable, grumpy, and half asleep. The consulting psychiatrist diagnosed David with pediatric bipolar disorder (bipolar II, mixed), and a trial of Risperdal (risperidone) proved relatively successful in reducing the depressive episodes and emotional volatility. David was referred for assessment to determine intellectual potential, academic progress, and emotional status. ASSESSMENT RESULTS While in the alternate school placement, David was assessed by the psychologist, who found that David’s intelligence on the Wechsler Intelligence Scale for Children was in the high-average range overall, at the 79th percentile (IQ = 112, range 106-117). There was minimal discrepancy between Verbal Comprehension and Perceptual Reasoning abilities and no indication of problems with Working Memory or Processing Speed, which were within the average range. Academically, although reading and math were at grade level, written expression was about a year behind and in need of remediation. David demonstrated problems with grammar and organizing his ideas. During his clinical interview, David talked at length about his real mother and said that he was having problems because she left. He said that he was sure he would be better if she would return. On the Achenbach System of Empirically Based Assessment (Achenbach & Rescorla, 2001), David’s father’s ratings on the Child Behavior Checklist (CBCL) placed David in the clinical range for Anxious/Depressed (T = 72), Attention Problems (T = 78), and Aggression (T = 74). His father endorsed the following items as very true (occurring often) for the three significant scales: Anxious/Depressed scale (worries, talks of suicide, nervous, feels worthless, feels unloved, cries a lot), Attention Problems scale (acts young, problems sitting still, impulsive, poor schoolwork), and Aggression scale (argues a lot, mean, demands attention, destroys own things, destroys others’ things, disobedient at home, screams a lot, mood changes, sulks, temper, threatens others). Other items that were endorsed significantly included brags, shows off, talks too much. David’s teacher did not endorse significant problems for the Anxious/Depressed scale (T = 64); however, she did see significant difficulties with Attention (T = 78) and Aggression (T = 72). Social Problems were in the high-risk range (T = 66). Similar to his father, items endorsed by his teacher for the Attention Problems scale suggested high rates of hyperactivity and impulsivity (acts young, noisy, brags, fidgets, disturbs, impulsive, talks out, disrupts discussions, irresponsible, shows off, talks too much). Aggressive behaviors that were significant included argues, is mean, demands attention, destroys own things, attacks, screams, explosive, sulks, temper. On the Beck Youth Inventories, David rated himself as significantly depressed (T = 70), aggressive (T = 82), and with low self-concept (T = 40). His score for anxiety was in the at-risk range (T = 66). During the course of the assessment sessions, David’s moods vacillated abruptly. He could be very cooperative and engaging, but in the next moment, he could become difficult to engage and irritable. During one of his more expansive moods, David stated that he hated the school he was attending and that he could teach better than the teachers in “this dump.” He also said he believed that he was going to be very successful when he grew up and was intending to be a rock star or a movie star. When asked if he played an instrument or was ever involved in a school play, he immediately changed the subject. 1. Given the DSM-5 diagnostic criteria, would David’s symptoms meet criteria for bipolar disorder (BPD), and if so, what symptoms does he exhibit and what type of BPD is David most likely to be diagnosed with? 2. David has significant symptoms of irritability, which can be challenging in making a differential diagnosis in children. Based on the DSM criteria for BPD and DMDD, address how you would conduct a differential diagnosis and what your likely conclusion would be as to the nature of David’s primary diagnosis. 3. Given his age and symptoms, based on current research findings, what other disorders might David be at risk for developing? What led you to these conclusions? 4. Suggest a treatment plan for David based on current research findings. What are the main components that your treatment program will need to address (be specific)? SCIENCE HEALTH SCIENCE NURSING PSYCH 349

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