Teacher's Letter to Doctor

I am Ben's Classroom Teacher, and I am writing this letter to you at the request of Ben's mother, Janine. Ben is a grade three student at "...." School. There are 19 students in his class.

At the beginning of the school year, Ben experienced a great deal of difficulty transitioning into grade three. He exhibited oppositional behaviors quite early in September. Ben required cues and redirection for tone of voice, refusal to work, talking back, and put downs to others. He connected with another student, and both were extremely disruptive to the learning environment of the other students.

Ben often blurts out silly, rude, and inappropriate comments intended to make the students laugh or make someone feel badly or uncomfortable. Cues, redirection and discussions about his behaviors, shows little to no emotion during these times, and does not accept responsibility for his actions.

Ben's interaction with teachers outside of the classroom has been quite challenging. Ben doesn't always respond to adults when they are speaking with him. Many times he refuses to answer them and avoids eye contact (ignores them). Quite often, Ben does not follow the rules of the classroom. He is quiet and sneaky about his defiance. Instead of asking for permission, Ben usually does what he wants to do when he thinks you're not watching him. Other times, he outwardly defies adults, choosing to ignore them when his behavior is addressed. Many times, Ben repeats the same inappropriate behavior over and over.

Ben experiences a great deal of difficulty when working with other students (partners, or groups). At times, he is silly, off task and disruptive. Ben also wants to have things done his way. If this doesn't happen, he usually leaves and sits at his desk, or asks to work by himself. Ben is quite rigid in his thinking, and unresponsive to problem-solving strategies which are modelled and suggested to him.

During recess, he was observed to walk around, not playing with the other students. Ben didn't like going outside during the winter months, and often stayed in to play with a few other classmates. He has been going outside with the other students since the nicer weather.

When playing with toys during Indoor Recess, Activity Time, or Free Time, Ben leaves if the students won't play his way, or if he can't "control" the situation. He often plays the same activity each recess (sets up 200 domino's in a snake pattern and tips them over to watch them fall). Ben shows interest in limited topics and really focuses on those specific areas. (tunnel vision).

Ben's behavior fluctuates, and sometimes depends upon the tone of the classroom. Please let me know if there is anything that I can do to help.

Sincerely,
Julie
Grade 3 Teacher

In like a Lion

So this month of March hasn't exactly started out lamb like, but just as the saying goes in like a Lion! I am not referring to the weather...
It all started last month with a decision to take Ben off of Vyvanse, a decision that needed to be made due to side effects that we just couldn't bear to see our 8 year old live through.

I really was hopeful that this was going to be the drug that was going to work for Ben's ADHD, it had great promise being that it was a long lasting stimulant. It seemed to give him the focus he needed to be able to pay attention in class and stay out of trouble. He rarely bothered anyone, and was co operative when asked to perform tasks. We had great conversations, asking deep thoughtful questions about life and why things work the way the do. Our lunch time breaks from school together where very enjoyable as he actually listened and obeyed simple requests to turn off the TV, or computer to eat or leave to go back to school. He gave me few arguments and went to school with no complaints. It seemed to good to be true. Unfortunately it was.
After taking the medication for 2 months the initial concerns seemed to wear off, most of all his insomnia. The lack of appetite although still present, didn't seem to be causing any weight loss and he did eat small portioned meals but along with multi vitamins seemed acceptable by the doctor.
The effects of the medication seemed to be wearing off sooner in the evening as we started into the 3rd month of treatment.  After school became very difficult for Ben to contain his hyperactivity. He was unable or just plain refused to do homework, often claiming not to know how to do the required tasks. He became very angry, picking up on any excuse to start a fight with his younger siblings. Then his anger and adjutaion turned into uncontrolled laughing and giggling, being loud and obnoxious, rude and belligerent.
At this point the school was also starting to see Oppositional behaviors starting to emerge once again. Refusal to complete tasks, unwilling to join in group activities, but still observing improved ability to complete assigned tasks and not getting caught up in the antics of others children.
I met with Ben's teacher around this time, and unfortunately we must have both been at our breaking points that day, because the meeting did not go well. We both lost our "cool" heads and said things that we both regret in the moment. That being said, one thing she did say about Ben will never be forgotten. She said that he was a liar and a manipulator. This is very hard to hear from a person that is with your son on a daily basis, and is suppose to be supporting you in the journey to help him with his disorder.  At the time it hurt me as a mother deeply, as it exposed a problem that really showed how a child with these complex issues can be viewed by others. As liars and manipulators.......the fact is that Ben is a very intelligent child and I can concede to say that he may at times manipulate to get things his way...in fact I think he does that on a daily basis as he rarely doesn't get what he wants....but a liar he is not. He never perceives his actions to be wrong...he always perceives that he is justified and that everyone else is to blame....and if he ever does tell an untruth he will admit to it...but NEVER will he agree to something he feels he has not done or is being accused of...as he rarely feels he is wrong.
After this meeting with the teacher, which led to also meeting with the principle of the school I was able to have a minor adjustment to Ben's educational expectations.  He was no longer expected to complete and/or hand in homework assignments.  We will encourage him to focus on the "important" things at school, and only ask that he continues reading when at home. We also got paper work in line to have the school physiologist and social worker observe and work with Ben to help him with any "issues" they observe.  We then made a date to meet again as a co ordinated group to discuss any further plans for him.  I also let them know that I was meeting with the doctor to discuss adjusting medications due to the behavioral problems we were having.
I met with Ben's Pediatrician and we decided to add Strattera back into his daily dosing, as the Strattera seemed to work best from Ben's ODD, and the Vyvanse on his ADHD. So his dosage would be 20mg Strattera (10mg in morning and after school)  and 20mg Vyvanse in the morning, hoping the Strattera would provide support for after school behavior.
After this addition to his medication I was hoping for some improvements, unfortunately I don't recall there being much change to his agreeableness or co cooperativeness, in fact now that I look back on the past few months it may have been the combination of these two drugs that maybe caused the side effects that brought us to taking him off Vyvanse.....hmmm....it's funny how until you actually reflect and write out your thoughts that connections can be made....

This combination therapy began just before Christmas break and over the past 2 months Ben's "normal" handicaps started becoming very debilitating. He has always been a little OCD about certain issues, like what he will eat and how it's to be cooked or prepared. This became very exaggerated to the point that he ate next to nothing because it wasn't prepared to his liking...either it was burnt or undercooked, even though I cooked to exact timing to ensure it was to his "normal" requirements. He would go an entire day on nothing but a Yop and a granola bar. He also became extremely anxious about so many things...lots of big "what if" type questions, he was ultra sensitive to what he thought his classmates or others thought of him to the point that he insisted on wearing deodorant because he thought he was being avoided in class due to being smelly. He also began cracking his knuckles in a uncontrolled manner similar to a tick (again something that comes up in different forms when he is dealing with anxiety). These issues all became almost unmanageable, arguments ensued between us, and all out refusals to go to school, to eat or even get out of bed in the mornings. He also started becoming very paranoid, started hearing things and seeing things in his bedroom at night keeping him awake to all hours with his lights on.
Near the end of February Ben didn't get out of bed on a Saturday morning till about 10:00am, knowing he had a poor sleep the night before I didn't question it. He finally came downstairs and almost immediately started causing problems with his brother and sister. He continued being unmanageable to the point where he needed to be given "time and space" to settle down and was sent to is room to give him this opportunity. Within a few minutes he began screaming at the top of his lungs, I ran to his room meeting him half way in the hallway. He was visibly shaken, white as a sheet and crying uncontrollably....he was unable to tell me what had happened until much later in the day. He began to describe a feeling that something was emerging from beneath the bed and was about to come out from under the blanket with a loud rushing noise, when he screamed he said it stopped and wasn't able to see what it was. He also told me how early that morning he didn't get out of bed because he was being held in bed by a skeleton and he was to scared to scream for help. Not knowing what was happening to him, I assured him that he was just dreaming and imagining things, not to worry. Later that night he was scared to go into his room for bedtime. I brought him into my bed and layed with him.  I could hear his anxiety, his breathing was quick and shallow and his eyes were as big as saucers. I asked him what was wrong, and he said he was seeing a snake with razor sharp teeth coming out of the ceiling at him. I held him in my arms and told him not to worry that Mommy was there and nothing was going to hurt him. I assured him that his mind was just imagining things and that he was going to be ok.  I repeated this several times before he was calmer, and it took hours and a Gravol to get him to close his eyes and fall asleep.
It was decided then that Vyvanse was the cause of these hallucinations, and he would no longer be taking this medication.  I continued the Strattera at same dosage.
I met with the doctor the following Monday, and he supported my decision to stop Vyvanse and would have done the same. We decided that we would monitor Ben's behavior and see if he is managable without trying anything new, but to continue Staterra.

So March has started rough, hoping that is will end more lamb like.