So a lot has happened since the last post. Sorry for the delay in updating everyone. Christian has arrived and has been staying with us. I couldn't be happier! The first night with Christian was rough get more doses of how this effects everyone in the family. Christian went to bed for the night and I decided to peak in on him before going to bed. I found Christian sitting on the bean bag on the floor. When I asked Christian what was wrong he just started crying. Christian says he misses Joseph so much and it was hard being in Joey's room without him. Christian and I cried together. Christian asked questions I didn't really know how to answer, Why did Joey have to get sick? It was one of the first times I think Christian really opened up about his feelings, I'm glad I could be there for him, I just wish I had more answers for him.
Now on to Joey. The neuropsych evaluation report is very thorough and I am extremely impressed. I won't go into the history portion of the report because well I've all ready done that in the blog but here is the rest.
Findings:
Behavior: Joseph was on time for the appointment, and was accompanied by his mother and staff from the residential facility. Joseph appeared to be slightly older than his stated age, and was properly dressed and groomed. His level of cooperativeness was variable throughout the evaluation and he was alert with consistent eye contact. He completed paper and pencil tasks using his right hand with appropriate grip. Joseph appeared to understand test instructions and did not require frequent repetition. Spontaneous speech was fluent with no noticeable articulation problems or word finding difficulties. There was no unusual voice intonation. His thinking was goal-directed, with no evidence if a formal thought disorder. No difficulties with social reciprocity were detected until he did not want to complete a task. At this point he became defiant and required frequent prompting which resulted in variable responses to positive reinforcement. Joseph made the examiner uncomfortable on occasion due to his quick tempered nature. Nevertheless, he calmed down when tasks were stopped and something else was initiated. Joseph exhibited difficulty with behavioral self regulation including impulsivity. He also presented with mild physical restlessness, All other areas of motor functioning appeared to be normal, except for mild bilateral resting tremors of his hands. Joseph demonstrated no difficulty with sustaining attention. He reported sad mood and presented with frustrated and irritable affect. He would react with frustration and anger in response to failure or difficult tasks . His overall approach to testing was frustrated and testing could not be completed, as later in the afternoon Joseph refused to continue. He became very angry and walked out of the room. Thus, the evaluation was discontinued. Unless otherwise noted, results are believed to be an accurate assessment of his current neurocognitive functioning; variable effort/impulsivity appears to have vitiated a few of his scores.
The next several pages of the report are all the scores so I am just going to jump to their impressions.
Impressions:
1. Joseph has been historically diagnosed with ADHD, psychotic disorder NOS, bipolar, ODD, PTSD and IED.
2. Because of Joseph's emotional and behavioral challenges, current testing was limited to the morning session, as he refused to continue after lunch break and effort was variable on a few tasks. Nevertheless, we were able to assess multiple cognitive domains. Results indicate intellectual functioning to below average. He scored consistently or better than this level on tasks of gross motor strength, visual perception, expressive language, and speed of processing. While his scores on attention testing were lower than expected, hos effort of these particular tasks is questionable.
3. Although Joseph has a history of an ADHD diagnosis, a description of his behavior from both Ms. DiCola and facility staff as well as unsuccessful treatment with neurostimulant medication do not support this diagnosis. Rather, it is more likely that his aggression and impulsivity is better accounted for by a psychiatric disorder. Based on Ms.DiCola and facility staff report, it appears Joseph's aggressive and explosive outbursts are more behavioral in response to not getting his way.
4. Information from a review of records and clinical interview with his mother and facility staff indicate that Joseph has had a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms have been violated. For example, he often bullies others, initiates physical fights, has used a weapon that can cause serious physical harm to others, has been physically cruel to people, has deliberately destroyed other's property, lies and has run away from home on multiple occasions in which police have been called. Also, Joseph appears to have little concern for feelings, wishes, and well-being of others given his aggression towards people. Also, it was reported Joseph can misperceive the intentions of others as more hostile and threatening and can respond with aggression. Facility staff reported that Joseph lacks appropriate feelings of guilt or remorse as he frequently tries to put the blame on others. Thus, Joseph meets criteria for Conduct Disorder. Research states that self-esteem is usually low with those of conduct disorder and facility staff reported that Joseph frequently makes statements indicating low self esteem. Associated features are also usually poor frustration tolerance, irritability, and temporary outbursts, which are observed with Joseph. These problems have precluded his attendance in school or living in the home. A diagnosis of Conduct Disorder precludes one from being diagnosed with ODD or IED.
5. Emotionally, results from self-report and parent/caregiver report are consistent with the diagnosis of Major Depressive Disorder, Recurrent, Mild. His conduct behaviors are likely exacerbated by his depressed/irritable mood. Reportedly, Joseph has reported feeling sad/empty, irritable, fatigued, difficulty thinking, recurrent thoughts of death, and has experienced past auditory hallucinations. It may be that the hallucinations were secondary to the severity of his depression/mood given that they were congruent with his mood at the time. Joseph has a historical diagnosis of bipolar disorder. This is a diagnosis best determined by multiple observations rather than a one time assessment. However, Joseph's changeable mood during the day, which has been termed "rapid cycling" is too rapid and not typical of bipolar disorder. Therefore, we suggest that the diagnosis be reverted to a rule out diagnosis of bipolar disorder. Joseph has a historical diagnosis of PTSD; we had hoped to ask him more questions about his current symptomatology regarding this diagnosis, but testing was discontinued secondary to his refusal to continue. We believe it highly unlikely that a traumatic event that occurred at such a young age could result in current PTSD symptoms, as a person must remember the traumatic event.
Recommendations:
1. Joseph's physician is encouraged to refer him for a neurology consult for a more comprehensive medical work up. While a remote possibility, it is important to rule out an organic cause given the severity of his violent outbursts. His neurologist may want to consider an MRI or EEG.
2. Ms.DiCola reported no successful treatment of Joseph's behaviors with his current medications. She is encouraged to discuss this with his psychiatrist. Joseph may benefit from treatment in an inpatient psychiatric facility for medication assessment.
3. Joseph is encouraged to continue with outpatient psychotherapy. To date, the most promising approach is multisystemic therapy for conduct disorder.
4. Due to the severity of Joseph's behaviors, we recommend continued placement in a residential facility.
So there it is in brief. The whole report is actually 12 pages. So how do I feel? I'm torn. There is more research and approaches to treating conduct disorder however those who are unsuccessful in treatment grow to be termed antisocial personality disorder. Secondly I feel the time clock is running out on treatment for Joseph. Where he has should minimal improvement they have started home visits. We are past the 6 month mark of funding from child services and I think that because Joseph has parents and family who are involved they will push to move him out. Now please don't misunderstand me I want Joseph home more than you can imagine but not before he is ready otherwise all progress we have gained will be lost and things will get worse. I guess time will only tell right now. Joseph has court on the 26th and I believe the court will be a HUGE power figure in deciding what the next few months will bring. In the mean time I am scared and tired. I am tired of always having to fight to get him care. And scared because we aren't rich he will pushed out before he is ready. In the meantime I just keep fighting.
