June 24 Post Three

             Thomas has turned 3 and has continued to demonstrate improvement in his speech therapy. One issue associated with a cleft palate is ear infections which can result with an accumulation of fluid in the ears. Over the past year, Thomas has been to the pediatrician three times for ear infections with fluid in his ears. The Hooks were referred to their ENT, for frequent infections and fluid buildup can result in a hearing loss. Thomas underwent a hearing evaluation which revealed that his hearing was normal. The ENT explained that children with a cleft palate are prone to fluid collecting in their ears which is known as “Glue Ear.” Since Thomas has had these recurrent ear infections and fluid buildup, the ENT recommended a surgical procedure to insert tiny tubes called grommets. He stated that it will help to ventilate his ears and reduce the chance for fluid to collect in his ears. It could help reduce the chances of damage to Thomas’ hearing. He added, that the tubes tend to fall out after 6 months, and could require reinsertion. He also explained that ear infections are no longer an issue as the child grows older. The Hooks agreed to the procedure which was done in the hospital as an outpatient. In addition to the recurrent ear infections, Thomas had seen the dentist twice over the past year and required fillings in 4 teeth, some of which had dual surface involvement.

            During their last visit to the pediatrician, the Hooks brought up their concerns that Thomas has demonstrated an increase in ADHD behaviors. From squirming and an inability to cuddle, his parents have noticed an inability for Thomas to maintain an interest in any toy or activity for very long. He would run around the house and fall frequently due to what appeared to be clumsiness. It is not uncommon for children with ADHD to be accident prone due to their impulsivity. They act without thinking and consequently have more accidents than the average child (Web MD).

 Thomas also displayed problems taking turns when playing with his peers in the park. He would push his way onto the ladder of a slide instead of waiting his turn. Children with ADHD act on impulse and do not delay gratification. When they want something, they want it now. At this age, many parents of boys fluff this off as “boys will be boys.” They do not see it as a sign of a disability such as ADHD.

Given Marcus’ history, his son’s behaviors sparked concern. His parents took him to their pediatrician who told them that Thomas was still young and may outgrow this. Aware of Marcus’ history, he did add that if the behaviors continued or grew worse, Thomas may need to be evaluated for ADHD. He recommended that they enroll Thomas in a nursery school program to provide the training through experiences with peers in a structured setting. He suggested seeing how that goes and if there was no sign of improvement then bring Thomas back and he would provide them with a referral for further evaluation.

ADHD is difficult to diagnose. Doctors often rely on a family history, interview with child, reports from school, etc. Doctors are often too quick to diagnose a child as having ADHD so the Hook’s pediatrician is not discounting the ADHD diagnosis but feels further information is needed and had made a recommendation that would provide insight into another setting other than home.

The Hooks left their pediatrician’s office feeling conflicted. They were happy that he hadn’t dismissed their concerns and made suggestions for follow up. His recommendation for a nursery school program posed several issues. First, there was the issue of full day vs. half day, and then the resulting financial implications. A full day program would cost more and still require child care for the gap in time from when school ended to when they returned from work.  Half day programs cost less, but involved the additional cost of child care. Another consideration was whether Thomas at 3 years of age, could handle a full day program given his issues of impulsivity, and limited attention span. The thought of all this, along with the medical, dental, and behavioral issues that have plagued the Hooks over the past 3 years, left them feeling overwhelmed. Understanding the stress the Hooks were under, a friend from their church offered to take Thomas for a weekend, so that Marcus and Taylor could get away. They returned rested and were better able to consider their options and make a decision. They worked out an arrangement with their current child care provider, which reduced her time by the amount of time in the half day nursery school. They were also successful in finding an affordable program in their Hoboken community that would meet their needs.

Stress is experienced by all new parents who have to cope with the demands of an infant and the life style changes to their marriage. This is only compounded by having to deal with a first child who has a disability. Studies show that having a child with a disability can destabilize marriages and lead to divorce. Some parents refrain from having a second child due to the stress and strain it puts on the couple physically, emotionally, and financially. There is also the fear that it could happen again. Studies suggest that “raising a child with a disability decreases subsequent fertility, both by directly decreasing the likelihood of subsequent   childbearing and indirectly increasing the likelihood of marital disruption. Decisions to have another child are based on more than a first child with a disability, but on a variety of social and demographic factors, such as a woman’s age, race, social class, educational attainment, marital status, and labor force participation.” Positive factors for the Hooks were their community support, they were college educated, had jobs, and had reached an age of maturity when they had Thomas, as opposed to being teenagers. They were also a white middle class family.  Stress is higher among poor, unmarried minorities in disadvantage areas, who are unemployed and have a limited education (NCBI).             

The Hooks experienced some relief after resolving the issues with nursery school and child care. Thomas’ first year at nursery school was fraught with frequent reports from his teachers regarding his calling out, inability to share, and his inability to sit still. There were isolated episodes of temper outbursts when he was prevented from doing something he wanted.  The teachers were patient and made every effort to work with Thomas. They agreed to keep Thomas at the school and asked that Mrs. Hook speak to her pediatrician about possible medication to help improve Thomas’ behavior in school. Although there wasn’t a definitive diagnosis of ADHD, all of the reports from the teachers, Taylor experiences with Thomas at home, and the knowledge of a possible genetic component, all seemed to indicate that Thomas suffered from ADHD. There was a part of Taylor that feared her own drinking may have caused his ADHD. The idea that she could have caused this was devastating.

              The information available on the causes of ADHD provides numerous possibilities. There is no single direct cause. Some cases are believed to be genetic; some are alcohol or drug related, some are believed to involve neurotransmitters while other cases appear random with no apparent etiology. Treatment options include medication, psychological and behavioral therapies (Web MD).

1)    What ADHD treatment alternatives are available for Thomas?

2)    What role does diet play in children with ADHD? I.e. chemicals in certain foods

3)    Is a referral to special education for Thomas inevitable? Why or why not?

Decision Point: Does Taylor get medication for Thomas or does she decide to pull Thomas out of the nursery school program?