Tyler's Story

Meet Tyler. 

I first met him when he was 10 years old, in the fifth grade. He is one of the best illustrations of the complexity of children and why we must remain constantly watchful for developmental changes and the effects of changing environmental demands and expectations. 

Tyler’s mother brought him to me with concerns about his underachievement at school, poor social skills, increasing frustration and anger, difficulty with task completion, and constant, nervous fidgeting. These had been longstanding problems although, up until now they had seemed manageable. In addition, his mom had assumed they were largely the result of her parenting style and was continually restructuring her consequences in an effort to improve his behavior. 

TylerTyler’s speech was often rapid and disjointed and he clearly had difficulty organizing his thoughts, which then affected his ability to accurately express himself verbally. He also seemed unable to modify his behavior in response to behavioral consequences, whether this was in the form of reward or punishment, and found himself forever being corrected and/or punished for the same problem. When he got an idea in his head or decided he wanted something, Tyler was relentless in his pursuit, to the point of obsessiveness. He was a bright, verbal, and charming young man but was highly distracted, with racing speech and trouble staying on topic, even in the one-to-one setting in my office.

After a thorough evaluation, we diagnosed him with Attention Deficit Disorder, Anxiety and traits of Obsessive Compulsive Disorder. He exhibited difficulty sustaining his attention and complained of racing thoughts and constant worry about everything and anything. In contrast to this, he would sometimes Tylerbecome locked onto an idea or task and be unable to let it go, even in the face of drastic consequences. This trait would eventually cause him significant problems, both socially and personally.

His teachers reported concerns about his poor focus and concentration and difficulty completing assignments and following directions. Reports indicated that he was a very “bright young man” but was not “applying himself” and “not working up to his potential.” His verbal impulsively or his tendency to interrupt and blurt out comments, sometimes unrelated to the task at hand, caused frequent reprimands in the classroom, which often led to embarrassment in front of his peers. 

At home, Tyler’s mother reported that he had always been a “high maintenance kid,” requiring constant prompting and redirection to follow directions and complete tasks. He was bright and affectionate with a great sense of humor and above average vocabulary. Remember how this can work against him-adults think that if he can say it, he can do it! She agreed with his teachers that he was very capable academically but could not consistently “apply” himself, (e.g. sustain attention on demand). His constant arguing and pursuit of his own agenda made discipline next to impossible, although he would often verbalize his desire to do the right thing and not get into trouble. In fact, he hated the idea that he was causing conflict in the family in spite of the fact that he often found himself in the eye of the storm.

A note about his family history: Tyler lived with his mother and younger sister. His parents were divorced when Tyler was four years old although he had regular contact with his father. Family history was positive for anxiety, mood disorders, substance abuse, attention disorders, eating disorders, and obsessive compulsive behaviors. This history, combined with the effects of the divorce and separation from his father, clearly placed him at risk for developing emotional issues.

Tyler was quite insightful and self-aware and was open with me about his social and academic problems. Even though he could often describe his problems, he was clearly frustrated by his inability to improve them. Our initial treatment of Tyler included medication to treat his attentional instability and his anxiety, educational accommodations to reduce the volume of his work at school, and ongoing counseling to improve his understanding and acceptance of his strengths and weaknesses. His mother was his greatest advocate and became well-versed in his diagnoses and treatment. With support, treatment, and educational advocacy, Tyler’s academic performance and behavior improved during sixth and seventh grades.

In eighth grade, Tyler began a gradual disintegration. His obsessive nature became pronounced and the frequency and intensity of his rages increased. His school performance suffered and became more erratic which, in turn, aggravated his already fragile self-confidence. His mood was also more unstable and seemed to dictate his every move. Tyler became more reactionary, negative, and pessimistic, convinced that disaster was lurking around every corner. My efforts to walk him through these events and remind him of the difference between disaster and disappointment were fruitless. At this point, we made a referral to a psychiatrist who diagnosed him with Bipolar Disorder (discussed in detail in chapter 4) and made a number of medication changes over the next several months. In spite of this, Tyler continued his downward spiral. His rage was tangible and often unleashed on his mother, cursing at her, calling her names, and blaming her for all of the perceived injustice in his life. 

In my office, he would often be loud, angry and demanding. His mood would shift quickly within the hour from enraged to pleasant to sobbing and back to anger. After months of this instability, he also began to blame me and his psychiatrist for failing to make him better. Interestingly, during this nightmare, Tyler was consistently compliant with his medication and his appointments with me in spite of his defiance and rage in every other area of his life. I often find that when children are at their most unstable, sometimes the only “effort” they can make to get better is taking a pill and showing up for an appointment. During the worst of times, he would sometimes scream and cry, stating “Do you think I like this? Do you think I want to be like this, the psycho of the family? Don’t you think I know you’d be better off without me?” etc., etc. In hindsight, I believe that Tyler knew this monster in his brain was bigger than all of us and was terrified that it would eventually destroy him and his family. In all of his ranting, he certainly came across as manipulative, spoiled, self-centered, and defiant. When he was in the middle of one of these (usually unprovoked) meltdowns, no amount of talking, consequating, punishment, or negotiating would calm him. Our goal at these times was to diffuse the situation with as little damage as possible.  This approach was very difficult for his mother since her parenting instinct was to teach him that he couldn’t act this way and expect to get what he wanted. She also worried about the lessons she was teaching him and how this would affect his future. I continually reassured her that he was so irrational and disconnected at these times that the only lesson he would carry was whether or not she understood him during his time of crisis. 

As you can see, Tyler’s diagnostic picture is complicated and is obscured by his adolescence and the impact of hormonal changes, increasing academic demands, transition to high school, and ever-changing peer relationships. His treatment also had to account for this complexity and address the many faces of his illness. As of this writing, Tyler is doing very well. He is a high achieving high school junior, has his driver’s license, and has definite plans to attend college and be a teacher. As expected, the frequent phone calls to me have subsided and he only sees me on an as needed basis since he can now think through any problem he encounters.

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