A little child with a big challenge

Copied without permission from the Austin American Statesman
Aaron's grandparents use medication, psychotherapy and loving, vigilant intervention to help
By Theresa Walker Orange County Register

Irvine, Calif. -- Aaron Szilveszter splashes around and floats on his back in his plastic swimming pool while his grandmother chats with visitors.

He appears content. Then he walks over and spits a mouthful of water on one of the visitors.

His grandmother jumps to her feet and is at his side, in his face, within seconds.

``Aaron! That is so rude,'' Grace Macotrigiano-Bennett tells the dripping 5-year-old in a firm voice. ``Do it again and you go inside.''

Moments later he is out of the pool again, scaling the 6-foot-high wooden fence separating his back yard from neighbors at his grandparents' home.

His grandmother keeps a watchful eye as he perches on a narrow rail, too tired to fight another battle with him. She knows there will be plenty more confrontations. Continually.

Sure enough, Aaron is later sent inside after he sends scatological language and water spraying everywhere.

To someone who doesn't know him, Aaron would appear to be a brat who could use a good paddling. But discipline alone can't change Aaron's behavior.

He is not a problem child. He is a child with a problem.

His grandparents are treating that problem with medication, psychotherapy, and their own loving vigilant intervention.

A year ago, Aaron was diagnosed with Attention Deficit Hyperactivity Disorder, or ADHD, the most common childhood behavioral disorder in America.

``Sometimes,'' Macotrigiano-Bennett says wearily, ``telling them `No' 100 times is needed for them to learn that something is inappropriate.''

100 times a day

What makes this statement remarkable is that she's talking about 100 times in the same day.

Children with ADHD are impulsive, fidgety, inattentive, easily distracted. They can't sit still or wait their turn. They blurt answers in class. They butt into other children's games.

They say and do things -- hit, kick, spit, fight on the playground, defy parents and teachers, engage in risky behavior -- with a frequency far beyond what other children would dare.

They alienate playmates at school or in the neighborhood, rejection and failure deflating their self-esteem. Unless they get help, many as teen-agers find themselves in trouble with the law or drifting into harmful activities.

Their behavior disrupts family life, threatens to torpedo any chance of success in school.

For most children with ADHD, the right medication in the proper dosage can produce a profound change, calming them down and stretching their attention span.

Coupled with behavior modification and adjustments in their schooling, they can cope with a disorder that will be with them all their lives.

More severe cases might take intensive intervention, such as that provided at the University of California-Irvine Child Development Center, where children spend up to a year learning techniques to control themselves so they can return to regular classrooms.

Maybe it's something else

But so extreme is Aaron's behavior that the psychiatrist who sees the little boy at least once a month wonders if he isn't struggling against something more devastating than ADHD.

Diagnosing ADHD is not an easy call: It is subjective, with doctors and therapists relying on observed patterns of behavior.

Other factors in a child's life -- family dynamics, socio-economic environment, cultural influences, physiological problems -- can lead to disruptive behavior that mimics ADHD.

Often ADHD occurs in tandem with learning disabilities or other disorders. With Aaron, there is a family history of manic-depressive psychosis. His mother has suffered with it since her teens and lives in a board-and-care home for the mentally ill. His paternal grandmother also was manic-depressive, or bipolar.

He has not responded well to the medications typically used to treat ADHD. His psychiatrist, Dr. Mike Brase of Los Alamitos, Calif., says he can't be sure about Aaron until the onset of a manic episode, something that won't happen -- if it ever does -- until the boy reaches his teens.

``This is controversial,'' Brase says, ``but I would say that some bipolar kids are misdiagnosed as having ADHD. Other people might say that people who are bipolar had ADHD as children.''

The possibility frightens Aaron's grandparents, who have raised him since he was 9 months old.

``I'm praying to God it's ADHD,'' Macotrigiano-Bennett says. She does not want to repeat with Aaron what she and her husband are going through with their daughter. ``I'm scared. From day to day we look at his behavior and we say, `God, if we don't get some control over that, what are we looking at at 14 years old?' ''

Aaron's grandparents, both in their 50s, knew something was different about the boy from the time he began toddling around. At first they thought his behavior was the result of being separated from his mother and from his father, who is financially unable to raise him.

``I felt like a blind man,'' Macotrigiano-Bennett recalls. ``We kept questioning ourselves. Is it us? Are we too old for this? But we knew something else was going on.''

He would climb on anything and everything, regardless of the risk. When he was 18 months, he unlatched his bedroom window, climbed out and ran to the street.

Naked.

When he was 2, he took a younger boy from his day care out through the garage and down the block. They were missing for 30 minutes before construction workers found them and called police.

Disruptive behavior got him kicked out of his first preschool after only three days.

This year he's repeating preschool, mostly to learn how to get along with other children.

Academically, Aaron is ready for first grade. He's a bright kid who can count to 100 and read aloud his favorite ``Sesame Street'' story, ``The Monster at The End of This Book,'' cover to cover.

But his social skills and maturity are more like those of a 3-year-old.

That's why he didn't have any friends all last year. That's why he has trouble getting other kids to play with him.

The teachers at Camino for Kids Child Development Center are aware of his problem and work as a team with his grandparents. With three teachers in the room at any given time and no more than 15 kids, Aaron can get more individual attention.

The drug therapy has been an uncertain process.

``I was looking for a miracle medicine to make this all better,'' Aaron's grandfather says. ``It doesn't work that way. You have to keep at it.''

Ritalin initially was bypassed because of concern that it could exaggerate or worsen a twitch in Aaron's eyes. An alternative medication made him more aggressive; another made him so depressed he cried all day.

Medication side effects

The one medication that seemed to stabilize him the best, Haldol, can cause long-term side effects, such as permanent smacking of the lips.

When Dr. Brase took over Aaron's psychiatric care, he tried Ritalin. The drug had the opposite effect it typically does with ADHD, accelerating rather than slowing Aaron's hyperactivity.

Now Aaron takes Depakote, a drug used to treat seizures. He focuses better and is calmer, but his aggression remains.

``If he doesn't get his way, he's pretty verbally and physically abusive,'' his grandmother says.

Brase is considering another drug, since Aaron's dosage is as high as it can go without being toxic. The prospect of more experimentation scares Macotrigiano-Bennett. Yet she believes medication is a necessary evil.

``You feel like your kid is a guinea pig with all this, but if you don't do it, it makes it really impossible for them to function in society.''