A 7-year-old child with Down syndrome and disruptive behaviors

Steve is a 7-year-old child with Down syndrome who was referred to the Developmental and Behavioral Pediatrics Clinic for increasing hyperactivity and disruptive behaviors. He is followed closely for complex congenital heart disease, oxygen dependent pulmonary hypertension and chronic lung disease. He is accompanied by his mother who, while greeting the staff with a smile, apologizes as Steve attempts to get out of his stroller. His mother reports that the pulmonologist requested an evaluation of Steve's disruptive behaviors during recent clinic visits. She states that new people and unfamiliar surroundings cause Steve to become "over-stimulated." He moves around the room, plays with everything available for brief moments, is difficult to examine and difficult to redirect. His mother states that these behaviors are limited to the doctor's office. However, she is even more concerned about his behavior since his recent discharge from the hospital 8 days prior to the clinic visit. Steve was hospitalized for two weeks with a febrile illness associated with pulmonary edema. He required an increase in oxygen and maintenance of his usual medications: digoxin, furosemide, aldactone, an inhaled steroid, levalbuteral, and potassium chloride. During the hospitalization, sildenafil was increased to manage pulmonary hypertension and lorazepam was prescribed for disruptive behaviors. Steve's mother observed that the increase in sildenafil was associated with a significant change in behavior including difficulty following directions, impulsivity and over activity. She worries that he will hurt himself accidentally. Behavioral techniques that were previously helpful at home are no longer are effective. As Steve's mother describes the behaviors, she began to cry. She recently adopted Steve, whom she has cared for since his birth but now confides, "I may have made the wrong decision." She also cares for her biological adult daughter who has Down syndrome. Steve has remained home for several weeks as a result of his physician's recommendations in order to prevent another infectious illness. At home, his mother is struggling with his behaviors and talks about her increasing sense of frustration and anxiety. At the clinic visit, Steve is an active child with physical features typical of Down syndrome. He is wearing a nasal canula with a protective plastic cover, acyanotic and breathing comfortably. He looks at a book and colors on the pages briefly but then loses interest. Steve is in constant motion and interested in exploring the examination room. He particularly likes to climb onto the examination table and look at a mirror while playing with various objects. Steve has limited responsive to redirection. He speaks only a few single words, but he understands simple directions.