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| Hpathy Ezine - June, 2004 | ||||||||||||||||||||||||||||||||||||
Behavioural and Psychiatric Problems of Children- by Dr. Jawahar Shah |
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CASE V : Hypersomnia with Oppositional Defiant disorder A very naughty 3+ and stubborn 3+ five and half year old child was brought to my clinic with the complaint of Hypersomnia. She would become unconscious while sleeping and would not come to consciousness for 2/3 days or more. Life situation: Mental state: This child was extremely obstinate & headstrong; whatever she said was the ultimate. If it was not accepted, then there would be trouble! Looking after her was like looking after 10 children together. When she had her mind fixed on something, she would repeat it over and over again till it got resolved. She would not listen to a single reasoning. She would not respond to her mother’s call till she was repeatedly called at least 10-12 times. When punished by mother, the child would hit her mother back without any feeling. She was very hot tempered and would fight with everybody around. Her idea of playing was hitting, pulling and pushing around, thus irritating everyone. She could not remain in one place. She kept calling her mother to play with her and demanded a lot of attention. The mother was so fed up with her that she decided to send the child to a boarding school. Basically, this child was very intelligent, curious and sharp, but all the faculties were used in the wrong way. Her school teacher says that her IQ is much above average, but she will only do things if she feels like doing it. She knows all her studies, but when asked, she will not reply. For e.g. she knows all the days of the week, but if you ask her what comes after Sunday, she will not answer. She never does homework work. Her handwriting is bad. She has a habit of sharpening her pencils and crayons till they are unusable. She is not scared of her class teacher / principal or anybody else. She imitates her mother or her teacher in front of other children. If she goes to the neighbor's house and is asked to go back home as the children are studying - she would do the same when the neighbors would come to her house. She has a very bad habit of repeating everything. If her mom or teacher scolded her or hit her, it would make no difference to her at all. She was completely indifferent to it and had absolutely no feeling at all. Obstinacy 3+, a simple example was when she came to see me. She was given placebo pills, she asked for more pills -- once, twice, thrice but when she demanded plain pills for the fourth time, we refused. She was so persistent that she would not budge from that point. She has this habit of irritating the other person till he gets fed up and gives her what she wants. She played the same trick on us, and finally we had to give her the pills on her persistence.
Clinical examination Weight 35Kg B.P.90/70 Cavities in teeth Dark ring around eyes Hyperextensible fingers Glands cervical + Loss of vision. Gross - papilloedema 3. Capacity to differentiate colors lost. Grade IV hypertensive changes. Investigations Urine examination Gram - ve Bacilli Kidney size 7.0 * 3.2 : 7.9 * 4.4 S.po4 5.9 S.Chol 187 S.Na 137 Albumin +++ in urine. Diagnosis Hypersomnia Glomerulonephritis and Oppositional Defiant disorder Past history: Early 1993 – The child’s pupils were dilated and she was rushed to a hospital in Dubai. She was in coma for 1 day and she had to be put on a ventilator. At this time, she was in hospital for about 1and a 1/2 months. She was wrongly diagnosed as a case of tubercular meningitis & was put on steroids. She was brought to India where MRI was done & she was diagnosed to have a tumour -ganglioneuroblastoma. March 1993 - She went into coma again for 5 days. She was operated for the tumor. After such a major operation, any normal child would have been frenzy with pain. She did not feel any pain after the operation].Even after the tumor was removed, her breathing was very shallow, her CO2 level went very high and O2 level was very low. Doctors suggested that she should reduce weight. Her breathing was much less during sleep. Jan 94 – Pneumonia in Dubai, for which she was admitted to hospital. She stopped breathing; she turned blue & was on the ventilator for about 2 months. After she was discharged, she was brought to Bombay and was admitted in a hospital for a check up. At that time, she still had Hypersomnia, was more violent and aggressive. The doctors gave an explanation that this is because of low oxygen levels reaching the brain. Life situation: The child’s parents got married in 1987. Her father was a drunkard. Mother did not know about the father's condition when they got married. Father would regularly hit his wife, beat her and abuse her. Their home was like a big arena for fights; quarrels were an everyday affair at their house. These quarrels affected her mother a lot. Her mother would never reconcile with anybody and was disturbed and depressed since she got married. Symptoms: The child’s indifference, lack of reaction to surroundings and unfeeling are very striking features of the case. Also, painlessness after such a major surgery becomes the most peculiar symptom of the case. Thus, symptoms considered for the case are: A pattern of · Negativistic, · Hostile, and · Defiant behavior lasting for 6 months or more during which: 1] The child often loses temper. 2] Often argues with adults. 3] Often actively defies and refuses to comply with adults’ requests or rules. 4] Often deliberately annoys people. 5] Is often touchy and easily annoyed by others. 6] Is often angry and resentful. 7] Is often spiteful or vindictive. The disturbance in behavior causes clinically significant impairment in A] Social and B] Academic functioning.
The symptoms of Opium which were on the surface had gradually improved. On reconfirming her other basic traits of behavior like obstinacy, anger, restlessness, etc., Moschus was administered.
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