DEPARTMENT OF PSTCHIATRY

William Greenleaf Eliot

Division of Child Psychiatry

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MBDICIITE
AT WASHINGTON UNIVERSITY MEDICAL CENTER

August 7" 1995

.faie*'..ad isereSa lremorr. Olttrr L35 llalnut Ridgre Drive 620Lo Bethalto, Illinois Dear Mr. and Mrs. Demontmollin: Enclosed please find a copy of our final pslrchiatric assessment
Adam Demontmo1lin,

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D.O.B. O9-26-9L

on

We

appreciate the opportunity to serve you in the care of this child. ff you have any questions, please contact me at (31-4)
454-624L.

Sincerely,

Karen Horgran, U.S,w.

Tnf artt /Preschool Cl

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inic

Ixashington University Schml of Edicire

400 S. Kingshighway
St. Louis. Missouri 63110

(Medical School Box Bl34)

WASHINGTOryUNIVERSITY SCHOOL OF MEDICINE THE CHILD AND ADOiESLNVT PSYCHIATRY

CENTER

Patient Name: Date of Birth: Chronological Age: Parents: Date of Visir: Physiciat-* Clinician: Referred by:

Adam DeMontmollin

9/26/97

Karen Morgan, lvLS.W. Dr. Leu

5/15, 6/5, 6/12, & 6/?679;Jmn lrrb5r, f{.D.

3 years, 8 months James & Teresa DeMontmollin

Adamisa3vear,*
Adam due to his inabili!,, O to ,1.u" oo*rr-*-J?uu asleep at nighr. Adam has never_ been known 3 L/2 months us",rrirg""i to b-e a good sreeper. From birth to if day and staving awake d"ri+ *.*".irir"-.oosisred of sleeping all tne nigni-i|'ug"

m"*y1#i}"#;$" Ed;;; .-,-* hi, .k"fo ,s

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Adam rhen *ur rrorpiiuulJo;y" "ppr"oJ.I"Ti*p"&lL of 11 p.r,. ro 5 am. davs 16r iiespiratory infecrion. was not able to return He to a we, .g,irut"a Jr""piog rou-ins. The DeMontmorin's berieve that the excessive holding they gave

p#"rrti;;-lilt;**;a; ffi-.nrige s r/2monrtrs and stab,ize his steeping pafterns ro an

Adam's

him in pajama's, Adam uoiue aoo i";; i ,,o.y. -gave lie on rhe floor oiaour"t u"j:"t ,Tg-h" appeared Dad would then usualry occurred *ora^lr-pr" asleep. This at which ti-" dad would ineak of Adam's bedroom. out join his mom and dad By 3 ,-i.- Adam *",rrJ&pi.ally wake up and ii hi, parenrs bed, Adam would falt asleep His p*uot, fr"o buying l"+"ir"r"rr. waterbed like theirs i" t Adam a rp"Jt *orto .-ui, in his own bed "

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throughout the night. Yet, he still wanted to sleep with mom and
dad.

currently, Adam's bedtime routine consists of a bath and watching TV with dad until dad can no longer remain awake. Dad takes Adam
to his room where Adam falls asleep. Adam, however, continues to wake up at 3 am. and join's his parents in their bed. Often Adam will not want to sleep next to his parents, but will want to lie on top of one of them. The majority of the nights Dad will move ro the couch to sleep. occasionally Mom will move to Adam's room or sleep on the couch to make room for Adam in their bed. Notably, his sleeping habits are verlr disruptive to hi.s parents. Tr+,ice a month Adem'1n $fep sister stays at the De&Ionmollin's. Adam wans to sleep in hcr rrxrm therrefore his prents will set up a cot for him in his sistet's bedroom. By 3 am. Adam still wakes up and joins his parents in their room. parents have been giving Benadryl to Adam to help him sleep. Adam's pediatrician prescribed the medication initially to be used as a PRN. However, the DeMontmonunollin's began using it on a more regular basis in response to the chronicity of Adam's sleeping problem.
several other potentially related behavioral problems are also does not coincide with his parents'. He is not hungry during scheduled meals; but, then requests to eat right before he goes to bed. Mom and Dad differ on how to handle this situation. Mom wants to allow this off-scheduled eating. Dad wants to refuse Adam food unless it is a scheduled meal or snack. Adam rlisFilels resressed behavior indrrced by exlrressing feelings abmranriry b be a'bab5f and dlfficuhy toiler-training. At 20 months Adam began toilet training. When his parents wanted to progress to a pull-up he often requested to return to diapers. It is notable at 3 years, 8 months Adam is not toilet trained. He often shows oppositional behavior about using the potty. For further information about toilet training and other pioblems see, the developmental history in the initiat assessment.

It is important to note that over the past tz-lg months Adam's

presenl Adam's eating schedule

father and A 50 minute interactive free play was observed between Dad Adam. Dad prim*trv initiated and directed the play themes' At demonstrateO attentiveness and also followed Adam's Cues' ho-" dad and Adam's play is more "ruff and tumble" with little use oi ioyr. Both dad and AOu* separated smoothly when it was ,"qo-"rt"d that dad step out of the playro-om for a few moments' was O-u^ring dad's absence Adam's play with this examiner of 4" ptuv characte dzed^ .ggr"tsive. aourn initiated the majority angry themes. When Ad;; and dad were reunited, Adam appeared and told his farher not to come back in the ptaSrooT - For the Fenfifoit pfrtiln of m' sEirm, Adam o}nJAed with the examiner rriln his back torvad dad- On serreral occasions the eraminer attempted to include dad in the play activitY- but Adam resisted and remaiied focused on the examiner. During the session, Adam exhibited no evidence of bizatre or disorganized play. There was no evidence of psychosis. His mood was bright, play was exploratory and Adam's communication was coherent and in complete sentence format. Fine and gross motor skills appeared within the normal range for his age.

SFMI-STRITCTITRFN INTERVIEW WITH MOTHFR

In ttris segment, Adam and his mother were videotaped in a-semist uct rrei interview. This consisted of four segments thought to
simulate common experience at home.

ln rhe firsrt Adam and his mother enjol"ed a fn'e minute period of his iuice, mom iunce md cookir:s Wten Adam accidenally spilled iook Adamls napkin and wiped up the mess. Adam immediately

began crying and told mom he wanted the napkin back under his cookiet and could not eat the cookies unless the napkin was underneath them. Mom quickly complied with Adam's demands and Adam ceased his crying. Notably, Adam appeared irritable and mother seemed "on-guard" given the need to help to Control him. This seemed potentially stressful and therefore made the segment appear less enjoyable for mom than we might hope-

The following segment consisted of a structured teaching task. First, mom was instructea to teach Adam how to build a bridge with three

blocksandatowerusingfoulsmallblocks.MomthenhelpedAdam Iastly, mom had the option create various designs using _th:^irlr.kr. wut ihowing Adam how to WttU" -"of reading u uoo-fl r";J;] of what the his -rrrom version the bridg"'r"i'ar*"r, Adam built insisted that Adam build build utl. bridge urrd to*L rn.rfA look way. Adam said the bridge and to*"r in the appropriate then complied with Adam's ,,yl-u ;"k" it fof irli; fufo* aggressiv"ly,
plan.

mom had a free ptay period In the following segment A9t* and of development. Adam played fu;;i using roys appropriate f.I hir He had no response to

angrl'' w'ith his back to-ilot anA appeared mmns afrsnPB [s eogAge hirn^

Duringthelastsegment+du*andmomhadabriefseparationand on the door, mom left the reunion. when th-e examiner i;;k"d or sno* distress about mom's roon,. Adam did not make d;;;;*.i*as working on a pt,ozle box and absence. prior to her leaving iA"* go in' Ouring her absence mom wnat notes eacfof the shapes asking Whln mom re-entered the talked lfi*1; thtoogn ,fr" iast'^ Adam trelo' Yet he did tell Mom he room, Adam did oot look "p oi*V shapes- This represented a could not find the right holes ior the of re-engrying with of a more negativ" uoJd"pendent.way Throughout the display ttt" history. his mother that has been r"po*"J-io ^Slhe sessionmom.Saffectwasflatandmoodappeareddysphoric.Sheand appeargd stressed to many of Adam'r a"-*as. conformed "pyt oiit" Ad.*'s emotional it was evident that she trad toconstantly His affect was bright "fires". Adam's mood *ut ntliJ;*gitig' whenevertheexaminerenteredtheroomyetwhenalonewithmom and tended to "act-out"' he had diffl."6;"g"I"titg his emotions pla)' and Adam demonstrated There n-as ,,o erridence or arl"ri"oir"a gross and fine motor smgeryrralory w- B"aht'trmrumons and skills appearea appropriate for his age'

Adam,sSeveredysregulationofsleep,to{gtinsandemotionsrequire The etiology may stem in immediate and long-term intewention. processing dfficulties part from ,"rrrory ind/ o' Prganuattonal inappropriate sleeping, present at birth. His continoo,rs putterns of ttressful for his parents' As a eating and elimination ut" io.i"iti"gfy structure for Adam given his result there i, ;fi;k o1neeaea prreitl+ Through the video taped tendency ao ,"u.t ,troogfy ugiitt iL

Session we Saw mom'S avoidance

of power Struggles as a^means of avoiding Adam's temper tantrums. The manifestation of dysregriation can ahb be seen through the intensity of Adam's .orrtrdUiog and defiant behavior. It is recorlmended t1.at the DeMontmollin's gradually impose more structure to Adam's daily
routines.
a The Infant/preschool Clinic can assist with this process through is also io*r" of dyadic play therapy for mom and Adam. Ittheir son for the recommended mom and dadattend sessions without purpose of establishing the most optimal parenting interventions needed for Adam-

PSYCTIIATRIC

DI

GNCNTS ACCORNING

TO I-'SM IV

Axis I

Axis II Axis III Axis IV Axis V

Oppositional Defiant Disorder 3 13-8 1 Cirladian Rhythm Sleep Disorder 3O7 -45 None Asthma
None 65

RECOMMENDATIONS

Mom and Adam are encouraged to participate in dyadic therapy to help establish better regulation in multiple domains. At the onset of treatment we reco--"od"d that parents wean the child off of the fenaOryf due to it's negative effects on sleep architecture- Alti-ough thb h6, b33n aoaomrylitfud' milfille additional plans to normalize the child s sleepwake cycle and to establish independent sleeping habits were also discussed. As part of the therapy will explore mom and dad's anxiety that may contribute to their hesitation to impose limits. We will explore the relationship of these factors on Adam's dysregulatory problems in multiple domains.

Director of the lnfant/Preschool Clinic

Joan LubY, M.D.

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