Attention-Deficit/Hyperactivity Disorder and Disruptive Behavior in a Child With Eosinophilic Esophagitis and Failure to Thrive

Ryan is a 6-year-old boy with a history of eosinophilic esophagitis (EoE) and poor weight gain referred to developmental-behavioral pediatrics (DBP) for attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Ryan's mother was concerned about Ryan's defiance and daily emotional outbursts, which could last up to an hour. Ryan's teachers frequently contacted the family due to disruptive behavior, impulsivity, and sneaking food.Ryan was born prematurely at 28 weeks and required nasogastric feeds for 1 month in the NICU. He has a history of reflux requiring proton pump inhibitors and failure to thrive at age 2 (currently at 6% for BMI). At age 4, he was evaluated by pediatric gastroenterology and subsequently diagnosed with EoE. Complete elimination of dairy, wheat, soy, eggs, nuts, and seafood/shellfish was recommended as per standard of care for EoE. The diet was difficult for the family and Ryan to maintain, and Ryan often had tantrums around foods/snacks. He would sneak into the pantry to eat things he was not supposed to, causing significant parent-child conflict. Food restrictions were particularly challenging at school. Ryan would ask classmates for their cheese sticks and cookies; snacks he was not allowed to eat. Despite a 504 plan in place, his teachers were unable to monitor his intake.Parent and teacher behavior rating scales were consistent with ADHD-combined type and ODD. Cognitive and academic testing demonstrated academic underachievement in math and reading; however, these results were thought to be an underrepresentation of his true abilities due to easy distractibility and impulsivity observed during assessments. Behavioral therapy, IEP evaluation, and trial of ADHD medication were recommended.Given his poor weight gain and inability to swallow tablets, a nonstimulant, guanfacine immediate release (IR) was initiated. Guanfacine was helpful, but titration was limited due to daytime sedation. Ryan was placed on homebound services due to frequent EoE flares and concerns that school could not adequately monitor food restrictions.GI recommended elemental formula as his primary source of intake due to nonadherence to diet. Ryan required a gastrostomy tube (g-tube) due to his refusal to drink elemental formula. Although EoE symptoms improved, Ryan had increased oppositional and defiant behaviors with his homebound teacher and parents. An extended-release oral liquid methylphenidate stimulant was started in conjunction with guanfacine and resulted in significant improvement of ADHD symptoms. Ryan experienced weight loss and decreased BMI to 3%. Periactin was initiated to help with appetite and sleep quality.After 3 months, Ryan started feeding therapy and behavioral therapy with a family component. He was also approved for home nursing support and respite hours. Several months later, Ryan endorsed missing his friends and wanting to go back to school. He agreed to sign a behavioral contract stating that if he returned to school, he would not sneak/steal food.What are some recommendations to consider for addressing Ryan's behavioral challenges?