Attention-deficit hyperactivity disorder, disruptive behaviors, and drug shortage

CASE: Kyle is a 10-year-old boy with Down syndrome and intellectual disability who is being followed up by adevelopmental behavioral pediatrician for attention-deficit hyperactivity disorder (ADHD) and anxiety. Kylewas initially taking a long-acting liquid formulation of methylphenidate for ADHD and fluoxetine for anxiety.Several months ago, the liquid formulation was on back order, and the methylphenidate formulation waschanged to an equal dose of a long-acting capsule. Kyle is not able to swallow pills; therefore, the contents ofthe capsule were sprinkled onto 1 bite of yogurt each morning. Over the course of the next month, Kyle'sbehaviors became increasingly difficult. He was not able to tolerate loud or crowded places, and despite avisual schedule and warnings, he would become aggressive toward adults when directed to transition awayfrom preferred activities. Fluoxetine was increased from 0.4 to 0.6 mg/kg/day at that time.One month later, his parents reported that although there may have been slight improvement in Kyle'sirritability since the increase in fluoxetine, they felt he was nonetheless more aggressive and less cooperativethan his previous baseline. Kyle was returned to the long-acting liquid formulation of methylphenidate atthat time, and a follow-up was scheduled 2 weeks later.On return to clinic, his parents reported that Kyle's behaviors had continued to become increasingly difficult. He was described as uncooperative and aggressive at home and school. Kyle was easily upset any timehe was not given his way, his behavior was corrected, or he felt that he was not the center of attention. Whenupset, he would yell, bite, kick, spit, or throw his body to the ground and refuse to move. At 110 pounds,Kyle's parents were no longer able to physically move his body when he dropped to the ground. This was asafety concern for his parents because he had displayed this behavior in the parking lot of a busy shoppingarea. Because of Kyle's aggressive and unpredictable behavior, parents no longer felt comfortable taking himto public places. Family members who had previously been comfortable staying with Kyle while his parentswere out for short periods would no longer stay with him. Overall, the behaviors resulted in parents beingunable to go to dinner as a couple or provide individual attention to their other children. The parents described the family as "on edge."How would you approach Kyle's management?.