What do you treat first?

[ck1]

My 16 year old difficult child son is expected to be released from the Residential Treatment Facility (RTF) in a few weeks, after a 90 day stay. He's been doing very well there and they feel that they can't do any more for him, also that if they tried to get the insurance to pay for any more time, they'd be laughed at. I think I agree, but, of course, I'm a little nervous. He is a teenager after all.

However, my question for you is, which disorder is treated first? His current diagnosis is ADHD, Major Depression/Mood Disorder, and I can't remember the other one. Anyway, he has bi-polar coming from both sides (my mom and his bio-dad). According to the book, "BiPolar Child" if you have bi-polar in your family, you shouldn't take a stimulant or an anti-depressant.

My son is currently taking 100 mg seroquil and 25 mg zoloft (weaning off) and nothing for the ADHD, per his request. My sister, who has a child diagnosed with ADHD and is very knowledgeable, is pushing me to ask why the ADHD isn't being treated and says that we're setting him up for failure if he isn't given anything.

Uugghh!! I feel very stuck and don't know what to do. I know I can ask the psychiatrist and I will, but honestly, I think you all are much more informative because you've been there done that. People who know about it are not always as helpful as people who live with it.

Also, if anyone has an opinion about music, I'd like to hear that too. My sister is also pushing me to take ALL of his music away. Ok, I don't like what he listens to. But, taking it away, to him, is like taking away his air supply. He lives for his music (at least that's what he calls it, I have another description for what he listens to). I'm just not sure if I'm ready to fight that fight, even though it may be worth it, I don't know!!! How do you know what's right????

 

[KFld]

Not quite sure how to answer the question of which disorder to treat first. I think the psychiatrist could answer that best.

As far as the music? That is a tough one. I know my difficult child listened to some pretty horrible music and I went through the stage of buying him the sensored tapes and cd's, but when he left the house he listened to whatever he wanted too. You can only control what they do when they are home. Once they leave and go to friends houses etc., you have no idea what he's listening too.

It may be a good start to not allow it in your home as it will set an example, but I don't think I'd get too carried away with it.

 

[Mikey]

IANAD (I am not a doctor), but I personally feel that ADHD is the root of all evil in the world. However, unlike some of the other issues you've listed, I've not heard of anyone becoming actively suicidal or intentionally self-harmful from ADHD (other than when I, er, "they" got the wrong medications).

Unfortunately, in my humble opinion only docs you trust can guide you on this. Treatment with psychoactive drugs is always serious and dicey. Therefore, I feel that the only people who can give you the info you need are docs that (a) are competent to treat the illnesses you list, (b) that you trust, and (c) know your son and all his little quirks and oddities (for instance, my son and I can take Focalin and Ritalin all day, but become murderous thugs on Adderall).

As to music, that's a mixed bag. For some addicts, music is part of the "environment" in which they indulge their addiction. But that's not always true, so it's a hard call. I know my son likes to listen to Sublime, Kottonmouth Kings, Cypress Hill, and other bands that have a definite "drug culture" orientation. But I could never stop him from listening, even if I wanted to. I did, however, introduce him to some other styles of music that he ended up liking (techno, dance, trance, etc..). They carry their own "drug culture" connotations, but not for my son. So for him those "styles" were relatively safe because they weren't part of his drug habituation.

But with all that being said, in the end it didn't matter one way or the other. Music wasn't the evil driving McWeedy to drugs, and removing it wouldn't stop him from doing drugs. The only thing along those lines that might have helped (if we could have done it) would have been to change his friends, not the music. But we couldn't change or affect his choice of music or friends, so ultimately it didn't matter.

But then again, that's my situation, not necessarily yours. This might be something else to talk to your docs about, though - especially if you think music (or certain types of music) are part of his drug habituation, that may be something they can address along with whatever other treatment is recommended. I don't know what they (or you) can do, but it might be worth looking into.

I don't know if that helps, but I hope it does.

Mikey

 

[BusynMember]

I would treat the bipolar and skip the ADHD. Sometimes ADHD even goes away when bipolar is stablized--it can be thought that a person has ADHD when it's really untreated mania. I'd do one thing at a time. I think the bipolar will get him into more trouble than ADHD. JMO

 

[Suz]

I agree with MWM. Everything I've ever read in books or on this board says to get the person on a mood stabilizer and get the bipolar squared away first, then treat other symptoms, if necessary.

Suz

 

[goldenguru]

Often the symptoms that look like ADHD are really symptoms of bipolar disorder. When my hubby is manic, he exhibits many ADHD characteristics.

With that said - I would consult an adolescent psychiatrist if you can find one. One that is well versed in dual diagnoses.

I agree with Suz and MWM. Get him stable on mood stabilizers then if ADHD symptoms persist - then begin to think about treating them.

 

[NOLA]

Hi-I'm happy to hear he'll be coming home soon :flower:

My first reaction to your situation is 'treat' the family communication first. If he is to be weaning off of the current medications over the next couple weeks I think family therapy would be the absolute best medicine to kick start his return home and keep the lines of communication as open as humanly possible. Only if his psychiatric thinks medications are an absolute necessity for his well being would I stay on that track.

The music.....I wouldn't take away the music but that's just me. I wouldn’t allow the blaring of 4 letter words throughout the house for all to hear but I was (and still am) a rebel without a cause and would not view that 'censorship' in my best interest.

 

[jamrobmic]

I don't know whether your son has been in any trouble, but with my son, I was leery about putting him on any medication that had the possibility of making his behavior worse than it was. I was afraid if he did have a bad reaction to a medication, he would do something that would get him in real trouble, and I would have a hard time convincing anyone it was a medication reaction. There is also a history of bipolar in our family (my sister, and possibly my dad and husband's brother). At one point, his psychiatrist started to put him on an antidepressant (before his bipolar diagnosis), and I questioned it due to our family history. The psychiatrist agreed it could be a problem and put him on Seroquel instead.

He did take a stimulant (Adderall) for about six months (again, this was before the bipolar diagnosis, and before I knew there was a possibility it could worsen his behavior). It didn't really seem to affect his behavior much one way or the other. He wasn't worse on it, but he wasn't better, either. He did focus better at school, and seemed a tiny bit less impulsive, but that was it. I don't think he was taking a full dose most of the time, so maybe that was why it didn't make his behavior worse.

When his bipolar was stable, we still saw ADHD symptoms, but he hated taking stimulants, and I still wasn't willing to risk antidepressants (Strattera), so we left it at that. I don't think he feels his ADHD is a problem (actually we were told ADHD had been ruled out in his case, but everyone who has dealt with him thinks he does have it).

As far as the music, if it's that important to him, I wouldn't take it away. As the others said, you might control it at home, but you can't control it away from home. If it's offensive to you, or you don't want your younger kids to be exposed to it, I would insist that your son respect your wishes and only play it where you and they can't hear it. If you can stand to listen to it a little, it did give my son and me something to discuss during a time when we didn't talk much about anything. I told him what I didn't like about the music (he was very much into rap, especially Eminem and Dr. Dre), and he told me what he did like about it. It was funny, but he didn't hear the same things in it that I did. There were even some songs that I actually ended up liking. And he seems to have outgrown rap; these days he's more into Korn and groups like that. He still calls me into his room from time to time to share music he likes; sometimes I'm surprised to find it's a remake of something I used to listen to (back in the Stone Age, lol).

Anyway, that's my 0.02 worth, based on our experience (IANAD, either). I hope your son continues to do well once he gets home.

 

[SunnyFlorida]

my difficult child 1 was diagnosis with ADHD around 3rd grade. Somewhere along the way it morphed into BiPolar (BP).

psychiatrist had him on Seroquel as monotherapy (using one drug alone). This worked for a very short time. The seroquel made him calmer but didn't really do the trick. It wasn't until he was put on a mood stabilizer (lithium) that we noticed a big difference. Since then, anxiety reared itself and a second mood stabilzer (lamictal) and neurontin was added. This combo is working for him. He still has ADHD sx, but they are managed.

In short, in my humble opinion, I'd have psychiatrist tx the BiPolar (BP) and not worry about the ADHD. The music is a basket B (Ross Greene). He's a teen, it's what teen do. If you don't like the words, have a rule that it's not blaring where you or other minors can hear it.

 

[DDD]

I agree with Sunny and those with the same experiences. Your
sister is trying to help (and may later criticize you for not following her advice, sigh) but in my family we have not banned
any music but have placed reasonable restrictions on volume and
place. Frankly I have never said this before to anyone..not even
on the board, lol..but I would bet that the most vulgar of music
has been blaringly loud from our home when easy child/difficult child was alone or with friends only. We live in an "old" neighborhood where over half the people have been retired for years. I am thankful that
none of them have shared their displeasure of hearing gross/loud
music during the day.

My other thought has to do with his current placement. Wouldn't
it be ideal for you all to get together and discuss the issues
of medication, music, houserules, etc. why your son is still there? He is doing well and is going to be discharged. With
professional people around him I suspect you would be able to more easily find a meeting of the minds. Good luck. DDD

 

[goldenguru]

When my daughter was in her darkest period - her music was very dark. She has explained that listening to it gave a voice to her frustrations. She would often write out the lyrics in her journal. She has said it helped her to realize that she was not the only person dealing with such tumultuous feelings. So for her - it was therapeutic in a weird sort of way.

As a Christian person I had a huge issue with her music. But, I tried to listen to it with her occasionally to open dialog. It really did start some good conversations.

Thankfully, she has moved out of this phase - just as she moved out of the 'dark period' of her life.

I personally would not forbid the music. Boundaries - yes - forbid it? No way.

 

[susiestar]

First, your sister is probably not an expert. And neither are we.

Second, your gut instincts are what you listen to first. And second. Everyone else is later.

Everything I have read, and heard from adults and teen with bipolar, says that you stabilize moods first BECAUSE many of the other medications can make the moods cycle. If the moods are stable, THEN you can evaluate to see what next to treat. If moods are NOT stable, all the other medications in the world will not help.

As for music, EVERY generation seems to use this to rebel. Even in the Amish cultures this is sometimes seen - part of the reason for the period of time for a young adult to go into the secular world for a period of time. Then they can make a choice.

Music is NOT a battle I would fight UNLESS it contributes DIRECTLY to his behavior. I had a roommate who would listen to Guns and Roses every single time she binged and purged. Part of her treatment was to NOT listen to this.

I personally insist that music that is offensive to the parents is NOT played outside your bedroom. Exceptions are made for listening with headphones and NOT singing the lyrics.

I think you have some bigger battles than music. Talk with your difficult child and the staff at the Residential Treatment Center (RTC) to make rules and address these issues.

The BIG issue here, in my humble opinion, is that with a 16 yo you need to set general rules, but you also need to have them in a COOPERATIVE method as much as possible. If your 16yo is totally against ADHD medications, then forcing him to take them may not be the best you can do. It might be needed, but I would make it a last resort.

If you come on too strong it may seem to your son that his opinions are not important to you. You need some cooperation from him, and so maybe the Aunt needs to be quiet.

You know your kid. Better than anyone. Do what you can to work WITH him, rather than AGAINST him. See what rules he thinks are reasonable, and what rules you think are reasonable. You may be on the same page. Pick the rules you totally MUST have, then work with the rest to find a reasonable middle ground.

Hugs,

Susie

ps. Many of us get pressure from family members, and we all have to cope in different ways. Is your sister an expert on the other diagnosis, and how to tell one from the other?? IF she is, can I send my child to her, because NO doctor we have seen claims this. Each child is different, as is each family. It may work for your sister to take all music away and start a war, but it may not for you. It is OK to tell your sister you are doing it a different way because THAT is what is best for your family.

 

[ck1]

This is really good advice--everyone. Thank you!!! Today was the discharge meeting, he'll be home four weeks from today. He's being discharged after only 90 days, fastest that anyone's been through (at least with his therapist and the staff that we talked with). Not sure that's a good thing, but, it is what it is. I'm certain that it would not have been that fast if he hadn't spent the five weeks before that in the detention center.

You all confirmed my gut feelings but wasn't able to put it into words. The seroquil is treating the moods and that has to be stabilized first. In his current setting, he isn't showing ADHD symptoms, so there's no reason to treat it. We're going to have family-based therapy when he comes home and will continue working with a psychiatrist so if we need to treat the ADHD later, we will. I'm not sure why I didn't think to just tell my sister that before, but I will now.

You all have also confirmed my feelings about the music. Mainly that it's not worth a HUGE battle. The one thing that I've let get out of control is allowing him to walk around with his ipod and one earphone in. I really hate that, besides the fact that it's quite rude!! I told him today with his therapist present that that will no longer be tolerated. He can listen to his music in his room at a reasonable volume. In the car, he'll have to use headphones. This will be enforced (we actually did have that rule before but I wasn't always good about enforcing it).

KFLD: limiting the music in my house is the best I can do. I can't control him outside of the house and really, if that's as much as he listens to it, what harm would it really do??

Mikey: I think you are very right about finding a doctor we trust. I haven't been able to so far, but I'll keep trying. I also think that it isn't because of the music that my son started his three week drug use because he was listening to far before that, so in that sense, maybe it's not so bad.

MWM and Suz: That's probably right, the mood disorder will cause him more problems than the ADHD, so I'll worry about that later. Also, my difficult child is very aware of how he is feeling and how the medications work or don't work. He also doesn't give me a problem about taking them.

NOLA: it's funny that you would say that about the family communication because that's exactly what difficult child and husband say needs to be worked on. I came up with a plan for all of us to better be able to say what we're thinking, so hopefully that will create the open communication that we need. ha ha about the 'rebel without a cause'!! that's definitely not me, I'm way too conservative but I sometimes wish that I wasn't

jamrommic: I had never considered a bad reaction to medications. We haven't had that experience before, at least that I know of. It's possible that a lot of this happened over the summer because his dose of Adderall was too high, but he was also really depressed, so I just don't know. My son likes the same type of music as yours and says the same thing. We don't really hear the same thing and he says he really doesn't listen to the words that much, he just likes the beat (if that's what you call it even in rap music).

SF & DDD: thanks, too for your input. I really appreciate it! We are definitely going to talk with his current therapist. The hard part is, the rules that will be in place when he gets home are the same rules that have been in place for years!!! I didn't let him run around and do whatever he wanted, so I just don't know how we got where we are!!

GG: thanks for the information about your daughter. I do believe that's how my son views his music but I hadn't been thinking of it like that. Maybe I'll ask him to journal when he's listening to it to get a feel for how's he's feeling when he is listening to it???

Susiestar: I love your example about your roommate and will use that when the topic comes up with my sister and husband (since he hates the music too). I do not think that his choice of music is directly related to his behavior. He doesn't get into a lot of trouble but I'm going to watch his moods more closely.

I'm the baby of my family so I seem to get the most advice from the others, even when I don't ask for it. The funny thing is, they all come to me and ask for advice because they think I'm the most reasonable and logical!!!

by the way, SusieStar--is the name Gracie Lou Freebush from a movie? It sounds so familiar but I just can't think of which one.

 

[flutterbee]

A few things.

ADHD is either there or it's not, so if he's not exhibiting symptoms, it would make me wonder if he really suffers from it. A lot of things can mimic ADHD including mania, anxiety (took one therapist 8 months to decide my difficult child was not ADHD; that it was anxiety) and even depression. With depression you probably wouldn't see hyperactivity, but definitely inattentiveness...an inability to focus. Of course, it could just be with the other things stabilized, he's able to maintain better control over the ADHD.

Seroquel is an atypical antipsychotic, not a mood stabilizer. It is used for short term treatment of mania, but it will not stabilize moods. It is also useful with a major depressive episode in helping with impulse control. I took risperdal (another atypical antipsychotic) when I was suffering from a major depressive episode. I couldn't take it daily because I couldn't think on it and it caused nightmares, but I took it PRN when I was feeling like I wanted to come out of my skin. If they are thinking bipolar he's going to need a mood stabilizer, probably in addition to the seroquel.

 

[ck1]

Heather: thanks for the feedback. I do believe that he has ADHD, he's pretty classic. I think he's not showing the signs because of the small class-size and lack of distractions (ipod, cell, laptop) and choices. I'd believe ADHD is the right diagnosis before any of the others but I think you're right about his ability to control it if the other symptoms are controlled.

He has taken risperdal in the past, but I think his highest dose was .5. He started taken seroquil again because he said it helps him more. He takes 100mg at night. He has seen I think six psychiatrists in the last 13 months and all have said no bipolar but do say mood disorder. One of those that said no to the bipolar works in the childrens bipolar clinic in Pittsburgh so she sees it a lot.

Now that I think about it, the seroquil was started by the psychiatrist when he was at boarding school last semester and was VERY depressed so I wonder if it will keep working?

 

[susiestar]

Gracie Lou Freebush is the name Sandra Bullock's character creates for the beauty pageant (sorry, scholarship competition) in Miss Congeniality.

My daughter suggested it and it just fits my idiot cat.

One communication item my husband and I find helps us avoid manipulation and triangulation is to keep a pen and notebook in OUR bathroom. The kids use the other bathroom. Ours is for Us. We jot down any problems, rulings, issues, decisions, etc that have come up. Then, we each glance through it while we use the facilities.

Seems to be really helping us, and thwarting them!!

Susie

 

[flutterbee]

Out of curiosity, why are they weaning him off zoloft? Are they planning on trying another antidepressant?

As one who has suffered from both Major Depressive Disorder and Dysthimia, I can tell you first hand that an antidepressant has been life changing for me (that and the progestin, but I'm a girl :smile: ). It took a while before I found one that worked and when I was in that scary, oppressive, severe, borderline psychotic depression NONE of them did a thing. But once I hit my baseline again (dysthimia), antidepressants have been a blessing. For the first time since I was 10, I knew what joy felt like.

When I had my heart attack, I told my doctors that they better make sure whatever they gave me worked with my AD because I was NOT changing it. It took too long to find one that worked for me.

As far as therapy, CBT is best for depression. He may even find EMDR to be helpful, especially if he has any anxiety.

 

[ck1]

Susie: thanks for the reply about Gracie Lou, I knew it was familiar. I LOVE that movie!!! I like your system to avoid the manipulation. I think we'll do that too because sometimes we (more me) forget what we've said or didn't know what the other one said, this will fix that. Thanks!!

Heather: he's being weaned off the zoloft at his request. He says he doesn't feel any different being on the anti-depressant so why take it? I'm not sure what CBT and EMDR therapies are...could you elaborate? Also, in your opinion then, if he starts getting very agitated or grumpy when he comes home, should I keep in mind that he's not taking an anti-depressant but may need one?

 

[flutterbee]

Probably, then, zoloft isn't the right medication for him. I had to go through several before I found one that worked. And none of them worked when I was in the darkest part of a major depressive episode so I quit taking them. In fact, I was taking celexa when my last major episode (and by far, the worst) happened. I was begging for ECT (shock therapy) because nothing else was working.

CBT is Cognitive Behaviorial Therapy. What makes depression so hard to overcome is that the way a depressed mind thinks and views the world becomes learned behavior. IOW, even once the biological part of the depression has been treated - either with medications or (in my case) it's run it's course - the depressed way of thinking still exists. CBT retrains the brain. The longer depression goes untreated, the harder it is to overcome. And each major depressive episode increases the chances of having another.

When I'm feeling up to it, I'll share with you my very long personal story of going through what your son is. It's incredibly difficult for one who hasn't experienced it to understand. The best way to explain it is: There's a man drowning. A rescuer comes to his aid, but in his desperate attempt to keep his head above water and stay alive, the drowning man almost drowns his rescuer. The desperation felt with a severe depressive episode is very similar to that. At least it was for me. I was struggling to keep my head above water and couldn't see far enough ahead to realize what toll my actions were taking. For me, it was a struggle to stay alive because a very big part of me wanted to die more than I wanted anything else in the world. For several months, I didn't live; I merely existed. Friends and family would get upset with me because I slept so much or whatever. My response was...at least I'm alive. That was the truth. They couldn't understand it, but staying alive was about all I could do at that time. That took up all my resources, so there wasn't much left for anything else - being social, going for a walk, just normal stuff.

So, to answer your question, I would say if he's grumpy or agitated then yes, it could be because he's not on an AD.