I FINALLY got the psychiatrist's report!!!

Discussion in 'General Parenting' started by klmno, Jan 4, 2008.

  1. klmno

    klmno Active Member

    They faxed the psychiatrist's report, her recommendations, and the results from the one test the Ed Spec gave difficult child. I'm still working on getting the Ed Spec full report and recommendations for IEP- but I need that quick. Anyway, psychiatrist's report answered some questions but raised others-

    1) She diagnosis'd him with Adjustment Disorder. She ruled out Conduct Disorder because she said his "acting out" was secondary to the AD- he has trouble with (basicly no) coping skills for psychosocial stressors and handles it by self-destructive behavior, misbehaving at school, and breaking the law. (I thought that would mean CD was comorbid)

    2) She ruled out Bipolar because she said his symptons were not suggestive of Bipolar and that he does not meet the criteria for it. (Really?)

    3) She said he needed a New tdco to deal with AD and coping skills for stressors. She says it should be cognitive behavioral therapy and psychotherapy (this will surely get the MST guy out of the picture YYYEEEHHH!!!)

    4) She said he should stay on a mood stabilizer until this therapy is in effect. She said the mood stabilizer is probably maintaining the mania but he might also need to be back on prozac to help with depression for a while (but isn't that bipolar???)

    5) Once he has effective therapy, she recommends slowly coming off all medications

    She said she's known difficult child's regular psychiatrist a long time- through professional working relationships. Any chance she really thinks that difficult child doesn't experience mania at all but she just doesn't want to be that blunt about it in a written report that regular psychiatrist will see?

    What do you all think of this? I mean, it's obviously good news if it works- and she had ALL history, previous assessments, everything, and spoke to regular psychiatrist. I do know that she told psychiatrist she thought difficult child should have an anti-depressant added back. She's one of the best in the state and heads a mood disorders clinic. She did mention in the meeting, though, that she doesn't like formal diagnosis's because they can lead to trying to make one fit into a mold and that too often they stick too long when they shouldn't.

    Oh, the Ed Spec had given difficult child a test for ADHD. The results say he can't be given that diagnosis because 50% of answers met ADHD criteria and 50% were extreme in opposite direction. (my words of course) Well, this one didn't shock me because when difficult child had full neuropsychologist testing done 2 yrs ago, several of the many test came back wierd like that, too. The Ed Spec has a copy of those tests and report so I guess it's no wonder it's taking him so long to figure out what's going on in difficult child's head!! Has anyone else ever seen this? What is it indicative of? When the regular psychiatrist mentioned bipolar (not pertaining to testing results) I did think maybe the results were that way due to rapid cycling or being in a mixed state.

    Thoughts, comments, questions, suggestions??
  2. totoro

    totoro Mom? What's a GFG?

    How did this psychiatrist come to this conclusion? How much time did she spend with difficult child? I am always a bit nervous when someone quickly gives a diagnosis or a R/I or a rule out without spending a long time with the child...

    Our psychiatrist took K's ODD diagnosis away this summer, well her medications were kind of working... now she is very ODD, so does he put it back??? I dislike that way of thinking.... I don't mind that it is off of her chart... but my goodness... you don't see it one day, Oh it is gone!!!

    I don't know what your child's diagnosis is, but these things are SO complex, to say it is or it isn't just blows my mind. It is like when I have met a psychiatrist and they so quickly would say there is no way your child is Autistic. I take offense to that statement, because seriously how do they really know?
    Just because she makes eye contact?
    Come on...
    Spend some time with the kids... talk to them, engage them.
    I do hope this has answered some questions for you... and that your psychiatrist is right. I hope your son is not BiPolar (BP)... Maybe the psychiatrist is that good!!! We never know???
  3. LittleDudesMom

    LittleDudesMom Well-Known Member Staff Member

    I'm sorry that I don't remember the specifics that led you to this psychiatrist and exactly how much time she spent on his evaluation. But I think, were I you, that I would be a little confused with the absolutes.

    "....she doesn't like formal diagnosis's because they can lead to trying to make one fit into a mold and that too often they stick too long when they shouldn't." I kinda like this way of thinking. No one child presents a formal diagnosis exactly like another child.

    We seem to forever be trying something new, something else. If you feel comfortable in your gut, take her recommendations and see what happens. Or, speak to his long time psychiatrist about all this and she was her thoughts are.

    Sorry I couldn't offer you any more.

  4. klmno

    klmno Active Member

    It was a multi-discipline evaluation. There's a post on the faq forum that describes how this works. We didn't have all disciplines listed on that post- just a psychiatrist, Ed Spec and psychologist. It takes mos. to get them because most info and all release forms for every place the difficult child has ever been are sent in before you get there. It's not like a regular psychiatrist visit- or like the "initial" psychiatrist visit. The application is 1/2 inch thick and includes all history and why you're requesting the evaluation. In this case, I specifically asked for a review of diagnosis (this place is supposed to specialize in taking all the "little pieces of info pertaining to difficult child" and help distinguish between which, if any, mood disorder they have) and I asked specifically for treatment and IEP recommendations. This is why the report focuses on that- except I don't have the IEP portion yet. They spent a few hours with us- about 1/2 hour -45 mins of that was the test they gave difficult child and Ed Spec talked with him just a little. We only had to spend a few mins. in the waiting room- the rest of the time was with the team. A few days later the psychiatrist spoke in person with regular psychiatrist about it all. (With my permission)

    It was Plan B since I couldn't get difficult child in for the 2-4 week inpatient evaluation (which was not the same as a few day stay at an acute facility where they give you a recommendation). I understand what you guys are saying, but since I specificly asked for this kind of assessment, I would have been TICKED if I'd gone in and heard she needs a year to form an opinion! I've been trying to get this since spring when difficult child went on his 2 hour crime spree and got put in juvy. I desparately needed something more than a 2 year old neuropsychologist report (still valid for school but doesn't impress judges or GAL's too much!) and something more than a letter from psychiatrist who gives 15 min appts, although he did do a medication wash and we watched all behavior this summer so he could do his own evaluation- it's still not the same level of evaluation.
  5. flutterbee

    flutterbee Guest

    I mentioned Adjustment Disorder to a couple of difficult child's psychiatrists and tdocs to see if they thought that was a possibility. They all said that Adjustment Disorder has a duration of 6 months. If the behavior persists after 6 months, it's no longer Adjustment Disorder; it's something else. It doesn't mean that it didn't start out as Adjustment Disorder, but after 6 months they have to consider something else.

    I haven't kept up with that one, though. I don't know if they're looking into changing the diagnostic criteria. But, as listed in the DSM-IV, it has a duration of 6 months.
  6. tammyjh

    tammyjh New Member

    Just wanted to add that while I think lengthy evaluations are the best, when a dr. "gets it", it doesn't always have to be a lenthy evaluation. or visit. We had one of the best reports from a neuro who spent an hour and a half with my daughter and I. She looked over past reports, listened to me, observed my daughter and one of her first comments on her report was dead on. Unfortunately, we only had that one consult with her while daughter was an inpatient at the hospital. We're trying to figure out what hoops we need to jump through to get back to see her as our reg. neuro doesn't feel the need to see her. Anyway, if you are in agreement with the new doctor and feel this is what you need to try, go for it. I hope the new changes and information helps you and your difficult child.
  7. klmno

    klmno Active Member

    Well, your responses give me "points to ponder"- Thank you!

    When I first glanced over the report, I thought it meant a lot of sudden, drastic changes. But after carefully reading it through it, it appeared to really only changed the label- at least for the short term. She recommends staying on current medication (mood stabilizer), possibly adding in an anti-depressant, for the time being. (The evaluation was done when difficult child was only on lithium- there was no doubt this wasn't sufficient so I knew something else needed to be done re. medications). Regular psychiatrist and I discussed it and decided to try depakote instead of anti-depressant first. Anyway, medications are a work in progress either way. Thursday, regular psychiatrist agreed that now since difficult child is on depakote and it seems to have helped more than lithium, we'll try (very slowly, as this is difficult child's "troubled" time of year) to decrease liithium and see if depakote alone will do it.

    The "label" change I understand, kind of, because of things she said verbally while we were there. (by the way, the report was actually written by her scribe- an intern who was there taking her notes- I "pushed" them to send me whatever was in difficult child's file to get something in hand. Anyway, she felt like difficult child should have underlying issues (that "triggered" all these problems to begin with) dealt with first. Then, she said (in person), we can always go back and add "more on" later if this doesn't solve the problem. Well, I liked that and very much agree because I couldn't get anyone (tdocs, sd, etc) to even acknowledge that there were underlying issues, much less address them. And I definitely agree that if they are not addressed, difficult child will continue to self-destruct by destroying his life- whether with legal problems or self-harm. So, putting what they put in writing gives me something to show the sd and tdocs and carries much more weight than just me saying something that sounds like I'm making excuses for him. Like she said in person, if he still has conduct issues after dealing with underlying issues, that will obviously need to be dealt with, too. Right now, behavior is not the big problem so it doesn't need to be the primary focus as long as he's "maintaining". Whether or not it turns out that he's CD or BiPolar (BP) or both, I have always wanted someone to deal with the underlying issues he has (they are justifiable) but as I said, couldn't find the right situation to get that done, so now maybe I can. As far as diagnosis's- by what she said, I was left with the impression that she believes a psychiatrist can always add a diagnosis if needed, but if a diagnosis has been put out there to sd, courts, etc., it's much harder to get that label removed.
  8. klmno

    klmno Active Member

    What I really didn't understand was her acknowledgement of cycling, mention of mania and depression, but then saying this wasn't bipolar. What else could it be?
  9. TerryJ2

    TerryJ2 Well-Known Member

    Sounds like good info and you've made some progress.

    Were you the one who talked about cycling and she nodded in agreement, or did she say she actually saw cycling? Either way, it could be related to the medications. I don't have much to offer except support.
  10. Steely

    Steely Active Member

    Hmmmm...........All, I have to say is.........
    Isn't it an anti-depressant that started this whole mess with your son? Isn't this when he began cycling and getting in trouble?
    If so, there is no way I would add that back into the mix. NO WAY.
    And did not the psychiatrist just say to decrease the Lithium? If you decrease the Lithium, and add an anti-depressant, it sounds like a recipe for disaster.
  11. smallworld

    smallworld Moderator

    This is my understanding of mania -- it can be triggered by many things, such as antidepressants, bipolar disorder, anxiety, even brain injury. However it is induced, mania is treated the same way -- with mood stabilizers and/or atpyical antipsychotics.

    My daughter, for example, became manic while taking the SSRI Paxil initially prescribed for depression. We treated her with mood stabilizers (first Depakote and then Lamictal) and then added in the SSRI Lexapro because she was still depressed. She is currently very stable. We don't know if she has BiPolar (BP) or not. We plan to d/c Lexapro this spring to see if she's still depressed (because she's been on it for a year and depression can be episodic and remit). We at some point will test her off Lamictal as well to see if she still needs it.

    Your difficult child's mania could have been induced by Prozac, even if he doesn't have BiPolar (BP).
  12. klmno

    klmno Active Member

    Thanks, All! Your opinions mean a lot to me-

    She said in person "well, he's definitely cycling" then something like "whether or not it was the prozac or he was well on his way before we just don't know at this point, but since it was the issues with his father and a cancer scare for Mom (me) that started the whole thing, let's deal with that first. It may be that the behavioral issues will stop once this is taken care of". I should add 3 things- 1) English is her second language but I think I understood her correctly- especially after receiving the report, 2) my family history has no bipolar but does have depression and anxiety (me, my mom, and my dad)- none of us took medications long term and I've never taken medications for it but have gone through therapy, which helped a great deal, and go short-term to a therapist when I have an "issue" I want help with. She discussed this with me and asked if I felt this was a confortable solution for me, I do because I'm functional and after my therapy, it's not "stood in my way". After this discussion she asked me if I had the same goal for my difficult child- that he would learn how to manage his problems and life without medications. I said of course, if possible, but if not, we'll work thru it. She said something, don't remember exact words, that kind of lead me to believe that because of this family history and success with certain therapy and no medications now for me, there was a strong possibility that this would be a successful path for him. Not an absolute- but worth trying. And 3) she said enough to let me know that she knew the importance of wording things a certain way in writing- that sd's and judges don't always treat difficult child's with certain problems in a way that helps them

    WW- regular psychiatrist seems to think prozac caused mania. I, on the other hand, think there's still a possibility difficult child was manic in Jan., 2006, when I took him to psychiatric hospital- which is where he was put on prozac. He was a clear danger to self and maybe others then. difficult child was starting to show signs of instability in Jan/Feb 2007 so prozac dosage was increased. Then, crime spree. So, who knows- prozac made him manic, prozac sent existing mania to different league, prozac had nothing to do with it, it wasn't mania at all?????? I wouldn't be comfortable trying an AD again until I'm a little more comfortable with an answer to that question- psychiatrist and I agreed to wait a little on that. I really wish I could have gotten him in for that inpatient evaluation because it would have been profs watching him 24/7 for weeks instead of me saying "I think he's crossed the threshold".

    Can you cycle like this and not be bipolar? Then what it is?

    by the way- WW, I've been watching your post because I feel for what you're going through. I didn't respond on the thread because I haven't been there done that, but I do feel for you and it sounds like your difficult child has a great Mom!
  13. smallworld

    smallworld Moderator

    Cycling can occur with any mood disorder. It is not necessarily specific to BiPolar (BP). Furthermore, BiPolar (BP) is a neurobiological illness and is lifelong. Do you recall when I posted about my son and his diagnosis? In a previous post, I said not one doctor that we've consulted (and we've seen a ton at this point) will tell us definitively whether he has BiPolar (BP). They will say that he has a mood disorder with anxiety, depression and mood lability, and they are prescribing medications used for the treatment of BiPolar (BP) (both mood stabilizers and atypical antipsychotics). But they will not commit to a BiPolar (BP) diagnosis because they are not certain what he will look like as an adult. I think the same may hold true for your son.

    by the way, we don't know of any BiPolar (BP) in our family either -- just a slew of anxiety and depression.

  14. klmno

    klmno Active Member

    Smallworld, I just read your response (and the previous one). This is very helpful. It made me recall that she did say the mood stabilizer was taking care of some things but that she thought he needed to be put back on an AD because he still needed something to take care of the depression, until he has therapy that has dealt with it(assuming of course that therapy and coping skills can take care of it without medications). Whether or not he'll always need medications for it,I still want him to get the therapy that teaches him better coping skills, preventative measures, etc.

    Yes, I remember your post before. (Sorry I didn't PM- I'm not in your area though so a therapist around Difficult Child wouldn't help much, unfortunately.) Thanks for trying!

    This is just SSOOO confusing. Regular psychiatrist and psychiatrist on evaluation team have different personalities and approach things differently- I'm glad we got her opinion. I'll still take what I'm comfortable with from it (like the therapy recommendations) but keep the rest in the back of my mind to see what might develop in the future. She might be correct- it's depression- he needs an AD- but then will he always need a mood stabilizer to counteract mania caused by an AD? Really, I have to go back to the fact that he was acting pretty manic to me before he was ever on any medication. But, then I hear raging and erratic behavior can be depression - especially if it's going along with other major depression symptons and it's an adolescent boy.

    I'm confused. Doesn't matter- medications are still going through same process- the evaluation will help in court and with sd and hopefully, will help get a therapist on board to deal with things that should have been dealt with by first therapist I took him to.

    I really appreciate everyone helping me get through this process!
  15. susiestar

    susiestar Roll With It

    It sounds like this woman has a pretty good handle on the way the courts work. She also seemed to spend a good deal of time with your family. Personally, I tend to agree more with reports issued fairly soon after the evaluation than reports issued a month or many months later. (mostly this is because a social worker evaled difficult child and called me with one set of things then her written report 2 months later mentioned nothing that she told me and nothing that related to my child. I have had several psychiatrist evaluations come out the same way. :frown: )

    I would keep on pushing for the 2-4 week inpatient evaluation if at all possible. Otherwise, it sounds like an interesting report. I do think that moods can cycle because emotional/family events and NOT bipolar. If bipolar, then medications can control it but it won't ever go away. If triggered because events/issues, then therapy and medications can help you learn to deal with it and it may not be a lifelong issue.

    I personally have had issues that therapy helped a lot with. My husband says that the therapy certainly helped (and he HATED therapy).

    Not sure what adjustment disorder is, but maybe it will be easier to get the court to help with this diagnosis?


  16. klmno

    klmno Active Member

    Ok, I've been trying to digest this-

    I thought cycling between mania and depression WAS bipolar. Now, I see that's not necessarily the case. Either way, cycling can be treated with medications. If the underlying problem is depression, they might need an AD as well. If it's not true bipolar, it might not last a lifetime.

    How am I doing?

    Re. the inpatient evaluation- it's out of the question now, unless something changes. This is why judge got GAL on board- to help with this. I had been told my insurance company would pay for it but charges needed to be reduced in order for them to take him in. Gal was working on getting charges reduced then I found out insurance company wouldn't pay. I asked GAL if county would pay, she got social services involved- I thought to get county to pay, then find out she (GAL) was having them look into Residential Treatment Center (RTC). psychiatrist and I thought that was a little premature and I felt like nailing down the diagnosis would lead to the best treatment. Anyway, social services looking into this left door open in other ways and my bro filed for custody. It was a nightmare. Now, bro is out of picture, as is social services, and I have sworn to GAL that I don't want anymore help from this county.
  17. smallworld

    smallworld Moderator

    You basically have the gist. My understanding is that the only way to treat the manic part of cycling is through medications. The depressive end of cycling can be addressed through psychotherapy or through medications, but the mood must be more stable before therapy can be accessed. medications for depression do not necessarily have to be ADs. Lamictal is a mood stabilizer that addresses the depressive end of mood disorders but is also being used with increasing frequency for treatment-resistant unipolar depression (it's been a great medication for two of my depressed kids). Atypical antipsychotics like Seroquel are also used for anxiety and depression.