Discussion in 'General Parenting' started by buddy, Nov 2, 2011.
Hi! Wondering if today was the day for the psychiatrist. How did it go????
Thanks for remembering and asking, buddy - that was thoughtful. Well, nothing ever goes as we imagine, right? So I can't really recall what I was imagining with this psychiatrist but anyway, it wasn't like that
He seemed very approachable, slightly eccentric, in a huge office with beautiful bits of artwork around the place. He began by asking Jacob, not me, questions, speaking to him like an adult or a much older child - where he lived, where he went to school, when he saw his father, where his grandmother lived, etc. J was gyrating around the chair but sitting still. The doctor asked him to draw a picture of himself by his house while he talked to me - I told him about the adoption, the divorce, the problems of aggressivity, impulsiveness, the being oppositional if I was authoritarian. The doctor then spoke directly to J - I was rather surprised by this! - in a stern voice, telling him that just because his daddy lived in Morocco and he lived with me that he was the man or the boss of the house; mummy was the boss, he said, and he had to do what she said... J during this was hiding his head in his arms, kind of playing at being intimidated - I could see he was not really. The doctor looked at his picture and asked him again in this stern voice why he had drawn a picture of himself with a belly button like a baby when he was a big boy. He then said it was clear Jacob was very intelligent and asked me about school; I said there were no problems during class but more in the break times. He said that it was very clear that he was hyperactive but that the problem was that hyperactivity had now been lumped in with attention deficit disorder which J does not suffer from - he said that many conditions have been lumped together and that this had something to do with it being made easier to prescribe catch-all drugs. He repeated several times that Jacob was very intelligent and he seemed particularly struck by this. Also talked about him being tyrannical, egocentric because he was in search of an identity, having to impose himself on others because he didn't really know who he was, moving between three cultures and languages. There is probably something in this but I don't know how much.
Anyway the upshot is that he recommends he sees a colleague of his, a psychomotricien (a profession that does not seem to exist outside of France, a kind of marrying between the physical and the psychological) who is a man - this is rather rare - as he thinks it important for him to work with a man and he will see J occasionally after receiving a report from him.
Not really sure how I feel about this - I realised as I was sitting talking to him that I had ludicrously somehow been hoping for a miracle, hoping that he would somehow magically be able to provide a means of sorting everything out A quite unconscious piece of absurdity... The psychomotricien, he said, would help teach him to calm himself and how not to be constantly hyperactive. So that is obviously important.
On the way back, I talked to J about seeing the psychomotricien and that he is going to help him calm down. "It will not work with me!", he said... Out of the mouths of babes and sucklings.
First, this psychiatrist is brilliant, in my opinion. Because so much of what you described, just didn't jive with ADHD to me, either. (between family members, I'm sure we have a dozen variations or more...)
Hyper - yes. To me, what the psychiatrist is saying is that J has "executive function deficits"... difficulty with transitions (shift), initiating, completing, planning organizing, thinking-before-doing (inhibit) and so on.
medications do NOT work for executive functions issues, generally... or at least, anything that does, is extreme and so reserved for extreme cases.
What does work is... being taught how to work with YOUR deficits. That is, J has to learn to use other parts of his brain, to compensate at least for now... AND learn how to use stuff OUTSIDE his brain to help too... from "mommy-help" to written plans, reminders, etc.
Getting good help for exec functions NOW... is a gift.
This guy is wonderful. Can we borrow him please?
The simple fact that he listened - to you, and to J as well - and then suggested a specialist, says to me that he is one of those rare psychiatrists that evaluate, then work with what's possible and plausible instead of (cough, choke) "behavior charts"...
Step... do you need to ship Oynxx to France??
The county would make out ahead..... if they do a one way ticket! But warn Malika before she leaves!
Well, it actually sounds really interesting. I suppose it is a little disappointing not to have a "fix it" kind of answer we all dream of. This other guy sounds interesting. I love what J said to you. I have heard many comments like that...they know too much. Q asked why I didn't think he was ready to come home the other day and I told him I didn't think the medications were working still. He said, I'm just too tough for you, huh? I said no, I can handle anything, but I want you feel better. He is always fishing for my weaknesses and trying to assert his being in control.
So, do you have an appointment yet, are you thinking you will even try this guy out? (well, haha, not YOU try him out....sorry bad choice of words. Will you utilize his therapy services for your son?)
Yes, actually it would (in all seriousness) probably be very good for Onyx to see this doctor - I'm sure he speaks English. Sometimes a completely unusual, unexpected input can be the creative and successful one. But I realise of course it's not on the cards
Actually, I think the point the doctor was making really, IC, is that nowadays J would be labelled ADHD, because there is nowhere else to label him (as far as we know) but this is because the label itself is inaccurate. There used to be a diagnosis of, simply, hyperactive before it was put in with the attention deficit disorder... It does all seem to come back to "what's in a label"? As you say, the point is to get help with the things that cause problems in his life - and the lives of those who deal with him.
Interesting that you thought he was good, Step. Yes, he did listen attentively and although his comments were rather left field, why not? Actually he seemed really stern and severe with J and I thought "my goodness, he really is a hard nut" but right at the end, when the session was "over", he was absolutely beaming at J and looking at him with a real twinkle in his eye... So it was a kind of therapeutic performance, I suppose.
The "new" term here is "executive function deficits". It covers all the exec function issues that don't fall under other dxes... its not just ADHD... Autism Spectrum Disorders (ASD)/Aspie can have that as well, and there are others that just don't come to mind right now.
What is being recognized is that it is possible to have JUST this problem with the executive functions, and NOT all the "other stuff".
At some point, somebody will make the case for an official label! Meanwhile, "executive function deficits" may be as close as you get...
Well... unfortunately I am in a place where this won't be talked about or offered as a diagnosis at all. J is just going to be called ADHD and since he does have almost all the listed symptoms of that, maybe it doesn't matter. I forgot to mention that this doctor spoke a lot about his reservations about Ritalin and the fact that the long-term side effects are just not known - he seemed to say, which is my own feeling, that if we can get away without medicating J, we should not medicate. So in that sense the diagnosis is not actually all that vital, in the end. Everything is going to be clearer in a year or so when we see more what is happening at school.
Interesting, its commonly understood here that Ritalin (and related) doesn't impact executive functions much... it has a huge impact on attention management, IF it works. (for us, it does) SO... not medicating with Ritalin if there isn't an attention issue definitely makes a LOT of sense. Did you see the article over in the news section, about a dopamine-related gene that seems to indicate if a person is receptive to these medications or not? Sure makes sense to me. As you're not going down that road, I won't go into the "long term effects" discussion...! (there is a lot more known than some psychiatrists will tell you... the older standards seem safer than some of the new ones, but the jury is still out on the new ones as there is no long-term use to compare to!)
What works for executive functions is accommodations and interventions - not medications. Accommodations include outside help in providing direction, limits, etc. that normally you'd expect a kid "this age" to not need.,.. and interventions, essentially, are behavior management and cognitive work... and the interventions need to be applied to all environments where the issues show up - home, school, etc. Good news is... many of the executive functions are eventually grown out of to some degree (e.g. Janet's Cory...); somehow, about age 25, they catch up with themselves. Not perfectly, but it is amazing.
Actual LABEL isn't as important. Its more about knowing what works...
To me... your discussion with the psychiatrist today means that YOUR current approach (modifying parenting and trying to get school to modify teaching...) is the RIGHT approach.
The big question is how to get SCHOOL on-side with this...
The long term side effects of ritalin arent known? What planet is this guy from? I would say country but I know that one. Ritalin has been in use for at least 40 years I believe if not longer. We know the long term side effects.
That's all interesting, IC (genuinely - sometimes "interesting" in British English is used as a euphemism for... well, less than interesting ) You don't mention hyperactivity, though - constant, restless movement - which is really J's hallmark and his most obvious "issue". Will he grow out of that??
That doesn't seem to be correct, Janet. Typing in "long-term effects of Ritalin unknown" into google came up with many sites. Wikipedia, presumably reasonably neutral, has the following to say:
[h=3]Long-term effects[/h] The effects of long-term methylphenidate treatment on the developing brains of children with ADHD is the subject of study and debate.[SUP][/SUP][SUP][/SUP] Although the safety profile of short-term methylphenidate therapy in clinical trials has been well established, repeated use of psychostimulants such as methylphenidate is less clear. There are no well defined withdrawal schedules for discontinuing long-term use of stimulants.[SUP][/SUP] There is limited data that suggests there are benefits to long-term treatment in correctly diagnosed children with ADHD, with overall modest risks.[SUP][/SUP] Short-term clinical trials lasting a few weeks show an incidence of psychosis of about 0.1%.[SUP][/SUP] A small study of just under 100 children that assessed long-term outcome of stimulant use found that 6% of children became psychotic after months or years of stimulant therapy. Typically, psychosis would abate soon after stopping stimulant therapy. As the study size was small, larger studies have been recommended.[SUP][/SUP] The long-term effects on mental health disorders in later life of chronic use of methylphenidate is unknown.[SUP][/SUP] Concerns have been raised that long-term therapy might cause drug dependence, paranoia, schizophrenia and behavioral sensitisation, similar to other stimulants.[SUP][/SUP] Psychotic symptoms from methylphenidate can include hearing voices, visual hallucinations, urges to harm oneself, severe anxiety, euphoria, grandiosity, paranoid delusions, confusion, increased aggression and irritability. Methylphenidate psychosis is unpredictable in whom it will occur. Family history of mental illness does not predict the incidence of stimulant toxicosis in children with ADHD. High rates of childhood stimulant use is found in patients with a diagnosis of schizophrenia and bipolar disorder independent of ADHD. Individuals with a diagnosis of bipolar or schizophrenia who were prescribed stimulants during childhood typically have a significantly earlier onset of the psychotic disorder and suffer a more severe clinical course of psychotic disorder.[SUP][/SUP][SUP][/SUP][SUP][/SUP] Knowledge of the effects of chronic use of methylphenidate is poorly understood with regard to persisting behavioral and neuroadaptational effects.[SUP][/SUP]
Tolerance and behavioural sensitisation may occur with long-term use of methylphenidate.[SUP][/SUP] There is also cross tolerance with other stimulants such as amphetamines and cocaine.[SUP][/SUP] Stimulant withdrawal or rebound reactions can occur and should be minimised in intensity, e.g. via a gradual tapering off of medication over a period of weeks or months.[SUP][/SUP][SUP][/SUP][SUP][/SUP] A very small study of abrupt withdrawal of stimulants did suggest that withdrawal reactions are not typical. Nonetheless, withdrawal reactions may still occur in susceptible individuals.[SUP][/SUP] The withdrawal or rebound symptoms of methylphenidate can include psychosis, depression, irritability and a temporary worsening of the original ADHD symptoms. Methylphenidate, due to its very short elimination half life, may be more prone to rebound effects than d-amphetamine.[SUP][/SUP][SUP][/SUP][SUP][/SUP] Up to a third of children with ADHD experience a rebound effect when methylphenidate dose wears off.[SUP][/SUP]
All I can say is...psychiatrists are sure different in France than in the US...kind of more Freudian. I am not sure I think it's better. At any rate, hope this helps J. and you a lot!!
Keep us posted!
Do you feel that this doctor is the right one for you and J, that he'll be helpful and communicative, back you up when needed, test when needed?
This happens to Q. He HAS to be dosed at 3.5 hours if he uses short acting ritalin or he just falls off the deep end of hyperactivity (not rage stuff, just totally WILD and can't follow a direction to save his life, literally). One of the big reasons we are looking for supportive medications right now is that he is on such high doses of Ritalin/concerta and clonidine. These both can cause serious cardiac issues and blood pressure issues. He has to be monitored a lot and we were told that since he has been on for 10 years it is pretty serious. He seems fine now but even in the hospital, pulse rates and BiPolar (BP) have once in a while shot up and it didn't seem to be related to any upset or anything. It doesn't make sense that there would NOT be a risk with such a serious brain altering medication. All I can say is, despite the fears, thank God it is available because without it we have no chance right now at our house.
Short answer - sort of.
As in... he will not lose the advantages of those energy bursts. Rather, he will learn how to manage them, rather than those bursts being in control of him... As his executive functions mature, and/or he learns solid skills to deal with the gaps, the "trouble" parts are reduced... but the things that make him unique, will still be there.
In the long run, it becomes less obviously physical. Give him 10 years (even 5 makes a difference), and some of that roaming and bouncing and such is replaced by toe-tapping, finger bouncing sorts of activity... add another 10 years or so, and its small fidgets and more "mental" hyper... Brain hits warp speed... trust me, it can be a REAL advantage depending on your career!
I don't think there's one kind of psychiatrist in France, MWM, just as I'm sure there isn't just one kind in the US I myself was a little surprised by a few of his comments. But basically what he said seems common sense - he recommended that J see a physical/psychological therapist and he said that his problems of aggressivity/impulsivity are due to a combination of factors, neurological and circumstantial, which seems to me doubtless true. The human being is a complex mechanism.
Just to say, in relation to this... it occurs to me this evening that in some (many?) ways, parents are the experts on their "different" children, not doctors. This doctor we saw yesterday had some valuable things to say, some good insights but... really he didn't seem to understand that J is not the way he is because he doesn't have a full-time father but because of things that are far more entrenched than that, that reach back much further in time, and that dealing with these explosive children is a whole art, something that the people on the ground get to understand and implement in a way that really has to be respected. Hence the value of the shared wisdom of this forum, for example...
Had a bad headache this evening and J was really so sweet. He said "Come and sit on my lap!", wanted to rub my head and insisted on taking off my boots for me... Took a paracetamol and by the end of the evening had cheered up with his amusing, affectionate chatter... Parenting him rubs both ways.
The sweet sides of them are always nice, even (especially?) when we're feeling bad. Good for you both that he has that, and hope you're feeling better.
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