Help for my Son
joann sciacca
jbsciacca at optonline.net
Sat Mar 17 21:43:17 CDT 2007
Bud, I am pasting below a discussion board from medscape re Bipolar. It is
just the first page but I assume you can read all as well as ask questions.
Hope you find this helpful!
Joann Sciacca
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Lets write our own diagnostic criteria for the "NOT BPD" kids
Topic created Jan 31, 2007 by Adam_Mike_Selene
Of course, mania in childhood exists. However, there seems to be a
significant portion of us who would like another dx for kids who are
explosive but don't show the episodic change from normal functioning that
characterizes the conventional definition of mania written about in DSM.
There is also a general feeling that there is no existing dx category for
many of these kids.
I am inviting us all to write our own category. What do you think?
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An_1298847 - 07:49am Jan 31, 2007 (#1 of 144)
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noe49 - 11:24am Jan 31, 2007 (#2 of 144)
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I never thought 'explosive' children as 'manic'. Temper tantrums, tyrannic
behaviours, inability to tolerate frustration and prohibitions are always,
in my experience, linked with corresponding parents failure in emotional and
educative 'containment' of that child from the very early years, for social
or relational causes. The few cases I remember, of children who became BP as
adults, had diagnosis of dissociative episodes in one case, when I saw him
at age 10, and true manic episode in others aged 13. I work especially as
child psychiatrist and I luck informations about evolutions as adults of
many children I did follow. This is a problem.
An_1818256 - 01:55pm Jan 31, 2007 (#3 of 144)
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I thought the recent Child Psychiatry guidelines was a good place to start.
I copied them to the lamictal/mood stabilizer thread.The original document
included some outcome studies.I hope it will improve the reliability of data
we get about kids diagnosed with Bipolar 1 disorder over time, by
allowing/encouraging people to use Bipolar NOS for kids who don't meet
criteria. I think the "NOS" kids will be hard to define and are a somewhat
hetrogenous group, but it would be great to set some "local" (as in among
Child Psychiatrists) standards as to the severity of symptoms and
accompanying treatments reccommended before prescribing atypicals or
anticonvulsants.Personally, I like to use the "Overt Aggression Scale" and
work on anger management skills ( for kids over 10) and behavioral
interventions, if only to assess families ability to comply with treatment.
Don't really have a "score" in mind, but I expect to see physical aggression
against people, in addition to verbal agression, and agression against
property, and in more than one setting. I'm not saying I define this as a
disorder, but I consider it bad prognostically, regardless of the cause.
While a chaotic family and their "bad" genes may be considered causal,
knowing that doesn't fix the problem, and I think worsens the prognosis. I
had a mother call me yesterday about resuming treatment with her 9 y.o. son
after a one year hiatus. I had seen him after a transfer of care with a
diagnosis of ADHD, but he had failed several medication trials. Appointments
were frequently missed, finances were the reason they would not persue
reccommendations for "therapy", and various situational stressors kept them
from following through with cheaper "parenting classes". He was ultimately
sent away to live with his father, the reason being his step-grandmother's
illness was making it too difficult to follow through. He is back now, he
has since been "diagnosed" with "Bipolar Disorder", prescribed a blend of
meds, but recieiving only stimulants via peds for the last six months until
the pediatrician ( my son's doc, husbands collegue, and frequent referral
source), cut them off and referred to me. I'm afraid I was a little curt
with mom, and demanded she hook up with a therapist first. Things remain
chaotic, finanaces tight, and patient has been suspended several times. I
say she should be cautious about the bipolar label when looking for a
therapist, that she might be better served with integrated services offered
by the county ( but generally not available if you have insurance). She
acknowledged that even with the fancy diagnosis and medication blends,
things remaiined pretty bad. I let her know other Child Psychiatrists might
see this differently ( but I know there isn't another Child Psychiatrists
for maybe 35 miles, let alone one that takes insurance).This scenario comes
up for me alot.
Shrinkrap
rjacobson2 - 11:30pm Jan 31, 2007 (#4 of 144)
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>but I know there isn't another Child Psychiatrists for maybe 35 miles<
That's average shopping distance in L.A. We go that far for a latte or
Chinese food.
I agree with Noe re>Temper tantrums, tyrannic behaviours, inability to
tolerate frustration and prohibitions are always, in my experience, linked
with corresponding parents failure in emotional and educative 'containment'
of that child from the very early years, for social or relational causes. <<
These symptoms are usually clearly different from real mania which does
occur, although this we have discussed as to specific features and we don't
always agree on these. I also reiterate that some of these kids are early
Borderline PD's, but I haven't seen anyone take up that particular analysis
in the journals. Borderlines have to start somewhere, and I don't think it's
all related to abuse.
Last point. Do we really need another diagnosis. Kids are in the formative
years, so are their emotions, and their diagnoses. Maybe we need to simplify
diagnosis, not go adding new ones, but I know AMS must be having a
frustrating day to pose the question.
An_1818256 - 02:10am Feb 1, 2007 (#5 of 144)
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"That's average shopping distance in L.A. We go that far for a latte or
Chinese food"
I kinda remember that; I moved there from New York. Had to live in Westwood
so I could walk to things.
Shrinkrap
noe49 - 11:31am Feb 1, 2007 (#6 of 144)
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<Borderlines have to start somewhere, and I don't think it's all related to
abuse.
As always question is (italian proverb): is one born or it is become (BL)? I
think learned habits can take someone long way both in the road of normality
and pathology. One does learn how to front reality around him from his very
first days, as I see things, and he does learn the ways of cope with stress.
That It will be very difficult to change bad habits, as we know. All that
affects very much the development of capability to front emotions, feelings,
stress, frustration, responsibilities, etc, or the way of avoiding them and
escaping in pathologic retreats. I think DSM has failed: I guess why there
is no a DSM for medical illness. I wonder if one could speak of co-morbidity
of hyperglicemia, retinopatia, renal failure, etc, without to comprehend all
that in diabetes and it's effects on different organs. DSM model calls
'disorders' the symptoms, assigning value of (genetic) illness to sets of
symptoms, and puts attention only to individual aspects, without to consider
relational/interactive aspects, habits and learning. That is IMO a choice a
priori. Or maybe pharmacologists cannot see other aspects, of course, they
lack necessary tools. But we have already spoken long way of that...
In my mind I use to do diagnosis of functioning,of different actors in the
whole scene. So I try to work where I see break points: individual, family,
school etc, or all together. Of course I consider DSM, or better, in Europe,
ICD10, for statistic, epidemiology and medico-legal necessities.
An_2410023 - 08:40pm Feb 1, 2007 (#7 of 144)
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By definition, a kid can't be borderline. Here's the real problem, I think.
If you try to squeeze borderline into a rating scale, you will fail.
Borderlines develop over time. Abuse can be a factor, but so is neglect. But
the most important factor is response to a crazy making parent who clutches
a kid, invades the kids psyche, gives chronic mixed messages, and makes all
love conditional.
There are plenty of abused kids who grow up to be OK adults. There are many
borderlines who were neither physically nor sexually abused.
So if you want to diagnose an incipient borderline, you had better take time
to talk to the kid at length, really get to know his, and get to know the
family. This is not a managed care friendly endeavor.
An_2410023 - 08:42pm Feb 1, 2007 (#8 of 144)
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The bipolar kids all have emotional exaggeration as the key. If you get to
know the kid, you will discover that the kid's emotions tend to all be
appropriate reactions, but way, way too extreme.
Again, you have to engage in a not managed care friendly endeavor.
An_1818256 - 10:13pm Feb 1, 2007 (#9 of 144)
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There is a borderline syndrome of childhood
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_u
ids=2189868&dopt=Abstract> &db=PubMed&list_uids=2189868&dopt=Abstract
and
Conceptualizing borderline syndrome of childhood and childhood schizophrenia
as a developmental disorder
Journal of the American Academy of Child and Adolescent Psychiatry (J. Am.
Acad. Child Adolesc. Psych.) ISSN 0890-8567 CODEN JAAPEE
This is the first attempt to define and validate criteria for an early
onset, chronic syndrome of disturbances in affect modulation, social
ralatedness, and thinking. This study formulates and tests five hypotheses
that follow from conceptualizing this syndrome as a developmental disorder.
The advantages of viewing this syndrome as a developmental disorder are
discussed and compared with alternative formulations such as childhood
schizophrenia or borderline syndrome of childhood
and
Multiple Complex Developmental Disorder: The "Multiple and Complex"
Evolution of the "Childhood Borderline Syndrome" Construct. Journal of the
American Academy of Child and Adolescent Psychiatry, August, 2001 by
GREENFIELD, BRIAN Content provided in partnership with
ABSTRACT
Objectives: To provide an overview of the history, evolution, and nosology
of the diagnostic constructs for "borderline syndrome of childhood," also
known as "multiple complex developmental disorder." Method: The authors
synthesized information found via electronic searches of databases (MEDLINE,
PsycINFO, Current Contents, Humanities Abstracts, and Social Sciences
Abstracts) and bibliographic directed searches. Results: Although early
publications (prior to 1980) were either highly anecdotal or lacking in
scientific rigor, they were nonetheless ...
Shrinkrap
An_2638944 - 10:36pm Feb 1, 2007 (#10 of 144)
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diagnosing in early childhood, who is to say it does not become a self
fulfilling prophecy? Genes and environment absolutely play an intrical role,
but maybe we turn on genes due to this self fulfilling prophecy and create a
chronic diseased state
An_2410023 - 10:47pm Feb 1, 2007 (#11 of 144)
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Shrinkrap, do not confuse proposals for nosology or pathology with
acceptance of those proposals.
Of course it is self fullfilling. Can you image what it must be like to be
given a diagnosis as a kid? Can you imagine having every outburst or foible
then interpreted as a sign of your pathology?
An_1818256 - 11:18pm Feb 1, 2007 (#12 of 144)
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I don't know if I'm following the last two posts. Are you saying if we
didn't label kids their would be no mental illness? I am not a fan of labels
( today's pet peeve; "crack baby"), believe me, but I think the above
constucts are more formulation than label. Surely I understand that
environment shapes personality from temperment, but I also believe in
temperment, and various cognitive deficits, including deficits in
frustration tolerance, impulse control, and perhaps reality testing.
Shrinkrap
An_2638944 - 12:07am Feb 2, 2007 (#13 of 144)
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"Are you saying if we didn't label kids their would be no mental
illness?...I also believe in temperment, and various cognitive deficits,
including deficits in frustration tolerance, impulse control, and perhaps
reality testing."
A kid /c a diagnosis is a kid treated differently. By being treated
differently you realize there is something wrong /c you. It also can allow
you to not have to take responsibility for what you do or what happens to
you because you have a "disease". By "labeling" children you stigmatize, by
stigmitizing you create a self fufilling prophecy. In turn they stay on a
maladaptive developmental path.
noe49 - 05:41am Feb 2, 2007 (#14 of 144)
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Agree with above posting: I think 'labeling effect' is a 'side effect' one
must take account of, as in every medical intervention, when the remedy can
be worse of the evil. Too often we have not in mind that risk, I fear,
seeing how many ( not motivated?) psychiatric diagnosis and drugs are done
and prescripted, only because some child meets the criteria of some DSM
category. We have had some examples also in these threads, some time ago,
now in archives...
An_1298847 - 07:42am Feb 2, 2007 (#15 of 144)
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Psychiatrists are notoriously sloppy about diagnosis and reassessing
diagnosis. I think this grows out of the older analytic idea that the
diagnosis was useless because you didn't know what was really going on until
the end of the analysis. Although DSM was supposed to correct this, DSM is
not all that good, and, I read a study once that 89% of practioners ignored
it anyway except for coding bills.
There can be no question that mislabeling a kid will lead to trouble and
self fulfilling outcomes. No one here is saying avoid diagnosis, rather,
take you time, make sure you are correct, and don't be afraid to reformulate
the whole thing in the face of additional information.
An_2638944 - 10:18am Feb 2, 2007 (#16 of 144)
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Agree /c An_1298847. The point is that because a child shows up /c
behavioral issues does not mean they are "diseased". It means they need
help. Medication may mask the problem for a time, to suit the parents,
however the underlying cause is still there and needs to be addressed. If it
goes unnoticed and not treated then true psychiatric and potentially
neurological illness will arise.
As medical practitioners it is our duty to not do harm. To "label" children
and prescribe them medications /c disastrous, sometimes fatal, side effects
is barbaric and inhumane. We do not know the long term damage of these meds,
and furthermore do not know if we are creating true psychiatric syndromes or
structural defects that destroys a chance at normal functioning.
That is not to say that meds are completely evil for children, just that
careful consideration and all other resources have been exhausted before
meds are brought into the picture.
We want the quick and easy, but life is not quick and easy. Children
especially are not quick and easy, and patience and intensive training is
what they NEED. Medications do insurmountably more harm than good. Plus what
are we teaching our kids? Anytime we have troubles or need help, we should
resort to drugs?!! You should be ashamed!
rjacobson2 - 11:56am Feb 2, 2007 (#17 of 144)
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Agree with the last 3 posts which are right on the point.
DSM diagnoses are descriptive generalizations, and we all now how poorly the
formulations are when it comes to psychodynamics and the relationship to the
environment and temperament, etc. They are not specific provable diseases,
and use of them as "explanation," when given to patients or their families
furthers the misuse of the terms and the consequent lack of understanding by
those being treated.
An_1818256 - 02:06pm Feb 2, 2007 (#18 of 144)
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I agree with everbody too! I want to be one of the informed, "good" Child
Psychiatrist, if there can be such a thing. Am I missing something? Did I
maybe post something supporting a DSM diagnosis or medication without
realizing it? Is there a page one to this thread that someone is responding
to? The links I posted were studies of diagnostic constructs and there
histories...am I being defensive? (smile) Lately I've been feeling "preached
at" when I post here. I feel reticent to share anything.t makes me wonder if
I come across that way too....
Shrinkrap
addendum; oh I get it; here's my admonition
"do not confuse proposals for nosology or pathology with acceptance of those
proposals"
The proposal has not been accepted. Got it. I didn't mean to apply it would
be in the next DSM. Still, I think the two articles shed some light on how
to think about the kids that present with this diagnosis. My confidence is a
little shaken, but I'm going to share this anyway ( I was born with an
impulsive temperment ! ). The latest child academy journal includes a study
of a "Maintainance Model of Integrated Psychosocial Treatment in Pediatric
Bipolar Disorder". Labels aside, I think it represents a step forward in
viewing these kids as something other than a chemical imbalance.
Adam_Mike_Selene - 03:25pm Feb 2, 2007 (#19 of 144)
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I believe all psychiatric diagnoses are syndromes. My thought was to develop
a description of a syndrome, that many of our kids display, that would
describe the disorder without making unwarranted conceptual assumptions.
The kids with the "new bipolar" dx have presentations that may be seen as
analogous to adult manic or mixed states, but without the distinct
episodicity in the adult criteria. And apparently, they turn into adults who
tend not to meet standard criteria for bipolar disorder as well.
I think that an analysis of the thinking that leads to classifying these
kids as having bipolar disorder would be interesting. To me it seems that it
comes from a Platonic idealism, that there really is an abstraction that is
Bipolar Disorder, while I am more of a nominalist.
Given the freedom to change the definitions, patients and disorders can be
classified anyway we want to if the "we" is big and authoritarian enough. I
do n't think it makes any sense to ask what these diagnoses are "really", as
they are abstractions. The question is, what are the concepts most useful to
us to use.
I would keep kids meeting DSM criteria for bipolar disorder with this
diagnosis,but would want to come up with an empirically accurate and
clinically useful descriptive syndrome for those kids who come to us for
help who do not fit into an apt specific syndrome, unless we distort Bipolar
disorder to fit them. I would reserve, if I could, Bipolar Dis NOS for kids
with mood episodes that do not meet the full duration criteria or full
symptom criteria for BAD.
The kids who present with a state analogous to a continuous mixed mania
(labile and explosive emotionality) as well as the kids who consistently
show a marked over-reactivity to frustration need a diagnostic home. There
really is no diagnostic home for kids with temper-tantrums in the DSM other
than ODD, and not all of them meet criteria for ODD.
Regarding family dynamics, I strongly disagree that all these kids come out
of a family that is "dysfunctional" in some way. For example, some of these
kids look "normal" in the hospital, while some don't. Some of these kids are
more "organic," with soft or hard signs, epilepsy or "soft" eeg or other
brain findings. In any case, whether or not these kids problems come from a
familial behavioral pattern is an empirical not conceptual issue.
I am looking for syndromic definitions that are empirically consistent, but
that don't rely on theoretical assumptions about underlying causes.
Adam_Mike_Selene - 03:35pm Feb 2, 2007 (#20 of 144)
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"By definition, a kid can't be borderline".
We really should label disorders not people. I know it is frightfully
cumbersome, but I try, and would hope that people make the effort. The is a
statement in DSM about it, which is honored less and less, and I think that
this is indicative of a general value shift in the profession.
The more important point I would like to make is that the diagnostic
universe is not covered by DSM. (I believe that is also in DSM, unless they
took it out)
We may use any diagnoses we would like (and accept the consequences)
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_____
From: list-bounces at grouptalkweb.org [mailto:list-bounces at grouptalkweb.org]
On Behalf Of BARNETT WEISS
Sent: Thursday, March 15, 2007 10:08 PM
To: list at grouptalkweb.org
Subject: Help for my Son
Dear People:
As difficult as this is to open this discussion publicly, I feel that I must
as there is always the possibility that one of you who have seen and done so
much may be of help.
I am looking for a contact with anyone who has had significant success in
treating multiply hospitalized psychotic and Bipolar persons. By that I mean
someone who has worked with such individuals who have subsequently remained
out of hospital for at least 5 years and pretty much have insight into what
happened to them and are in control of their lives and living fully.
My Son had his first psychotic-manic break at age 17 December of 2001. He
has been hospitalized 8 times over the past 5 years with 4 times in a year
and a half beginning when he was 17, then a period of some stability
remaining on Lamictal for 3 years gradully coming off it under psychiatric
supervision using the Caligari method 10% per week decrease remaining off
meds for 8 months and all suppliments for the last few months and then
beginning to break down becoming more and more manic ending up being
hospitalized again in November of 2006 and 3 more times over the past few
months at first due to enormous good stress in terms of somethings that he
had accomplished and recognition that he received as well as an enormous job
offer from the leading person in his field. He has been hospitalized now
four times over the past 4 months due primrily to the stupitdity and lack of
competence of thoose in charge of these hospitals including St Vincents and
Bellevue in New York City. He is coming out this coming week and will be
maintained on Abilify and Depakote. HIs diagnosis is Bi-Polar and he really
thinks that basically there is nothing wrong with him. THe perfect
description of him is in the title to a book which everyone should get
immediately by Xavier Amador, I'm not sick. I don't need help. This book
will be required reading for everyone in the field within a few years. The
research in it showing the efficacy of this approach for compliance and
highly significant reduction of the revolving door cycle for psychotic and
other seriously mentally ill persons is undeniably impressive. It is a short
book as well.
My Son is a genius of enormous proportions and his particular genius shows
up in his music both compositions and keyboard artistry and improvisation.
We are looking at getting him into Windhorse which is one of the finest of
the therapeutic Communities in the world started by Edward Podvoll, MD who
was mentored by none other than Harold Searles. The book describing the
work at Windhorse and it's foundation and the background for this kind of
therapeutic community coming out of a profound understanding of the
psychotic process through the years is Recovering Sanity. With all the work
i have done over the years dealing with psychotic patients both privately,
publicly in sessions at the Theater in New York, and in my role as the
chief Social worker at a large municipal psychiatric elective admissions
ward, I have never come across such clarity in written form and hope for
real human down to earth encountering with deeply psychotic patients. It has
lead me in a path of research toward deeper understanding that I simply
didn't even know existed before. Do you know who John Perceval was? or John
Custance, or Henri Michaux or the township of Geel in Belgium or Asoka of
India? None of the over 50 persons I have spoken to in then field some of
whom are scholars who have references to history in their work knew any of
this though they had heard of some of the names. Mention Eugen Bleuler and
Rhineau Switzerland and some ears perk up but they are not sure. These
people are all significant predicessors of Moreno's. I would bet that he
knew about them in depth and may have met Custance or Michaux. Anyway, the
book and the journals that it points to of these persons are enormously
important in my view and the view of people like Frieda Fromm-Reichman and
Searles in whose tradition, Podvoll grew.
Thanks for your consideration of my request. I am ever hopeful that we may
find a resource that will assist my son in being truly in charge of his
life. He is so enormously talented and can have a wonderful life if he
recovers himself.
Blessings all, Bud
Barnett J. Weiss, MA, LCSW
7410 Ridge Blvd 2D
Brooklyn, NY 11209
PREFERRED Contact Budweiss at verizon.net or Cell (917)-751-3395
Home/office: 718-680-4919
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