Monthly Archives: May 2010

An Apology

At The Captain’s appointment last night with the psychiatrist, The Doctor told him that he needed to apologize to his brother about having attacked him with a piece of wood.

Inwardly, I rolled my eyes.  We have had this conversation with this boy.  It does not work.  He does not apologize, or if he does, it is never, ever heartfelt.

The Captain responded with obligatory answers and nods.

The Doctor said he needed to buy a card for his brother, and write his apology in it.  He said that would be a big deal and that we would all be very proud of him for doing it.  He told us to make it a HUGE deal, and celebrate the moment with cake.

Eyes still inwardly rolling, we left and stopped at the store on the way home for the card.   He picked out a blank card with cats on it, and wrote “I’m sorry for hitting you” on the inside, and drew a picture of a person crying a lot.

When we got home, he gave the card to his brother and watched him open it.   His brother smiled and The Captain wrapped his arms around his brother, without prompting, and said “I’m sorry” and “I love you.”

We were amazed.  And The Captain noted that the cake was indeed, not a lie.

Afterwards, we had cake, and he was really, actually, very proud of himself.

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The Week in Review

Monday, May 24th – The Admiral said that The Captain had some issues today, mostly arguments over commands and transitions.  I witnessed a bit of the same when I got home.   The melatonin again knocked him out at bedtime.

Tuesday, May 25th – Again, still argumentative over things during the day.  Both boys skipped homeschool group.  The Captain knew he would not be able to handle himself there, and The Explorer feigned sickness to avoid it.   When I got home from work, The Captain was obviously heading into a mood, so we gave him an extra .5 mg of Risperdal.  The boys had avoided their chores, so I made them do them when I got home.   The Captain found new energy and mowed the back lawn and weedwacked in addition to normal chores.   Quiet time was good until it switched to Bed time, where The Captain threw a fit about going into his room (there’s nothing to do!) and kept coming out of his room, until eventually, the melatonin kicked in.

Wednesday, May 26th – The Captain woke early.  Had a semi-good day, with oppositional behavior to parental requests.   Met with his therapist, which went “Fine.”  Bedtime woes again, until he passed out.

Thursday, May 27th – Day behavior about the same.   Early wake ups all week.  Appointment with The Doctor in the evening.   Two developments… One:  he noted that aggression was gone, but oppositional behavior still existed.  He upped the dose from 2mg to 3mg.   Two:  he discussed apologizing to his brother, which I’ll cover in a separate post.

Friday, May 28th – Woke early again, in a good mood.  I am hopeful.

He who fights with monsters

“He who fights with monsters might take care lest he thereby become a monster. And if you gaze for long into an abyss, the abyss gazes also into you.”

– Friedrich Nietzsche, Beyond Good and Evil, Aphorism 146

Not the most optimistic quote, but it resonated with me.

New Research in Juvenile Bipolar

I’m reading about new research regarding childhood bipolar, which includes changing the way they categorize the disorder into a dimensional approach, because of the frequent overlap (comorbidity) of other disorders.

Other symptoms of juvenile bipolar disorder (all of which are true for The Captain except the nightmares):

  • deflects blame
  • suffers horrendous nightmares
  • antagonizes siblings
  • excessively craves sweets and carbohydrates
  • functions in mission mode
  • wets the bed
  • sleeps hot
  • takes excessive risks
  • hoards food
  • has many ideas at once
  • interrupts or intrudes on others
  • experiences periods of self-doubt and poor self-esteem

One of the phenotypes they’ve identified is the “Fear of Harm” phenotype (The Captain’s matches in bold and red).

Territorial Aggression

  • is willful or refuses to be subordinated by others
  • argues with adults
  • defies or refuses to comply with rules
  • is easily angered in response to limit setting
  • is bossy towards others
  • relentlessly pursues own needs and is demanding of others
  • blames others for his/her mistakes
  • has protracted, explosive temper tantrums
  • displays aggressive behavior towards others
  • has irritable mood states
  • lies to avoid consequences of his/her actions
  • is intolerant of delays
  • has difficulty maintaining friendships

Attention / Executive Function

  • has difficulty organizing tasks
  • demonstrates inability to concentrate at school
  • is easily distracted during repetitive chores and tasks
  • attempts to avoid homework assignments
  • has poor handwriting
  • is easily distracted by external stimuli
  • has difficulty estimating time
  • able to focus intensely on subjects of interest and yet at times is easily distractible
  • has auditory processing or short-term memory deficit
  • has difficulty making transitions

Mania

  • has periods of high, frenetic energy and motor activation
  • has period of excessive and rapid speech
  • has many ideas at once
  • has elated or giddy, goofy, silly mood states
  • is easily excitable
  • interrupts or intrudes on others
  • is hyperactive or easily excited in the PM
  • displays abrupt, rapid mood swings
  • fidgets with hands or feet
  • is very intuitive and/or creative
  • tells tall tales; embellishes or exaggerates
  • has exaggerated ideas about self or abilities

Harm To Self Or Others

  • Makes clear threats of violence to others or self
  • Makes moderate threats of violence to others or self
  • Has made clear threats of suicide
  • Curses violently, uses foul language in anger
  • Has destroyed property intentionally
  • Is fascinated with gore, blood, or violent imagery

Self-Esteem

  • feels easily criticized and/or rejected
  • feels easily humiliated or shamed
  • experiences periods of self doubt and poor self-esteem
  • complains of being bored
  • has periods of low energy and/or withdrawals or isolates self
  • has decreased initiative

Sleep/Arousal

  • has difficulty getting to sleep
  • has difficulty settling at night
  • sleeps fitfully or wakes in the middle of the night
  • has difficulty rising in the AM

Sensory

  • is extremely sensitive to the textures of clothes, labels, and tightness of fit or socks and shores
  • exhibits extreme sensitivity to sound and noise
  • complains of body temperature extremes or feeling hot despite neutral ambient temperature

Hypersexuality

  • displays precocious sexual curiosity
  • exhibits inappropriate sexual behaviors (openly touches self or others’ private parts)

PPSO

  • wets bed
  • has night terrors and/or nightmares
  • hoards or avidly seeks to collect objects or foods
  • has acknowledged experiencing auditory and/or visual hallucinations
  • craves sweet tasting food
  • has concerns with dirt, germs, or contamination

Anxiety

  • displays excessive distress when separated from family
  • exhibits excessive anxiety or worry

…  and what does that all mean?

The expectation is that, when we identify the causative genes for bipolar disorder, we will be able to point to a network of signaling pathways in the brain that regulate specific behaviors associated with the condition. Once researchers are able to isolate the genes involved and understand their functions, the development of more targeted treatments becomes a real possibility.

Bipolar Mission Mode

When I read in The Bipolar Child about “Mission Mode,” it really hit home.  The Captain at least once a day finds an unreasonable request that he must continually ask for every five minutes.

Mission Mode is the bipolar child’s intense need to do something, where no amount of reasoning or discussion can deter them.

Their sheer persistence is all-encompassing and they become very adept at blocking out any agenda but their own (which they are feeling very intently and very urgently)

They are inflexible–they perseverate or can’t move off a topic, they can’t anticipate that this kind of behavior will bring negative reactions from those under assault by their perseverative plans, and they have impulse control problems and cannot wait for something. (They may also be anxious that they will forget what it is they want; or they may be using this sudden gusto about a project or new idea to focus their thinking.) The new idea may be a stabilizing force that supplies an external structure because deep down inside they are afraid they are disappearing down the rabbit hole. They experience their need as an emergency situation, and so urgent that it is as if their very survival depends on their getting whatever it is they think they have to have. Any refusal on the parent’s part seems to make them feel unprotected and unloved.

From what I gather, once a child is stabilized with medication (which I am not sure yet if The Captain can be described as such), ignoring him and repeating your response, and using cognitive mediators is the solution to this.  (see links above)

ADHD Symptoms

And just for good measure, here are the symptoms of ADHD (all of which apply to The Captain, so I won’t bother bolding or coloring the text).

Inattention:

  • difficulty paying attention to details and tendency to make careless mistakes in school or other activities; producing work that is often messy and careless
  • easily distracted by irrelevant stimuli and frequently interrupting ongoing tasks to attend to trivial noises or events that are usually ignored by others
  • inability to sustain attention on tasks or activities
  • difficulty finishing schoolwork or paperwork or performing tasks that require concentration
  • frequent shifts from one uncompleted activity to another
  • procrastination
  • disorganized work habits
  • forgetfulness in daily activities (for example, missing appointments, forgetting to bring lunch)
  • failure to complete tasks such as homework or chores
  • frequent shifts in conversation, not listening to others, not keeping one’s mind on conversations, and not following details or rules of activities in social situations

Hyperactivity:

  • fidgeting, squirming when seated
  • getting up frequently to walk or run around
  • running or climbing excessively when it’s inappropriate (in teens this may appear as restlessness)
  • having difficulty playing quietly or engaging in quiet leisure activities
  • being always on the go
  • often talking excessively

Impulsivity:

  • impatience
  • difficulty delaying responses
  • blurting out answers before questions have been completed
  • difficulty awaiting one’s turn
  • frequently interrupting or intruding on others to the point of causing problems in social or work settings
  • initiating conversations at inappropriate times

Early Onset Bipolar Red Flag Symptoms

IN reviewing the “red flag symptoms” of bipolar in children, here’s how The Captain stacks up (ones that match are bolded and red):

Very Common Symptoms of Early-Onset Bipolar Disorder

  • Separation anxiety
  • Rages & explosive temper tantrums (lasting up to several hours)
  • Marked irritability
  • Oppositional behavior
  • Frequent mood swings
  • Distractibility
  • Hyperactivity
  • Impulsivity
  • Restlessness/ fidgetiness
  • Silliness, goofiness, giddiness
  • Racing thoughts
  • Aggressive behavior
  • Grandiosity
  • Carbohydrate cravings
  • Risk-taking behaviors
  • Depressed mood
  • Lethargy
  • Low self-esteem
  • Difficulty getting up in the morning
  • Social anxiety
  • Oversensitivity to emotional or environmental triggers

Common Symptoms of Early-Onset Bipolar Disorder

  • Bed-wetting (especially in boys)
  • Night terrors
  • Rapid or pressured speech
  • Obsessional behavior
  • Excessive daydreaming
  • Compulsive behavior
  • Motor & vocal tics
  • Learning disabilities
  • Poor short-term memory
  • Lack of organization
  • Fascination with gore or morbid topics
  • Hypersexuality
  • Manipulative behavior
  • Bossiness
  • Lying
  • Suicidal thoughts
  • Destruction of property
  • Paranoia
  • Hallucinations & delusions

Less Common Symptoms of Early-Onset Bipolar Disorder

  • Migraine headaches
  • Binging
  • Self-mutilating behaviors
  • Cruelty to animals

Asperger’s Syndrome Symptoms

In reviewing a checklist of symptoms for Asperger’s Syndrome:

Asperger’s Symptoms that match The Captain

  • failure to develop peer relationships appropriate to developmental level
  • lack of social or emotional reciprocity
  • apparently inflexible adherence to specific, nonfunctional routines or rituals
  • stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

Asperger’s Symptoms that do NOT match The Captain

  • marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
  • a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
  • encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
  • persistent preoccupation with parts of objects

On The Spectrum

During the in-patient program at the hospital, one of The Captain’s new acronyms was PDD, or pervasive development disorder.  The definition of this is sufficiently vague, and includes Autism and Asperger’s.   The psychiatrist did not go into any specifics at the time, so I can only assume his lack of specifics means that he meant PDD-NOS, pervasive development disorder, not otherwise specified.

Pervasive Developmental Disorder – Not Otherwise Specified, or PDD-NOS, for short, is a condition on the spectrum that has those with it exhibiting some, but not all, of the symptoms associated with classic autism. That can include difficulty socializing with others, repetitive behaviors, and heightened sensitivities to certain stimuli.

There seems to be some disagreement as to whether PDD-NOS is the same thing as HFA, high-functioning autism.  And, I’m not sure which label I prefer, as PDD-NOS sounds too vague and sounds like a developmental problem, where HFA, while having the stigma of autism, includes the phrase high-functioning, which sounds nicer to me.

The current psychiatrist has said he is on the autism spectrum and has referred to him as high functioning autism.   Perhaps it would be best to say that he has Autism Spectrum Disorder.

The Doctor had us go through a checklist and he scored high on it.  If I recall, you had to match 12 of the traits listed to be considered, and he matched like 15 or more.  Below are some examples, but the actual checklist we went through was much longer and more detailed.

Interestingly enough, his dad, The Admiral, matched several of the checklist criteria as well.

Austistic Symptoms / Traits That Match The Captain

  • Have trouble understanding other people’s feelings or talking about their own feelings
  • Repeat words or phrases over and over (echolalia)
  • Give unrelated answers to questions
  • Get upset by minor changes
  • Have obsessive interests
  • Flap their hands, rock their body, or spin in circles
  • Have unusual reactions to the way things sound, smell, taste, look, or feel
  • Does not understand personal space boundaries
  • Avoids or resists physical contact
  • Is not comforted by others during distress
  • Hyperactivity  (very active)
  • Impulsivity (acting without thinking)
  • Short attention span
  • Aggression
  • Causing self injury
  • Temper tantrums
  • Unusual eating and sleeping habits
  • Unusual mood or emotional reactions
  • Lack of fear or more fear than expected

Austistic Symptom / Traits That Do NOT Match The Captain

  • Not respond to their name by 12 months of age
  • Not point at objects to show interest (point at an airplane flying over) by 14 months
  • Not play “pretend” games (pretend to “feed” a doll) by 18 months
  • Avoid eye contact and want to be alone
  • Have delayed speech and language skills
  • Avoids eye-contact
  • Prefers to play alone
  • Does not share interests with others
  • Only interacts to achieve a desired goal
  • Has flat or inappropriate facial expressions

New Tools Discovered

I’ve been doing more research on early onset bipolar disorder, via internet searches and books.  I’ve read quite a bit even previous to The Captain’s diagnosis, having suspected for years that there was more going on in his head than ADHD.

One interest resource I came across was PsychEducation.org, where I first learned about how bipolar relates to the Circadian rhythm and about light and dark therapy.   I ran out and purchased some yellow bug lights from Ace Hardware and installed F.lux on all of the computers.  I’m not sure if the yellow lights in The Captain’s room have had any effect, or if the software is working, but it’s certainly worth a try.

Yesterday, I started reading The Bipolar Child by Demetri & Janice Papolos.  Much of it was information I had already run across, but it too discussed light therapy and Circadian rhythms.

It also suggested the use of Melatonin to aid in restorative sleep and the use of Omega 3’s or fish oil which may be able to act as a mood stabilizer themselves.   I didn’t have time to absorb all of the Omega 3 section, but I got the part about the melatonin, so while we were out yesterday, I got some melatonin supplements from Walgreen’s, at about $8 for a bottle of 5mg.

Last night, I gave The Captain a pill just before quiet time, and he calmly, quietly went to his room, and very soon after was sound asleep.   I’ll have to wait to hear how his day went, but the rest of my evening was wonderful.