We were very disappointed today to meet with our new local, not gifted-specialist but otherwise seemingly good psychologist, only to have her ask whether we would consider trying medication for our DD9, who is having various social issues in school. What disappointed me most is that I discussed with this psychologist at our intake meeting that we aren't sure whether DD is gifted + ASD (I think most likely), or gifted + ADHD, or gifted +ASD +ADHD, or also +ODD (don't think so), and how we had gotten what we thought were incorrect suggestions in the past, and had even given her several printouts of summaries of the James Webb (-type) discussions of these issues (I think even from the Davidson's site, thanks Davidson!). So the question, aside from anything else is, is it proper to suggest trying (ADHD) medication and seeing what happens, as opposed to trying to figure out what the 'diagnoses' actually are and then trying to treat them accordingly? I just think that probably any kid (even a 'normal' one) would become more pliable on ADHD medication and that the teacher would be likely to report 'improvement' (i.e., kid's not causing as many problems now) regardless of what disorders they did or didn't have. We aren't going to do it at least for now because I don't think that DD's ADHD-ish-ness comes from ADHD--at least not until somebody who is in a position to know evaluates and explains it, which we are working on. But very disappointed to keep running into this kind of thing locally, especially after we've made efforts to raise awareness and to discuss it. (ETA--just wanted to add, we're not necessarily opposed to medication in the right circumstances, just that DD fits with the James Webb-type differential description of gifted as opposed to ADHD, so what's up with psychologists not listening to us???>>>!?)

She is your kid. You have no obligation to put her on medication until you are convinced it is the solution. If you believe there are other options that should be explored, don't let them pressure you.

I know there is a culture of try it, see if it helps, but it has been shown to also "help" the general population, so that one doesn't fly for me. ALL medications have side effects and risks, so the throw stuff at the wall and see what sticks has never been something I've been willing to entertain when it comes to medications.

I'm not saying she might not need it. I'm saying you should be convinced it is the right choice - not doing it under these conditions.

Just my opinion. YMMV

I might be facing this same issue at some point once DS4 enters school. For now our view is NO meds unless he becomes violent or dangerous ... and we would consider meds if he became unhappy with himself and miserable ... medicating as the easy way out (for doctors, teachers, etc) is not our way of doing things.

That said, I was very anti meds yet had to give up on it when DS4 started having serious sleep issues ... as in going on 2-3 hours of sleep per day (or night). He's now on a serious dose of Melatonin and sometimes Hydroxyzine (strong antihistamine) to get him through the night. So, all my good intentions of non-medicating have already gone out the window.

We went in to see a Psychiatrist in August officially seeking to confirm or rule out ADHD but also with suspected Asperger's or other form of Autism. The Psych for now ruled out the ADHD and is going with PDD-NOS but we will be doing further testing regarding where on the Autism spectrum DS really is. In line with the current diagnosis, I wouldn't want to medicate for something that may be presenting as ADHD but very likely is NOT.

Dbat, both of my older two daughters have been trialled on ADHD medication. One is HG+ and we thought had innattentive ADHD but did not feel had any other LDs, and did not suspect ASD in any of it's forms. Medication works in the classic "magic switch" manner for her, there are multiple easily measurably differences in her. She's MORE herself, not less, more creative, engaged, more everything. She wants to take her medication, wants to take it every day and for it to last all day. It's not 100% side effect free but it's very clear, for now, that medication is worthwhile for her.

My older daughter, who is somewhere between bright and MG (variable IQ test response), and clearly has multiple LDs and some combination of ADHD/ASD did not have nearly such a clear response and after a decent trial we stopped medication as there seemed no point in giving a fairly serious medication for no definitive gain, from our perspective or hers. It is possible she had some mild improvements of the sort you are worried would show up in any child, but it was a completely different ball game to her sister.

I tend to agree with you that the medication trial should come after a clear diagnosis of what is wrong. But I have to say that my eldest daughter is an onion that no-one has found easy to peel. She's got a little bit of everything going on, when I say little I mean "almost diagnosable, or just barely diagnosable levels", but is not absolutely clearly any one thing. So despite having seen what seems like every possible person we could trott her out to see she did in fact trial medication before we came to any final conclusions (we still aren't there although Aspergers is now looking likely).

What problems are you seeing, both at school and in other contexts, and what is the severity of these problems? That is, to what extent do these problems interfere with your DD's life, and, if the problems meet the severity threshold, are they also the problems that these meds are designed to treat? That, to me, is the question that determines whether meds would be appropriate or not.

Our DS (2E, autism) improved his behavior significantly with the help of both a med for anxiety and one for attention. This was not something we leapt into, but something that we gradually became desperate enough to try. The biggest win was in DS's self-esteem; with the decrease in negative behaviors he felt much more able to manage himself, and he stopped feeling so awful about his own behavior. He was also much more able to access the other kinds of therapeutic teaching we were doing with the help of the meds, so they started a virtuous cycle for him.

One has to be careful in medicating kids who are on the autism spectrum with stimulant-type ADHD meds because they can sometimes increase anxiety, and therefore can also increase the negative behaviors that are associated with anxiety. We use an expert prescriber (not our regular pediatrician) who really knows both our kid and the med options. We started DS on Strattera, which is non-stimulant; now, at age 10, he can handle the stimulant med and it is more effective in helping him manage himself.

ADHD meds don't necessarily make a child more pliable; they increase focus and decrease impulsivity. I wouldn't be that worried about a "false positive" from these meds; if they help, they help.

Hope that helps.
DeeDee

Mine too, and mine's based on having been a researcher on the pharmacology and drug-mechanism side of things with SSRI's, several stimulant classes including tropanes and analogs thereof in the midbrain. Those drugs are nowhere NEAR as 'harmless' to try as many clinicians believe.

Dbat, I think there is an ethical issue of offering a drug in lieu of diagnostics. No more appropriate than a doctor giving out antibiotics to everyone with a runny nose.

But there clearly is such a thing as a false positive from ADHD meds, at least in terms of academic achievement.

I'm quite haunted by this article:

http://www.nytimes.com/2012/10/09/h...s-to-help-in-school.html?pagewanted=1&hp

Is the psychologist NOT suggesting pursuing further diagnostic work about ASD? I know you had been skeptical about diagnosing for a variety of reasons. To me, your best path would still be to seek a diagnostic rule-in / rule-out from someone who specializes in ASDs and has seen a lot of girls in their practice.

DeeDee

Woah, woah, woah. Are you sure you saw a PSYCHOLOGIST? Because psychologists do NOT dispense medication, nor should they be recommending it. If anything, they should refer you on to a psychiatrist or other medical doctor who CAN prescribe meds. A psychologist should be diagnosing and possibly doing therapy of some sort.

Personally, I would RUN from a psychologist who attempted to suggest meds for a child without a diagnosis.

This happened to us as well (sort of). The difference is that we have an ADHD diagnosis from one psychologist and another psychologist who thinks DS8 is ASD suggested using the ADHD meds diagnostically, and "when you see that they don't work, you'll see that it's ASD and not ADHD." I just smiled politely while I was shoveling everything he said into my brain's trash bin.


I'm not sure if this is true, although you hear stories of people trying to buy meds so they can score better on tests. I don't know. I would think that if the medication wasn't right there might be side effects?



We haven't done it either. We are also not opposed to meds in the right situation, and if DS's diagnosis was clear cut we may have tried them. However he's a bit of an enigma, and I'm not a fan of medicating diagnostically.

Yes! This sums it up nicely for me too

Thanks for all the thoughtful comments. We thought this year was going well until a couple of weeks ago and so are the more disappointed to find out it's not. epoh, I simplified the explanation--the psychologist showed us a questionnaire from the teacher, which indicated 'clinical' levels of I think inappropriate physical activity (can't remember the technical term) and suggested that we consider medication--for which I assume she would refer us to a physician, so I'm not worried about that part of it. DeeDee--I agree; we are going to go forward with seeing a specialist, particularly now that DD is still having difficulty with school behavior. We're just working with this local psychologist at the teacher's request to try to help improve DD's behavior and help the teacher deal with her, which I think is helping the teacher somewhat even though she's not seeing the improvement in DD's behavior we had all hoped for. I'm in the process of trying to arrange further appointments with a specialist, but it's an eight-hour drive (or a 3-1/2 hour drive, if I can hook up with another new one, which I may need to do if it's going to take more than one or two sessions). I just liked this psychologist and thought we were kind of on the same page more or less and plus I had shared our concerns about 2e stuff not being handled well at all last year, so I was disappointed when she seemed to jump over all that and suggest medication--without a formal diagnosis. And as I've said, I'm really not convinced DD has ADHD--I think she's 'gaming the system' to get out of stuff she considers boring by, for example, going to the bathroom or going and getting a book to read. I wish the teacher would try some kind of 'point system' or something with DD because I think that would work well, but the teacher is being as nice as possible and is really trying in her own way, so we really can't complain. But it's still very frustrating, especially because we have had some great teachers in the past and so I really think DD can succeed in the right environment, without medication. I guess we'll tell the teacher and psychologist that we need a diagnosis and will be seeing a specialist about it before considering medication, but I bet that won't make either of them very happy. Thanks again for all the thoughtful comments--it really helps to bounce this off other people besides DH, who is also somewhat upset by all of this.

So she gets up and moves around, and/or tries to leave? What else?

The specific kind of psychologist is important. A talk therapy type of psychologist isn't going to be able to do much about this. A behavior therapist would get some traction by helping your DD get any missing skills and incentivizing her to change her habits, preferably after observing her in the classroom and strategizing with her teachers.

Behavior therapy is notoriously ineffective for ADHD in elementary-age children; if that *were* the problem (not saying it is) meds would be the likeliest strategy for the medium term while working on building other skills.


That would also be a classic autism spectrum move: not valuing the activity for its own sake, and not feeling the social cues that suggest that one should do it anyway, one just leaves. (Again, not saying she has ASD either-- I don't know.) One can learn to stay checked in, but lots of positive reinforcement and skill-building may be needed.


It is not your job to make them happy.

I'm glad you are pursuing a diagnosis-- if you see the right expert, it will make a huge difference in your (and the school's) ability to see what your DD needs.

DeeDee

My DD has spent a LOT of years using both of these things as avoidance tools. There's absolutely no pathology going on-- she's just figured out that these are generally techniques that result in at least SOME intrinsic reward in addition to the primary goal of avoidance, and tend to be less readily called out for what they are... and therefore, they are more successful in terms of manipulation of the situation to what she sees as her advantage (wheee-- I didn't have to do math today! Bonus!).

I mention that because of this statement:



That seems like a real red flag to me, though I'm admittedly no expert on either ADD or ASD. If she responds to some environments and people with completely appropriate behavior, then it doesn't seem very likely to me that this is either thing. Or am I misinterpreting that you've had prior placements that worked well?


Is it possible that your child has just figured out that this particular authority figure is especially amenable to this kind of manipulation?

Does your DD tend to manipulate adults in other situations when it suits her?

(Mine does, though it's very deft and very subtle-- it takes someone who REALLY knows her well to see it for what it is.)

DeeDee--she also has difficulty making friends with some kids and behaving in socially appropriate ways (although she has a handful of BFFs--if she gets along with a kid, they usually get along great and can resolve disagreements without help). She usually overreacts if there is a change in plan so that she doesn't get, or get to do, something she was really looking forward to (i.e., pitches a fit)--but not all the time; she doesn't have a problem in changes with routine. So there are definitely some ASD-type issues, but we only see social issues, not the repetitive/restricted stuff in the "B" part of the DSM list. But these social issues can be managed, and we manage them at home with reminders and incentives/disincentives--to Howler's point, she very definitely can and does try to get away with doing what she wants, and explores the limits with every adult she knows. So the teachers she had in the past who called her on her behavior right away and had some incentives saw (from what we heard) much better behavior overall although there were still some problems with her hugging other kids too much, overreacting to joking/teasing, etc. that needed guidance and correction. She has an excellent abstract understanding of what is appropriate, but seems unable to put it into practice in the moment, which I think can easily be confused with what I think is the other part of just not caring about other people's priorities and wishes--which I kind of think of as the 'gaming' behavior, because she often gets more of what she wants that way. It's kind of funny, too, trying to explain this in a polite way to babysitters--but at least that's only for a couple of hours, so she can't do too much damage This discussion has been really helpful, though, in crystallizing what I think we need to do next, although it doesn't really solve our problems with finding a good school for her--we don't have too many options here.

Hi Dbat--

I can see why she's hard to diagnose, yet I can also see where it would be beneficial to have school actively and systematically working on these issues, which probably only will come with an IEP.

The social misunderstandings tend to get worse approaching teenagerhood, where the rules become less black/white and other kids get more subtle; if you can get help in addressing this in the elementary years, it's a good idea.

I know what you mean about the manipulation/gaming. In my DS's case it's not so much that he sets out to be manipulative; it's just that what he wants is so much more present in his mind than what we or teachers want that it sometimes takes a big effort for him to stay on track.

DeeDee

ultramarina

Thank you for posting this article!


http://www.nytimes.com/2012/10/09/health...pagewanted=1&hp

I saw that a couple of weeks ago when it was just published. I was HORROR-stricken. I think that article may be one of the most chilling things that I have read in a long, long, LONG time.

This gets to what I have been saying for years, by the way-- that 'trialing' drugs is just very seldom as clear cut as clinicians would like to think, precisely because they do impact pretty much everyone in quite predictable ways. There is no such thing as "paradoxical" effect in terms of the pharmacology involved, in spite of popular mythology. What is also true is that underlying cardiac abnormalities can be catastrophic with ANY of these drugs. Many drugs have seeming paradoxical effects in pediatric populations, too. But that doesn't reflect the underlying pharmacology, per se. That's just pediatrics-- it's known to be goofy. Probably the reason has a lot to do with undeveloped neurological function, at least in psychotropics.

These drugs will help with certain executive function just as anabolic steroids will "help" just about anyone in terms of building physical endurance and muscle mass, not just those people who have a "need" for steroids to treat medical conditions. Also similar is that such a truth does nothing to diminish the real conditions that require steroid treatment.

Anyone that uses caffeine should know better than to think that: a) there's no observable benefit unless you are "deficient" somehow, and/or b) they aren't really addictive, so it's fine to just "try" them and see. Docs who think that, IMO, probably ought not have the ability to prescribe things that they don't understand. I realize that sounds pretty harsh, but physicians who hand out stimulants and SSRI's (among other catecholaminergics) like candy are really playing with fire, IMO.

Dbat, I hope you find the right provider for dd. It sounds like this psychologist really broke your trust. It is so difficult to pull apart the small nuances of ADHD vs ASD while keeping in mind giftedness. You may find that there is no "exact fit " and that her diagnosis nay change over time even as she matures. You've mentioned hoping the teacher would set up an incentive system. I wouldn't worry to ask the teacher about this. A well-planned system will hopefully decrease the amount of correcting/reminding/reprimanding a teacher needs to do. It can also be very helpful to see how much influence a child really does have over their behavior. Kids who are extremely hyperactive/impulsive may not be able to suppress their symptoms even if motivated to earn a reward.

As for the article, 15 years working in the mental health system leaves me jaded. There are many, many things (overprescribing meds to kids, using psych hodpitalization as respite, faking ADHD to get drugs to sell them)
that no longer surprise me. That in itself is sickening.

Thanks, Evemomma. We did mention to the teacher that incentives had worked before, and work at home, but for some reason she seemed cool to the idea; maybe she thinks DD is enough work as it is, but I do think that it would make her work easier as you suggest. And DD would still need 'extra' reminders, but a lot less, at least from what we've seen. We have an appointment with a specialist for a couple of weeks from now and hope that will be helpful. I'm just worried because we really don't have that many school options here, and DD is actually very happy where she is, for now. But we'll see, and keep our fingers crossed.

Sometimes teachers have a hard time seeing how the short term investment of focused work on a problem will yield the long term result; and if they're not used to this way of thinking, it can be hard for them to see why some kids need the incentive when most don't. ("You're so bright, why can't you just behave," etc.)


A dx would not necessarily mean a change in school placement; one can accomplish a lot by educating teachers and getting resources pushed into the current environment. A professional might help you get the school and the teacher on board to make it an effective environment for her.

Try not to worry too much. Worrying itself doesn't yield progress...

DeeDee

Thanks, DeeDee. I am hopeful that a diagnosis might not lead to us changing schools, but the teacher seems to be losing patience so we are concerned given our reluctance to medicate at this point.

I've been wondering about the medications you found for your DS. The local psychologist told us there were not medications for ASD-type behaviors, but you said your son benefits from Strattera for helping with his attention issues, even though it sounds like he doesn't have a formal ADHD diagnosis--is that correct? How did you find your expert prescriber? (feel free to PM me if you would be more comfortable)

Dbat - there is no federally approved medication to "treat" Autism. There are, however, a slew of medications often used to treat the symptoms of Autism and co-morbid disorders. From the reading I've done, ADHD has a very high co-morbidity rate among those with Autism, and for some reason, non-stimulants have a higher rate of success with these children. Our DS is on Tenex to treat his ADHD symptoms, and Risperdal to treat his mood swings. Neither med is really 'for' his PDD-NOS, but they both help tremendously. Our son did have a formal ADHD diagnosis prior to us medicating him, though. (He was originally informally diagnosed with a 'mood-disorder' before we came to PDD-NOS & GAD.)

The vast majority of pyschotropic meds are prescribed off-label to children. There are very, VERY few psychotropics that are actually indicated for 18 and under and even less for 12 and under. Six and under? Only a handful.

Dbat, I'm PMing you details.


Correct: there is no "autism drug." However, people with autism very commonly have problems with attention and anxiety; attention can be treated with the meds that improve ADHD, and anxiety can be treated with SSRIs or other antidepressants (depending on family psychiatric history--one has to be careful about that).

One is treating some symptoms of the autism, not the totality of the autism, by giving these meds. The social deficits of autism will persist; however, relieving anxiety and improving attention can vastly improve a person's ability to access behavior therapy to improve social functioning and other issues associated with the autism.

Anxiety and attention mix in a complicated way. Relieving anxiety can calm down the brain enough so that it actually can pay better attention. Fixing an attention issue can help a person feel they're not missing stuff by drifting off in the middle of something important, which can make them feel less anxious. Seeing only an expert prescriber who really takes the time to understand the patient is very very important to figure out how best to treat the particular symptoms.

DeeDee

My eldest DD has a diagnosis of ADD, in progress of diagnosing with Aspergers. When she started stimulant medication the primary change she reported was reduced anxiety. Both general and social. We were aware that this might be due to improved attention reducing her anxiety about missing things, misunderstanding, doing the wrong thing, and helping her be more able to keep up and join in socially. So we stuck with the trial despite reduced anxiety not being what we were expecting her to report. After a few weeks she decided it wasn't really doing much after all and we were unable to clearly see a difference either (unlike our second child, in whom we see a daily difference). So she's no longer taking medication, but we are absolutely aware of that connection between attention and anxiety.

I know for my son the knowledge that he's not doing what he's "supposed to" makes him very anxious and upset... so the ADHD meds helping him to whatever he's meant to be doing greatly calms him down. He hates the idea that he's being "bad".