Psychiatry - August 2008 - (Page 46)

was started on a stimulant. But the stimulant had not helped after a few weeks, and his parents took him off of it because it also interfered with his sleep and appetite. PRACTICE POINT: UTILIZING SCHOOL INTERVENTIONS PROPERLY FOR THE PATIENT WITH ADHD A parent who believes that a child has a handicapping condition that is interfering with educational progress can request a multifactorial evaluation (MFE) through the school. The school is then obligated under federal law (the Individuals with Disabilities Education Act [IDEA]) to provide this evaluation and, if indicated, to collaborate with the parents to develop an Individual Educational Plan (IEP) for the child. The special tutoring arranged for Mr. S, while well-intentioned, may have been too nonspecific for his particular needs. Often, parents are unaware of their rights in the school system, and the counsel and support of a physician can be of incalculable value.17 The abrupt initiation of medication without a complete evaluation, as well as proper education and preparation of the family, is often unsuccessful. Even if medication might be indicated, the family and patient may not have come to terms with what is going on emotionally or educationally. Without proper education and preparation, they are likely to focus on adverse effects of medication and drop out of treatment rather than work with the psychiatrist to reach an appropriate regimen.18 An ADHD parents group is helpful, both to educate parents about their child’s condition and to help them come to terms with their feelings about their child’s difficulties. Both of these points illustrate the need for continuity of care for this chronic condition. in school when he was younger, but he had “grown out of them.” Presenting as initially frustrated and angry, Mr. S’s parents were tearful when they talked about their once happy boy who was now withdrawn and talking about killing himself. They had tried “tough love,” obtained extra help in school, and had taken him to a doctor, but little was working. The clinician acknowledged their sadness, and then went on to ask the father more about his childhood. He revealed that he had “given up” on school by the fifth grade, being regarded as stupid and lazy by his teachers. His parents, who were now deceased, had hoped he would go to college, but were forced to give up their aspirations for him. He himself developed an interest in electronics, and became skilled as a radio technician. He had little social life in high school: “They all thought I was a loser.” As a senior in a science class, he proved to be far ahead of his most successful classmates when they studied electricity; he remembered the class valedictorian asking him, “How did you get to be so smart?” He did not go on to college but specialized in electronics in the service and found steady employment thereafter as a mobile technician. Throughout this discussion, Mr. S showed rapt attention. PRACTICE POINT: RECOGNIZING FAMILY HISTORY OF ADHD Unconscious recollection of his own trauma led the father to repress and deny an identification with his son and suppress his recognition of Mr. S’s sadness. His response of anger and frustration resulted in part from an unconscious identification with the aggressor, in this case the school system. His social isolation and immersion in electronics was an adaptation that proved eventually to be productive for him. However, this constellation of defenses interfered with early identification and remediation of Mr. S’s condition. The clinician very skillfully addressed this by asking the father what his experience was like as a child and adolescent. The mention of the problems the father experienced growing up was a red flag to the clinician about the son’s condition, and addressing it in this time of crisis proved to be therapeutic.11 The clinician explained to the family that it was very likely Mr. S had ADHD, and that his problems were not due to laziness or delinquency. His father replied that a neighbor had once suggested this, but that he disagreed at the time and paid no attention. The clinician, sensing that the father might be feeling responsible for his son’s difficulties, immediately mentioned to the parents that often many parents receive unsolicited advice from others on a regular basis, and the matter seemed to pass. The clinician went on to suggest that the entire family should have an opportunity to discuss these matters further with an experienced practitioner, and provided a referral. The process of education for the patient with ADHD and his or her family begins with the initial contact. The issue of parental guilt and responsibility is often a chronic issue. However, a direct reassurance of “innocence” may presuppose feelings that are not present or are not ready to be addressed. By indirectly acknowledging the possibility of these things with generalization, the clinician in the case of Mr. S allowed for further work in the future. EPILOGUE The family was provided a referral to a medical home clinic, since they did not have a PCP for Mr. S and needed multiple services. At the clinic, they were connected with a therapist who saw Mr. S and his parents separately and together. A consultant child and adolescent CASE EXAMPLE, CONTINUED Mr. S’s father mentioned that he had had some of the same problems 46 Psychiatry 2008 [ A U G U S T ]

Table of Contents Feed for the Digital Edition of Psychiatry - August 2008

Psychiatry - August 2008 Editor’s Message Editorial Advisory Board Contents Borderline Personality Disorder: Are Proliferative Symptoms Characteristic? Short-acting versus Long-acting Medications for the Treatment of ADHD Baby Stimuli and the Parent Brain: Functional Neuroimaging of the Neural Substrates of Parent-Infant Attachment These Boots Are Made for Stalking: Characteristics of Female Stalkers Managing Attention Deficit Hyperactivity Disorder in the Emergency Department Obstructive Sleep Apnea, Hypoxia, and Metabolic Syndrome in Psychiatric and Nonpsychiatric Settings Improving the Quality of Life in Patients with Alzheimer’s Disease The Process of Getting New Drugs to Market Journal Watch Classified Advertising Information for Authors

Psychiatry - August 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.