A couple responses to the TDD post

I started replying to comments but decided to post the replies here to the main page, since it's such an interesting and new subject.  Several people have left comments on the TDD post; here are my responses to the last two.

@Essie:
I wonder what the social attitude/stigma towards "Temper Dysregulation Disorder" is going to be in five years time.  I do hope it doesn't become the "spoiled brat" diagnosis.  Then again, it would probably have to compete with ADHD for that label.

I was recently discussing with my friend and neighbor how according to the DSM-V, her son doesn't have Asperger's anymore. He now has plain "autism spectrum disorder".  She said she was actually relieved, because Asperger's has been getting a reputation as "not a real problem".  Her son does so well academically that he's in a gifted program, but he's also got some major special needs and just can't function in regular junior high school without extra supports in place.  They've had to struggle hugely, even to the point of getting a lawyer, over the services he needs to stay in school.  They've noticed that over the last decade as the awareness of Asperger's has grown, and the negative stigma has decreased, there's a sort of reverse positive stigma -- "it's just that they're extra quirky" -- that isn't helpful at all in terms of getting him supports.

It's such a fine line. Labels can help us get help for our kids, but they come with such huge baggage... social stigma, inaccuracies, false predictions.

@marythemom:
I've watched some documentaries on childhood bipolar and read some articles, and from what I can tell, true, unmistakeable mania is way beyond what I've seen from my son. There was a little girl talking -- very calmly and with a smile on her face -- about how she wanted to cut off her mom's head with a knife. Children who thought they were invulnerable and could jump off roofs or out of moving cars. Children who kept seeing weird sexual hallucinations during the daytime. These weren't children who had attachment issues; I think all of them were bio kids from regular families.

I have a feeling that future studies are going to show that some anti-psychotics are going to work equally well on TDD and childhood bipolar.  I really hope someone will do some therapy studies as well. When we started out, we had so many ideas for how to manage fits, but I've had to disregard most of them as worthless.  They may work for regular, developmentally appropriate temper tantrums, but they don't work for my son.

And as a side note, I realize a lot of them are based on "the hydraulic theory of anger", a disparaging term I've heard a few times.  It's the idea that anger builds up inside you like steam, and to get rid of the anger you have to express it somehow in order to release it.  That makes intuitive sense -- we want to believe it's true -- but nobody has really been able to back that up. Extend it to other emotions and it doesn't make sense. If you're happy, and you express your happiness by jumping into the air while pumping your fists and shouting "I FEEL GOOD" does that release your happiness like steam so that you suddenly stop being happy?

I do think anger/rage/temper causes extreme physical and mental tension, and part of defusing it is releasing that tension, but we have to figure out how to release the tension in ways that don't involve expressing the anger, even against inanimate objects.  That just creates a habit of expressing anger.

Helloooo Temper Dysregulation Disorder with Dysphoria

Last night, after hearing and reading this story on NPR, I've been carefully reading through every document concerning TDD at the DSM-V site.  Is that enough acronyms for one sentence?

The new rules are eventually going to have huge implications for children in foster care or adopted from foster care.  These kids are the always the ones that get the most diagnoses and the most medications.  They're really the front line... or more cynically stated, they're the guinea pigs.  The NPR article doesn't address the issue of children in foster care, but they do provide a good summary of the importance of the DSM-V.

Doctors faced with kids struggling with explosive moods felt the diagnosis was appropriate and said that the bipolar medications they gave to children worked. Research psychiatrists worried that the children were being given a label that wasn't right for them, and saddled with the sentence of a serious mental illness for the rest of their lives.

In a move that could potentially change mental health practice all over America, the American Psychiatric Association has announced that it intends to include a new diagnosis in its upcoming fifth edition of the Diagnostic and Statistical Manual — and hopes that new label will be used by clinicians instead of the bipolar label. The condition will be called temper dysregulation disorder, and it will be seen as a brain or biological dysfunction, but not as a necessarily lifelong condition like bipolar.

The DSM is the official dictionary of mental disorders recognized by the American Psychiatric Association. Doctors use the DSM to diagnose patients, and insurance companies use it to decide on reimbursement, so it's incredibly important in the profession of psychiatry.
By adding this new entry, the American Psychiatric Association is trying to use the considerable institutional power of the DSM to curb use of the pediatric bipolar label.

I'm cautiously optimistic about these changes.  I realize that the process of making these diagnoses is sort of like asking a blindfolded person to draw a line using fingerpaint to encircle a seemingly random scattered pattern of symptoms... projected onto a moving target.  But in this case, that line might be drawn slightly more accurately than the previous one.

Here are the new criteria for TDD - Temper Dysregulation Disorder with Dysphoria.  Sunny, when off medication, fits every single criteria.

Temper Dysregulation Disorder with Dysphoria

A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.

1.  The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property. 

2.  The reaction is grossly out of proportion in intensity or duration to the situation or provocation.

3.  The responses are inconsistent with developmental level.

B. Frequency: The temper outbursts occur, on average, three or more times per week.

C. Mood between temper outbursts:

1.  Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).

2.  The negative mood is observable by others (e.g., parents, teachers, peers).

D. Duration: Criteria A-C have been present for at least 12 months.  Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.

E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting. 

F.  Chronological age is at least 6 years (or equivalent developmental level).

G. The onset is before age 10 years.

H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX).  Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.

I.  The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.

When he's on his medication, he only has 0-3 violent fits a week.  Off medication, he had 1-2 every day.  On medication, he's happy most of the time, except for his rarer crabby days when he seems irritable and looking for an excuse to argue, cry, fight or have a fit.  Off medication, he's irritable and miserable most of the time.  On medication, he's been doing well in school; off medication, we had to temporarily take him out of school so that he wouldn't hit his teacher.

I think he also has anxiety issues and trauma separation issues and ADHD issues, but these don't fit his pattern of behavior nearly as well as the TDD definition. 


Now that the TDD definition is in place, some serious studies can be done that show long-term outcomes and medication appropriateness and so on.  But reading through the summaries of the existing studies, I'm optimistic that what he has will ameliorate as his brain matures, and that he won't have to be on medication for all the rest of his childhood.  Right now, Sunny's atypical antipsychotic medication is working for him, and we're not going to try to take him off it again until next year.  We're just going to keep trying every year and hope that the therapy and the work that we've done between those times will eventually allow us to do so.

I like the fact that the discussion documents stress that TDD is not at all less serious than "real" childhood bipolar.  Children with TDD end up in RTCs quite frequently.  I could imagine that happening with us. Without his medication, Sunny a) would not be able to go a regular classroom b) would need one of us to stay with him constantly and be prepared to restrain him multiple times a day.  Very few people could handle that.  I don't know if we could handle that.  An older couple with less physical strength definitely could not handle that.

The documents also discuss some of the social ramifications of these disorders.  Childhood bipolar overdiagnoses started partly as a well-meaning response to stigma around Conduct Disorder.  If your child had Conduct Disorder, they were a Bad Kid (and/or you were a Bad Parent) and there wasn't really much anyone could do.  If they had childhood bipolar, they had some genetic or chemical bran imbalance and it wasn't their fault and it wasn't your fault either, and it could be fixed with the right pill.  Kids won, parents won, drug companies won... but it turned out this wasn't such a happy ending.

I do feel lucky that we've ended up in a situation where Sunny is on a medication that really helps him and doesn't give him any side effects (so far), and that we've finally found a therapist, on our fourth try, who's actually helping him get a grip on his behavior.  I know a lot of other parents aren't so lucky.

I'm still frustrated with the fact that I don't really understand why Sunny's med works for him, and why it doesn't work for kids with similar issues.  And, of course, I'm terrified that it's going to cause some kind of long-term issue, sort of like that Halloween III: Season of the Witch movie where the demon masks make the kids' heads explode.

Anyway... hello TDD! Nice to meet you.  I'm sure we'll be hearing a lot more from you soon.

Follow-Up and Miscellaneous

From the therapist (I love quoting emails, it's so easy).

Thanks again for the update.  I wanted to address the issue with visiting your cousin in greater detail than I was able to last night.  First of all, I think it was extremely savvy of you to figure out the emotional connection for [Sunny] between visits with your cousin and his biological mother.  It sounds like you hit the nail on the head and were able to deescalate the situation quickly as a result.  As I mentioned, [Sunny] and I discussed grief and bereavement and read a story about losing a loved one through death.  He seemed interested in the story as he sat quietly throughout, which is unusual for him.  He struggled to talk about the story afterward, likely due to the discomfort he experiences in facing his emotions head on.  We have been and will continue to work on this as I think it is the heart of the issue for him.  To answer your question regarding whether or not he should be allowed to continue with visitation, my answer is most certainly.  It is important to show him he can visit your cousin and say goodbye to her and that the goodbye will not be forever.  I would also encourage you to verbalize this to him (i.e., let him know when you will be coming back) and acknowledge and label his feelings for him (i.e., sad, scared, etc.).  This last part will be extremely important in whatever you are doing as it seems [Sunny] may not always know what he is feeling so the more help he can get with the identification of feelings the better.  Please let me know if you have questions.

I've tried reading books about loss with him before, but it's very difficult.  When we read Everett Anderson's Goodbye, he was crying bitterly by the end of it, and told me he never wanted to read it again because it was too sad.  It's nice to finally have some professional backup and guidance.

However, it's not entirely true I was able to "deescalate the situation quickly".  It took about 30 grinding minutes and felt like an eternity.

To a commenter who asked what medication Sunny is taking: it's a popular atypical antipsychotic that also begins with the letter A. If you look up any reference on that drug class it'll be right there.  That's the only med he's on.  I don't have him on any of the strictly ADHD drugs.  His foster mother tried Adderall at one point, but said it made him "act mean", even though it did improve his ability to concentrate.  Given his generally good academics, and the fact that I don't think he has standard ADHD, I don't want to give him any med that will change his personality, as long as he can get along OK in school with the support of his 504 plan.

Thanks to everyone else who's commented!

Later today, I'm going to start working on a blog post on the media around Haitian "orphan" adoption.  I need to get back to some controversial posts after a long string of just-about-family ones.

No Hell Week Part II Post! Purgatory, at the Most.

We made it.  Whew.

Tuesday was the worst. I outlined the basics in the email to the therapist that I posted on Wednesday.  Sunny was in a terrible state.  He seemed full of hate.  It was like the hate came from outside and took him over.  He took the hate out on us, but I could tell, more than anything else, he hated himself for being that way.  When he told me in the car about the voices in his head that said "I hate you", it made me feel so sad for him.

We started him back on his old med that night.  Wednesday was a little better, but he still got called him from school for acting out.  We had a school meeting about him on Thursday -- we kept him out of school that day -- then let him go back for a half day on Friday.  He made it.

Thank goodness I can trust the people at his school. They're treating this like a "lost week".  They're full of sympathy for him.  There won't be any lasting consequences.  At another kind of school, they might have been talking expulsion or a move to a special education classroom.

By Friday, he was begging to go back to school! He was missing his "Math Message".  I don't know exactly what that is, but he sure does love it.

He had a sleepover with Nana on Saturday night.  Guy and I took a much-needed date night and saw The Imaginarium of Dr. Parnassus, then went to Loca Luna for tapas.  We didn't go to bed until midnight and slept in until 10AM.  Then we met Sunny and Nana and another friend of ours for dim sum.  Overall, this has been a pretty good weekend.  The smile is back on Sunny's face.

The situation in Haiti, of course, has been weighing on my mind.  I emailed a Haitian friend I met through the Obama campaign and asked him how his relatives were doing and if we could do anything else besides donating (which we've already done). 

This man worked harder than anyone else on the campaign, and he couldn't even vote.  He must have registered hundreds of new voters.  When our small group went on a weekend vanpool together, he drove the whole time.  And he knocked on twice as many doors as any of us, with a bigger smile on his face, in the blazing summer heat... all while wearing a three-piece suit.  I really admire him and I feel terrible for what he and his family (a wife and six very sweet kids) must be going through now.

Sunny's therapist talked to him a little bit about the voices.  She told him that when he heard voices inside his head saying mean things about him, like "I hate you", he could tell himself positive things, like "I'm nice".

So we're back to square one with his medication.  I guess we'll try taking him off again next year.  I don't want him to go through the rest of his childhood on meds, but I can't risk 1) his  school and 2) our sanity.  Thinking about my younger cousin and his life, the thing he really regrets most bitterly is how he was warehoused in special ed because of his behavior, and never even learned to write until middle school.  He made me promise that I would never do that to Sunny.

Hell Week Part I

Hello [therapist],

Unfortunately, we have had a very bad week so far. On Monday, [Sunny]'s behavior in school was bad and we got a note from his teacher. Tuesday, [Guy] had to pick him up from school early because he was pushing other kids in line, and then had a tantrum and threw things when the teacher confronted him. They told [Guy] he was "out of control". They are having a meeting Thursday morning.

Yesterday, his gym teacher also said he behaved badly and was almost asked to leave the class. I also had to restrain [Sunny] numerous times yesterday. Once in the morning and once after school and twice after gym class. He would get very, very oppositional and when he was asked to do something say "I don't have to!" or "I hate you!" or "you're ruining my life by not letting me (watch TV/do XYZ)". We eventually got the routine done: dinner and reading and bedtime. [Guy] is especially stressed out.

[Sunny] is grounded (he can play outside but not go into anyone's house) and also has no TV privilege until he can have at least one good day at school.

One thing I have been worried about is that in the last week or so [Sunny] has seemed to hear voices when no one is talking. Sometimes I won't say anything, but he will ask "what?". This seems to have increased. I talked with him about it last week, and asked him if he was hearing voices that weren't really there. I didn't make a big deal out of it (he's kind of a hypochondriac so that would encourage him to get carried away). He said he does hear those voices sometimes and they say things like "I hate you".

He told me in the car yesterday that he was hearing those voices, that they were bothering him, and that "maybe he should see a doctor". Again, I didn't make a big deal out of it, I just asked him some questions about them. He knows they are not real. They don't come from the front or the back, they come from the inside of his head. I'm very concerned because I don't think he would say he wants to see a doctor unless he was really hearing them. He's not a big fan of going to the doctor, because that almost always involves getting a shot (though he loves going to the dentist because they have video games in the waiting room).

With all of this going on, I made the decision to put him back on medication. I just read that [the atypical antipsychotic] takes a long time to fully clear out of the system. So his good behavior last week, off the med, was not really indicative. He had a pill last night. This morning he did OK.

Response:

I am sorry to hear it has been such a rough week. I would agree with your decision to put [Sunny] back on the medication. I would also speak with his psychiatrist about this. You are correct that it takes time to clear the system of [med] which is likely why he did so well when he was initially taken off of it. In terms of the voices, auditory hallucinations actually seem as if they are coming from outside the body. In other words, it seems as if someone who is not present is talking to you. More than likely, [Sunny] is experiencing self-deprecating thoughts he is unable to control which translates (in his mind) to a voice of another. This is likely to abate once the medication becomes effective in his system. I would encourage you to monitor it to see if it changes over the next few days. Thanks again for the update. Don't hesitate to contact me with any additional questions or concerns.

The Light at the End of the Tunnel?

Sunny is down to 25% of the dosage of his old med.  Today, he's going off it completely.  It's also the first day of school.

New Year's Eve, he had a monster fit. It was probably one of the more unpleasant New Year's Eves I've ever had in my entire life.  But since then, now that the new med and the old med are working out of his system, he seems to have improved his outlook.  He isn't putting on his "pick a fight" face. He seems happier and less angry.

The other night, when he I told him we couldn't visit my cousin at the clinic until Wednesday, he burst into tears.  He really misses her and worries about her. But after we hugged him and comforted him, he stopped crying, instead of escalating to screaming.

Later that night, Guy and Sunny were playing Yahtzee together. Sunny was throwing around the dice too wildly and Guy warned him to stop.  On his last throw one die flew off into a corner of the room.  Guy told him to go look for it and explained (in a calm voice) that the consequence if he didn't find the die was that they wouldn't be able to play Yahtzee anymore.  Sunny complained a bit but kept looking for the die.  Eventually, they found it.

Later, Guy told me, "Something really weird is happening.  I was bracing myself because I thought I knew exactly what was going to happen.  Sunny would throw the rest of the dice at me and scream that I was ruining his day. Then you were going to have to step in, and hold him down, and he would try to bite and hit you while calling us "&%$#@ *^%$ ^&$#@!" until he got hoarse. Meanwhile I'd be down in the basement office pounding my head against the wall and threatening to kill myself.  But then... none of that happened. What's going on?"

We're both cautiously optimistic.  I think the old med had both a negative and positive effect on Sunny.  Perhaps the positive used to outweigh the negative, but now it's the other way around, so taking him off is going to be the best thing.  We've had a six-month honeymoon, then a year of intermittent raging.  Maybe we're ready to move to a new stage now?  Or, he might have gotten tired of being angry on his own.

The real test is how he does in school this week. Towards the end of the year, his behavior was getting worse. We had a special conference to discuss problems with pushing other kids, throwing, and one incident where he slapped a crayon out of his teacher's hands.  Whereas his angry, physical episodes had been only 1-2 a day at the beginning of the second grade, they'd increased to 3-4 by the end of the year.  That was one of the reasons we considered the disastrous med change in the first place.  But maybe he'll be able to manage his behavior the same, or better, with no meds at all.  I guess I'll find out soon.

We're also lowering our expectations for him a little bit in the area of being alone. We're not expecting him to play "alone" at all, even for 10-15 minutes. We switch off so that one of us is always doing something with him, or else letting him play chess and board games on the computer.  He'd prefer to play the more high stimulation games at places like Lego.com, but the chess game is a good compromise.  They don't wind him up and make him as agitated as the other games.

Med Change Failure

It's been 11 days since the med change.  The psychiatrist gave us a schedule which included a quick ramping up of the new med (the anticonvulsive) and a slow ramping down of the old med (the atypical antipsychotic). For the last 3.5 days we've been at 100% new med 50% old med.  It is NOT working.

- Sunny started having abdominal pains where he says "my waist hurts!"  It was probably gas and intestinal discomfort.  We started giving him some fiber pills and that seemed to help a lot.  We were hoping this symptom was just a temporary one that would go away when his body became adjusted to the new levels.

- He used to bedwet 1-2 times a week, now it's almost every night.  He's also been spot-wetting during the day, which used to be a fairly rare occurrence.

 - He became much more irritable and oppositional.  These last few days, it's been at least a fit every day, sometimes two. He jumps more quickly to accusing us of wanting to hurt him.  For example, when I said he had to wait until after dinner to eat a chocolate-covered pretzel, immediately, it was because I "never wanted him to have nice things, ever".

- This morning Sunny had hives all over his face and chest.  He was miserable. I gave him a benadryl. A rash is one of the rarer side effects of the anticonvulsive.

The rash sealed this. We're taking him off the new med right away. Not even one pill more. I just called and left a message with the psychiatrist.

Our only question now is whether to try and take him off the old med entirely now that we're at the halfway point. That way we could check his baseline. I have a feeling that he really needs his old med in order to regulate his emotions, and that if we raised his levels, he'd be able to regulate them even better. But then he might start drooling and ticcing because of the side effect profile.

UPDATE: The psychiatrist was out for the holidays but he just called me back shortly after I left a message on his answering service. He said we should stop the new med entirely and could go right back to the full dosage of the old med.  We'll make an appointment in a month, which should be enough time for the new med to clear his body entirely.

Happy Holidays! And a mini-update.

I have a lot of stuff to catch up on. 

Summing up: my cousin had another really bad breakdown, which we think is exacerbated by involvement in a particular local 12-step group that has mutated into something secretive, hierarchical and cultlike. Then we had an extended-family dispute over Thanksgiving that was very depressing to me, but I'm not going to talk about it any more.

I received some documentation on BB that states he was meth-exposed, which I half expected.  I did not expect that learning about BB's medical issues would give me so much insight into Sunny's issues. Really, it's like a lightbulb went off in my head. We don't have much medical info on Sunny beyond basic hospital stuff, because he didn't come into foster care until he was almost three.  But by all accounts, he had almost exactly the same issues as an infant that BB is having now.

On advice from Tubaville, I'm going to make an appointment with a neurologist ASAP.  This makes me really sad for Sunny. Much of his behavior must come from the fact that his brain was literally damaged by  destructive chemicals. Again, it's a possibility that was always in the back of mind, but I never really brought it to the front.  It's up there in the front right now, for sure. And unlike ADHD, which I feel confident about discussing widely, meth-exposure has a greater stigma, and so that raises huge privacy issues for me.  If this blog goes private for a while, that will probably be the reason why. On the other hand, this is really, incredibly important stuff for other parents to know about, and we stay ignorant when we don't listen AND talk... it's hard to say.

We're also halfway through a med change for Sunny.  We're switching from an atypical antipsychotic to an anticonvulsive. It's supposed to have less potential side effects, but Sunny has already been complaining of stomach pain, which is really worrying me. We're going to keep it up because so far the pains have been intermittent, haven't affected his appetite at all and there's a chance they'll go away as his body adjusts to the new medication.  He has a new diagnosis -- IED -- and if you know what that stands for, it's sort of a baloney diagnosis, but then again I take all these diagnoses with a grain of salt.

I'm mostly keeping up with my fitness plan. I'm getting burned out on Debbie Siebers but I still do Burn It Up a couple times a week and I'm exercising at least 5 days a week. 

So far Christmas is going OK.  I IMed my dad in Hawaii the other day and wished him a Mele Kalikimaka (Hawaiian for Merry Christmas).  I expected him to IM back something like "I don't believe in that garbage" or "you will burn in hellfire forever".  Instead, he wished me a Mele Kalikimaka right back!  He really has mellowed a lot in his old age.  Maybe one day he'll even buy me a present on Christmas, or let me buy one for him.

We're going to have a small Christmas, and my cousin is getting a day pass from her clinic to join us.  Sunny has been tracking Santa and making calculations about the chimney size.  I'm a bit stressed but staying in good spirits.

I'd also like to congratulate Thorn, who has a special visitor this season.

Sunny Calmed Down Yesterday

We had a visit break yesterday. We were planning on taking Sunny over to NN's hotel after his gym class, but NN's ankle injury was acting up and it was rainy and we just decided to get together tonight instead, at my mother's. They'll be here until the end of the weekend.

I think this break worked well for Sunny. He was pretty calm yesterday and got all of his stars for good behavior.

At this point, Sunny hasn't had a hitting episode in more than two weeks. He did have a major screaming meltdown last week in the car with Guy, but it didn't involve hitting. I've had to restrain him a couple times since then, but each time I was able to let him back up within seconds.

If this keeps up and maintains for a while, I guess we can start thinking about taking him off medication entirely. The new psychiatrist we saw last month had us do something very smart: get a blood test to make sure the medication wasn't creating any long-term chemical imbalances. They said it would be important to establish a baseline before doing any kind of change. We have a follow-up appointment in October.

I would also be open to a medication change as long as it was a medication with less potential side effects than the one he's currently on. He's never had any side effects yet, but I'm still worried.

I don't think a specifically ADHD drug would help. Sunny's foster mom said that their psychiatrist had already tried him on Adderall... and it greatly improved his school performance, but also made him "mean" and unhappy. I'll take his current average-with-supports school performance over that scenario. The thought of medicating away Sunny's naturally joyful personality is horrifying.

Celebrity ADHD?

I thought I had absolutely no interest in blogging about Kanye West, who seems to be the number one topic of conversation in the blogosphere over the last few days.  I don't have TV, much less cable, and haven't watched MTV in decades.  One celebrity was mean to another celebrity because they got an award they thought should have gone to yet another celebrity... yawn.  I'm usually interested in looking at any kind of racial analysis in the media but I care so little about the celebrities involved that I didn't muster up the energy in this case.

Then I read this post at the Republic of T that casts the episode in a different light...

In fact, four of the five most common social problems experienced by kids with ADD/ADHD could easily apply to West.

* Interrupting others – One of the primary symptoms associated with ADHD is impulsivity. The uncontrollable urge to speak makes it hard to listen. Additionally, kids with ADHD have difficulty focusing on one thought for very long, therefore getting their thought out may be more important than joining in the rhythm of the conversation.
* Failure to understand others anger – Kids with ADHD don’t perceive their inconsiderate actions as rude. They may not be able to understand why the schoolmate they interrupted 10 times in a five minute conversation was angry. After all what’s wrong with joining in on the conversation.
* Being Perceived as Self Centered – Self centeredness can be a serious problems both for kids and adults. The ADHD personality may come across as one that doesn’t understand the feelings or needs of others. If this trait is carried forward into adulthood it can be very problematic in personal relationships. For kid with ADHD it often causes problems with schoolmates, parents, and teachers.
* Not respecting others space – Little Johnny sat behind Sara in class. He continually bumps her chair and when no one is looking pulls her hair. Little Johnny doesn’t understand why he keeps getting in trouble, after all he likes little Sara. Kids with ADHD struggle with the concept of personal space. When you combine the disregard for others personal space with ADHD symptoms such as hyperactivity and inattention, classmate Sara should ask for a different seat assignment immediately!
* Poor sportsmanship – One of the common traits of ADHD children is becoming easily frustrated. Frustration can spill over into other activities such as sports; leading kids with ADHD to cheat if they fall behind and throw temper tantrums if the outcome isn’t acceptable. Often poor losers have trouble finding others to interact with socially thus adding to their already unpredictable behavior.

And in West’s behavior, I recognize at least one symptom of ADD/ADHD.

Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequence

I have mixed feelings about using ADHD as a label. I think it's used too often to label and limit kids. But there's also power (for the good) in understanding the way they think and benefiting from the experience of others with similar conditions.

All the above behaviors also apply to Sunny. I do think he has ADHD. After talking with NN, I think it runs in his maternal family, just like it runs in mine.  As I've often said, I don't think Sunny's ADHD is as severe as my cousin's or my uncle's. ADHD is just a bracketed subset along a mental spectrum. Sunny has a lot of problems with interrupting, personal space issues and so on, but he can function in a normal classroom with a fairly light set of 504-plan accommodations.

I almost hate to say it, but Sunny's personality seems rather Kanye-ish. He has a strong and very rigid sense of fairness. He interrupts others and speaks loudly. He expresses whatever he feels at any given moment, whether it's love, sadness or anger. He has a huge amount of confidence and thinks he's great at everything. He's very popular with other kids, but they also get mad at him at all the time. Sunny's ten-year-old friend often gives him lectures about his behavior! If he had a blog it would probably be in all capital letters.

This is not to say that he's helpless to change the more negative aspects of his behavior. We work on sportsmanship all the time and we've made some decent progress. He's capable of good sportsmanship, it's just more difficult for him than for the average child.

I agree with the blogger Terrance that if Kanye has ADD/ADHD, it isn't an excuse. He was still acting like a jackass (as Obama said). Or maybe he was drunk. Likely it was all three at the same time: he was being a drunk jackass with ADD/ADHD.

Terrance, who has ADD, offered this piece of advice for challenging situations based on his own experience. It's one I'm going to keep in mind for Sunny.

My strategy, for those times, is to fall back on a rule I taught myself years ago: “If I don’t say anything, I can’t say the wrong thing. If I don’t do anything, I can’t do anything wrong.”

And I almost forgot, my stepfather was diagnosed a few years ago (in his late fifties) with ADD plus PTSD.  He has horrendously bad impulse control.  I love him, but he's totally helpless in many ways and if it wasn't for my mother he'd probably be sleeping in a ditch somewhere.  Medication (a varying combination of Ritalin, Wellbutrin and Lexapro) has vastly improved his quality of life.  He had to discontinue the Ritalin for a while because of his Hepatitis C, but he wants to get back on it.

Restraint Concerns: The Gruesome Details

Sunny asked me last week if he could take karate classes. He asks me this every so often. In light of his increased rate of fits recently, I had to laugh bitterly and say "hell no!" I mean, why would I pay money so he can get lessons on how to beat up his mom and dad? I'm not going to be compliant in my own ass-kicking.

I know the argument is that martial arts increases self-confidence and self-discipline. In our case, it's not a valid argument. We already have therapy appointments for self-discipline. And Sunny doesn't need any more self-confidence, he does quite well in that area already.

At the now-defunct blog Toots and Noodles (I hope the family is doing OK!) the mom probably regretted having her daughter take karate lessons, although they worked great for her son...

More bad

Toots blew up again yesterday. Was it because I told her I couldn't take her shopping when she wanted? Did she get mad when she was asked to leave her brother alone? Don't know.

Anyway, she grabbed several bottles of assorted medication, ran outside, danced around on the lawn, took some, scattered the rest of the pills across the lawn. Patrol cars and an ambulance were involved. Oh, she also used her karate skills to whack me and Lew in the head, groin and arms. Hard.

She's not in grave danger, but she spent the night in Pediatric Intensive Care.

More to come.

I don't think Sunny's issues are anywhere near as severe, but I like to keep the worst-case scenario in mind.

Sunny asked me when he would be old enough to take karate classes. That's a fair question. I told him I would put him in classes after he had a whole year of no violent fits with no hitting. That gave him some food for thought.

We used to take Sunny out to the car to have his fits, but now that they're shorter in duration, we've found it's easiest to just use a carpeted area inside the house. I use a restraint where he's laid on his back, and I sit with bended knees on either side of his upper thighs while holding his arms down.

I know a "basket hold" is most commonly used, but I don't see how that doesn't leave you wide open to painful backwards head-butting.

The other hold that works for us is sitting down next to him, on a couch or on a car set, in a looser hold, legs draped over his upper thighs so he can't kick out. That way, when he head-butts, he's doing it into a cushion. The only problem with this hold is that it's a bit of a struggle to keep him from biting our arms.

This Friday, Sunny had a bad fit, and I wasn't there. Guy called me as I was driving home to tell me about it. I don't think Guy handled it well, so we're talking about adjusting the "action plan" if it happens again when it's only him. I'm not blaming Guy. If it was just me alone, I might have screwed it up in a totally different way. We didn't have an argument. It was more of a breakdown and "lessons learned" session.

Guy ignored the initial stages of the fit for too long. Sunny had starting throwing things down the stairs. He should be tackled as soon as he throws the first thing. Ignoring the behavior for several minutes gave him an opportunity to build up his anger more and more, so that when the time came to restrain him, he was pumped full of adrenaline and fighting really hard. Then, once he engaged, Guy couldn't get him into restraint fast enough. Sunny bit him, then he had to hit Sunny on the arm to get him to stop biting. Luckily both of them are fine and don't have any noticeable bruises.

I couldn't figure out why Guy wasn't able to restrain him until yesterday, when Sunny had another fit (very short, thank goodness), and Guy watched the way I restrained him and figured out why he couldn't do it exactly the same way. He's just not flexible enough. He can't fully sit on Sunny's upper thighs. That gives Sunny enough wiggle room to work his knees out and lash out with his legs.

In the future Guy is going to have to stick to the couch/car seat hold.

We're also buying Sunny a punching bag and trying a new experiment: encouraging him to punch the bag in the early stages. Asking him to take a deep breath or go yell in a pillow is just not working at all. We've been asking him to do that for six months and he's never staved off a fit that way. I did not want to buy him a punching bag before, because I was worried it would teach him how to do more effective punches, but Guy thinks it's worth a try now, and I agree.

One thought I've been having lately, and it's very disturbing, is this one... what would have happened if Sunny had been adopted by a much older couple or single parent, or if they were physically less able, and could not restrain him? He probably would have been disrupted very quickly once the fits came on. Or perhaps medicated into a drooling stupor.

Looking back, I'm reasonably sure that there was a tacit conspiracy between his foster mom and the worker to downplay the potential violence of his tantrums during the matching process.

He's getting stronger every day, and we're getting older. I guess it's time to get serious about fitness, and maybe sign us up for an aikido or wrestling class.

I know this sounds awfully grim, but I'm just facing the facts. I see a lot of good progress based on the fact that his fits are getting shorter and shorter in duration.

Back to School - Transitions can be Tough - Fit Update

Today is back to school day for Dekalb County. Sunny will be starting second grade. He has not been taking it well. He's been wetting the bed more and having more fits than usual. He also wet himself during the day a couple times last week, and tried to hide it (we don't punish him for wetting, so that wasn't a motive) . Our new therapist agrees that his behavior is definitely in response to the transition, and represents temporary regression.

We're definitely tightening things up and getting stricter. Some upcoming changes we've talked about:

-- no video game time on weekdays
-- no playing or going outside until homework is done on weekdays
-- no going inside the neighbors' house on weekdays until he can be trusted not to wheedle them into letting him play video games
-- going back to reading books at night. We had slipped into the habit of reading him classic Spider-Man. From now on, reading Spider-Man to him is conditional on first reading something else on his own.

There are a few more "consequences" we're instituting:

-- When I 'm talking to him and he puts his hands over his ears, I will assume he doesn't want me to speak to him, therefore I will not say anything at all to him for five minutes (I don't have the heart to do this any longer, he is generally crying his eyes out after a couple minutes).
-- If he refuses to read a book at night in bed, we will go out in the hallway and read the book there.

I've started up a formal behavior chart again. The five entries are: Do Homework with No Complaining, No Fits, No Backtalk, Flush Toilet and Read Books Nicely. Flush Toilet is the "gimme". He usually does it anyway, it's just really nasty when he forgets.

He already lost the "No Backtalk" star for today. This morning, while I was making breakfast, he got to the screaming point about a class he's taking at school. I could tell it wasn't really about the class. He was really casting about to find something that he sort of wanted, but I wouldn't immediately give him, so that he could have an excuse to blow up.

He's been having 1-2 fits every 7-10 days. We're both very used to them. When he gets to that point of cold rage, there's nothing else to do but tackle him and pin him down. It sounds horrible, but there's no other option. The only variant is that if he's not on a carpeted surface, we carry to him to a surface that is carpeted, and then we pin him down. This variant is often quite painful, since it gives him a chance to get in some kicks and punches.

I used to softly reason with him during these fits, but our new therapist, who has experience working with kids in a residential treatment facility, tells us not to say anything at all until Sunny calms down, and the rage will fade away a little faster. It turned out to be good advice. He's not listening to a word I say during that time, anyway.

Guy is learning how to handle the fits better. He used to almost go into a rage himself. It was the cursing. When he came to us, Sunny's strongest curse was "poopoohead". His neighborhood friends taught him a lot more. Now during fits we get random strings of really nasty curse words, including M-F. I had no problem ignoring these but it took my husband a while to develop tolerance.

He had a fit just last night. The names he uses during fits are bad, but oddly enough, the threats are awfully mild. I've heard of much, much worse threats from other foster/adoptive parents. For example, he doesn't say "you're not my real parents". He'll say, "I hate this crazy house!" or "I wanted to stay with (foster mom)!" or my favorite threat (I've got to find the humor where I can): "When I'm 18 I'm leaving this house!"

After the fit, when he's truly remorseful (sometimes he fakes it, then tries to hit or bite me when I let him go), I hug him and rock him for as long as he needs, then he goes and hugs Guy and apologizes. The only bright side is that they're a bit shorter than they have been in the past. They're rarely longer than 15 minutes now, whereas in the past, they've lasted up to an hour. Then we talk about how he needs to work on controlling his anger, and not let his anger control him, and to try harder next time to fight back his anger and take a deep breath instead. We've had the exact same talk a gajillion times but hopefully at some point it will sink in.

I don't think that negative consequences after the fact do much to stop them. So we don't punish him for them, other than sometimes taking away DVD time or video game time for the night. We're trying to reinforce positive consequences for "No Fits" instead.

We also talk candidly about the things we're doing to stop the fits, such as neurofeedback and medication. I told him yesterday that it was especially important to help him stop the fits now, when he was young, because when he was an adult, if he had a fit, the police might shoot him. He said, "that's not very nice of them!" and Guy said, "No, but it doesn't matter if it's nice or not when you're dead."

I know that sounds pretty bad. We shelter him from a lot of negative things in the world but I believe in total honesty in this area. I so often read news like this -- Mentally Ill Offenders Strain Juvenile Justice System -- and it scares me so much. I could barely stand to read that article.

If he still has behavior like this as a teenager, we'll be in a Catch-22 situation. I would have to call the police on him, but then I'd have to make sure the police didn't shoot him.

Obviously, that is the worst-case scenario. Ideally, he'll grow out of it... and these are just extra-strength tantrums that will pass once his brain develops more. Or maybe he does have some variant of bipolar disorder, but will learn how to control it with a combination of medication and therapy.

Anyway, I worry about this stuff, but it doesn't consume me. I was just saying to Guy last night that we have to be happy in the present -- there is no other time to be happy! That sounds a bit sappy, I know...

I'm hoping that some of Sunny's stormy behavior will turn around after the first week. He says he hates school, but when I ask him what he doesn't like, it's 1. having to do homework 2. having to do "boring stuff" in class sometimes. He has a ton of friends and loves most of the stuff he does in class.

We're working out rewards for the behavior chart this week. I'm trying to work out a few things that aren't just treats or extra minutes of video game time, but involve him getting more control over his environment in some way. I know control is very important and lies close to the root of much of this behavior.

This stuff sounds like a battle. It can be... but I think of it more as a game of chess. In fact, I've been playing some computer chess just to make sure I can keep beating Sunny at chess. He got very good at the game very quickly after chess camp! At the ending tournament, he won second place (4 out of 5 games) in his age division. Sunny is very smart, uses aggressive tactics and would quickly overwhelm a less prepared opponent. Beyond that, the parenting/chess analogy breaks down because he doesn't really know what he's playing for, but I do.

Also, I added the "Nurtured Heart" book that zunzun has been recommending to my wish list, and I'll get it in the next batch of books I order. I'm looking forward to reading that. Guy also took Sunny to see a new psychiatrist. They gave us an order for a blood test to get baseline chemical levels and make sure his atypical antipsychotic wasn't causing any serious imbalances. The test came back all clear. We'll be taking him back to the psychiatrist in a month or so for a follow-up. I like the cautious approach.

I'm a Legal Mom, and Other Updates

Our adoption finally went through last month. Yes, I'm way behind on the news. Sunny is our legal son!

I'd like to report that some pre-adoption behavior cleared up, but things are pretty much the same. I don't think the adoption ceremony meant that much to him. In the future, it's going to end up figuring a lot more in his thoughts, but he'd already accepted us as his permanent parents a while back.

We happened to draw the oldest, palest, gloomiest judge in Atlanta. He said some nice words, but also gave an odd speech about how hard it was to make a success of yourself in this cold cruel world even if you came from a family with two biological parents and no troubles. My mother cried. I videotaped everything. Sunny loved getting to dress up and shake hands with the judge. It's a striking picture... Sunny in his sharp black dress pants and black dress shirt, the judge in his long black robes.

We have to wait a while for the amended birth certificate, and then get a new social security number. The amended birth certificate is a terrible practice and the source of needless injustice for adoptees. It won't harm Sunny, in practical terms (I have several copies of his Original Birth Certificate, which doesn't list his father's name, and he knows quite well who his biological mother was) but I wish it wasn't the common practice.

In practical terms, now that he's officially adopted we can:

• Allow our friends the neighbors to drive him to the pool or to the movies
• Have a babysitter without making them get a drug test, a physical and fingerprinting
• Sublet our basement suite or use it for charitable purposes like hosting
• Go on trips without getting permission first
• Get him a passport so he can visit Japan or Mexico with us
• If anything horrible happens to us, he won't be taken right back into the foster care system

Another thing we are now allowed to do, which we weren't before, is spank him. And this was something we did try, on the advice of our therapist. It's embarrassing to blog it. But I thought it was worth a try. Her argument was that it shouldn't reactivate trauma for him because we know he wasn't ever physically abused. And it would help him internalize that hitting people is wrong. We tried it several times -- three swats on the butt -- when he went into a violent rage and lashed out. At first, it worked. It completely stopped a rage that would normally last 15-20 minutes and made him enter the remorseful crying stage right away, instead of at the very end when he was exhausted from being held down.

Then spanking stopped working. It just didn't affect him at all anymore. The rages -- two or three times a week, 15-30 minutes in duration -- were unaltered. The last time we spanked, he yelled that he wished he was bigger, because then he would spank dad back... "WITH A PADDLE!". We might have gotten another favorable "short-circuit the rage" effect if we'd stepped up the physical punishment beyond three mild swats, but that's something we had agreed way beforehand we wouldn't do. One try, and then we'd move on. But I can see that's how parental abuse gets started. A little works, but then it stops working. So try a little more... and I don't want to go there.

I don't have much experience with physical punishment. My father used to whack me on the top of the head when I was a kid (and tried to do it into my teens, actually) but it never had the effect he wanted.

Scratch that technique off the list. No more spanking, ever.

We're starting to see a new therapist. I don't want to discount our old one, and we'll continue seeing her irregularly. She's given us some great advice in the past. She's a mature African-American woman with a ton of experience who is incredibly insightful when it comes to a lot of stuff, but we're going to try someone totally opposite: a young white guy who lists foster care experience and has a PsyD instead of an LCSW. We'll see how that works. I'm also setting up an appointment with a psychiatrist (a new one, not the icky stupid one) in August to discuss medication.

One technique we're going to start soon, suggested by a friend of my mother's, is audio/video feedback. This means recording the bad language and hitting he uses during a rage and showing him later, when he's calm.

I'm a bit skeptical about the neurofeedback treatment. It doesn't seem to have altered his rage frequency in any way. But the one thing I do believe it has helped with is his sleeping. Since he started neurofeedback, he hasn't woken us up at 4AM anymore, liked he used to do about once a week. And that's really huge once you start thinking about it. It improves our quality of life and mental state tremendously.

He used to have frequent nightmares about a man chasing him with a chainsaw trying to cut his foot off, but he rarely reports those anymore, and I ask him every morning. I'm sure he still has nightmares, they're just not as strong or frequent, and he's learned to put himself back to sleep after waking up to one.

His foster mom said he used to wake up the whole house at 5AM on Saturday morning, just running out in the hall and screaming and screaming until he made sure all 10+ family members were awake.

I'm not sure if we're going to continue with the full course of neurofeedback, and my high hopes for it have adjusted somewhat. Still, I think the sleep improvement was worth it.

We're arranging a visit with his bio grandma in a few months. She'll be driving over and staying with us for several days. I think this will be a good chance for them to bond a bit more and talk about his maternal family.

She sends us pictures of BB every Wednesday, which is when she has visitation. And BB is doing well, but it's gotten so depressing for me to even look at the pictures. Is this my son, or not? He's going to be walking soon. He's going to be a year old soon and I wasn't there for hardly any of it. It's not important to him that I love him now. It will be in the future, whatever happens, but not now.

In happier news, although it hit a stifling 96 degrees this weekend, Sunny was having the time of his life at the water park. He loves the water so much. He spent almost all this weekend having aquatic fun. The last four days have all been fit-free, and if he makes it to seven he knows he's getting a nice bonus from his sticker chart.

Edited to Add: I reread this post and realized how negative it all is. I should have just done a separate "We did the adoption ceremony and it's great we're officially legally a family." If I put up a picture of the event, you'd see we're all smiling, even the gloomy judge.

Return of the Raging

Sunny has been doing really well for the last several weeks. In fact, last week, his behavior marks in school have been some of the best he's ever received.

He's had a few tantrums where we had to hustle him into the back seat of the car, but they've blown over in a few minutes.

Yesterday night, he seemed really hyper and out of control around bedtime. It took a long time to get him to bed.

Today, he had two rages. The first one was in the early afternoon and took 10-15 minutes. I was driving him to dance class, and he was really angry because I had enforced the "no Legos" rule and told him he couldn't bring his Legos in the car. We only got a few blocks from home before I had to pull over. I don't know if I handled it well, perhaps I could have de-escalated better somehow, but I wasn't thinking on my toes... when I pulled over and just sat there silently for a few seconds thinking about what to do next, the silence wound him up to the point that he started throwing and screaming, and I had to get into the back seat to hold him down for a while.

I ended up driving back to the house because I didn't think he was in a good enough mood for dance class, and we also would have been late because of the altercation anyway. I thought he was doing better. We've established that any attempt at hitting means no TV or DVD for the rest of the day, but I let him play outside for a while instead.

Then, as we were all getting ready to go to my mother's house for dinner, he had another and even stronger raging episode. It started because I asked him to put away the Uno cards he'd been playing with.

I had to hold him down for a long time. This takes so much out of me, emotionally and physically. He would cry and scream that I was hurting him, holding him too tight... I kept telling him "I love you, but I won't let you hurt other people or hurt yourself" and "you're a good boy, I know you don't want to do this, you can calm yourself down" and "I will let you go once you take responsibility for your behavior." If I loosened my hold on his wrists for even a second he would slip free, try to kick out the car windows, try to bite me or punch me in the face. Then when I held on to his wrists harder again, it would be back to the "you're hurting me."

The worst were the few times he fooled me by saying he was sorry, all he wanted was a hug, then when I relaxed my hold, he would try and attack me or scream insults at me.

I knew he was finally coming out of it when he patted me on the arm softly while he was sobbing. I could finally let him go and hug him.

Guy was watching outside the car during this time. I would rather hold Sunny down myself. I can do it showing less negative emotion than Guy, and I'm also much softer, so there's less chance of Sunny actually getting banged or bruised.

When it was all over Sunny was very remorseful. We had a frank talk. Guy asked Sunny what he would do if someone tried to hit him like he tried to hit us. Sunny said he would hold them down or hit them back... we said we would never hit him back, and hitting is wrong.

I told him we all had to do work to control his anger, and that the neurofeedback was part of trying to teach him how to control his anger. I also told him that I would keep holding him down when he started hitting, but in a few years, I wouldn't be able to do that anymore, because he'd be way too strong. And when that happened, and he hurt anyone, we'd have to call the police instead. He asked if they would take him to jail. I said no, little boys wouldn't go to jail, but he would go to the hospital, and it wouldn't be fun at all. Which is why we had to work hard right now to make sure he could control his anger and calm himself down before he started hitting.

He's already very, very strong.

We've already talked about the worst case. Guy was driving me crazy with scenarios when the raging first started... he was literally keeping me up at night worrying about it. My attitude is that we'll worry about it when it actually happens. We have a few years to turn things around before we get to that tipping point. Recently, Guy has arrived at the more pragmatic stage, and we're both maintaining there. In fact he reminded me again, today, "we have several years."

I'm not angry about it, just mildly rueful, but I've realized that there must have been a tacit conspiracy to downplay Sunny's behavior. Sunny's worker talked about tantrums, but said he was not violent towards other people... that the worst he did was kicking his feet. When you hear that, you imagine "kicking feet at floor" not "kicking feet at glass windows and other people's heads".

Anyway, his foster mom confirmed he had some of the same behavior when he was living with them... in fact, she wondered how long it would take for it to show up with us. The answer was about eight months.

We'll just have to wait and see. There've been only been four sessions of neurofeedback so far. Later, we can also see if going off meds will help, or perhaps even increasing them... if that's what he really, really needs.

I also don't want to get complacent about holding Sunny down. I don't want this to become our new normal. There has to be something else we can do to stop the raging before it erupts. I can see it coming, but so far I just feel powerless to stop it.

His adoption finalization date is within a month. It's hard to know what it means to him. We've talked about it, I've even told him it's OK to feel weird or sad about it, he just doesn't seem to attach any importance to it that I can tell. We're already mom and dad.

This is so depressing. I just want to get back to worrying about more typical things, like the CRCT testing and his soccer team and his next round of clothes and so on.

We went to my mother's house and had dinner and Sunny behaved pretty well, although Guy noticed that his positive and negative reactions seemed to be more intense than usual. And then he went to sleep easily, unlike last night. Maybe he's worked it out of his system for a while.

How Blogging Communities Can Help Kids - Neurofeedback Example

As anyone who's been reading this blog for a while knows, our long-term goal is to get Sunny off his atypical antipsychotic medication. We tried at the end of last year, but his performance at school plummeted. Right now we're trying neurofeedback. I've researched it extensively, I understand the mechanism and I think it might work for him.

The diagnostic testing has already confirmed what I already thought. Sunny doesn't have "typical" ADHD. He has overactive areas of his brain that hurt his ability to focus on a task without becoming distracted or emotional. They also hurt his ability to self-soothe. The goal is to teach him to consciously or subconsciously lower the frequency of his brainwaves. It's like showing him a series of exercises for his brain, and the more he does these exercises in the sessions, the more he'll be able to flex those muscles (thereby calming himself) in real-life situations.

Sunny loves it, of course, because it involves playing video games.

We hit a major roadblock on the first week, though. We were planning on two sessions a week. Apparently, one of these sessions is going to use a neurofeedback variant called the "LENS System". Instead of the usual passive sensors reading brainwaves and displaying them on a screen, part of this system involves feeding low-voltage electric waves into the brain via a sensor cap.

Whoah!

This was not explained to me well. After I did the research, the whole thing sounds fishy. For example, one website claims "Symptoms associated with ADHD, depression, anxiety, OCD, migraines and Asperger’s can improve significantly with LENS". Where is the study? I realize it's difficult and expensive to do truly good double-blind studies, but I can't find anything.

I'm extremely suspicious of alternative therapies, especially ones marketed to parents of special needs children. I know about the placebo effect and I don't trust anecdotal evidence. Extraordinary claims demand extraordinary evidence. I also want to know how something works before I try it.

I'm suspicious of traditional medicine as well, considering that Sunny is on his current medication not because a caring expert made an informed decision, but because some psychiatrist who met him for less than five minutes kept prescribing him a rainbow of different medications and finally stuck with the one that happened not to have too many apparent short-term side effects.

Anyway, the main neurofeedback doctor assured me that the LENS System treatments administered by the other doctor are safe, effective and would speed up the treatment process. I told him I had to do some more research and would get back to him. These were my concerns:

1) the LENS system was feeding electricity into my son's brain. That doesn't sound safe.
2) but if it is safe, and the voltages are so low that he can't even feel it, then they're too low to do anything at all, which means I'm paying a huge amount of money to watch my son sitting in a chair with a funny hat on.
3) Unlike regular neurofeedback, I do not understand the basic mechanism for how the LENS system functions.

Later that day I thought of Brenda McCreight, a neurofeedback therapist and adoptive parent of many special needs children. She wrote the scariest book in the world, which is how I knew of her in the first place. It's an awesome book, it's just very scary. If you've read it, you know what I mean. Then she started up a great blog focused on her adoptive parenting.

So I emailed her. I introduced myself and described my situation in detail, then asked, "Can you please tell me if you have any experience or knowledge, for good or bad, of the LENS system? I would be very appreciative of whatever advice you would care to give. Thanks!"

Here is her email response:

Hi,

Thank you for contacting me. I use neurofeedback extensively in my practice but I have chosen to not use, or get training in, LENS at this time. I am always concerned about putting anything into the vulnerable brains of our childen and although I have read extensively on LENS it has yet to sell me on the safety or even the efficacy- there simply isn't enough research to back it up at this time. For older children and adults with anxiety, I am now using HeartMath http://www.heartmath.com/ but I find it's too challenging for most 6 year olds so I stick to NF with them as well.

You will be able to find thousands of practitioners who swear by LENS, and maybe it's my own lack of understanding, but I won't use it on my own children or my clients. Maybe in a few years when there is more research, but not now.

I can only give you my opinion as I am not an expert in LENS, but you asked for my opinion - so there it is.

Good luck with your adoption - 6 is a wonderful age.

Brenda

I asked her for permission to post this response on my blog, and she consented.

I told the doctor that I am not comfortable with the treatments at this time. We're going to have to reschedule or go to once-a-week treatments. If I see some studies, I could change my mind.

I'm really glad that I was able to get such helpful and reasonable advice from Brenda McCreight. I'm also grateful that she is so forthright about putting her advice out in the open. So many professionals like to keep things behind closed doors for fear of offending their peers.

I've lost some trust in the main doctor. I feel like he sprang this on me. But I'm going to stick with the regular treatments.

Plan of Action - Implemented

Well, he did wake us up at 6AM, like I thought he might. It was obviously a power play... nothing to do with nightmares this time.

We burned through stages 1-3 pretty quickly, and ended up in the car. By the way, I like using the car (the email comment a few posts ago gave me the idea) because it's a safe place to have a tantrum in. It's padded. He can't get out because of the child locks, he can't throw anything, he can't destroy anything -- it's Guy's car, which is a lot older than mine and the upholstery is nothing we need to worry about. Guy and I took turns sitting in the front seat.

When he started hitting I went into the backseat and held him down. I hate, hate, hate doing this but it has to be done. He'd struggle for a while, then promise to stop hitting, then I would let go of his arms... then he'd hug me and cry some more. I'd tell him, "I love you, I won't hurt you, but I will not let you hurt other people."

We told Sunny he could leave the car either when it was 7AM (his normal wakeup time) or when he apologized and wrote ten sentences. We ended up staying in the car until 7AM, but he did apologize.

I'm going to tell our agency that this has been going on and how we're handling it. I want to make sure we're covered and that I'm following all the discipline rules, which are pretty strict. As our trainer once quipped, "you can't lock them in and you can't lock them out." I would think it's OK to lock them in a car, as long as you're in the car as well.

I asked Sunny why he was doing this all of a sudden, but he didn't know. We also told him we were willing to do this every morning if necessary, and he was going to get to know the inside of the car really well if he choose to continue this behavior. He also lost all his TV time for today.

I'm proud of Guy... he kept his head and made it clear to Sunny that we're on the same page.

As soon as we got back into the normal morning routine, Sunny was in a great mood again.

Tomorrow morning might be easier because Sunny will have had swimming after school, so he'll be a more tired out. Guy is also planning to take him on a nice walk with the dog.

I'm just choosing to be very detached about this rough patch. I'm not going to let it emotionally exhaust me. We're thinking about getting his medication upped, but we're going to try and wait it out until he's well into his neurofeedback treatments.

So It's Not Just Me

I had a nice talk with Sunny's foster mom last night. She said she was wondering if he was going to have those big, way-out-of-control hour-long fits with us.

When he first came to them he was "fine", but after a while he started having those hourlong tantrums. That's when they started trying a series of medications, ending up with the atypical antipsychotic he's on now. She said he still had the fits, and they could be set off by an adult or child in the house telling Sunny what to do... and the pattern was pretty random.

She said "I was beginning to think it was just me!"

Now I feel the same way. Whew, it's not just me. This is not the absolute worst Sunny has ever behaved.

She believes he has something neurological that makes him behave that way... of course he doesn't want to do it, he feels compelled.

It's impossible to put a finger on exactly why. I seriously doubt he has real (i.e. genetic) ADHD. I don't think he has any kind of bipolar either.

Here's a pretty broad list of childhood bipolar symptoms with my remarks added. I'm aware of a lot of the controversy regarding overdiagnosis of childhood bipolar, and I'm taking the list with a grain of salt.

• an expansive or irritable mood (Sometimes)
• extreme sadness or lack of interest in play (Never. He's very resilient. He'll get sad, of course, but he recovers quickly)
• rapidly changing moods lasting a few hours to a few days (No. He's consistent. He's either energetic and sweet, energetic and cranky or just plain energetic.)
• explosive, lengthy, and often destructive rages (Sometimes)
• separation anxiety (Yes, definitely. But he's OK at school or playing with other kids or other adults.)
• defiance of authority (Sometimes... more at home than at school)
• hyperactivity, agitation, and distractibility (Yes, although he's able to focus for quite longer periods of time on things he really enjoys, like Legos)
• sleeping little or, alternatively, sleeping too much (not really, 10 hours a night seems to be his natural time)
• bed wetting and night terrors (Bedwetting yes, night terrors yes, but rarely)
• strong and frequent cravings, often for carbohydrates and sweets (Come on, this is a ridiculous "symptom")
• excessive involvement in multiple projects and activities (yes, has a harder time staying on activities in school compared to his classmates)
• impaired judgment, impulsivity, racing thoughts, and pressure to keep talking (Yes, very impulsive and talkative... impaired judgment, not really)
• dare-devil behaviors such as jumping out of moving cars or off roofs (No. He's daring, but has a great understanding of his physical limits.)
• inappropriate or precocious sexual behavior (No)
• delusions and hallucinations (No)
• grandiose belief in own abilities that defy the laws of logic -- ability to fly, for example (No)

He doesn't fit any other diagnoses. I think FASD is out of the question. He was more than 8 pounds when he was born, and many of his particular mental strengths are the mirror image of the problems that kids with FASD tend to have. He's a Go Fish expert card-counter, and his sense of direction and memory for landmarks are better than my own.

I don't think these fits have changed my basic approach to Sunny's issues. Number one, he's a strong-willed child. He'd be a strong-willed child even if he had a totally normal and boring childhood. Number two, his mother was not consistently there for him when he was an infant and toddler, and then he lost her. Other people were there for him, which is why he doesn't have attachment disorder, and why he's so trusting . But it's still a huge loss. Knowing that she died is another loss, but I think it affected him less than the initial loss... the time he knew for sure he was never going back to live with her.

We can't change Sunny's basic personality. I wouldn't want to. But I'm confident we can help him grow out of these fits, and that he will find ways of untangling the complicated knot of loss/control/anxiety he's been forced to live with. I think when he can be alone in a room by himself, at ease with himself, this will be a huge marker of progress. It sounds so simple...

Adoption Tax Credit Clarification, Plus Some Obnoxious Opinions

I got a lot of comments on the last post, so I thought I'd elaborate a bit.

First of all, the tax credit isn't really $10,000; it's increased every year and I had an older figure in mind. For tax year 2007, it's $11,390 and it should be $11,650 for adoptions finalized in 2008. This link at NACAC does a good job of summarizing the situation for foster care adoption families.

Basically, you can get the whole credit if you've finalized a special needs adoption. If you're getting any kind of state adoption subsidy, that means it's a special needs adoption. It doesn't matter if the adoption was free. You don't have to claim expenses. If your adoption in 2007 was free, you get $11,390. If your adoption cost $5,000, you get $11,390. This is in the form of a tax credit. So if your tax liability is less than $11,390, the rest of it rolls over to another year. NACAC has some examples and a link to the IRS publication.

I'm going to pay some money for my adoption finalization, which should happen this year very soon, so I'll expect to get this tax credit money next year. My finalization isn't going to cost anything at all, because I get a reimbursement from Sunny's state. My trip expenses for the first trip visiting him are also going to be repaid at that time.

One thing I don't understand very well is the situation for non-special-needs adoptions from foster care. I suppose these would be children who were fostered from birth. In foster care, "special needs" is a very inclusive category and encompasses plenty of kids who are quite healthy. Here's the definition from Georgia:

In the State of Georgia a child who is considered special needs for the purpose of adoption meets the following criteria:

a. Any child eight years of age or older.
b. Any child of African-American heritage who is one year of age or older.
c. Members of a sibling group of three or more who are placed together.
d. Members of a sibling group of two where one is over the age of eight or has another special need.
e. Any child with documented physical, emotional or mental impairments or limitations.

People who do private domestic adoptions and international adoptions get the same tax credit, but they have to file expenses. So if they paid $5000 for an adoption, they would only get $5000 back. So at least in that one way, special needs foster care adoptions are privileged.

Here's my first obnoxious opinion in response to Sang-Shil's comment/question. I don't believe people who are not independently wealthy should be encouraged to adopt internationally using short-term lures like the tax credit. It's just too dangerous.

This doesn't mean that working class and middle-class people can't be great adoptive parents. It's not a judgment on parenting skills. It's a judgment on the terrible state of children's healthcare in this country. I've just heard too many horror stories.

It's not easy for families who have adopted from foster care to get services, but at least we have Medicaid and subsidies. When things go wrong for international adoptive families, there's no safety net. When they start off, they don't think anything will go wrong. The agencies certainly don't have any vested interest in telling them scary stories about attachment disorder and PTSD and fetal alcohol syndrome. If they're lucky, and they usually are, things will go reasonably well from a health perspective. If they're not lucky, they will end up shattered, bankrupt and their children will be taken away and age out in foster care.

I've heard so many of these stories. Here's a comment that a person just now left at the link I gave for my tax credit policy suggestion:

derinever
1/15/2009 10:44 AM
I adopted a child internationally. There is no social suport for these children He is not able to be educated in America's failing education system. These orphaned children have a risk for learning disabilites and psychological problems from neglect abuse malnutrition and lead posoining. Stop the adoptions until America can commit to helping these kids. My son has NO school. He is eight years old. We have tried to get him help paying more than fifty thousand dollars of failed therapies and tutoring. Tax credits wont change his future of less hope due to poor education help

Just another example. Sunny's foster mom has adopted several children with fetal alcohol spectrum disorder. I want to do a detailed post about some of these children later, so I won't talk about them much more. I was shocked when I found out that one of the girls was 14, because she looked and acted like she was 10 years old. She was also an incredibly sweet, caring and peaceful girl. Sunny's foster mom worries about their future, obviously. But she knows a lot about their disorder. Their medical care doesn't cost her anything... and one of them was hospitalized for months, at death's door, when he was Sunny's age.

His foster mom told me that one of her neighbors had adopted a girl from Russia, and sort of sadly shook her head. She had severe FASD. The family put the girl in an institution when she was 12 years old and she's been there ever since. I wonder what kind of toll that took on their family.

I think that a lot of parents adopt internationally, realize they're in over their heads, then pull it together and scrape up all their resources and work through it. But the ones that don't... I wish there were more statistics about the intersection of international adoption and the foster care system.

There have been about 20,000 international adoptions a year in the past decade. So the tax credit is costing the government $200 million a year. I think this money could be better spent 1) regulating international adoption agencies and preventing corruption 2) ensuring potential parents are educated about the psychological AND cultural needs of international adoptees 3) scaring the hell out of them (the same treatment foster care adoptive parents get in trainings) so that they know for sure what they might be getting into 4) ensuring better healthcare, or at least educating parents about what services are available.

I realize that a lot of what I'm saying could be taken as pathologizing international adoptees, so I feel like I should apologize for that. But I'm coming from a background where you assume an adopted child will have issues due to a traumatic background, so that you're pleasantly surprised when they don't.

Take my dad, the international (non-transnational) adoptee. He's incredibly strong, tough, brilliant, humorous and independent. He's also got some attachment issues. The more I learned about adoption as we were researching, the more I realized how losing his parents in the war affected my father and could have caused him to behave in some really extreme ways that almost permanently alienated me from him when I was a teenager. Ah, the fistfight episode. I'll save that for another post someday.

Anyway, I think that ALL children and families should receive the best care. In a better system (and I hope an Obama administration gets us there as quickly as possible) all families will never have to worry about giving up custody of their children because they couldn't afford residential treatment. Ultimately, this is a problem that affects adoptive AND birth families of all varieties.

Second obnoxious opinion: I am not quite so sure about removing the tax credit from private domestic adoption. Ultimately, I don't think the tax credit there is a good thing. But I've heard one convincing argument that it ultimately relieves strain on the foster care system and helps some children, because otherwise some of these children would end up in the foster care system, with all the huge delays and potential for disrupted attachment that the system entails.

I hesitate to put out that argument. Private domestic adoption is not a subject I blog about, but I do know that there is a lot of stigma on women who voluntarily give children up about adoption... popular ideas that they do it because they're hopelessly dysfunctional and drug addicted and so forth. It's a stigma I don't want to contribute to. I think that today, women decide to relinquish for really diverse reasons that are linked to a lot of factors involving class, race, ethnicity and religion.

However, stating the opposite -- that there's no overlap between mothers who voluntarily relinquish and mothers who get involved with CPS and go through involuntary termination of parental rights -- would be false. There is a small degree of overlap. I've heard many cases of women who "voluntarily" relinquish via a private adoption, because they've had other children who ended up in foster care, and if they didn't do a private adoption, they know they'd have their baby taken away by CPS anyway. At least with private adoption, they have a greater degree of choice.

(This certainly wasn't the case with Sunny's mother. She had a case open with CPS because of Sunny, but everyone, especially her caseworker, was pulling for her to keep BB. If she hadn't died, she certainly would have kept him, and I like to think they would have been very happy together)

So the countering argument is that maybe the tax credit for private domestic adoption does serve a societal purpose. It can also help encourage African-American parents to adopt privately, thereby increasing intraracial adoptions. I've heard a lot of African-American parents are leery of paying any money at all for private adoption because of moral reservations as much as financial ones.

Ultimately, I still don't agree with it. I think it should be replaced by more specifically targeted tax credits and subsidies. And private adoption agencies are so poorly regulated that I wonder how much of the adoption tax credit really goes to the parents. Like I said in the original post, I wouldn't be surprised if an agency would just build the subsidy into their fees and treat it as pure profit on their end.

Also, when it comes to private domestic infant adoption, there's no shortage of parents due to money. There is a deeply disturbing hierarchy where healthy white babies cost the most, and black and/or disabled babies cost the least. There are only a few infants that are in danger of ending up in foster care because their potential adoptive parents can't afford to adopt... and these babies are the ones that cost the least. I don't blame private adoption. I'm pretty neutral on it, from a perspective of policy. It simply reflects the screwed-up values of our society, no more, no less.

What I hope is that as our country improves its safety nets, there'll be less of a need for things like adoption subsidies. Also, the need for adoption will decrease and there'll be less waiting children. Poverty isn't the single driving force behind adoption, but it's frequently a major contributor. For example, if you're a mother with a combination of mental health and addiction issues, and you come from a family with resources, you'll probably keep your children. If you have the same set of problems and come from a family with no resources, or grew up shuttled between foster homes, you'll probably lose them.

In the short-term, until we get to that better place, special needs adoption subsidies are vital. I don't know what would happen if I had to pay for Sunny's medication on my own. The very thought gives me shivers. Right now, I'm proud that what we give Sunny is not too far away from the very best. Non-generic-available medication, therapy, a tutor that specializes in ADHD, the prospect of experimental neurofeedback treatment, a college savings fund, all the way down to organic fish oil vitamins. I'm lucky because Sunny's needs are really not that severe, but if they were, we would be able to pay for much more treatment without bankrupting ourselves and driving ourselves to the limit emotionally.

Sunny's Getting Bigger (Another Medication Post)

Sunny has gained quite a bit of weight since coming to us. He's about ten pounds overweight for his age. The scary thing is, it's all muscle. He doesn't look particularly big... he's just very, very solid.

His old swim teacher explained to me that he had a tough time teaching Sunny because of his muscular build. Skinny kids float, chunky kids float, but Sunny sinks unless he forcefully uses his arms.

I think the 15% weight gain is turning his medication into a proportionally lower dose. It was already a very low dose... now I'm forced to consider the horrible prospect of raising it.

The medication is just so closely linked to his school. When he forgets it in the morning, or when we were trying to get him off it last year, his school performance just falls apart, and he can't write at all. He becomes so much more unhappy. He keeps falling into a cycle... frustration, anger, attempt to leave the situation that's making him angry, rebound back because he's scared of being alone, getting angrier, melting down, blaming himself. He still goes through those cycles on the medication, they're just a lot more frequent and severe when he's not on it.

Last night it was a simple request "please come over here, it looks like you need some chapstick" that started it off.

I don't want him to have to take medication for the rest of his childhood. He doesn't have any side effects now, but what if we raised the dose? What if he stays on it for years?

I'm going to try something new... neurofeedback. I've been researching it a lot. I'm not a believer in alternative medicine at all -- I think scientific trials are better proof than anecdotes or tradition. Neurofeedback seems like it's in a different category: promising, though not fully proven. The medication carries just as many if not more unknowns, however. With neurofeedback, the beneficial effects are supposed to be permanent.

The medication is free, because of Medicaid. A full treatment of neurofeedback might cost more than $5000. It's not covered by any insurance. The cost makes me nauseous. What if it doesn't work and turns out to be a complete waste?

I'm just thinking out loud. I haven't come to a decision yet, but I'm leaning toward giving the neurofeedback a try.

It's not like we're completely at the end of our rope. Sunny's behavior can be annoying at times, and I'm very worried about his future in school, but most of the time he's just a great little peppy kid.

On the plus side, he's had times recently when his focus is fantastic. Honestly, I never thought he would be able to play with his Star Wars Lego kits. Their boxes even say they're really for ages 8 and up. After a few rocky starts, he's starting to get the hang of it. He can focus and work on putting them together for up to half an hour at a time.

Sunny also spent more than half an hour yesterday taking apart a coffee machine. Guy likes to give Sunny small broken appliances to take apart, using real tools (hammer, miniature power screwdriver, pliers, wire cutter). Guy says the trick is to cut off the power cord first so Sunny won't be tempted to plug it into anything. Every ten minutes or so, Sunny would run into the house, show us a piece of the coffee machine, and breathlessly explain his theory behind why it worked.

We're also considering child modeling for Sunny. It's something he might really enjoy, because he's a total camera ham. Maybe we could pay for his neurofeedback that way! Errr... that sounds unethical, but I have to be honest, it's crossed my mind. Anyway, that's an easier decision. If he likes it, we do it; if he doesn't like it, we don't.

Mixed Bag - Frightening Episode

Sunny did very well in school on Monday. Then Dad came home, and everything was great. However, we had a very disturbing episode at dinner.

While Guy unpacked, I took him to his tutor, who lives in Nana's neighborhood, and then we went over to Nana's house to have dinner.

At the end of dinner, Sunny pushed away his plate, said, "I'm outta here!" and got up. He wandered off about ten feet and then circled around.

That's totally unacceptable to do at the dinner table, and he knows that. He came back and sat down for a bit, but it was like something flipped in his mind. He became oppositional and verbally threatening. "I'm never coming to Nana's house again!" "I'm never talking to Mom again!" He started talking to himself, and when we asked him any questions, he told us to be quiet because he was busy talking to himself!

I didn't want to to cause another full-on meltdown right there, so we didn't do a time out. I just told him that because of his bad behavior at the table he lost the privilege of blowing out the candles after dinner, then we left.

In the car, he kept on backtalking. So I told him, "You really need to be honest about what you say. You can't just say angry words you don't mean. If you really want me not to to talk to you, I'll do that. We'll try it for this car ride back. I won't talk to you at all until we get back home."

He told me he didn't mean it. Then he called me a meanie, and said he wasn't ever going to talk to me again. He cried and was very upset for most of the ride back. He patted me on the shoulder a few times, and I patted him back and squeezed his hand, but I didn't say anything. He kept up a constant dialog with himself. At one point he sobbed, "I don't know why I'm doing this, I'm getting myself in trouble." Then he went back into "Mom is a meanie" mode for a few minutes.

When we got back home, I gave him a hug. He also got a hug from dad and a long talk about what just happened. He apologized.

Sunny said he missed his foster mom. Guy and I talked later, and I don't think that's what's behind all this. Sunny misses his foster mom a lot, and that's only natural. He's very expressive about that, he doesn't hide it in any way, and when he brings it up, we talk about it and offer to call her on the phone.

I tend to take Sunny at his word when he says "I don't know why I'm doing this."

My mother said she was very shocked at his behavior and had not seen anything like it before, especially the way he was talking to himself. It's almost as if there were two Sunnies. For example, at some points he was saying things like "leave me alone" or "don't talk to me" but he would move closer as he said "leave me alone", and he obviously wanted me to talk to him and got very upset when I didn't.

I think I handled it well in that I kept it from escalating. He got through the worst of it in the backseat of the car. I'm not sure if not talking to him was a good idea. But then again, if I had talked to him, it would probably have upset him just as much.

Afterwards, and then again in the morning, Sunny was his normal self again.

Maybe moving his medication half-dose to the morning helps him in school but hurts him at home.

We'll talk about this with the therapist. I'm up in the air as to how much of it is specifically adoption-related. He could be thinking that bad behavior might get him back to his foster family. But he seems pretty secure in his place in the family... and I tell him all the time that I love him no matter what his behavior. I know that "I'm going to push you away first because I'm scared you'll push me away" is a common theme but that just doesn't seem like it explains the episode, especially the strange dialog he was having. I do know that he was profoundly anxious, torn and confused during the episode.

Given what I know of Sunny's personality -- how expressive and articulate he is, how much he loves finding reasons for things -- it doesn't makes sense. Maybe this is something that no one has any control over, except on the chemical level.

I'm going back to reading about childhood bipolar. I said I was 99% sure he didn't have that, but now I feel more like 50/50. Maybe his medication was at the right dose, and now that it's at half strength, he's starting to have hypomanic episodes. If that's the case, he needs to go back on it, and soon. I want to talk to the therapist, and wait just a bit longer to see what develops.

We're also going to try putting him to bed at 8pm instead of 8:30, in case he needs more sleep.

ETA: I talked to our therapist. She told me it was probably a good idea not to talk to him in the car. Her take is that the episode was caused by too many emotions (from his complicated past) cycling back and forth. Sunny is good at expressing and naming his emotions, but if they come too fast, he loses that ability. She thinks the medication helps him handle those emotions, and supports putting him back on a full dose if necessary, until he grows up a little bit and gets more of an emotion vocabulary.

She also gave me a great specific recommendation: that we get a CD player for his room. He can choose which discs to play when he goes to bed and put them in himself. This will give him more control over his environment and help him practice how to calm himself down. I'm going to try that starting today.

We'll check in with her when we see her next weekend.