clinical study--Zoloft helps kids, too

I found this link describing a clinical study of 376 -- that's a fairly large sample--children, who improved over a ten-week period on Zoloft. It's an SSRI, which means it regularizes serotonin levels in the brain. More on this later.

Here's the link:
http://www.usatoday.com/news/health/2003-08-26-depression-children_x.htm

zoloft, miracle drug?

I had this feeling . . . just a hunch, just intuition, Mother's intuition, maybe, but I had this nagging sense that we should try an anti-depressant again for Nik. I knew we had to be careful, since anything "up" can send this kid into screaming, lunatic mania-land quicker than you'd believe. Actually, he doesn't even need a stim or anti-depressant to end up there. But we'd only tried ONE dose of Prozac ONCE, about three years or so ago, and since he became very agitated and aggressive just a couple of hours later, we thought maybe we shouldn't try the ad route, again. Many kids along the Bipolar spectrum can't take anti-depressants for exactly this reason. The lift in mood sends them into mania, increased agitation, anxiety, etc .

So, to sum up, I asked his p-doc if we could try another anti-depressant. Just seemed like sloppy thinking to rule out an entire class of very helpful meds based on one small dose, one time. So she suggested Zoloft. Lately, we'd been hearing more of the morbid, "kill me," "I deserve to be shot" kind of talk, and beyond sympathizing with him for feeling so low, I'm beginning to wonder about the effect on Anna of hearing this ultra-violent, morbid, wacko, very disturbed talk all day long. So the doc agreed, said Zoloft might be less activating than Prozac.

We started off at a very small dose, 12.5 mg. once a day. And yes, he did become more manic-like, and yes, things went south at school. He became even more difficult, swiped at a teacher with his open hand, opened a door into another teacher's body so it was a contact type of thing, definitely aggressive, went back to level 1 on their level system (he had been at four or five), and I started getting the phone calls throughout the day again. But I didn't want to blame it on the Zoloft (though it probably was due to this) too quickly, said let's hold tight and just wait a few more days, weather this storm. Sometimes, the initial reaction to a med doesn't last.

I had a talk with him about the word "assault" and informed him that teachers have been known to press charges against bigger kids who attack them. He sobered up. He lost his lunchtime stuff, and had to spend a morning in the time-out room. And---Matt gave him Tenex and put him back on Risperdal, and I know that helped. The next day was better.

And most encouraging of all, the kid is noticeably HAPPIER, and his mood is brighter--most def. Matt and I agree. It's one of those things you can't quite put your finger on, but it's different. He's talking purposefully about the future, talking less about death and killing and being devil's spawn. He is really, really happier. God BLESS the evil pharmaceutical industry. More later.

worth the pain, morning reflections

At this moment, I'm doing something I never would have dreamed possible even a year ago: I'm watching my three month-old baby boy kick and punch the air like a tiny boxer, trying to reach small dangling birds, cows, and plastic beads from his baby gym. His eyes are still blue, and hair still quite reddish, and I'm sure this can't last. Both Matt and I are blonde, with greenish hazel eyes. Still, I can hope that, through some miracle of recessive genes, he will keep the blue eyes, maybe even the red hair. He is a miracle. After many, many years of infertility and no need to even bother with contraception, along comes this baby just when I was sure nothing like this would ever happen. He is a ray of sunshine in my life, as my Mom predicted. He is a miracle, as his Dad has said more than once.

It's reassurance of some kind, I suppose, some kind of bulwark--or distraction, maybe--against the sadness and discouragement I feel this morning, thinking of my oldest son. He starts a new medication today, and by now I know not to get my hopes up. But they're up, anyway. I can't help it. Maybe I don't want to help it. Maybe I want never to stop hoping we'll find the "thing" that lifts him out of his sadness, his darkness. How could anyone be depressed, truly depressed, and so troubled, at only nine years old? Actually, I can remember him talking about hating himself much younger, as young as four or so. He feels like he messes up, does the wrong thing all day, every day, again and again, and concluded long ago that he doesn't like himself much, that he's a bad kid, that only someone "pure evil" (his words) would do the things he does. His impulsivity is so hard to overcome. His self-regulation is so very poor. Yet he also has a conscience, the ability to feel and express love, and he knows many of the things he does are just plain wrong. Yet he does them over and over again, then feels so guilty about it all and so hopeless about himself that he is filled with darkness, blackness, morbidity, and he feels alienated from all that is good in the world. And the thing is, no matter how hard I try and wish and pray, no matter how much I yearn for him to just FEEL BETTER, be happy, be content, not hate himself, I don't seem able to change it, change him. How many nights have I held him, telling him again and again how precious he is, how much he is loved, that no one is a mistake, that God loves him just the way he is, as do we. I tell him no one is all bad or all good, that we're all a mixture of the two. I try everything, say everything. And sometimes he feels better, but it's just a band-aid, just for the moment. Apparently, I can't change him from sad kid to happy kid, no matter how I try. It's humbling, the limits of a parent's influence and direction in a child's life.

The big question is, is he depressed for more psychological reasons--guilt and despair over himself and his impaired functioning in the world? Or is it a more genetic destiny kind of thing, in which he would feel depressed anyway, more from a chemical imbalance resulting from genetics or early environmental factors? If it's the latter, maybe an anti-depressant can help, if he can tolerate it, which is far from certain, since he also is diagnosed wth Bipolar Disorder. Many people with Bipolar cannot take anti-depressants, or if they do, they're so activating that they become manic. I shouldn't have my hopes up. Maybe one day I'll learn not to.

But if I lose hope, I guess I've really lost him. Maybe I can hold onto hope for improvement while not putting so much of myself into that hope, that I'm destroyed when it doesn't materialize.

working memory, the new iq?

Found this article on yahoo yesterday. Seems researchers are concluding that working memory is the most important factor in how well a person learns academic material. It attracted my attention because N's testing revealed deficits in working memory; this is very common in people with ADHD, FASD, and and other neurologically-based problems. Put very simply, it's the ability of a person to remember several things simultaneously, holding one in place while incorporating other bits of info, without losing the first bit. So if you're reading one of those reading comprehension passages on a standardized test, you'll do pretty well if you have good working memory. If, on the other hand, you don't, then you might have forgotten the point of the first two paragraphs by the time you get to paragraph # 5 or 6. It also probably explains why so many of our kids have problems with daily functioning--it explains one piece of the puzzle, anyway. Sometimes, it isn't that they're disobeying or being lazy or whatever, just have trouble remembering what they're supposed to be doing. N., for instance, routinely blows up if you give him more than one or maybe two instructions at a time. We've learned to break things down and only tell him one thing at a time.

Anyway, here's a link to the article on working memory:

http://news.yahoo.com/s/nm/20080302/sc_nm/memory?learning

"What You Pawn, I Will Redeem"

I've been reflecting lately on a wonderful short story I read a few years ago, by Sherman Alexie. It's called "What You Pawn I Will Redeem." I believe it was published in The New Yorker, and later won some awards. It's the story of a middle-aged, articulate, native American alcoholic man living on the streets of Seattle. In the story, the man (who calls himself Jackson Jackson) walks into a pawn shop with some friends one day and sees his deceased grandmother's regalia headdress in the window, for sale. He tells the owner it's his grandmother's, to no avail. The man wants a thousand dollars for it, period. He says he will hold it for twenty-four hours, and if Jackson can bring him the money, he'll sell it to him. He even gets him started with a twenty (or maybe ten) dollar bill. So Jackson Jackson sets out on his quest. He believes for a moment that if he can get that headdress back, he might bring his grandmother to life again. He is a man on a quest.

The problem is, he's an alcoholic. He manages to make a few dollars selling the local homeless newpaper, feels pleased about it, closer to his goal, and then promptly goes out and spends it on booze for him and his friends. He does this over and over again, never giving up on his quest, but each time, ending up drinking the money away, then picking himself up and starting again. At the end of the story, he shows up at the pawn shop with five dollars in his hand, all the money he possesses in the world, showing up regardless of what he has, to claim the regalia. The pawn shop owner looks at him and asks one question: "Did you work hard for this money?" Jackson says yes. The owner walks over to the window and gets the regalia and hands it to him. Jackson walks out of the pawn shop with an ecstatic shout:

"Do you know how many good men there are in the world? Too many to count!"

Then he puts on his grandmother's regalia and goes out into the street and dances, blocking traffic but not caring because for a mystical moment, he achieves some kind of union with his grandmother and feels her presence again.

This story resonates with me not only because it's a beautiful statement of perfect grace, but because Jackson's seeming helplessness reminds me of the pattern experienced by those with FASD, in particular. They wake up with the best intentions, most likely. Then they spend the rest of the day doing the wrong thing, over and over and over again. They feel guilty. They might resolve to try to never do the thing again. But before the day is over, maybe before the hour is over, they'll do it all over again. And they'll feel like dirt, feel like they're bad beyond redemption. And every day, this is repeated over and over, the cycle. It's hell.

I see this so much in my son, and it is absolutely heartbreaking. You feel so helpless and frustrated, try to keep hope and not give up, try not to show how disappointed you are. But sometimes it comes through because we're only human. My son does the wrong thing all day long, most days. He asks me, "How can I be a good person if I do bad things?" "Why do you love me when I'm so bad?" I know beyond any doubt that he would love nothing better than to have more "self-control." If you ask him one thing he could change about himself, he'll say ADHD. ADHD is what we use to explain his disability to him, the way his head works. Of course, there's more than ADHD going on, and psychological problems on top of that.

It brings to mind a fundamental dilemma: How much personal choice does he really have? Can someone who is obviously impaired in the areas of impulse control, memory, self-regulation in general, be held to the same standards as non-impaired people? Yet accepting that he will be unable to control himself means giving up on him, in some sense, giving up on the idea of his ever living any kind of normal life. Should I not make him feel guilty about taking things that don't belong to him, or lashing out physically? If not, or if we dont' try to change him, that means without a doubt he will end up in a jail or some sort of mental hospital or residential facility. That seems unbearable. How do we protect him from the consequences of his actions, impaired or not? Of course, the obvious and cliched answer is that we can't. I know that. But it's a hell of a predicament. When we talk about changing him, we're talking about trying to fix a computer that's broken, and I don't know how. It isn't that he has NO control. When the stars align, meaning when he has an adult person or some very strong limiting factor RIGHT THERE two inches from his nose, he can choose -- sometimes -- to do the "right" thing. Sometimes the right environment can make this possible. But when he's not getting immediate feedback, reinforcement, control, whatever, all bets are off. And if he goes into fight/flight too quickly, the environment or management won't matter much.

I don't know the answer. I don't know how to balance "He's got to learn somehow not to break the law" and "He has to learn to function in society" with "I know there are certain things about him that can't be changed, and I know he doesn't have the same capacities for control and self-regulation that non-impaired people do." Would it do any good to try to teach a kid with a sprained ankle to keep up with the rest of his classmates in a fifty-yard dash, or to run without a limp? Staring me in the face is this frightening and crushing fact: At nine years old, after YEARS of giving it our best shot--reward and punishment, lectures, therapy, counseling, various parenting techniques, even a few mild spankings when he was younger (until it became clear they didn't help the problem), basically giving it everything we had--he is often as violent and defiant as he was at three years old. That same kid who threw his little plastic chair at the window at three is the same one who threw his notebook at me and hit me in the arm yesterday. And it's the same kid who felt so bad and guilty and low about his behavior that he called himself "pure evil" and "idiot" a few hours later and couldn't stop making references to killing and death. 

Something in this cycle reminds me of Jackson Jackson, of his doomed life and the futility of wanting to be a  better person. Maybe someday he'll be dancing in the street after someone redeems his pawned treasures, lets him off the hook in a moment of pure grace and pardon. Or maybe it really is hopeless. That's more how I feel today.