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Ask David Akiva Your Own Question

David Akiva
David Akiva, BA, MA,
Category: Mental Health
Satisfied Customers: 167
Experience:  Counselor; Behavioral Consultant
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Dear Doctor Thank you, XXXXX XXXXX - for taking our question We have a 15 year old daug

Customer Question

Dear Doctor:
Thank you, XXXXX XXXXX - for taking our question…
We have a 15 year old daughter who had been attending a Therapeutic Boarding school for the last year with the diagnosis of Oppositional Defiant Disorder/ probable ADD. The Therapeutic Boarding School does a lot of things well, but firmly believes that Meredith’s behavior (and all the girls in their care) is a series of poor choices. Lots of therapy and holding the girls accountable for actions, but pharmacological management is a “four letter [ x 6] word.” She had arrived on Adderall and Abilify (10 mg). The Adderall was d/c immediately, and the Abilify was decreased to 10 mg threed weeks ago, and discontinued last week.
On Tuesday night (3/29) Meredith drank bleach in front of a staff member after an otherwise strong day due to her frustration on having to wash a stack of dishes. She was taken to the local emergency room where she said that the act was impulsive and that she did not really intend (cont)
Submitted: 3 years ago.
Category: Mental Health
Expert:  David Akiva replied 3 years ago.

Duddy :

Welcome, I am a professional counselor, Behavioral-Consultant and relationship expert.

Duddy :

I've worked extensively in residential treatment program and foster care program development. I've provided behavior management intervention supports and individual psychotherapy to participants in these programs. I'd like to help you with a strong, practical answer. Do you mind if I ask a few questions to better understand your daughter's current situation more precisely and your concerns here?

Duddy :

I notice you are offline presently. So I will check back periodically for your response. Hope we can chat.

Customer :

I'm sorry that I missed your question, I was probably on the phone. I will be watching for you to come back online so that we can chat.

Duddy :

Hi. I am going to be doing a consult shortly. 2 interrelated questions. Is your question primarily about medication management, which is outside of my scope of practice, or I can I help you with evidence-based behaviorally oriented problem solving experience, and a joint problem solving chat?

Duddy :

I'll check back after my consult for your response. I can then work with you intensively, or opt-out so that a medically trained prescribing expert can answer your question.

Customer :

Hi Duddy:

Customer :

my question is about finding the best programs (i.e. programs that specialize in BPD) for Meredith. I would then filter those programs through our insurance (BXBS-NC) and their availability for a best fit.

Duddy :

Are you looking for someone to help you locate a specific program in your area? Also, you mentioned ODD and probable ADD (ADHD subtype). When you say BPD do you mean borderline personality disorder?

Customer :

Yes, i do mean Borderline Personality Disorder.

Customer :

You ask

Customer :

Sorry about the typos - I am typing on an overly sensitive keyboard - yikes.

Duddy :

Sounds familiar, me also.

Customer :

you ask about other possible diagnoses - that is our question as well. That is why we think it important to find a clinic/program that can work through that with her.

Duddy :

Alright. I think we can work together. I have some telephone work to do as mentioned. I'll be finished in 2 hours, can we meet them here for chat?

Customer :

You also asked about our desire to find a program in our area. Yes, we would love to find a local program, but feel that with the cloudiness of the diagnosis and how she can best be helped, we are weighing expertise over proximity.

Duddy :

Must go. will check for your response as stated....Please leave any detailed information for my review relivent to your question and towards further clarifying how I can best help you.

Customer :

I will make myself available for your guidance. To complicate matters, we have our oldest daughter & fiancée who lives across the country visiting to put the final plans together for her June wedding. All of this trauma and drama hit when she was thinking that we would be selecting flowers and taking engagement photos. We have put them "on hold", but have guilt in all directions. I tell you this because we are trying to get out for her prime request of a family hike up to Rainbow Falls from 2PM to 6 PM. Thus, I will have a phone with me but no internet connection.

Customer :

Could we converse by phone? could we schedule a chat time after 6 PM?

Customer :

Dear Duddy:

Customer :

Dear Duddy

Customer :

Change of plans, Larry and I are staying by our desks until 5 PM. Please converse when available.

Customer :

Change of plans

Customer :

Sorry for the repeats - the page did not scroll down with new information, and I didn't realize that my response was going through. Will wait for your direction.

Duddy :

Hello. I'm back. I am so sorry to hear about how this interfering with family harmony and wedding planning. Regrettably, I am prohibited by contract from phoning or otherwise consulting with customers via JA.com. But I can certainly have an exchange with you here even over days if necessary. What are your thoughts?

Duddy :

I would be interested in some behavioral snapshots of some of your daughter's core life-interfering behaviors; - short descriptive examples that allow that me visualize the common behavior patterns.

Duddy :

I'd also be interested, as far as exploring evidence-based treatment options, to learn about the basis on which such an early syndromal diagnosis is being considered as BPD. I have worked with adults with BPD and a number of teens, where this diagnosis was anticipated to develop later in early adulthood, with symptom intensification. There are also adaptations of dialectical behavior therapy for adolescents, which have shown excellent results.

Duddy :

I'll be back to check for your response.

Customer :

Hi Duddy;

Customer :

I am just beginning to catch the meaning behind your questions after talking extensively with Dr. Hopkins (local Psych Doc in Cody who added the diagnosis) and Ron at Magellan who coordinates (aka gatekeeper) care for BCBS-NC.

Customer :

My understanding from both individual is that a) incredibly stigmatizing diagnosis because the patients with this label are traditionally annoying, and have little chance of changing.

Customer :

Wow - sorry for the broken sentence structure, but I hope you get my meaning.

Customer :

It sounds like you want some short, descriptive examples of what might make someone think that Meredith really deserves this debilitating label. Understood. Before I knew the impact of the label, it would have been easier. Some, actually many of the descriptives really fit - spot on. But Ili find myself backing away for fear of unfairly saddling her with a liability.

Customer :

In short, I will refer to Dr. Hopkins' thoughts with couple of caviats;

Customer :
  • All the more important to get her to a center that can offer the correct diagnosis. if this is it - let's face it and do our best to give Meredith the tools to help herself to the best her ability. If Dr. Hopkins is wrong - let's get her to a clinic that can better define her challenge and then help her to meet it. What a shame to have an individual taking unnecessary drugs and carry an anchor that is not theirs to carry.
Duddy :

I do get the meaning, don't worry about sentence structure in informal chat, I'm learning not to. Your right, about the stigmatization. In my experience working with hundreds of adolescents with serious emotional and behavioral disorders, maybe 2 were worthy of the diagnosis they were given. In most cases there were adult behavior changes that were needed in the treatment environment that never took, because of the "extra role behavior" (extra work it represented) or for lack of staff understanding and buy in to the basic treatment principals. The second major problem that all evidence-based programs for these kids have is a control for the negative peer influence and "peer deviancy training" effects. It is so important to use least intrusive but systematic behavioral or social learning interventions properly to truly rule out non-environmental causes. I've read what you wrote above. We're basically saying the same thing.

Customer :
  • On the other hand, it would be wrong of us to back away from a distasteful tag in the hopes of insulating her. After all, she is being held in a hospital without friends or family because she has pushed the envelope too far. She clearly needs help.
Duddy :

Have you looked at ho

Duddy :

me based programs like MST and FFT?

Duddy :

MST: http://mstservices.com (Here's a link to look at)

Customer :

I am hoping that due to her young age, we can look at the most difficult issue now - which sounds like BPD - and rule that out. At an older age, she can have it "thrown out"; after all the diagnosis is invalid (or at least inappropriate) for someone under the age of 18.

Duddy :

FFT:

Duddy :

http://www.fftinc.com/

Duddy :

These are some of the best evidence-based programs around. A strong residential program will replicate these treatment principals, and strongly control for negative peer socialization effects, usually through positive peer culture.

Customer :

After talking to the court attorney, Meredith would not be eligible to come home at this time. She was adamant about wanting to end her life (but oddly joking about it with the staff nurses at Park Co Hospital as we speak (which they find quite odd according to Dr Hopkins). In any case, the court evaluator will insist that she be placed in an in-patient setting.

Duddy :

What was triggering her beyond having to wash the dishes?

Customer :

I see the website above; what will that give us?

Customer :

About the dishes; I will give you my take on things. I am stretching here as we have not seen Meredith since May, 2010 (nearly 10 months).

Customer :

1) On the phone today, she expressed sadness that we had not come to see her in 10 months.

Customer :

2) Her therapist of 10 months plus her previous stay of 7 months (5/09 to 2/10) had left a month ago (mid Feb). She was reluctant to open up to the new therapist (Justin) who is probably very good, but we see him as more likely to push {maybe isolate?} her.

Customer :

3) may, or may not be a factor; as mentioned in original note, her Abilify was cut in half at the beginning of Feb, and then discontinued last week.

Duddy :

Re MST/FFT links: Well with serious emotional and behavioral disorders there are important common themes in effective treatment. I think one of the most important things you can do as parents to support your daughter is to really learn about the behavioral treatments that get results. These are just educational resources for you. As you read into them, and eventually learn more about dialectical behavior therapy, you'll see that many of the basic treatment principals are the same or highly complementary.

Customer :

4) EMDR: Meredith began this in mid-December. It appeared to really help a despondent child turn the corner. We read today that it can also trigger old memories that are best left burried. Again, we don't want to point fingers; we are simply bringing forth all of the recent changes that could have contributed.

Duddy :

The evidence base says (and my experience confirms) that talk therapy or even solution-focused or skills development based therapies with youth most often make life-interfering behaviors (including emotional behaviors) worse, without environmental changes to support and link with the therapy. I'm not sure of an evidence-base for EMDR. As far as traumatic memories go, behavioral and emotional stabilization in the present are usually the clinical priority, before memory work. This also depends on the adolescent's intellectual abilities.

Customer :

I guess in summary, is her current behavior - as the people around her see it; one in which she had had it with the current system (had become unacceptable to her) desperately played the only card that she could to escape her current situation - simply revealed by the Trinity boundaries - or did their pressure take her over the edge.

Customer :

I must share with you that her readmittance to Trinity (5/2010) was completely by Meredith's choosing. We had brought her home and my husband, Larry, and I had retrofitted our home and lifestyle to be a two-man team of therapeutic counselors/staff. We had check off lists galore, and check-ins, and family meetings, and points piles. Our efforts were impressive, but ineffective in the end.

Duddy :

What do you mean by points piles?

Customer :

When she came home, she spent weeks writing long and touching thank you notes to the staff of Trinity. I still have copies of them. No one asked her to do this, if anything it would have been discouraged, but she wanted to do it, and we did not stand in her way. She also wanted to send gifts back such as boxes of oranges and the like. Again, we endorsed her grateful nature. I mention this because this same group (just weeks ago was extolling their virtues is now the target of her anger. She is vilifying them in every regard. No middle ground here.

Duddy :

Sound's like you've really worked hard hear and learned a lot. I'm strongly looking forward to some behavioral examples or descriptions, at home and in the program. I see what you're saying about the emotional extremes with the staff.

Customer :

More interesting yet (hang onto your seat for this one), in May she did an emotional 360 on us and in a relatively short time we became the enemy. I think it erupted over her other possible dilemma (something in the Asperger's spectrum) where she felt she wasn't "cool" enough for the other 8th graders and fixated on our insistence that she reach a certain "level" before she wear make-up.

Customer :

After spending an afternoon with her track coach who had a son near her age (whom she admired ) and who also had 3 or foster children, she fantacised about being a foster daughter in this same family. It also happened that she spent a few hours in the nurse's office with a girl who (according to the school nurse) had mastered the county judicial system on making her wants & needs clear to her newly blended family. I really know very little of this young lady's plight; only that the school nurse felt that she was feely abusing the legal power against her parents, and that she felt that she probably schooled Meredith on it's finer points.

Customer :

In any case, as Meredith unwound in a relatively short time period (5-10 days) we came to a point of complete defiance and we (in renewed disbelief) decided to drop her off a mile from home to "walk it off". Mind you, we were in rural Colorado - so no worry of traffic or such.

Customer :

She returned and still refused to do the small task (yikes - I don't think it was dishes, but it was something along that lines.... maybe making her bed? I know it wasn't about the task [I guess it never is], but the clear message of .. Oh Yeah... just try and make me!!!!. you can just go to ...

Duddy :

This incredibly well written.....I'll keep reading...

Customer :

Larry gently put her over her shoulder (I was watching - and we are well schooled on gentle and legal techniques) and put her in the car for a second drop off. what else were we to do?

Customer :

Our little lady found one of the few home in the area, knocked on the door, and announced that she needed to call the police. The nice neighbor tried to dissuade her asking for more example that could possibly justify such a rash action (Meredith had none), but she could not be talked out of it. Meredith called the sheriffe in two counties plus an abuse line that put spurred the result that she wanted.

Customer :

Meredith held to her story that she did not feel safe in our home. This is all scarey laughable in light of the fact that all she can say the court evaluator is that she desperately misses her mom and dad, and if she could just come and be with her exemplary parents all would be well.

Customer :

The school nurse gave her quite the talking to, the sheriffe could only tell her that she was really lucky that she wasn't his child, but she calmly (and with chilling disregard of what it meant to falsely accuse Larry of maltreatment) said that she wanted a new family - and the impact on us was regrettable - but unavoidable. she didn't use the term "collateral damage" - but that was the clear message.

Customer :

We

Customer :

We, in short and blurred order, begged Trinity to take her back in their care. On her first week of the return, she was angry, but it was quickly replaced by gratefulness.

Customer :

These ensuing months have been filled with regret and remorse - how deep- who knows, but she is tearful and so very sorry. She means it. But she also meant her actions when she stuck to her new foster family idea - no matter the cost to the ones she loved.

Customer :

I say this as a pertinant example of how her love and affection can be disrupted. To us in May - over makeup and the desire of a new {and improved} family. All kids have this idea, but not to the extent to do intentional harm - especially when counselled by multiple entities. We were awful - low down - bottom feeders - of the worst sort.

Duddy :

My goodness...

Customer :

We are now her very best friends on the whole earth. In fact, there have never been more loving parents. Trinity is on the devil end. There is no middle ground - they are dregs and really have always been.

Customer :

Well, anyway, I hope this serves as an example of the "emotional schizophrenia" with disconnects that we used to use when referring to our little sweetheart, before we ever heard of the term BPD. beyond this, she doesn't fit the mold (according to Dr Hopkins) of the typical BPD. He found her likable, funny, cleaver, and joyous. He says that is why he was so stunned by her affect (and turn around) for the world yesterday. He feels that it is a good thing that she doesn't fit the typical mold, however he is confident in the diagnosis.

Customer :

We watch from afar, simply knowing that there is a beautiful soul wrapped up in her confused mind that we want to help the best that we can.

Duddy :

What treatment does Dr. Hopkins recommend?

Customer :

I talked to Magellan (BCBS gatekeeper) who has sent me the link of hospitals. How do we find those that specialize in helping us/ Meredith define her issues (to the best of current Medical knowledge)?

Customer :

simple - it is in parallel with our goals.

Customer :

First: define diagnosis and any secondary issues. He is confident in his diagnosis, but readily endorses a second and third opinion.

Customer :

Second: have her be pharmacologically managed

Customer :

Third, have her treated with the only successful treatment for BPD which is DBT or the appropriate intervention of the diagnosis.

Customer :

Personally, we are grasping at straws. To repeat ourselves, she is a beautiful soul who is tearfully calling us from the hospital apologizing for all that she has done to hurt us and simply wants to walk a Godly path, but we are baffled by the whole thing.

Customer :

We have many talents, but don't have any pretenses that this is our field of knowledge.

Customer :

We humbly turn to the experts in the field to guide us.

Customer :

Can you help?

Duddy :

Well I think that a strongly behavioral program is essential here. A treatment foster care setting if out of home with highly behaviorally trained foster parents would be ideal. Environmental contingencies are so important where self directed behavior has not yet been learned....

Duddy :

It's so important to teach emotional self-regulation skills (i.e.relaxation training); joint problem solving and to implement these as target replacement behaviors within the context of a systematic teaching and learning environment. Behavioral data collection is also incredibly helpful to really see what's triggering and maintaining her emotional and behavioral responding....For example, what was really going on leading up to the dishes? Targeted skills development needed to reinforced contingently....

Duddy :

Motivation is critical in such a program using evidence-based treatment approaches like age appropriate motivational interviewing; - I'm reminded of behavioral activation therapy and the Premack principal. For example most evidence based treatment programs use point and level systems to link access to privileges and "high probability behaviors" for follow through on therapeutic learning tasks first, and then for follow through on the practiced replacement behavior when it really counts. If you're daughter new how to self invoke relaxation within seconds, and was cued to do so at some critical moment before the dishes episode, it could have been avoided.

Duddy :

Did your doctor have access to reliable documentation for your daughter's behaviors of concern and the typical events that lead up to them across various situations, or just intermittent examples of end-product emotional reactions and verbal reports?

Duddy :

Have least intrusive and systematic social-learning based interventions, been applied to help change the currently diagnosable patterns?

Duddy :

I'll get some links to clarify terms:

Duddy :

DBT: http://apt.rcpsych.org/cgi/content/full/8/1/10

Duddy :

Premack principal:

Duddy :

http://en.wikipedia.org/wiki/Premack%27s_principle

Duddy :

Behavioral therapy: http://en.wikipedia.org/wiki/Functional_analytic_psychotherapy

Duddy :

MTFC summary of research: http://tinyurl.com/3uzn5pk

Duddy :

I'll check back for your response a bit later. I don't mind continuing this mutual learning process and then refining a strategy to locate an ideal treatment program with you.......

Duddy :

...

Duddy :

Here is one resource I found. I hope this is your area:

Duddy :

http://www.troubledteensearch.com/directory/programs/behavior-modification-programs.html

Duddy :

http://www.troubledteensearch.com/directory/programs/behavior-modification-programs/1185-wyoming-behavior-modification-programs-troubled-teens.html?

Duddy :

I have really researched and this is one of the best aggregate care treatment settings I have ever read about. It appears to address every concern that I brought up in our earlier chat. It's not directly in your area but I thought I'd send it to you anyway:

Duddy :

http://www.suwscarolinas.com

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