A new Approach for Understanding and Parenting Easily Frustrated
participate in Plan B discussions, medication may help
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The Explosive Child A New Approach for Understanding and Parenting Easily Frustrated, Chronically I ( PDFDrive )
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participate in Plan B discussions, medication may help. Several classes of medications can be helpful, and stimu- lants are, again, often the agents of first choice. However, in some children, side effects, the lack of a positive re- sponse to stimulants, or complicating conditions may require consideration of alternative medications for en- hancing impulse control and reducing hyperactivity, such as a relatively new nonstimulant medication called atom- oxetine (Strattera). Side effects of this medication include upset stomach, decreased appetite, nausea or vomiting, dizziness, fatigue, and mood swings. An atypical antidepressant called bupropion (Well- butrin) has also been used to ameliorate hyperactivity- impulsivity in children. Bupropion may increase the risk of seizures; exacerbate tics; cause insomnia, nausea, head- ache, constipation, tremor, and dry mouth; and can ini- 236 The Explosive Child tially cause an increase in agitation. Antihypertensive medications, including clonidine (Catapres) and guan- facine (Tenex) are also sometimes used to reduce hyper- activity and impulsivity, but they may be less effective for inattention. Antihypertensives can also be effective at reducing tics. In addition, because of their sedating ef- fect, antihypertensives have been used to help children sleep at night. However, in some children, this sedation may be a problem during daytime hours and is some- times manifested in the form of heightened irritability. In those explosive children whose difficulties involve the emotion regulation pathway, increased irritability is un- desirable. Side effects can include headache, dizziness, nausea, constipation, and dry mouth. The tricyclic antidepressants, which include agents such as nortriptyline (Pamelor), desipramine (Nor- pramin), imipramine (Tofranil), and clomipramine (Anafranil), may also be prescribed to reduce hyperac- tivity and impulsiveness in children. An advantage of tricyclic medications is that they provide twenty-four- hour coverage and typically do not interfere with sleep. One of the rare but more serious side effects of the tri- cyclic medications is cardiac toxicity, which often ne- cessitates that children medicated with such agents undergo initial and then periodic electrocardiograms. There are a variety of additional potential side effects that may not be well tolerated by children, including Better Living Through Chemicals 237 dry mouth, weight gain, sedation, lightheadedness, and constipation. IRRITABILITY AND OBSESSIVENESS If irritability or obsessiveness is significantly interfering with your child’s functioning at home or school, or with his ability to participate in Plan B discussions, medication may help. Irritability and obsessiveness in children have most often been treated with a group of medications called selective serotonin re-uptake inhibitors (SSRI anti- depressants), which include agents such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalo- pram (Celexa), and fluvoxamine (Luvox). However, as of this writing, the use of these medications has become controversial owing to findings that these agents can cause increased suicidal thinking in some children (a fact that some of the manufacturers of these agents were appar- ently not completely forthcoming in disclosing). Other side effects include nausea, weight loss or weight gain, anxiety, nervousness, insomnia, and sweating. 238 The Explosive Child EXTREMELY SHORT FUSE If—despite heavy doses of Plan C—your child’s fuse is still so short that he is incapable of participating in Plan B discussions, a class of medications called atypical antipsychotics—including medications such as risperi- done (Risperdal), olanzipine (Zyprexa), quetiapine (Seroquel), and aripiprazole (Abilify) may be used. These medications have prompted much enthusiasm because they tend to be better tolerated than more traditional an- tipsychotics. However, these agents have been associated with sedation and significant weight gain, and may be as- sociated with extrapyramidal symptoms, such as odd mouth or tongue movements, eye rolling, rigidity in the limbs, fixed facial expression, blank emotions, and invol- untary movements. These symptoms typically subside once the medication is discontinued; however, in rare in- stances, they may persist even after the child is taken off the medication (a condition called tardive dyskinesia). Another class of agents—broadly referred to as mood stabilizers—may also be prescribed, including lithium carbonate, carbamazepine (Tegretol), and val- proic acid (Depakote). The mood stabilizers may be less effective in children who are predominantly dysphoric. Indeed, because these agents may produce drowsiness or fatigue, they may actually increase irritability in some children. All of these agents provide twenty-four- Better Living Through Chemicals 239 hour coverage and typically do not affect the sleep of most children. Lithium can cause sedation, nausea, diar- rhea, thirst, increased urination, mild tremor, and weight gain, and must be monitored closely. Valproic acid and carbamazepine may cause sedation, nausea, diarrhea, heartburn, tremor, and weight gain. Valproic acid can also cause liver toxicity, and carbamazepine can be asso- ciated with a decrease in white blood cell count and aplastic anemia, so the use of these agents requires peri- odic bloodwork. Less traditional agents such as flaxseed oil and fish oil have also been shown to have promising mood stabilizing effects. Indeed, some children may benefit from nontra- ditional, natural, or homeopathic agents. Although it’s fine to be open to the use of such agents, it’s important to note that they do have a chemical effect on a child’s body (we have a tendency to view “natural” agents as somehow more benign), can produce undesirable side effects, often have not been carefully studied (of course, the same can be said about many of the traditional psy- chiatric medications presently being prescribed for chil- dren), and must be taken under the supervision of a qualified professional. At the risk of redundancy, it should be clear that the most crucial component in the psychopharmacology pic- 240 The Explosive Child ture is a competent, clinically savvy, attentive, available prescribing doctor. But the doctor can’t treat your child successfully unless he or she receives accurate informa- tion from you and your child’s teachers about the effects of the prescribed medications. When all relevant adults work in concert with the doctor, side effects are handled more efficiently and adjustments are made more respon- sively. A discreet approach to medication is also recom- mended. Most children aren’t eager for their classmates to know that they’re receiving medication for emotional or behavioral purposes. And there’s a temptation for par- ents to keep school personnel in the dark about their child’s medication status as well. True to the collabora- tive spirit required for intervening effectively with explo- sive children, and because the observations and feedback of teachers are often crucial to making appropriate ad- justments in medication, I generally encourage parents to keep relevant school personnel in the loop on medica- tions. If there’s no way to keep a child’s classmates in the dark, it’s often necessary to educate the classmates about individual differences (asthma, allergies, diabetes, diffi- culty concentrating, low frustration tolerance, and the like) that may require medicinal treatment. If you choose to medicate your child, for how long will you have to use medication? That’s hard to predict. In general, the chemical benefits of these agents endure only as long as the medication is taken. Nonetheless, in Better Living Through Chemicals 241 some children, the behavioral improvements that are fa- cilitated by medication persist even after the medica- tions are discontinued, especially if a child has acquired new compensatory skills. Ultimately, the question of whether a child should remain on medication must be continuously revisited. 1 1 The Plan B Classroom A s hard as it is to help an ex- plosive child within a family, it may be even harder in a classroom in the company of an additional twenty-five to thirty kids, many of whom have other types of spe- cial needs themselves. Like parents, most general educa- tion teachers have never been responsible for helping an explosive child and have never received any specialized training to prepare them for this task. Fortunately, most explosive kids don’t actually show any signs of explosiveness at school. Here are a few pos- sible explanations for this phenomenon, including some mentioned earlier: 243 244 The Explosive Child • The embarrassment factor: They’d be embarrassed if they exploded in front of their peers. Since the em- barrassment factor can’t be replicated at home, em- barrassment doesn’t prevent the child from blowing up at home. • The tightly wrapped factor: The child has put so much energy into holding it together at school that he be- comes unraveled the minute he gets home, fueled further by normal late-afternoon fatigue and hunger. • The herd-mentality factor: Because the school day tends to be relatively structured and predictable, it can actu- ally be user-friendlier than unstructured downtime at home. For instance, if a child becomes confused about where he’s supposed to be or what he’s supposed to be doing while he’s at school, he need look no further than his classmates for cues. The herd-mentality factor can’t be replicated at home either. • The chemical factor: Teachers and peers often are the primary beneficiaries of pharmacotherapy, but the medications may have worn off by late afternoon or early evening. There are probably other possibilities. But just be- cause a child isn’t exploding at school doesn’t mean that The Plan B Classroom 245 school isn’t contributing to explosions that occur else- where. Lots of things can happen at school to fuel explo- sions outside of school: being teased by other children, feeling socially isolated or rejected, feeling frustrated and embarrassed over struggles on certain academic tasks, be- ing misunderstood by the teacher. And homework can extend school frustrations well after the bell rings at the end of the school day. So schools aren’t off the hook for helping, even if they don’t see the child at his worst. Of course, there are lots of kids who do explode at school. You may recall that Casey, one of the children you read about in Chapter 4, had a pattern of running out of the classroom when he became frustrated by a challenging academic task or difficult interaction with a peer. When he wasn’t running out of the room, he was exploding in the room, turning red, crying, screaming, crumpling paper, breaking pencils, falling on the floor, and refusing to work. Danny, another of the children you read about in Chapter 4, was also capable of the occasional explosion at school. On one particularly memorable day, the teacher desig- nated him to hand out doughnuts to his classmates after recess. Following recess, he hurried back to the classroom to hand out the doughnuts, but a parent-aide was already in the room and insisted on being the doughnut distribu- tor. Danny attempted to explain to the parent that he had been assigned the task of giving out the doughnuts, but the parent would not be deterred. The shift in cognitive 246 The Explosive Child set demanded by this example of reciprocal inflexibility was more than Danny could handle. Kaboom. Teachers and schools have little choice but to put some serious thought into how to handle the Caseys and Dannys in their midst. We live in the era of inclusion (by the way, that’s a good thing), which has encouraged in- cluding students with special behavioral and academic needs in mainstream classrooms, thereby providing these students with opportunities to interact with “ordinary” kids (and vice versa) and reducing the stigma of having special needs addressed outside of the classroom. Thus, a typical mainstream classroom is now likely to have nu- merous special needs students, some of whom have dis- orders their teachers have never even heard of, let alone worked with, before. Teachers must therefore have ex- pertise not only in the curriculum but also in the differ- ent emotional and behavioral issues presented by some of their students and how to handle those issues effec- tively. Unfortunately, in many instances teachers feel— justifiably—that they have not had the training and are not being provided with the kind of support they need to function effectively with students with emotional and behavioral challenges. To make things worse, in the United States we also live in the era of high-stakes testing, which places ex- pectations on teachers to try to ensure that every square peg fits into the round holes defined by the standards imposed by statewide mandated testing. Not even a The Plan B Classroom 247 good idea if you’re interested in raising standards, but most assuredly not a good idea if you want teachers to respond to the behavioral, social, and learning needs of individual students. And to make things still worse, the zero-tolerance driven discipline program in most schools is very much a road map for Plan A: It’s a list (sometimes a very long one) of things students can and can’t do and a list (some- times a very long one) of what’s going to happen if they do or don’t do those things. But here’s a true fact you might want to ponder for a moment: Standard school disciplinary practices don’t work for the students to whom they are most frequently applied, and aren’t needed for the students to whom they are never applied. In other words, the school discipline program isn’t the reason well-behaved students behave well; they behave well because they can. We have little to show for all the consequences—detentions, suspensions, expulsions, and so forth—that are meted out on a daily basis to the ex- plosive students in our midst. And yet the standard ra- tionale for the continued use of consequences goes something like this: Download 0.7 Mb. Do'stlaringiz bilan baham: 
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