Tuesday, May 19, 2009
We had a session a couple of weeks back with Karl and his Mum on a videoconference. Karl is always meek and mild, friendly and appears close to Mum. The story from Mum was different. Karl had had several enormous tantrums after a family argument he had watched. She demanded medication to settle him down, and thought he must have something serious wrong with him. If we listen to the story, there are several ways of understanding it. His problems could add up to an 'oppositional defiant disorder'. But what is there that might help settle him down? Clearly Mum does get to her wits' end, and given she has sent Karl off to relatives, my worry is that she may do so again. So under some pressure, I found myself promising to send out a prescription. I was going to use a tiny dose of a drug called respiridone at night which is said help kids to settle kids down while the parents regain some sort of control.
The more I thought about what I had promised, the less comfortable I felt. I had not actually checked Karl out physically, or taken a medical history - prescribing under these conditions is not good! Respiridone (in much larger doses than I had intended to use) is actually used to control symptoms of Schizophrenia. Why should I use an anti-psychotic (even in a small dose) to control symptoms which are not psychotic? In Australia you have to prescribe the drug 'off label' (ie off the public prescribing system) for behaviour problems. So the mother would have had to pay for the medication; why would I want to do that?
Eventually one of my colleagues reminded me I had not done what I had promised. It all jelled in my head, and I told my staff member my thoughts. The boy does not really have a diagnosis, and giving him drugs will not help. He is anxious about being sent away from Mum, and in the midst of family chaos seeks her attention and gets angry. She responds by getting angry back - which escalates the whole thing. He is really just an anxious, sometimes 'naughty', living in a complex family.
So, of course, my colleague set up another session - so I could tell the mother... Well, I did. The response was a surprise; I had thought the system would blow, and at the least Mum would abuse me. Instead she visibly relaxed, and for the first time began to discuss strategies which might help her son. Karl moved in under her wing for a hug. Interesting.