During the first session of the dischage conference on Tuesday (August 24) the resident reported that n. did not present the symptoms of bipolar disorder, with the qualification that n. had not been willing to discuss his thoughts with the team. The senior psychiatrist, Dr. Perlov, did not disagree but suggested that there may be a bipolar disorder which has not been diagnosed because it is hard to diagnose in teens with n.’s temperament and history of drug use. He qualified his remarks by saying he was not involved with n.’s assessment in February or last week and had taken over temporarily while n.’s assigned doctor, Dr. Katz, was away. He said he only had a brief time to review the material and a brief time with n.

He is the doctor who met with n. on Monday. From what n. said, he had asked n. to think about the fact that n. has been angry with me so much. N. believes that I was trying to control him when I visited and that I should not be trying to control him.
Dr. Perlov took a few minutes at the beginning to ask Jan and me about n. and how we had reached this point. We agreed that n. was stubborn. I thought that n. had learned to manipulate us to get what he wanted from one parent. Jan wasn’t as clear about that. We didn’t have a chance to say much about n.’s increasing alienation from the family after he started to hang out with the stoners and metalheads at school.
Dr. Perlov said that it appeared that n. was bright, and had loving and concerned parents. He noted that n. had been described consistently as having had a difficult temperament, being stubborn and resistant to changing his current activity, once engaged. He noted that there has been a diagnosis of ADD although that was later challenged. He thought that whether n. actually had ADD might be irrelevant. He said he would mix various models or metaphors of illness and treatment. He later said that he would use an ADD/ADHD (Attention Deficit Disorder and Attention Deficit-Hyperactive Disorder) Model.
Whether it’s temperament or neurology, the same behaviour traits emerge, and the same parenting problems emerge. When he began to talk about an ADD/ADHD model. N. interjected and said he would like to see a visual model of ADHD. The child’s actions provoke constant conflict. Adults – parents and teachers are always in conflict with the child, and the child’s actions inspire conflict between adults with differing approaches to child care (nurture versus stricter discipline). He said this will create anxiety for the child.
For the ADD child, the standard medications may treat the neurological problems without helping with the child’s behaviour, and the anxiety the child feels when adults respond to that behaviour. The child’s behaviour traits continue and become locked. The child deals with anxiety by being stubborn but actually needs positive support and validation. The child can’t get external praise because of his behaviour, and finds criticism from parents, teachers, and therapists to be extremely painful. The child’s behaviour is self-defeating. (I noticed that he did not address peer feed-back here. The child may get criticism from adults, and from some other children in their environment but they will get validation from some peers).
He said these children tend to become demoralized and to drop out, and some of them have real clinical mental health issues, which are not easy to diagnose. Some have adjustment disorders or personality disorders. He said that some children are misdiagnosed with ADD and adjustment or personality disorders who are actually clinically depressed. I’m not clear on how much of this is general and speculative and how much of this he can apply to n. without further investigation.
He had suggestions for n. and for Jan and me. He said that stopping n.’s drug use/abuse is vital. He said n. would benefit from regular long term access to a therapist who was prepared to work within the treatment models that he was discussing, and who n was comfortable with. He said he could not make such a referral within the hospital system. He said he could make a referral to an outpatient unit but he said that n. would only have access to that service for a year.
He said n. might be encouraged in an unconventional career pattern. He said that his parents should not expect him to survive in an educational and employment system that n. finds to be so stressful and demeaning. He said n. needs to find some external validation – and warned that he would not find it from the jobs he might be now. He suggested a hobby such as music or art where he might be able to spend his energy and get positive support. He said n. might have to try several things to find something that he liked and was good at. N. interjected and complained that I had been too cheap to get him voice lessons to help him become a metal singer. Dr. Perlov said that he would not suggest that n. live with either parent now, but that n. should spend some time with both parents.
He said that n. had a small chance of getting better and feeling better in up to 10 years. N.’s discharge conference is being carried forward tomorrow (Friday).