TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: That is the fastest I have ever learned to use an electronic device. And having never tested it . . .

FATHER: Oh, is that the recorder?

THERAPIST: That’s it. So we’re going to put this right here in the dancing girl. Now, Ruth, you don’t need to say anything because I don’t think “meow” is going to be a part of the transcript. I will get the forms for you by next time to take a look at and, again, nothing is harmed if we record it tonight because if you want to do it, that’s the end of that – after I post it on Facebook. (all laugh) [00:00:59]

I’ve looked at your material here and today what we’re going to do is sort of figure out what brings you guys in, but let me get the note opened up here real quick, since we hand-filled it out. I have to type it in.

MOTHER: Could I have done that online?

THERAPIST: Almost. I’m close. You can download online and then type it in and bring it with you or you can do it here at the office.

FATHER: We can make you do it.

THERAPIST: I’m very close to having a – you have to have special encryption to do it and there is a company that can do that for me. What’s your date of birth, Kevin, so I don’t have to put this in?

CLIENT: December 24th, 2000. (pause)

THERAPIST: Okay. So you’re just now 13 and a couple of months. What do you think of being 13?

CLIENT: It’s pretty fun.

THERAPIST: Oh, yeah?

CLIENT: Yeah. I get a lot more responsibility. [00:02:06]

THERAPIST: Are you a super young eighth-grader or a super old seventh-grader?

CLIENT: Eighth grader.

THERAPIST: So you’re a super young eighth-grader? You’re like the youngest eighth grader possible.

CLIENT: Actually, there’s a girl that just turned 13, I think.

THERAPIST: Wow.

CLIENT: Yeah, she’s real young.

THERAPIST: Nobody ever has babies in the summer because I’m sure you remember what it was like to be pregnant in early July. (laughs)

MOTHER: Oh. We actually adopted, so we don’t know what that’s like.

THERAPIST: Now how did I miss that in the paperwork? Okay, so you are adopted. And at what age?

MOTHER: Newborn.

THERAPIST: So you just skipped the July pregnancy completely, just waived it.

MOTHER: Yeah, I saw how much misery people were in, so we just jumped. [00:03:01]

THERAPIST: Is the other girl that’s your age adopted?

CLIENT: No.

THERAPIST: Oh, man. Her mother had a bad pregnancy.

(laughing)

THERAPIST: All right. Kevin is 13 and let’s see here . . . This is the boring part of the session where I do the paperwork. (pause)

FATHER: I could pay to have somebody watch me work.

THERAPIST: Yeah, this is really bad performance art. And you’re Wes, right?

FATHER: Yes.

THERAPIST: And you have given me your name on here so I can’t cheat.

FATHER: Maggie.

THERAPIST: Wes Maggie. That’s cute.

MOTHER: It took a long time to find somebody that would work with my name. I didn’t see a slot for my name, I don’t think. [00:04:07]

THERAPIST: There is a flaw in my paperwork and that is it. You just figured it out. It asks a question. It doesn’t draw for that. It says “the family who raised you,” which is where your name would go, except there’s no place for your name. It just says “mom,” so go figure. And you are a full-time student in the eighth grade. And people are apparently frustrated with you. Were you aware of that? (pause) Uh-oh.

CLIENT: Well, like my parents?

(laughter)

THERAPIST: Yeah, I guess I wasn’t clear. I didn’t mean everyone.

MOTHER: He’s like “what did you put in that paperwork?” [00:04:59]

THERAPIST: Like the players and the coaches of the Miami Dolphins are probably not frustrated with you. But these guys are, apparently?

CLIENT: Sometimes. Not a lot, well, yeah. A lot. Mostly. Yeah.

THERAPIST: So what brings you all in? I’ll just let anyone respond, preferably in sequence, but I do have two ears so I can listen to two people at times.

MOTHER: I think . . . (chuckles) I was born in – no.

FATHER: [ ] (inaudible at 00:05:38)

(laughter)

THERAPIST: That will not be a good transcript.

MOTHER: We are struggling with some issues. Let me reword again. We have some school issues that we’re struggling with as far as getting the homework accomplished and trying hard and just not enjoying school, those kinds of things. That frustration brings out some other behaviors as well. [00:06:08]

FATHER: We have some anger issues, at times.

MOTHER: Aside from that, yes.

THERAPIST: With him or you guys?

FATHER: They go hand in hand.

THERAPIST: It spreads throughout.

MOTHER: I think there are several different issues. School issues is one. He has been diagnosed ADHD and we’ve been on medication, different kinds of medication, and it seems to work for his focusing and helping him control his behavior; however the stuff that we really like prevents him from being able to eat, so he loses weight on that.

THERAPIST: And which stuff is that?

MOTHER: The first thing we tried that we loved was Concerta and then he’s tried other things throughout the years, but what he’s on now is Focalin; and that was working fine for all of last year, I think, but just now he’s not liking how that’s making him feel. [00:07:11] He has tried a couple in between there. Vyvanse was one that made him violent, scary violent. We finally figured that out.

THERAPIST: Like how so?

MOTHER: He did not handle any kind of disappointment or anything well.

THERAPIST: Very irritable is what you’re saying.

MOTHER: Well, it was beyond that. He kicked holes in walls.

THERAPIST: That’s pretty irritable.

MOTHER: He’s a big fisherman and hunter and he ended up having all his fishing knives and everything taken away.

THERAPIST: Oh, that’s nice.

MOTHER: But I think that was due to medication.

THERAPIST: I don’t know what you guys know about meds, like from a what goes into them standpoint and I’ll talk about that in a second. Who is prescribing for him? [00:08:03]

MOTHER: Howard Keeps. You know who that is?

THERAPIST: Yep, his primary care physician.

MOTHER: Yes.

THERAPIST: When did you all first – and I have to use a pronoun, so I’ll use “he” but I know you’re here – when did he first take medicine?

MOTHER: Fourth grade. I’m sorry, do I have to do that math? Yeah, four years ago.

THERAPIST: The air is coming in. Ruth is hiding in her thing. Fourth grade, okay. And you’re in eighth, so that’s been four years. There are roughly two forms of medication for ADD and you’ve tried both of them. For lack of a better, more complicated chemical explanation, there are the Ritalin products and there are the Aterol products, or amphetamine products. [00:09:09] Focalin and Concerta are both Ritalin products. They’re identical except for how they get into your system. Vyvanse is more of an Aterol product, although it is kind of a complex designer form of Aterol. A lot of people who have problems on Aterol like you’re describing do not have problems on Vyvanse, so it is wise for you to avoid all products, given what you said, that are Aterol based or amphetamine based. That’s a good thing. What was wrong with the Concerta?

MOTHER: The Concerta was awesome. Loved it, but he could not eat. He was 90 pounds and ended up getting down to 81. He was thin and he looked it. [00:10:04] We loved it, so we kept trying. He just was not hungry. We ended up putting him on Intuniv also because we heard that that can help increase appetite, but then he became extremely lethargic.

THERAPIST: Right, because it’s a blood-pressure medicine.

MOTHER: We didn’t like that for him, either, because that’s not a fun way to live.

THERAPIST: Right, and it actually doesn’t seem to work for very long.

MOTHER: Oh, really? Well, it was expensive, too.

THERAPIST: Yeah. I’ve been down all these paths at some point in my life. Here is the worry I have. How is the Focalin operating right now?

MOTHER: I don’t know, to be honest with you, because – Kevin, what do you think?

CLIENT: I still don’t feel good during the days.

THERAPIST: What do you mean by “feels good?” [00:10:55]

CLIENT: My stomach growls. I feel like I’m hungry. I feel like I need to eat, but I just can’t.

MOTHER: As far as school goes and the focusing issues, I’m not sure that the dose might be high enough or I’m expecting too much out of the medication because we don’t seem to be – your time management skills don’t seem to be there, staying focused. A teacher just e-mailed me that he’s still easily distracted in school and that kind of stuff.

FATHER: I think it’s not as good as the Concerta.

MOTHER: He’s bigger now, too.

THERAPIST: All of these things. Do you remember how much Concerta he was on?

FATHER: By the day?

THERAPIST: No, it’s got to be . . . That’s very funny, Wes. I got it and you’re going to be surprised by how perfectly that joke fits into what I’m going to say in a second. [00:11:59] His choices would have been 18, 27, 36, or 54.

MOTHER: The last dose he was on was 36. He started out 27, I believe.

THERAPIST: Right. Entirely possible.

MOTHER: The most recent he was on Concerta – I actually did all of this – March of 2012, I believe.

THERAPIST: So what dosage is he on Focalin? I don’t know those doses real well.

MOTHER: Twenty, 20 mg. He did try another one. Can I just throw this one out?

THERAPIST: Sure.

MOTHER: Just recently, Focalin was kind of working, but he was starting to feel icky with it so Dr. Hughes prescribed methylphenidate.

THERAPIST: Right. That’s the same exact thing. That’s the formula which Focalin and Concerta are made of. So he gave him a booster at the end of the day to take, right?

MOTHER: No.

THERAPIST: When did he take that?

MOTHER: This was separate from the Focalin. We tried to discontinue the Focalin and he tried that methyl-whatever.

THERAPIST: Methylphenidate. [00:13:01]

MOTHER: He was going to take 10 mg for seven days and then up it to 20 mg. But he took one pill and became beyond angry and blamed it on the medicine.

FATHER: I think there’s a combination of that being part of it and having an excuse to be angry.

THERAPIST: There are a few things that are a little confusing about the generic terms for these things because methylphenidate is the ingredient in all of those medicines, but I think it’s possible – was that an extended-release methylphenidate? Do you remember that?

MOTHER: Yes, so it would be an all-day. Yes.

THERAPIST: All right. Because these are all the exact same medicine. There is no difference in any of them. It’s how it distributes into your system that’s different. And just for your edification and knowledge because we want Kevin to be highly educated in this, Concerta is what I call the nuclear bomb of Ritalins because it comes in a little thing that’s shaped like, if you’ve ever been in an Air Force museum, it looks like a tiny atomic bomb. [00:14:13] It leaks material out through a hole into your system and then you poop it out. You drop the bomb. Out it goes. Okay.

CLIENT: (laughs)

FATHER: So it’s time released?

THERAPIST: But it’s a special kind of time release because Focalin is time-released, too, and I think it’s more traditional like time capsules maybe. It’s in a capsule, isn’t it?

MOTHER: Yes.

THERAPIST: Yeah. Then this methylphenidate is what used to be Ritalin XR and that’s just another way of putting out a time-released formula. Of the several, the one that seems to cause people the least trouble is the Concerta because of the way it goes out. That’s why it’s so popular. It just goes into your system. [00:15:01] It doesn’t last as long as they want it to, but it lasts longer. So that’s why I was wondering if it was an extended release because if it was a 10 mg methylphenidate fast-acting, then he’s getting that all within four hours and that could have explained it. These weren’t generic for very long. All of these have just recently become generic.

FATHER: And the episodes usually are evenings, nighttime.

MOTHER: Right.

THERAPIST: And you’re telling me – how long was he on Concerta?

MOTHER: I actually didn’t finish doing all of this, but it looks like back in 2012 at least until March he was on Concerta; and I don’t have Focalin written down until January of 2013.

FATHER: He didn’t all summer.

THERAPIST: Didn’t what all summer?

FATHER: The Concerta all summer.

MOTHER: I was doing this and I kind of forgot to continue, so somewhere in 2012 he switched from Concerta to Focalin.

THERAPIST: So I’m almost scared to ask because I probably already know the answer. Since fourth grade how often has he taken breaks, I mean dead-cold breaks, from the medicine?

MOTHER: I think this past summer was the first time.

THERAPIST: Okay. So that’s good and bad.

FATHER: I don’t think he did the summer before, right?

MOTHER: He didn’t want to take it, but the family dynamics are better when he’s taking it. So although there wasn’t school, it was helpful.

THERAPIST: So here’s what apparently you don’t know. I can dig up the article for this. It’s in the Journal of Neuroscience; and I only say that because I don’t quite know why nobody knows this because those of us that do this a lot know it intimately. [00:16:58] These medicines hit the same neuro-receptor sites as things like caffeine and cocaine – not that you should be doing that – and if you think about your friend coffee, if you drink coffee once in a while, boy, it’s going to really give you a kick. If you drink it every day, the more you drink, it will be less of a kick it will give you. That is exactly what happens – and I have two kids with ADD, so I live with this here and at home. You have to have regular breaks from it, roughly quarterly or, what we do with students, is every school break.

Now I understand the dynamic of which you speak. And when he starts driving that will become another concern. But nevertheless, the research tells us that after two years of continuous use, the response of your brain, the level of effect will diminish to the point where you can’t tell you’re on medicine. [00:18:11] Some people have misread that to say that these medicines don’t really work. That is not at all correct. They work quite well and if you take them and give yourself about a 14-day break every so often, quarterly or so, then they will stay at their greatest flourish. In fact, when you go back on them, you will have a renewed effect. So if you’ve gone up between the periods that you’ve gone off, you’ll get hit pretty hard when you go back on.

My first suggestion right out of the chute before we get into a lot of the other things that I know are important, is you plan breaks on holidays. [00:19:00] They don’t have to be the whole holiday or summer, but what we usually do is if you want to have someone on medicine for behavioral reason or driving or work or whatever in the summer, you do two weeks at the beginning of the summer and two weeks right before school starts – off. And then you can be on it in between. You might say wow – and you can talk to Dr. Hughes about this and tell him that this is my recommendation – you might say how does one do that? And if you go down slowly off of it, it just takes you that much longer, so usually going off pretty fast shortens the amount of time you have to be off. In the first three or four days you go through a kind of withdrawal. I don’t mean that like heroin withdrawal, but your neuro-receptor sites are suddenly starved for dopamine and so whatever this gentleman is like in his wild state with no medicine, he will be about five times more so. [00:20:04] If he’s argumentative, he will be more so. The best thing to do during that time is to choose not to get into it very much. Don’t make any decisions; don’t go to Disneyworld.

FATHER: We could go on vacation though.

THERAPIST: Well if you wish to leave him on a desert island or something with sufficient entertainment, video games or whatever, and he’s amenable to that, I will not judge you. (all laugh) One of my kids sleeps for three or four days coming off medicine and one of them dances around the house and is Mister Lively. It just depends on what you’re like off meds. Then after about four days he will be his core person. It’s sometimes a little longer than that. By the end of the four weeks, he’s free of all the effects of the medicine. That’s not because the medicine slowly washes out – it’s gone. [00:21:05] It’s because the effect of the medicine, the built-up receptor sites continues for two or three weeks. That will help him be in the least amount of medicine and have it be the most effective. Now if he just started back on in the middle of August and you don’t feel like it’s working very well at this point, it’s more likely that he’s not on enough medicine, as you described.

FATHER: Or he doesn’t want to take it.

THERAPIST: Oh, we shall address that fascinating concept shortly.

FATHER: My opinion would be I don’t want to force medicine on him. I think that should partially be his choice. I don’t know how he feels when he’s on it, so I can’t judge “Kevin, you have to take this.” [00:22:05] Although it would help the family dynamics, I have a hard time saying “you have to take your pill today” because I don’t have that experience.

THERAPIST: I shall ask you your opinion about that in a second, Kevin. One thing I know is that it is not incidental that he is not hungry on medicine. If you’re hungry on medicine, then you aren’t on enough medicine. Hunger and focus just happen to go hand in hand, not because they’re controlled by the same part of the brain, but because the medicines that are the original Aterol medicines, amphetamines, were not originally designed in the late ‘50s for ADD. They were designed as weight-control medicines and they found that after, guess what, two years they quit working, the same thing we realized with the stimulants for attention. [00:23:01] It is somewhat of a necessity to not be hungry. One of the things that has worked well with my kids and the kids I see here, and it’s a little more complicated than I can explain, but there are ways with some medicines to control the dosage, with the agreement of your physician, in much more incremental amounts than what you can do going a step up.

FATHER: So you don’t have to go from 24 to 36?

THERAPIST: Correct. At some point I will explain that to you. It isn’t hard, but it sounds like algebra when I explain. (laughs) And it’s not. When it was first explained to me I was just like, “I don’t even want to think about this.” It’s not that bad and it has to do with proportion of the medicine. But there are certain medicines you can do this with and others you cannot. You cannot do that with Concerta because you can’t make the pills smaller. It’s inside, it’s gone, and it’s going do what it’s going to do. [00:24:01] All right, so what is your opinion about medicine, Kevin?

CLIENT: I like how it makes me focus and everything but everything else I just hate about it.

THERAPIST: So I know the eating part you don’t like. What’s the other part?

CLIENT: I’ve always wanted to eat things. I can eat a whole jar of peanut butter. I’m not bragging about this at all. (laughs)

THERAPIST: Well then I don’t see you having any problem with medicine.

CLIENT: No.

THERAPIST: So what is wrong with the medicine then with peanut butter?

CLIENT: I just like to eat and I don’t like not eating because it’s kind of embarrassing at school – like I don’t eat anything.

THERAPIST: There is a slight cognitive problem here with everybody. I’ve never quite run into this this way before. Actually I have had this argument with one person I can think of, my son. Now that I thought about it, I do remember this. [00:24:59] Eating isn’t a voluntary response. (laughs) You kind of have to eat whether you’re hungry or not. What happens when you do that?

FATHER: When you eat when you’re not hungry.

CLIENT: 2. I don’t know.

THERAPIST: You haven’t considered this before? Oh. We’re going to have to work on that because this is such a common problem we have to work around it.

FATHER: I was thinking you said at one time you would eat but you almost felt like throwing up.

CLIENT: Oh, yeah. If I do eat when I’m on the medicine, I want to eat but when I do it feels like I’m going to throw up. That’s exactly how it feels.

THERAPIST: Well, you can’t probably have a buffet. I understand that’s probably true. How late in the day does this problem happen for you? Aren’t you hungry by about 7:00 or 8:00 in the evening? [00:26:00]

CLIENT: No, not with the medicine.

THERAPIST: You guys agree? I mean by observation.

MOTHER: I think part of that, Kevin, is eating a bag of popcorn before dinner – that you might not be hungry for dinner, but you’ve eaten a bag of popcorn. You’ll eat that at least.

CLIENT: Not when I’m on the medicine, though.

THERAPIST: Well you surely are eating something or you’d be dead. You look healthy.

CLIENT: That’s because I didn’t take the pill over the summer and I went up to 134 pounds. Sometimes I can barely eat dinner. I have to force it down usually.

MOTHER: Okay, you just told me today that you had a ham sandwich at school.

CLIENT: Yeah, but that was a little square that had two slices of cheese on it.

MOTHER: Okay, but how did you feel when you ate that?

CLIENT: I still had to force it down. [00:27:04]

THERAPIST: That I believe. I don’t dispute that. What time do you take the medicine?

CLIENT: In the morning around 7:20.

THERAPIST: When do you eat breakfast?

CLIENT: Usually around 6:00.

THERAPIST: So you eat before you take the medicine?

CLIENT: Yes.

THERAPIST: Well that’s right. What do you eat?

CLIENT: Oatmeal.

THERAPIST: Yeah, you need that, brother. That’s the right thing to eat.

CLIENT: That’s pretty much it.

THERAPIST: Alright. That’s the ADD people’s best food. Would you care to guess why? There’s a very specific reason. Do you want to guess why?

FATHER: Easier to digest?

THERAPIST: No, that’s a good guess, actually. It’s because oatmeal is a slow-release carbohydrate and where people get into trouble with medicines, in part, is because if they don’t eat then their blood sugar drops and then they’re annoying. [00:28:07] And you think it’s medicine and it’s really low blood sugar. Oatmeal is a slow-release sugar, so that actually gets him through the morning. That’s the best news I’ve heard so far. o you can do that every day, huh? So that’s one meal down. The thing about Concerta – I know you’re on Focalin – is that on the outside of the bomb, it actually has methylphenidate painted on it so you start getting a hit from it pretty quickly. It’s better to eat and at the very end of eating, take the medicine with your food. So you’re doing that right. The with Focalin – you said how much is it?

CLIENT: Twenty.

THERAPIST: And we’re back on that now, right? That doesn’t make you violent or anything, right?

CLIENT: Not as violent as I used to be.

MOTHER: He still gets angry, but not violent, I wouldn’t say. [00:29:01]

THERAPIST: Can you track that for us? Maybe you already know the answer to this, this blood sugar drop situation I’m concerned about. Do you know what time of day this anger problem happens?

FATHER: Any time.

MOTHER: Well, I would say like he said, eight-ish.

THERAPIST: In the evening?

MOTHER: Yes.

FATHER: Always later in the day.

THERAPIST: Okay. That is really important.

CLIENT: Or when my sister gets home.

THERAPIST: Well, sure. How old is she?

FATHER: Eight.

THERAPIST: Oh. That’s pretty difficult, isn’t it?

CLIENT: Yeah.

MOTHER: He doesn’t seem to handle frustration or disappointment or annoyances very well, so he’ll be angry before that but later in the night is when it gets kind of . . .

THERAPIST: So that’s when the medicine is washing out. All of the medicines are washing out and I think I have a good idea that’s going to fix some of this that you can get on board easily with. [00:30:06] First of all, how’s your sleep? [00:30:08]

CLIENT: It’s really good. I’ve been going to sleep really early. Sometimes I’ll wake up in the middle of the night and get something to drink.

THERAPIST: What’s really early to you?

CLIENT: 4:00.

THERAPIST: To go to bed?

CLIENT: Oh – yeah. (laughing)

FATHER: 2:00, or maybe at 3:00.

THERAPIST: I was going to be like, “Surely not.” Okay. What time do you go to bed if it’s early? When you think about it being early?

CLIENT: Probably around 9:00.

MOTHER: I’m sorry. I have to disagree. It’s never going to be before 10:00, probably 10:30 or 11:00.

CLIENT: But usually I fall asleep doing my homework.

THERAPIST: Yeah. Huh. Interesting. What happens is you get into wash-out with the medicine and two things happen, depending on his eating. [00:31:03] If he didn’t eat very well, that doubles down on the medicine washing out; so he has a blood sugar drop and he has the medicine wash-out period, which is a classic problem with all but about one or two medicines.

FATHER: What do you mean “double down” if he doesn’t eat?

THERAPIST: If you ate good and your medicine is washing out, you’re going to be irritable and we call this in my home quiet time. Nobody bothers any minors when they’re having quiet time because they’re having wash-out. Their frustration tolerance disappears. They’re really at their most vulnerable because they’re sort of in their in-between state. There are kind of two theories about that, forgetting food for just a second. One theory is that your brain has just worked all day, stimulated by medication, and as the medication washes out you’re just sort of worn out, which is why I wondered when he’s sleeping, if he gets tired. [00:32:01] The other theory is that it’s just part of the withdrawal process each day because this medicine is gone by a certain time of the day and, like that four-day period I was talking about, this is the mini version of it. The good thing is people usually bounce back after about 40 minutes to an hour of that and then they’re kind of okay – okay being it’s 10:00 at night and they’re worn out so they go to bed, but they’re not belligerent usually. If you didn’t eat well during the day – let’s say you aren’t even taking any medicine. If you don’t eat during the day and you get home, you will kind of be irritable and annoying because you don’t have a good blood sugar. And those of us who are type 2 diabetic know this intimately. If you take both of those problems and put them together at the same time of the day you get the effect you’re looking at. That’s why I was so critical in a way. [00:33:04] I’m not saying there isn’t a frustration tolerance at other times because he probably does have problems with that, but that’s when the critical time is. You want to do as little during that projected period as possible. That’s not the right time of day to say, “Why didn’t you clean up your room?” and blah, blah, blah. There are fine times of the day to do that (chuckles) or during the week, but that’s just going to set off a chain reaction.

FATHER: So that just says homework when you get home from school would be preferred.

THERAPIST: That would be the preferred timeframe for that. I actually have some ideas about that. We may talk about it at some point. (pause) I’m thinking which way I want to go. (pause)

FATHER: Let’s go east. [00:34:01]

THERAPIST: Or there’s always west and north and south. There are four different issues to hit. He’s never been on Daytrana, the patch?

MOTHER: No. I’ve heard about it.

THERAPIST: I think I would be getting mighty interested in that for a bunch of reasons. I’m a big fan of it. I promise you I do not own any stock in it, but I do get the discount card which is pretty nice. Daytrana is a patch and you stick it on your back. That will bypass all of your gastrointestinal system, which is kind of nice. It’s exactly the same medicine you’re taking right now, but it’s on a sticker. The advantages are multiple. First of all, it lasts a long time and they tell you if you want to take it off at 4:00 in the afternoon you are free to do so. [00:35:02] It’s the only medicine you can take off so if you have a day – maybe a Saturday or something – and you want to take it off early, then you’re going to get hungrier in the evening and all is good. If you need to do homework you can leave it on. It isn’t like it gives you too much medicine because it goes up like this and then sits at a plateau across the day and it really doesn’t ever wash out until a couple of hours after you take it off, it drops off. [00:35:37]

FATHER: I’m wondering how long it would take to . . .

THERAPIST: It goes on a long time and the reason I asked him about his sleeping is because he isn’t getting any negative side effect of sleep. Some people with ADD sleep better. I went to a workshop at APA one time and they talked about using it at night for people with ADD (chuckles) to help them get up in the morning; so there is a somewhat odd effect with dopamine and the ADD people. [00:36:06] It sometimes helps them sleep. I’ve had people who can’t tolerate Ritalin products because they get sleepy on it. He isn’t having that much of a problem, but it’s also not messing with sleep. Here’s the other property of the patch; and let us all remember that I am not a physician so your physician has to okay this. The patch can be cut literally with scissors and the material that is the adhesive is also the medication, so it’s not going to leak out. If your pharmacist tells you that you can’t do that, this isn’t true. The drug reps taught me this. This allows you to tailor the size of the patch to be precisely the amount of medicine he needs. So if Dr. Keeps is willing to give him what he thinks he’ll need by the end of the semester – let’s say 50, I think, is one of the patch numbers – and then you start off and that’s too much and he’s like “I feel way over medicated” or “I’m jiggery” or you see anger, cut off a part of it next day and give him less medicine. [00:37:21] My son, he’s going to be ten, and since he was seven or eight he can tell you if you need to cut each patch down. He can tell. He’s very aware. As his great quote was once, we were on the way home and he goes, “You need to cut my patch tomorrow.” I was like, “Oh, yeah? How come?” Because we had just gone up. He said, “You need to balance my tolerance with my focus.”

MOTHER: Wow.

THERAPIST: And that is exactly what you need to know. You are balancing focus and tolerance. His eating is also impaired, but he’s learned that though it has been difficult, you have to eat, whether you feel like it or not. [00:38:04] You can also get Ensure and use that with him to get his calories in him. Put it in a milkshake or something. Do you like milkshakes?

CLIENT: Oh, yeah.

THERAPIST: Put the Ensure in a small milkshake.

CLIENT: I used to have a protein drink.

MOTHER: You did. Muscle milk, I guess.

THERAPIST: Was it good?

CLIENT: Oh, yeah.

MOTHER: Then we just kind of forgot about that, I guess.

THERAPIST: He’s just got to get a certain number of calories and if you’ve got to get him on Ensure – I understand eating at school is an issue. I heard you when you said that, but if you can eat a sandwich like that at school and drink – I don’t care if you drink it in muscle milk at the cafeteria or whatever you want to drink – that’s got calories and nutrients in it, you’re good to go. Which brings us to the other point. [00:38:56]

My view of this is we have to all work as a team. You have input, you guys have input. What I have is 21 years of experience and I know exactly how to succeed with ADD and I know exactly how to fail. I can tell you how to do both. I’m writing a book about this right now. The fastest way to fail is to not adhere to medication and to be very precise about it, like we’re talking about today. You don’t want to be on too much and you don’t want to be on too little and on breaks.

FATHER: And you want to be consistent.

THERAPIST: And you want to be consistent. And the only inconsistency and we haven’t talked enough about this so I’m really not telling you that you ought to think about this right now, but it is something we did discuss. If you go to the patch, some people are okay on the weekends not taking it. I’m not sure you’re one of them because then they eat more and they can kind of get caught up on that. [00:40:00] Alternatively what might be more possible here is to do – and we do this – a much smaller patch on the weekend; and then he’ll still be able to focus but not as medicated as the eating would be impaired. These are things you can’t do with these other medicines. You can’t cut the other medicines. Vyvanse you actually can cut, but there is a whole other way you have to learn to do that and since Vyvanse didn’t work for him, we won’t even think about recommending that. I’m not a big fan of being off on the weekends completely.

FATHER: I think that would spike it.

THERAPIST: It does. You get all the problems of taking a medicine break and none of the benefits. The only reason is for somebody to eat and I would say you would be better off going and dropping dose just for the weekends and not taking him completely off. I think you will like that better because you will have more hunger on the weekend, but you won’t be all zany. [00:41:06] What are his symptoms when he is off medicine? And I don’t mean in the first few hours, like when he’s been off for the summer.

MOTHER: It’s awkward because he’s sitting right here. It’s a little awkward with him sitting right here, but he knows.

THERAPIST: Well that’s because we’re all on the team, aren’t we, Kevin? We’re on the team.

MOTHER: He knows. He acts very young.

FATHER: Yep.

MOTHER: Very low frustration tolerance. Very quick to be annoyed with Jessica or just anything.

FATHER: Combative at times.

CLIENT: That’s really rare, though.

MOTHER: And that might be more on the medicine than not. [00:42:01]

FATHER: I’m thinking maybe frustration or disappointment or when he doesn’t get his way.

THERAPIST: The ADD people don’t like to be uncomfortable, so any of those things are really uncomfortable. None of us like to be uncomfortable, but the ADD people have no tolerance for it. Uncomfortable and boredom are two things they don’t have good tolerance for.

CLIENT: That’s why I hate homework.

THERAPIST: No doubt that is true, sir. Uncomfortable and boredom.

CLIENT: Because I’m at school for like eight hours and then when I come home I have another 3 ½ hours of homework.

THERAPIST: That’s probably too much homework for you. Are you serious about that?

CLIENT: Yeah, math and algebra. She has us work these problems that take five to ten minutes each and she gives us 20 of them. [00:43:00]

THERAPIST: You should have 80 minutes of homework and no more. What is your read on that?

CLIENT: My mom just says, “Every person in the entire world has done homework.”

THERAPIST: That is true, but they shouldn’t do three hours of homework in eighth grade.

MOTHER: I didn’t mean to do this to you. A large portion of this is he doesn’t get homework done so he has today’s homework to do plus the stuff he didn’t get done; so it’s actually like twice as much a night as he needs to be doing.

CLIENT: Because I have so much the day before.

MOTHER: And it’s a lot. There is a lot of homework. I don’t know whether it’s time-management skills during the day that’s getting it done at school, but there’s a lot of homework at night and every night there’s something that hasn’t been turned in prior that he’s having to try to catch up on.

CLIENT: And then when I come home I have so much pressure put on me because she’s always – like right when I get home she’ll just pressure me so much about turning things in. [00:44:07]

THERAPIST: In what way?

CLIENT: Like she’ll get mad if I don’t have something turned in and I’ll get in in the mornings. I get up and then she reminds me that I have to go in and talk to a teacher about something. I don’t know how to explain it, but there’s just a lot of pressure put on me. I’ve told her about it and, I’m sorry, but I don’t really think that she understands because there’s just so much of it. (pause)

FATHER: I don’t think the homework takes that long. The process may take that long so it’s suggesting when to start the homework, the resistance, the procrastination, the annoyances or distractions. [00:45:09] I’m the type once begun, the task half done, if you just start it and concentrate at the beginning and no bring out your emotions and feelings and “I can’t do this” and “I can’t do that” and “I don’t want to do this;” if you just start it, that’s half the battle and it won’t take as long.

THERAPIST: Well that’s because you don’t have ADD.

FATHER: Right.

THERAPIST: (chuckles) You just did a really good description of what it’s like for the ADD people in this situation. But I’m also not saying that as an excuse because ADD is only an explanation. It can’t become your master. How many days a week does he have homework.

CLIENT: Every single day.

MOTHER: I would say five. [00:46:00]

CLIENT: Yeah.

MOTHER: I think every night.

CLIENT: In math she gives us super long assignments.

THERAPIST: What math are you in in eighth grade?

CLIENT: Pre-algebra; and I don’t want to be in that class because it’s way too hard for me.

THERAPIST: What’s the next step down?

CLIENT: Concepts of algebra. That’s what I would like to be in.

THERAPIST: How did you end up in pre-algebra?

MOTHER: The school designated that and, at this point, to switch him it would change the entire schedule around. He struggled with math last year, as well.

THERAPIST: How did they end up putting him in that class if he already had problems?

MOTHER: I don’t know. I don’t know.

THERAPIST: That was an unfortunate situation.

FATHER: But again, he’s getting an A in it.

THERAPIST: Wait a minute – you’re getting an A in it?

FATHER: He’s getting an A minus.

THERAPIST: Oh, I didn’t even ask because I thought it was such a disaster I hated to ask.

MOTHER: It is a disaster and yet they grade differently these days. The assignments are you turn them in and if you did the work and make the corrections, then you get the full credit for it. [00:47:05] So it’s not a true – like when we went to school if you missed it, you missed it. It’s not like that.

CLIENT: But on the test I did get a 91.

MOTHER: He did.

THERAPIST: That’s really good, Kevin.

FATHER: He’s a smart kid. He’s really bright. It’s not turning in assignments, so there’s zero out of five points or things like that. That’s where he gets hit a lot. I mean he’s smart. He’s very smart.

CLIENT: If they graded it on how I did, I would definitely have an F in that class.

THERAPIST: Whoa, whoa. What?

CLIENT: Like if they graded on how good I did and how many I missed, I would probably have an F in that class right now.

MOTHER: And that is true.

THERAPIST: So the first run through you don’t get them right; and then you go back and you make corrections and that’s where you gain back the credit?

CLIENT: Yeah.

THERAPIST: That’s very self-aware of you, Kevin. You understand that. [00:48:00] And if that’s true, then how did you get a 91 on the test? You didn’t get to go back and correct that, did you?

CLIENT: It was the very first test, which was really easy. We had been starting out on stuff that we had ended off on last year and some of the stuff that we even learned in sixth grade. On half of it we couldn’t use a calculator, but you could show out your work. Half of it was easy because you were able to use your calculator, but she never lets you use your calculator. Twenty years from now we’re not going to be using paper and pencil.

THERAPIST: Right because you’ll have Google glass on your glasses. You’ll just look and think about things and they’ll just add up; but you’ve still got to learn the basics. [00:48:58] I have many thoughts about this and then we’re going to run out of time and we’ll pick up here when we get back together. My first thought is you’ve got to change up how you’re doing this because he’s only in eighth grade and he’s going to give up before he gets out of high school if we’re on the path that we’re on right now. The number is you’ve got ten minutes for every grade level you’re in and he’s in eighth grade. The maximum allowable dosage of homework per day is 80 minutes period. I think we need to change the name of this to Study Time. Normally I say that because one should never ask a boy whether he has homework or not. That’s like asking him if he’s having sex with that girl you hate.

CLIENT: It’s about as common, too.

THERAPIST: (chuckling) There’s no way that he’s ever going to answer the truth, so you just say it’s study time. It starts a certain time and it ends 80 minutes later. [00:50:02] You need about 80 minutes. You need about two breaks in the middle of that, so it’s going to take a little longer than 80 minutes, but you don’t have to work more than 80 minutes. You need about a ten minute break every hour.

CLIENT: Usually she’ll make me do all of it at one time, but I just can’t do all of it at one time so sometimes I go downstairs and that’s where she gets that I’m procrastinating.

THERAPIST: Well I believe that you procrastinate like a big dog, so I have no doubt that’s true. You’re right, also, that there is a limit; and your limit is 50 minutes in one sitting.

MOTHER: That’s not really accurate, okay?

CLIENT: I just know I do so.

MOTHER: Well whatever is accurate in the past, let’s change it. You come home and it is true, regardless of what medicine you’re on, though I think the Daytrana will help with this, you need to do homework fairly soon after school. [00:51:05] And then once you’re done with it . . . No, I see I used the word homework; that was terrible. Study time. I’m trying to get better. Study time you have in two parts, a 50-minute period and then you need about ten minutes to just run or whatever you do. And then another 30-minute period and you’re done. I don’t care what happens. I don’t care if he’s finished. He’s got to be done. By then it’s just too much. But he needs to do that every night of the week except – go ahead.

MOTHER: A large portion of the frustration is that the assignments that have not been turned in in the past. I don’t know how to handle that.

THERAPIST: By this you mean they weren’t done or he lost them? [00:52:00]

MOTHER: They were not done.

FATHER: Or he has them and hasn’t turned them in.

THERAPIST: That’s the one I’m looking at here.

MOTHER: It’s very hard to monitor whether or not they’re done. He might tell us they’re done and they’re not, so it’s really hard to monitor all that. Just, for instance, out of 14 assignments in math already, seven have been late.

CLIENT: Because it’s so long and so hard.

MOTHER: Okay. In this formula you’re talking about, he has work that hasn’t been done because he’s not done it plus he has the new stuff. I don’t know how to . . .

FATHER: Catch up.

THERAPIST: He may lose all that work. There’s no conceivable way he can do more than 80 minutes of work at a time. It just can’t be done. He’s going to go to pieces. And if we need to go to the school and have them do reduced homework, then that is what we will do. That is a perfectly fine idea because some people get the concept after three problems and some people aren’t going to get it after ten. [00:52:58]

FATHER: Well they get more frustrated.

THERAPIST: (chuckles) Exactly. And so he needs to tolerate exactly the right amount of frustration and no more and no less; and 80 minutes for an eighth grader is the maximum. And if you’ve got ADD you need to split it into two parts of 50 minutes, 10 minutes, 30 minutes – that’s it. I mean he’s got to be done. This can’t just turn into a meltdown fest because he’s correct, that’s a lot of time. And they’re going to have to make modifications. On your end of it, Kevin, my version of reality is that at this moment in your life you’re probably going to have to do the 70 minutes every night, seven days a week. If I were you, my goal would be to get less days doing homework and the only way you can accomplish that is to get them turned in. The turning in process seems to be quite a problem for the ADD people. Homework seems to end up stuffed in the couch and on the floor of the car and in your locker. I don’t know. Are there things you do that don’t get turned in? [00:54:05]

CLIENT: Not really. Usually I just don’t finish them because I’m either confused and the teachers don’t understand. Like today, for example, in Spanish there was this one assignment that I thought we had already done. It was pages two and three and, except the directions, everything is written in Spanish and it’s kind of confusing. I’m sure that we had already done this page, and so I got in and I asked her if we had already done this page and she said, “No. It looks exactly the same. Everything is the same, but we’re just doing it again,” or something like that. [00:55:01]

THERAPIST: The ADD people’s version of hell is having to do the same thing over again.

CLIENT: Yeah. Yes. And so when she comes around to look to see if we had done it – because we’re just starting out; she’s just taking completion grades to make sure that you tried – she sees that I only had one assignment done out of the two because I thought we had already done the other one. And before I could say anything she said, “Oh, it looks like you’ve chosen not to do your homework again.” And then she walks away without letting me say anything.

THERAPIST: People have decided that your goal in life is to be a pain in the ass and you’re going to have to convince people that this is not true because the secret of happiness is how you organize your life. A good way to do that is to make people like you and if people think you’re sketchy, they aren’t going to believe you when you say “I think I did this already. I’m confused.” [00:56:07] If people think you’re just being a pain in the ass they’re going to get back at you, right? She was real snarky with you.

CLIENT: Yeah.

THERAPIST: Because she thinks, “Oh, I see you’ve chosen not to be in our class.”

FATHER: It could have definitely been worded better.

THERAPIST: Well, yeah, but he’s selling the wrong product to you guys and to them and people don’t have appropriate empathy for your situation. Like you said they don’t understand. I actually knew where you were headed with that, even though you didn’t finish the sentence. People don’t have empathy for you because they think you’re being a dick and we’ve got to get that done because people aren’t going to help you and reach out to you. I have this really nice college girl I see and everybody loves to do things for her and she is as ADD as you will ever be. She is so good at making people like her that they will just do anything to help her out. [00:57:04] “Oh, can I take notes for you?” “Sure. Whatever.” She’s actually great. She’s a good student and everything; but she is so good and she didn’t used to be when she was in high school. She was very shy and quiet and she has really come out of her shell and learned how to get people to do things for her and be really happy about doing them. We shall have to teach you how to do this because you aren’t getting there yet, but we will get it.

MOTHER: Part of that frustration is they can get their homework online and so the teacher put on there what the homework was, so for kids to come in and say “I thought we had already done that.”

THERAPIST: He did not seem credible, did he? He didn’t seem credible at all.

MOTHER: And so that could be part of the frustration, too.

THERAPIST: He’s going to have to be more credible. Okay, so we’ve got to wind up and we’re now right at our hour point. [00:57:59] I’m going to have you meet up with Sara and get another appointment and go look into these long lists of things and then see what you can figure out. I think he would benefit from a switch over to the Daytrana. There is a coupon online for that. I get mine for $5 and under, at this point. (chuckles) You can get up to $60 off the co-pay.

MOTHER: We pay a lot more than that for the Focalin.

THERAPIST: Right. I like to keep your costs reasonable.

MOTHER: That would be lovely.

THERAPIST: These are medicines that are lifetime medicines and so you have to learn to consume them economically and I know how that is. I get my Vyvanse for $30 and my Daytrana for [ ] (inaudible at 00:58:47).

MOTHER: Great.

FATHER: A quick thing. You have 80 minutes of homework that you’re supposed to do, but that means you’re doing homework for those 80 minutes.

THERAPIST: Thank you, Wes. I actually forgot to mention that. By cutting down your timeframe, which I am wisely doing because I am on the team, you have to be on the team and then actually, in that 50 minutes, your goal is to get as much done as you can and then you have a ten minute break and then you have 30 more minutes. Your ultimate goal is to try to get this down to roughly four to five days a week maximum because you shouldn’t actually have to do this on the weekend, but your mother is telling me you’re behind and so we need to give you a chance. And then next year when you’re ninth grade it will be 90 minutes, but let’s not look ahead to that for now. All right. See if you can get in in a couple of week.

MOTHER: In a couple of weeks?

THERAPIST: Yeah, that would probably be a real good idea.

END TRANSCRIPT