Wednesday, September 28, 2011

High School: don't assume staff actually communicate

#1 is now in High School. He seems to like it and we're proud of what he is doing. On the other hand, the school is short resources.

That's not a surprise. The lesser depression has been persistent. We were a bit surprised to learn, however, that at least one of his mainstream teachers didn't know much about his disabilities -- or even that he had an IEP.

We shouldn't have been surprised though. We're physicians, and we know docs have trouble communicating about patient care. I used to tell my patients to always copy notes and results and hand carry them between caregivers. It was by far the safest way to pass information.

So we've drafted a summary of #1 and sent it to all his teachers. Now they know a bit of his story, what his disabilities are, what he likes, what works best, etc. Seems to be helpful.

That leaves his aide(s). (Supposed to be plural, but it looks like he's got about 1/3 of an aide in 1 class.) Schools, for reasons I can guess at, make it very hard for parents to communicate with aides. Everything is supposed to go through the (overloaded) teacher.

There's a fix though. My son carries a "planner". We've started using that to pass messages to his aides through him. They write notes in the planner -- such as the assignments #1 invariably "forgets". (One advantage of a defective memory subsystem is that "forgetting" is an awfully convenient excuse.) Old paper and ink technology goes where email can't.

Update: Things get better.

Sunday, September 11, 2011

No credit

#2, Aspergers, wails and berates me for half the ride. Kind people glare at me. I am the worst father.

Then he climbs the big hill. He finishes it all. He is proud, happy. He will always remember this. He will remember how he showed his doubting father. It will empower him.

I will be forgiven.

No credit though.

Only satisfaction.

Monday, September 05, 2011

Guanfacine (Tenex) and working memory

#1 takes both Ritalin and Guanfacine (Tenex and other trade names) - longterm. So I track research on both meds.

Ritalin is as well understood as any brain med. As best we can tell it's unreasonably safe and effective for ADHD, despite a trashy article in a pop science magazine.

Guanfacine, a second line med for ADHD also used (off label) for "explosive" kids, is much less studied than Ritalin. The proposed mechanisms of action are interesting, it seems to increase certain kinds of neuronal connections and to perhaps facilitate learning capabilities.

On the one hand, this is encouraging. Working memory deficits are a significant component of most developmental disorders of the brain. On the other, it's disturbing. When clinicians hear "increased cellular activity" in brains we think "cancer" and "seizure".

Fortunately, so far, there's no sign of that (though we're in early days). There is, however, continued research on Guanfacine's effect on working memory and task performance in primates. Studies have recently moved to using elderly primates, but results are mixed. As best I can tell from the abstract, this was a negative result (A typical child dose of Guanfacine would be .04 mg/kg) ...

Effects of the alpha-2 adrenoceptor agonist g... [Eur J Neurosci. 2011] - PubMed - NCBI

Alpha-2 adrenergic receptors are potential targets for ameliorating cognitive deficits associated with aging as well as certain pathologies such as attention deficit disorder, schizophrenia and Parkinson's disease. Although the alpha-2 agonist guanfacine has been reported to improve working memory in aged primates, it has been difficult to assess the extent to which these improvements may be related to drug effects on attention and/or memory processes involved in task performance. The present study investigated effects of guanfacine on specific attention and memory tasks in aged monkeys.

Four Rhesus monkeys (18-21 years old) performed a sustained attention (continuous performance) task and spatial working memory task (self-ordered spatial search) that has minimal demands on attention. Effects of a low (0.0015 mg/kg) and high (0.5 mg/kg) dose of gunafacine were examined. Low-dose guanfacine improved performance on the attention task [i.e. decreased omission errors by 50.8 ± 4.3% (P = 0.001) without an effect on commission errors] but failed to improve performance on the spatial working memory task. The high dose of guanfacine had no effects on either task. Guanfacine may have a preferential effect on some aspects of attention in normal aged monkeys and in doing so may also improve performance on other tasks, including some working memory tasks that have relatively high attention demands.

The doses are interesting here -- much lower than a human therapeutic dose and much higher. They were also looking at a one time dose effect. This reads like a mini-pub as a research team gears up for the real research. It's a modest investigation, and they basically didn't find anything. (Give the cost and ethics of primate experimentation one assumes there's much more to come.)

So the results are pretty meaningless. What's interesting is that the research is gearing up.

We should learn a lot more about the risks and benefits of Guanfacine over the next five years. For now I'm comfortable with our son's use of this medication.

Sunday, September 04, 2011

The unpredictable upside

Spin type school combination locks have never worked. It didn't help that #1 liked the idea of a key. Alas, despite his remarkable reliability with his phone, he kept losing keys.

This year he likes keys less. It's part of not wanting to be different, which is both unfortunate (he is different) and another powerful behavioral lever.

So I geared up to again try to teach him the spin lock for school use. I drafted a table with directions on the left, drew the spin direction, and did the combination in large font in a separate column. Working to separate the idea of the common actions from the unique combination.

Next came the question of incentive. This is an anxiety producing activity coming from his father. He does very little of this nature without a short term reward. Computer time alone was not enough. He wanted a MacBook Air. We compromised with an account on my Air -- a machine that he's lusted to touch and that has been mine alone.

He did it in one. Then he did it again.

I can predict what my neurotypical child can and can't do. I can't predict him.