Insurance and other sh** (poop)

At 4:45pm yesterday, I got a call from the business office of the partial day hospitalization program that Kitty attends. They just wanted to let us know that as of Wednesday, Kitty was being "stepped down" to their outpatient program. The only thing this changes is she would see the psychiatrist once weekly instead of twice, and family therapy goes to every other week or stops all together ( I forget which). She still attends school and group therapy.

Which would have been fine except for the next part. Insurance pays for all of the partial day hospitalization, but SURPRISE this new program is considered "out patient" which means we have to pay a co-pay for the services. That's $25 A DAY! Starting that day. $125 a week! They don't take Medicaid so we have to pay the co-pay, which, by the way, they want to discuss how we plan to pay this and the $1500 deductible that their records show is still owed! If we don't pay then this will be like any other debt and will be charged off (sent to a collections agency).

Needless to say, I FREAKED out! We are broke. Beyond broke. Kitty's doctor bill co-pays are already draining, Summer is coming which means we have to find all day care (Grandma will do it, but 4 bored kids, two of whom are emotionally disturbed, requires some sort of activities - which will cost money and lots of supervision (unwanted by the kids) - which is asking a lot of my mom).

So on the way to family therapy this morning, I called our insurance. Medicaid had met/ paid our deductible when Kitty was hospitalized in January so even though the hospital hasn't submitted a claim for April (which I still find hard to believe - don't they want their money?), we are still covered. *Whew!* Nothing they can do about the co-pay though.

The hour and 45 minute "Family therapy" ended up being more about case management then family therapy, and we didn't even bring Kitty into the room. Every family therapy session we had, we questioned whether or not we were doing the right thing by keeping Kitty in this program.

Our concerns:

• Kitty is exposed to kids with way worse issues then we were led to believe. The kids in the PDH often interact with the kids from the residential treatment center (RTC), and the kids in the PDH are often just released from RTC and seem to quickly end up back there. This was the RTC we wouldn't even consider for Bear (who they planned to put in the ward for "aggressive boys"), because one of their first questions was "Are you OK with him getting beaten up daily?" Uh, NO!!



• Kitty has been kicked, cussed at and told she "smelled like a litter box," had her seatbelt repeatedly stepped on in the van, had her hair pulled, allowed to listen to Hip Hop on the radio (very big trigger for her), was exposed to a picture of a scantily clad female classmate while working on a team project on the internet, witnessed kids fighting and punching each other in the face...



• She has to be at the school bus stop (20 minute drive) at 6:45am and doesn't get home until after 5pm. Let's just say she is not a morning person, and often has difficulty with insomnia.



• This environment is SOOO much more stressful then public school that Kitty was coming home so triggered she had meltdowns almost every night. We had to remove everything stressful we could think of so that Kitty wouldn't get more overwhelmed then she already was (taking chores to a bare minimum with little enforcement, allowing Kitty to spend almost unlimited time outside on the swings, removing Grandma from any responsibility for disciplining Kitty...).



• The psychiatrist was on vacation for a week so Kitty had no med changes for the first 1 1/2 weeks in the program and then they seemed to want to change every thing at once to "make up" for lost time. They actually called me something like 5 times in one day changing their minds about what to start, when and how (the last call was at 9:30pm) and they still made yet another change the next morning.



• The Family therapist, who also does group therapy with the kids, seemed very inexperienced, and is actually only an intern.



• Kitty was not participating in group therapy, and while not completely superficial does not seem to really be dealing with any of her issues.



• Kitty has begun to mimic the behavior and attitude of the other kids. Trying on new personalities at the drop of a hat. Parroting attitudes and language at home. Often its talking "gangsta," or "I'm a teenager, I DESERVE to have..."



• She realized that she needed to behave at home as well as in the program in order to be released, and her behaviors at home miraculously improved (mostly). The PDH used this as a reason to "step down" her program.



• Kitty "has" to have a BFF (best friend forever), but has very poor social skills so has trouble maintaining friendships. The girls at the school also have issues, usually including poor social skills as well, so Kitty is constantly dealing with girl drama.



• If we remove her from the program and send her back to public school this sends a message to the insurance company that she is "better," and if we decide we need additional treatment (including RTC), we might have to start the process over again (probably including another trip to the psychiatric hospital).



• Our AT (attachment therapist) can only see her every other week, while therapy at the PDH doesn't seem to be helping much is it better than nothing? (She still sees the AT even though she's in the PDH). There don't seem to be any other alternatives.

The good things about the program:

• Until her meltdown last night (over being asked to clean up toilet water from a toilet she clogged and attempted to flush), she hadn't said she "hates this family" or talked about going back to Nebraska for a week. Of course we don't expect this to last when she is out of the program.



• There is generally a quick response to my/our complaints.



• They are actually required to care what happens at home (public school doesn't care what her behavior is like at home if it doesn't reflect on what happens at school).



• Someone is there to supervise med changes and watch for side effects and results.



• Adding Lithium has seemed to have a positive effect, although it's a little early to tell (5 days).

Once she's been "stepped down" we can't step her back up to the PDH, even if we start reintroducing stress into her life (like, Heaven forbid, actually expecting her to wash a dish!) and allow her to meltdown/rage again.


So after a long talk with the PDH psychiatrist and the family therapist we have decided to remove Kitty from the PDH on Monday. The public school has already said they will be happy to welcome her back and she will just go right into her old class schedule - which of course she was in when this (suicidal ideations and being miserable and angry) all started. Nothing is changing at home, so I'm thinking we might need to rethink the school structure. Possibly taking away electives and putting her in resource room classes instead.


OK here's the TMI (too much information) part about Kitty's bowels (I did promise to tell you how it all came out) so please feel free to stop reading now.




It's not too late!




OK, you asked for it.




Kitty finally pooped last night! The crazy doctor recommended I give my 14 year old, emotionally disturbed, sexually abused, major mom issues, daughter an enema. Luckily the nurse practitioner knew that was pretty much not going to happen and gave me some other alternatives.


Kitty took 2 doses of Miralax in apple juice, 6 teaspoons of mineral oil (to smooth the way) in an Activia yogurt, and a small bag of sugar free candy (she loved me for that one!). I didn't see this one so no disgusting descriptions of the anaconda in the toilet, but it did of course clog the pipe when she tried to flush it and the toilet over flowed (1/2 an inch of water everywhere). Hubby had to help it along and then insisted that Kitty help dry the floor. This triggered a meltdown, which while not of epic proportions was still pretty bad - no restraints or physical violence thank goodness.


She was disappointed that her tummy was not instantly flat. I assured her that there was probably still more in there, and this morning gave her Miralax in her Smooth Move tea (chocolate flavored laxative tea - can you imagine?!). If that works, the school can deal with it.


So now we'll see what the day brings.

Breakthrough?

We were hoping that now that Kitty has friends at the new "school" that the meltdowns at home would decrease, but no such luck.

Got a call from the PDH's psychiatrist. She's been out of town for the last week and now the insurance company is pressuring her to make med changes (since obviously that's all that's wrong with Kitty. *sarcasm drip*). So she called me and started suggesting new meds?! I asked her if she'd discussed these with Kitty's psychiatrist (who Kitty can't see while she's in the PDH program, but has a lot more info about Kitty's past then I do and she has been in his care for over 2 years). Nope. She hadn't contacted him about Kitty at all. I mentioned that the psychiatric hospital had planned to change her meds until they discussed it with our psychiatrist, and changed their mind. I was fine with any changes she wanted to make - as long as she had discussed it with our psychiatrist first.

She'd said she'd call him that day (Bear had an appointment that evening so we knew she hadn't called), but she apparently did finally make the call this morning. We're going to be changing a lot of meds for Kitty. Wellbutrin for the depression (not supposed to make bipolar kids manic and decreases appetite so we might get rid of those extra 50lbs Kitty has put on since this Summer). She'll start that tomorrow morning. Early next week she'll start on Lithium for the bipolar and once that's in place we can start decreasing the extremely high dose of Trileptal Kitty is on - assuming it works of course. Then Adderall in place of the Concerta. Who knows?! Maybe this will help?!

We're still questioning whether or not the PDH is the right placement for Kitty. She is getting so much more aggravated during the day (stress is higher at this school because of the type of kids she comes into contact with), that she is coming home and taking it out on the family - much worse then when she was in public school. She is having a LOT more meltdowns at home. She has also started cussing a lot more (and not "naughty" words, but real cussing). Some of it could be the schedule change. Instead of leaving the house at 8am for school, she has to leave at 6:30am. That's a LOT less sleep, and with the added stress, she's probably not sleeping as well either.

She is often justifying her behavior with "I have issues" and "that's just the way I am." That does NOT make it acceptable behavior, but I'm not totally sure how to address it either.

Because of her PTSD (which is not really treatable by medication) once she is triggered into "Fight, Flight or Freeze" mode she is no longer rational and is reacting purely on instinct. If she were a small child and behaving like this (typical for those terrible twos!), I would just put her down for a nap, and try to eliminate whatever stress triggered the incident (food, tired, overwhelmed...). No long term consequences of course. The problem is, while at the time she is a small child emotionally... chronologically and in the eyes of the other kids (and later even herself) she is not a small child, and therefore should be held accountable for her actions. Every time she "gets away" with this type of behavior she sees it as permission to continue with it.

Because of the RAD (again, not treatable by medication), most of her issues are at home with her family of course, so all the extra therapy she's getting at the PDH is, I'm sure, helpful, but not with this issue. Once a week family therapy that's not conducted by someone who is very familiar with attachment disorders will not solve this "issue." I'm a little concerned that by admitting she has "issues" with family to this therapist that she will now reinforce her self-perception as someone who doesn't need/want a family. In other words it will become part of "who she is." Just like being a "girly girl" or "friendly."

In the 2 1/2 years we've had Kitty she HAS gotten attached to us. She does trust us not to hurt her (I think as evidenced by the fact that she will hit and scream at us - which she would never do with a stranger or Bear- aren't we lucky?!). She will occassionally admit that she loves me, sometimes will let me cuddle her and tell her that I love her, and will even sometimes that she loves Hubby, but it's rare. Most of the time though she denies that she wants to be part of the family, says she hates to be touched, and rages about how much everyone hates her. If we tell her we love her, the first word out of her mouth is "NO." Sometimes it's so hard to remember to tell her anyway. It's easy to convince someone you don't love them, but how do you convince them you do?! Just keep doing what we've been doing I guess.

Kitty has been in therapy more then half of her life. She knows and uses all the buzz words like, "I have anger management issues" or "I need to work on my behavior management." She knows what the therapists want to hear and she is EXCELLENT at changing the subject with tangents or other distractions.

I have no idea what our alternatives besides residential treatment would be, and I can't see residential treatment as being a good alternative for her. She is becoming more violent, but it seems to me that most of her issues are caused by her Complex PTSD (which being around agressive kids would aggravate even more, in addition to the fact that she's already afraid she's becoming "like her brother" - out of control and violent) and her RAD (which should alleviate significantly when she's not around the family as much, but certainly won't help her progress any).

Though keeping her at home is causing major problems too. Hubby is starting to feel like the warden again. Bear's PTSD is triggered by Kitty's meltdowns (last night he had to leave the house), and of course the other kids aren't getting a lot of attention (although they are not scared of Kitty like they were of Bear). I have to admit I'm highly frustrated because I feel a lot of pressure to "fix" everything. Mommy guilt makes me feel like there's a "right" way to handle situations or a "right" thing to say that would make it all better. My head knows that's impossible, but...

We had our second family therapy session today. Much of the session was just Hubby and I talking about our concerns to the therapist (who now reads this blog, "Hi, Mr. O!" - so I better watch what I say!). When Kitty did come in she started the session with this new quiet voice that I've only really heard her use with this therapist. He commented on the fact that he's never heard her use this voice before either.

Then, breakthrough! He started talking to her about an incident yesterday (she witnessed two girls coming to blows at the PDH) and what happened when she got home (meltdown with Grandma that involved cussing and yelling and then the same with Hubby and I that denegrated to hitting Hubby). The "real" Kitty started coming out. She talked about her hatred for our family, gave the therapist several "real life" examples of her vengeance issues (he'd been asking us about it), and generally showed him the side of her that only us as her family and a select few of her therapists get to see.

Not a very productive session, but for some reason I always feel a little better when other people see her acting like this, and how we respond (calmly). I often feel like "they" think it's all in our head or we are "provoking" it (by yelling at her or treating her badly). With Bear it was a lot easier because he was unable to control his behavior at all when he "lost it" so it wasn't always directed at us. Kitty puts up the charming, friendly facade that is so typical for RAD kids.

So now what? What are our options?

1. We can put her back in public school where at least there was less stress at school. She will continue to fall apart, but it probably won't be as fast.

2. We can stick it out with the PDH and hope that the med changes will take effect quickly.

3. We can move her to residential treatment and hope that the neurological assessments make a big difference (and she won't be home while they make med changes which would be easier on the family).

4. ???!!! I've thought about an attachment intensive, but she has so many other issues that would make that so complicated. And more importantly (unfortunately) this would cost a lot of money and time that we just don't have. I haven't found a local therapist willing to do an intensive. Most of the few I can find on the internet are in Colorado (not just a hop, skip and a jump from here!). I do have family in CO, but the other 3 kids need us too. Not to mention that she is now 14 so attachment therapy at this age is VERY difficult. Of course emotionally/ developmentally she is only about 4-5 years old so maybe that helps.

Purplewalls - thanks for the suggestion regarding TinkerBear. I am strongly considering it! Say hi to the ladies at the C&C board for me. In my 3 computer change this year I managed to lose my user name and password and I can't get it to e-mail it to me. *sigh* Will keep working on it! Do you know if the user name is an e-mail addy or a name? That would narrow down the choices some.

Marythemom

Partial Day Hospitalization

Friday we finally had an appointment with the partial day hospitalization program. I'd been trying to get hold of them all week. It was a 3 hour interview with Kitty there the whole time. We discovered that evening that she hadn't taken her morning meds. Can you say hyper? Because she was referred by the hospital apparently it was a given that she'd get in (wish they'd told me that at the beginning of the week).



She started the program on Monday. There are 4 hours of school and she is in therapy for several hours (group, individual and family). Still no PE, but they have a ropes course and a gym they can play in. In the Summer they have a pool, assuming she's still there in the Summer of course. We disenrolled her from public school on Monday.

It is very far away, but they have a van that picks up the kids in the North. Big problem?! We have to have her at the van stop (20-30 minutes away) at 7am. Before she didn't have to be at school until 8:30am, and it was a 5 minute drive.

Kitty seems to be doing OK with going to bed a little earlier and getting up earlier, but no one else in the house is! Hubby is taking her to the van so he's having to get up almost an hour earlier then usual. I'm having to get up about an hour earlier and be dressed and ready to go so I can get Bob to school. The big problem is that Kitty is LOUD! She sings, talks loudly, stomps around, slams cabinet doors... She's not even aware she's doing it and doesn't seem able to stop, but no one in the house can sleep through it. The rest of the school year is going to be loooong.

Kitty seems to have many opinions about her new school. She told Bob and Grandma that it was nice, and she liked her teachers and made some friends.

In a 45 minute meltdown (luckily no physical aggression) she told Hubby and I that she hated the new school and was scared of the children (as wells as no one in the family cares about her, she's a bad person, and it's not her fault - because she has "issues" that excuse her behavior). I talked to a nurse during the day, when I'd discovered Kitty had left her lunch in our car, and she said Kitty seemed scared and upset. Usually Kitty is all smiles and super friendly to new people so this was surprising. Kitty got in trouble for talking during a quiet time, "teasing" a boy with physical threats, and not fully participating in therapy.

One thing I like about the new school is not only do they have point sheets at school, but they have them for the time at home too. With a large space for comments. Hopefully this will lead to good communication.

I've spent the last 2 days updating Kitty's timeline. Oh my goodness! It ended up being 23 pages single spaced 11 point type! It does have just about everything we know about her in it though. Cast of characters: biofamily, therapists, adoptive family, schools... and a brief description of everything we know about Kitty; moves (that took up a whole page right there), hospitalizations, meltdowns, reasons for meltdowns, consequences... I included a lot of Bear's information because Kitty was usually at the very least a witness to his issues.

I even included a description of a pre-meltdown conversation.