Archive for the ‘ADHD’ Category

Protected: More Than Meets The Eye

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Time In: The Zen of Parenting

We're taking a class entitled "Parenting the Challenging Child," that is being taught by our developmental pediatrician.  It's interesting, actually, because many of the techniques and philosophies being presented in the class are things that he has already presented to us in our appointments with him, but now we are seeing them presented in a much more methodical manner, rather than in the more bandaid-approach we've been getting. 

One of the key philosophies of the course is that techniques like "time-out" and ignoring undesireable behaviors only work effectively if it is time-out from positive attention.  So before adding the negative, reactive strategies to our parenting toolkit, so to speak, we are building our strategies for positive, proactive strategies.  Last week, we talked about the importance of "Time In." 

Time in is much what it sounds like – in many ways it's the opposite of a time out.  It is time spent with your child, but it's more than that.  It's not just ANY time spent with your child.  There are rules, you see.  Time in isn't an opportunity to teach.  It's not a time to discipline.  It's not a time to be a parent, per se.  It's a time to let your child BE a child, and for you to spend time with your child BEING that child.  You don't answer the phone, you don't do dishes or make dinner in the kitchen while you're half-paying attention to what your child is doing in the other room.  You don't ask any questions, you don't give any instructions.  Unless your child tries to do something truly dangerous like lighting the cat on fire, you don't issue any reprimands.  This time (15-30 minutes a day, ideally) is completely child-led play time.  You should try to see the world through your child's eyes for this brief period of time.  Instead of asking questions about what your child is doing, you should comment on, or narrate, what your child is doing, give lots of positive praise, and play along, or take directions from your child, but really let your child lead the way.  Your child should be the one to decide what happens during this time, you shouldn't be the one dictating any of the activities or the nature of the play.  Like I said, hard as it may be, this is not a time for teaching moments, or for interrogations (no questions!!  This is the hardest part!), or for reprimands.  Make sure that you've got a child-safe and child-friendly environment where your child is free to act like a child free from admonishments to not touch that, or not go there, or not do that, or whatnot. 

Get the idea?

This wasn't my first introduction to the concept of Time In.  Several books discuss the concept; most recently when I read Russell Barkely's "Taking Charge of ADHD" I was reminded that we should be practicing the art of Time In.  Dr. S. had emphasized the importance of Time In during our office visits.  But I'm not good at Time In.  I'm okay with generally spending time with my kids.  But this specific kind of Time In technique?  Not my strong suit.  Seth?  Seth is great at it.  He's a natural at this kind of Zen Parenting where you can just let your kid be a kid and let all the parenting instincts and teaching moments and reprimands go.  Seth gets in the moment and crawls around on the floor and builds legos and wrestles and lets J lead the way.  Me?  If you take away my questions, my teaching moments, my ability to lead in any way… I get tense.  There's no Zen of Parenting in Time In for me.  So the whole Time In thing has naturally fallen to Seth, not really on purpose, but because it's his strength and my weakness.  We're a team and we play to our strengths, right?

But that's cheating, according to Dr. S, and we have to learn to share responsibility and share the fun.  So last week, after our class on Time In, our homework was to practice our Time In technique.  Mommy isn't used to not doing well on her homework, so I was determined to make this work!  Thus began my first foray into the world of Time In. 

J was playing with Transformers and I started to play with him.  He didn't like what I was doing, so he switched Transformers with me.  I hate Transformers, passionately, so I was sort of at a loss for what to do or say.  "Golly what a nifty Transformer, and gee, how deliciously violent this game is" somehow seemed terribly inadequate.  I was tense and fairly miserable.  "Grr!" I said.  "My guy is attacking your guy!"  "No he's not," J said, "My guy has a shield and he blocked your guy! Take that! Kablam! Kablam!"  I stifled the urge to remind J that we don't like him making shooting sounds.  "Um, well, then my guy has shields too and um, your weapons can't penetrate them!"  "No, your guy doesn't have shields, and now I shot him," J countered.  This wasn't going well. 

"Gosh, J, this is a really neat Transformer!  Can you show me how to make him back into the sports car??"  Whoops!  The Time In Purist would be tapping the table to remind me that I'd just broken the cardinal rule of Time In… not only had I asked a question, but I'd redirected the play.  Fortunately, it didn't backfire this time.  "Oh yeah, look at this, Eema!  It is SO cool!  You do it like this, and you move that around, and then you…"

 I gradually became more comfortable playing with him, and we chased each other around the living room.  I became a giant transformer-eating monster, waving my arms about and stomping my feet in Frankenstein-like movements toward him. 

And then it happened.  I finally experienced the true moment of Zen Parenting:

J jumped up onto the couch, bounced over onto the chair, jumped to the automan, bounced back over to the couch and climbed onto the back of the couch and declared himself the winner (winner of what?  I'm not really sure).  J knows that my absolute most non-negotiable rule in the living room is that he may not climb up on the furniture and bounce around on it as if it is a playground.  He knows it is a sure-fire way to test what kind of mood I'm in.  But just as I was about to remind him to get off the couch, I remembered that would be against the rules.  Not only did I not have to reprimand him right then and there, I wasn't allowed to.  He wasn't in immediate danger, the cat wasn't about to be set on fire, it was time to just let this one go. 

In that moment I felt like all my tension just went out of my body and I was free.  Finally I could just let J be J.  I could just be with him and see the world from his perspective – perched upon the back of the couch, and you know what?  It looked really nifty from up there.  I understood what drove him to be up there, for just a moment.  For that moment I didn't have to be the mean old mom who has all these rules.  I got to be the cool mom who overlooked that relatively minor infraction in the grand scheme of things.  And then?  The giant transformer-eating monster scooped in, picked him up off the back of the couch, tickled him, and wrestled him down to the floor, giggling madly, with nary a reprimand to be heard.  Mission accomplished.  No arguments.  No fighting.  No pushbacks.  And without missing even a second of quality time with my son.

Since then, I've made it a point to spend time differently with J, even when it isn't specifically Time In time.  I try to be more animated while I'm talking with him, I let him lead the discussions more, I respond to the things that he's saying and I try not to just say, "uh huh" when he's talking about something I couldn't care less about (like transformers).  Even if I'm feeding the babies and he's standing there talking to me, I can still make him feel like he's got a few minutes, or even seconds, of my absolute, undivided attention.  And it's making all the difference in the world.

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The Punchline

I forgot to include the punchline in last night's post.

My head spinning with visions of CPT codes, diagnosis codes, claim forms, and murder plots, I told Seth he would have to take these claims to EAP which is a whole different process including a whole different set of information.  I would do it myself, except that the EAP office is an hour away from MY office and only feet from his office.

Yesterday, my beloved husband went over to the EAP office for me, armed with copies of all our invoices and claim forms.  He had a lovely conversation with the EAP representative, who was extremely helpful but could not process the claims for him.  Why? 

Oh, see, according to the lovely woman at EAP, the CPT code on these invoices is a – wait for it – medical procedure code.  Since it's not a mental health procedure code, it doesn't need preapproval from EAP, so there's nothing to be done on the EAP side.  This is, apparently, something the medical side gets wrong.  Often.

She called over to the medical claims department and explained that she was sending back these claims and that they needed to be processed and approved.  Needless to say, I'm not holding my breath.

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There's a lot "they" don't tell you about life.  Especially life with children.  And when you throw in triplets and an ADHD five year old?  Well, there's a whole lot that "they" edit out for fear of you running screaming from the room.  Today's topic?  Insurance companies. Today's blog subtitle?  Don't let the bastards get you down. 

Item the first?  I am *still* getting bills and EOBs for the triplets NICU hospitalization.  Note:  They were discharged from the NICU 1 year, 14 days ago.  I am still getting bills from the company that we rented Ellie's heart monitor for.  I'm getting these bills because the insurance company won't pay for them.  The insurance company won't pay for them because the bills are in Abby's name.  Abby never had a heart monitor.

But that's not what this post is about.  That's just an illustration of how stupid the insurance companies can be. 

Today's post is about ADHD and insurance companies.  You see, when you have a child with special needs, you're bound to run into all sorts of fun with insurance companies.  Insurance companies prefer you to have children who never get sick and who have no special needs.  They make money off of members who pay their premiums and never go to the doctor.  But when you have a child who starts going to a developmental pediatrician, a speech pathologist, a neuropsychologist, and heaven knows who else, well, the insurance company doesn't love you QUITE so much anymore.  

Here's the other fun part about ADHD:  ADHD is considered a mental health diagnosis, not a medical diagnosis.  Insurance companies don't really feel the need to cover mental health diagnoses without a lot of hoop jumping.  I guess they think you might abuse the system or something.  Because my favorite thing to do on a Tuesday morning is go see a therapist, or, say, a developmental pediatrician, just for kicks. 

Oh, and did I mention that most developmental pediatricians don't accept insurance?  At least not the ones in this area.  The ones that do are the ones that are affiliated with large hospital systems, but they have long waiting lists and aren't as good with personal followup.  My doctor is phenomenal about personally following up with everything and I get a call back within hours every time I call him for ANYTHING no matter how trivial.  He coordinates personally with every member of the J-man's team.  I wouldn't get that from any of the major medical centers – plus if I went to them, I'd STILL be waiting to get in for the initial intake appointment because their waiting lists are so long.  So no insurance.  We pay out of pocket, submit the claims to our insurance company ourselves and hope that they will reimburse us. 

For medical claims that are out of network, the insurance covers 60% of the allowable fee.  For mental health claims, the claims must be preapproved by the Employee Assistance Program (EAP), and are covered at 40%.  Mental health claims are also limited to 10 visits per year.  Each invoice includes a diagnosis code (J's is DSM IV's 314.01) and a CPT code (this is a procedure code).  The diagnosis code translates to ADHD, combined type.  The CPT code usually translates to "50 minute office consult", but has occasionally been "school assessment" or other things.

After our first several appointments with the developmental pediatrician, we submitted several claims to the insurance company, not knowing whether it would be covered as medical or mental health claims.  Astoundingly, the claims were covered as medical claims, at 60%.  It was easier than we thought!  Hooray!  After several more visits, and about $1500 in bills, I submitted another pile of receipts and waited.  And waited.  And waited.  And waited.  And waited.  No check.  No explanation of benefits (EOB).  Nothing.  Seth called the insurance company (it only seemed fair, since it's HIS insurance) and they said, "Oh, those claims SHOULD have been processed, but we accidentally denied them saying that they should have been submitted to EAP for preapproval.  We'll re-process them and you'll receive a check in 2-3 weeks."  Three weeks passed and we heard nothing.  So I called them this time, and I had the most infuriating conversation I've ever had in my life:

ME:  I'm trying to find out the status of these claims.
THEM: Oh those claims were denied.
ME:  I haven't received any EOBs.  Can you tell me why they've been denied?
THEM:  We denied them because they're mental health claims.  They need to be preapproved by EAP.
ME:  No, my husband spoke to you a few weeks ago and was told that they were mistakenly denied for that reason, but were being resubmitted for approval because they should have been approved.
THEM:  No ma'am. These are mental health claims, so they have to be submitted to EAP for preapproval.
ME:  I don't understand… in June you approved a claim with the same CPT Code.
THEM:  It doesn't matter, ma'am.  We don't use the CPT code, we use the Diagnosis code.  The diagnosis code on this claim is a Mental Health Diagnosis.  So it needs preaproval by EAP. 
ME:  But the diagnosis code last month was also a Mental Health diagnosis. 
THEM:  But last month, the CPT Code reflected a medication check, so it was a medical claim, not a mental health claim.
ME:  I thought the CPT Code was irrelevant?
THEM:  What is relevant is whether it is a medical procedure or a mental health visit.
ME:  Okay, so the CPT code drives whether it is covered or not, then?
THEM:  No, if it is a mental health diagnosis, it has to have preapproval by EAP.
ME:  You're not making any sense.  June's claims had the SAME Diagnosis code AND the SAME CPT code as this month.  The only difference is that in June you approved the claim and this time denied it.  Can you explain why? 
THEM:  Yes, it was denied because it's a mental health claim.
ME: No, it's a medical procedure, per the CPT Code.
THEM: No, it's a mental health claim, per the diagnosis code.
ME:  You're not understanding me.  Three weeks ago, my husband spoke with you and you explained to him that these claims were accidentally denied, but that they shouldn't have been.  They were to be reprocessed for approval because they should have been approved in the first place.  What you don't seem to be understanding is that you literally owe me thousands of dollars at this point, which prevents me from continuing to guarantee that I can afford appropriate medical care for my child when he needs it.  Can you at least understand where my frustration is coming from?
THEM:  Ma'am, the diagnosis code is a mental health diagnosis code, so the claim needs preapproval from EAP.
ME:  Then why did you approve an IDENTICAL claim in June?
THEM:  The procedure code in June was a medical code.
ME:  The procedure code on these claims is a medical code as well.  That's what I've been trying to tell you.
THEM:  Ma'am, as I've already told you, the procedure code has nothing to do with whether the claim is approved or denied; the diagnosis code drives whether it is considered a mental health claim or a medical claim, not the procedure code. 

I swear to you, I almost threw the phone across my office.  If it hadn't been the middle of the work day, I might have been driven to drink.  Except that drinking leads to more migraines, and that's no fun at all.

Studies show that the stress levels in parents of kids with ADHD are as high as parents of kids with autism.  I believe it, but sometimes I wonder if it's because of the ADHD, or if it's because of the insurance companies.  (It's both)

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Here We Go Again

I haven't written about all the ups and downs, backs and forths, various changes we've made in the J-man's medications, because, really? What's the point? I'd just be writing the same post again and again. He'll take a new medication for 5, 6, 8, maybe even 10 or 12 days. And then, he'll start refusing to take it. And he'll lose privileges. His beloved Bionicles will go into the attic. His legos will be put away. His rights to use the computer will be taken away. And those threats will work for a day or two. Until they don't work anymore.

But this latest medicaton? Oh my gosh! It's been working so unbelievably well! I didn't realize how incredible life could be until we switched to it! Life was beautiful. But it was an extended release capsule that we had to open up and break into J's food… and, well, THAT didn't go over well. Because the capsule contained these little teeney tiny beads. And the beads… well, J's super-sensitive to food textures. And whenever he decides he doesn't like a food texture, he starts freaking out. So we were putting the beads in yogurt, or ice cream, or pudding, or applesauce. And that worked. For a while. And then we had to start disguising it by putting sprinkles in with the beads. And that really worked. For a while. And that stopped working. And nothing, and I mean NOTHING, was working.

Today he simply wouldn't swallow any bite he put into his mouth. He spat it out. Today was not the day for him to refuse to take his medicine – he had an appointment scheduled with a neuropsychologist to have some testing done. He didn't know about the appointment, so I know his refusal to take the medication today wasn't just acting out to get at me. Plus, he'd told his teacher yesterday that he doesn't like his morning medicine and he's not going to take it anymore. So it's been coming.

I called the developmental pediatrician in desperation at 8am and left him a message. "What do I do? Do I cancel the appointment with the neuropsychologist that I'm paying thousands of dollars to? Or do I put a patch on him and hope that does enough to get him through the appointment? Help!" He called back at 8:30 and told me to put a patch on him. He sounded defeated. I hope he was just tired and rushed. I put a patch on J and tried to get him to calm down. The appointment was at 10am. Plenty of time for the patch to work… Turns out, the new medication works a LOT better than the patch. In comparison, the patch made it seem like he was nearly unmedicated. Sigh.

Sometimes these unmedicated (or in this case, undermedicated) days are a good thing. They give me a sanity check and remind me that the medication (the one he was SUPPOSED to take, but didn't) DOES work. It reminds me that I AM right to be medicating my child, despite how unpopular a choice it is. When I see how out of control my child is, how incapable he is of controlling even his most destructive impulses… it reminds me how desperately he needs the aid of this medication. When I see how crazed and wild he becomes without medication, I am reminded that his behavior was NOT all in my head, that I was NOT making it all up or exaggerating. I was not crazy, or just completely incapable of handling it. It was not normal behavior that I was simply intolerant of. Sometimes the unmedicated days are vindicating.

Today, however, is not one of those good days to be unmedicated. Today, J needed to be focused. Today, J needed to be optimally medicated. Today, J was not. Nevertheless, the neuropsychologist did the best that she could do, and said she'd do the rest at the next appointment in a couple of weeks. She's very flexible and she'll work within whatever limitations she can. And I got to read a good deal of a terrific book: ADHD & Me: What I Learned From Lighting Fires at the Dinner Table. Maybe I'll finish it at the next appointment.

I took the J-man to school and had a long talk with his teacher on the playground. His teacher has the advantage of having an ADHD son of her own, so she can give me a lot of her own perspective on this stuff. And we decided that if the developmental pediatrician is okay with it, we can try moving him to the short acting version of the medication. He already takes the short acting version of the medication on Mondays and Tuesdays at school in the afternoons so that he's focused for speech therapy. He doesn't mind the short acting medication because it's not little beads, it's a pill crushed into powder, so the texture doesn't bother him (…yet). The disadvantage to the short acting version is that it wears off in as little as 3 hours (versus 8 hours), so it has to be given pretty frequently, which means having the teacher give it to him at least twice a day, but she doesn't mind. And so prompted my SECOND phone call to the pediatrician for the day, making my fifth phone call to him in two days. I wish I could have frequent flyer miles with him or something. Sheesh.

And so… That's what we're doing. Switching to the short acting medication, which he'll be taking at 7:30, 11:30, and 2:30 (he'll get the 2:30 dose only on Mondays and Tuesdays… the other days I'll give him a dose when he gets home ONLY if I feel he needs it – otherwise his appetite gets suppressed too much. SIGH.). And really? If anyone thinks this is all too much for a little kid? They should take him for a day. UNmedicated. Because it may be too much for a little kid, but it's DEFINITELY too much for his mommy.

Did I mention I have a full time job in addition to being a full time mommy? Did I mention I'll be working on that full time job into the wee hours of tonight to make up for the time lost this morning trying to take care of him? Did I mention that I DESPISE that people try to suggest that mothers either work full time or they parent full time? I DO BOTH. I am home for all of my triplets' therapy appointments. I take J to ALL of his therapy appointments. I coordinate with all of the teachers, doctors, therapists, psychologists, and caregivers that function as part of J-man's team. I feed them, I shop for them, I love them, I hold them, I parent them. I do all of the things that a full time parent does. And I still have to fit a full time job in between all of that. For that matter, my wondermous husband also is a full time parent and works full time, so don't go thinking he's a slacker either, because he's not. So there.

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Some days I feel absolutely ill-equipped to be a parent of an ADHD child. 

I would elaborate, but really?  Is there anything more to say than that?  I don't know that I was cut out to do this, but then again, I wouldn't trust anyone else to do it better.

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