[krisrishere]

My fiance and I have custody of his 17 year old brother (we are 27). All of the children, including my fiance, have been moved around to various caretakers because of their irresponsible parents. His brother, the youngest, has been moved around about 5 times in the past 6 years. Every time his stay has ended due to his behavior. His normal actions consists of, not listening, lies incessantly, is disrepectful to others etc. All of the "typical" behaviors of a teenager. The last straw in his stay with his caretakers consists of running away, asking to be beat up, telling people he's been beat up, skipping school and threats of suicide. This episode has always ended up with them relinquishing guardianship of him. Well we ARE the last straw and we are AT our last straw. There is no where else for him to go other than foster care, and his behavior has reached the point were it is jeopardizing our jobs and new house.

As of right now, he is at a children's hospital that focuses on mental disorders. The doctors say he has textbook symptoms of schizophrenia, and after educating myself I see that he does have some attributes. His main symptoms are: flat effect, lack of pleasure in everday life, hygiene neglect, poor executive functioning and working memory.

My questions/concerns are:

Can he be faking?
If he takes medicine, will it help these symptoms because those are the only ones that are prevelant?
Will a good Foster Care program help or hurt his diagnosis in the end?
Will these medicines make him more "flat"?

I understand that many of my questions are ignorant, but I can't help but feel this way at the moment. He has a wonderful life here with us, but he doesn't seem to know how good he has it. His behavior has put many things in jeopardy, however what point do we have to think of ourselves? And at what point do we say, "well, we've done everything we could for him?"

Please advise.

[spiritual_emergency]

<blockquote>
It's worth noting that to the best of my knowledge, no one here is a doctor. Therefore, although we can give our opinions and provide some personal insights that might help guide you in our decision, we're not professionals. That doesn't mean that what we might have to say is of a lesser quality than what a doctor might have to offer, it could, in fact, be of a superior quality. My only point is that we're not doctors.

All of the children, including my fiance, have been moved around to various caretakers because of their irresponsible parents. His brother, the youngest, has been moved around about 5 times in the past 6 years. Every time his stay has ended due to his behavior. His normal actions consists of, not listening, lies incessantly, is disrepectful to others etc. All of the "typical" behaviors of a teenager.

....

The doctors say he has textbook symptoms of schizophrenia, and after educating myself I see that he does have some attributes. His main symptoms are: flat effect, lack of pleasure in everday life, hygiene neglect, poor executive functioning and working memory.

Here's a question of my own. How did the description of his behavior go from "typical behaviors of a teenager" to "schizophrenia"?

His main symptoms are: flat effect, lack of pleasure in everday life, hygiene neglect, poor executive functioning and working memory.

Those are what might be called "negative effects". My next question is, where's the "positive effects"?

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One of the puzzling things about medicine is the language used and I don't just mean the technical stuff. For example, a positive result in medicine often means that there is something wrong whereas a negative result means you're o.k. - or does it?

When it comes to considering positive and negative symptoms in schizophrenia, the meanings do change somewhat. In this context, ‘positive' actually refers to symptoms in addition to what might be considered standard behavior. Delusions and hallucinations would be considered examples of positive symptoms. By contrast, ‘negative' symptoms refer to components that are reduced or missing from the normal repertoire. Social withdrawal and poverty of speech would be two such examples.

Source: Positive & Negative Symptoms: a helpful concept?


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My concern would be that this is a clearly troubled young person who's not known any consistency of structure over the past several years and has probably not felt a lot of love, acceptance, and understanding during much of that period either. I think these factors could just as easily contribute to the "negative effects" that are being seen. As noted, I'm no expert but when first reading your post my thought was oppositional defiant disorder or perhaps something in a related vein, but not schizophrenia unless you've managed to miss seeing some fairly obvious symptoms in the positive line. Given that this boy has lived in multiple settings over the past few years, that's a possibility but without evidence of those positive symptoms, I think a diagnosis of schizophrenia or even psychosis would be premature.

I would strongly suggest a second opinion but not from the same hospital or same group of caregivers he currently sees. I would also suggest a consultation with a child psychologist who specializes in teen behavior. Note that I said psychologist not psychiatrist. Psychiatry's speciality is dispensing medication, not talking, and talking to someone might be of more benefit than medication.

I would also suggest that you contact his previous caregivers and try to put together a bigger picture of possible symptoms over the past few years if you haven't already done so. There may be something you've missed or misunderstood. Based on your own reports this child is a real handful so I would expect you're going to hear the awful side of his history -- the lies he told, the things he might have stolen, etc. Try to keep it in context. It might also help to ask those individuals to describe any positive qualities. Maybe he was always gentle with younger kids or pets in the home; maybe he has a hidden talent for drawing or computer graphics or building motors; maybe he's a creative cook or budding musician. There is a human being in there somewhere.

As long as you're talking with past caregivers, see if any of them seem willing to give him another shot. A stable loving environment would probably be best for him, preferably in the company of someone he cares for and feels cared for by them.

I can't speak much to the possibilities for foster care. I suspect that many of us have an idealized vision of what foster care really looks like but many children who have emerged from that system tell a very different story. Before making any decisions about foster care I suggest you research all the options available in your area. Go out and visit those enviroments. Spend a couple hours hanging out. Talk with the people who work there and especially, talk to the kids that live there! Are they happy? Would they recommend the place to other kids like them? Even though you may be at your wits end, I hear that you want to help this boy if you can. It's possible the right kind of environment could help, it's equally possible that the wrong kind could do more harm than good.

Once you've sought a second opinion, consulted with a child psychologist, and reviewed your local options, I would say it's time to sit down with your fiance and your brother-in-law-to-be and make some decisions about what you're going to do next.

Please post more if you think it will help. Otherwise, best of luck to you, your fiance and his brother.

[krisrishere]

He does have many good qualities. He's a fantastic student, he loves to draw, everyone sees a smart, fun-loving kid. We have had many in-depth conversations with his previous caregivers and all say the same thing, he's sweet and innocent outside the home. He's had many loving guardians, including ourselves, but he always has the thought that he doesn't deserve it, so he tries to screw it up with his behavior. He has exhibited the EXACT same behavior with every single person...to the T.

After speaking with the psychologist and psychiatrist he's working with now, they believe he does in fact have positive symptoms as well. I have never noticed this...Should I have been paying more attention?

I will also ask your question that you posed to me again, "at what point does typical teenage behavior turn into schizophrenia?" I have no idea, but I'm assuming any doctor with half a brain would know the difference between the two.

By the way, the doctors have just put him on Clozapine. Does anyone have any experience with a person who's on this medication?

[spiritual_emergency]

<blockquote>
We have had many in-depth conversations with his previous caregivers and all say the same thing, he's sweet and innocent outside the home. He's had many loving guardians, including ourselves, but he always has the thought that he doesn't deserve it, so he tries to screw it up with his behavior. He has exhibited the EXACT same behavior with every single person...to the T.

Again, speaking purely from a non-expert perspective, that doesn't sound like schizophrenia to me. It does sound like a repetitive trauma pattern.

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The Compulsion to Repeat the Trauma: Re-enactment, Revictimization, and Masochism
Bessel A. van der Kolk, MD*

During the formative years of contemporary psychiatry much attention was paid to the continuing role of past traumatic experiences on the current lives of people. Charcot, Janet, and Freud all noted that fragmented memories of traumatic events dominated the mental life of many of their patient and built their theories about the nature and treatment of psychopathology on this recognition. Janet75 thought that traumatic memories of traumatic events persist as unassimilated fixed ideas that act as foci for the development of alternate states of consciousness, including dissociative phenomena, such as fugue states, amnesias, and chronic states of helplessness and depression. Unbidden memories of the trauma may return as physical sensations, horrific images or nightmares, behavioral reenactments, or a combination of these. Janet showed how traumatized individuals become fixated on the trauma: difficulties in assimilating subsequent experiences as well. It is "as if their personality development has stopped at a certain point and cannot expand anymore by the addition or assimilation of new elements."76 Freud independently came to similar conclusions.43,45 Initially, he thought all hysterical symptoms were caused by childhood sexual "seduction" of which unconscious memories were activated, when during adolescence, a person was exposed to situations reminiscent of the original trauma. The trauma permanently disturbed the capacity to deal with other challenges, and the victim who did not integrate the trauma was doomed to "repeat the repressed material as a contemporary experience in instead or . . . remembering it as something belonging to the past."

...

Many traumatized people expose themselves, seemingly compulsively, to situations reminiscent of the original trauma. These behavioral reenactments are rarely consciously understood to be related to earlier life experiences. This "repetition compulsion" has received surprisingly little systematic exploration during the 70 years since its discovery, though it is regularly described in the clinical literature.

Source: The Compulsion to Repeat Trauma


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The last straw in his stay with his caretakers consists of running away, asking to be beat up, telling people he's been beat up, skipping school and threats of suicide.

Is the "beating up" behavior consistent as well? Has he been "beaten" in the past? What's coming through for me is a seeming desire for self-punishment.

After speaking with the psychologist and psychiatrist he's working with now, they believe he does in fact have positive symptoms as well. I have never noticed this...Should I have been paying more attention?

Positive symptoms can be more subtle in the prodromal phase but are generally impossible to miss during a state of active psychosis (or "altered state of consciousness" for those who may prefer the distinction). Some examples of positive symptom behaviors might include intense fear, a sense that the larger world is communicating with you through messages on the radio or television, self-identification with a religious figure or myth, etc. Psychosis can be a component of post-traumatic stress disorder so it's good be to aware of those links. This thread may be helpful: PTSD and Schizophrenia.

I will also ask your question that you posed to me again, "at what point does typical teenage behavior turn into schizophrenia?" I have no idea, but I'm assuming any doctor with half a brain would know the difference between the two.

As a general rule, doctors don't come up with a diagnosis of schizophrenia first and this is because a specific pattern of behavior over a period of at least six months is required to make the diagnosis. Individuals diagnosed as schizophrenic may have received a number of diagnostic labels before they get that one. For example, just yesterday someone joined this site who had previously been diagnosed as schizophrenic but the diagnosis had since been changed. Misdiagnosis is common.

It's also worth noting that teens in particular are gaining increasing attention in the field. There are some who believe that symptoms of schizophrenia can be recognized and identified in the prodromal phase, and possibly halted before a full-blown case of psychosis becomes reality. I'm wondering if this is the case with your brother's brother because you've made no mention of symptoms that would indicate an active psychotic state. Maybe the docs are concerned that he's in a prodromal phase and are hoping to catch it early. While there does seem to be some evidence that this has helped some teens, studies indicate that many of the teens identified as "at risk" did not go on to develop schizophrenia and therefore, were exposed to the significant risks associated with anti-psychotic medication as a means of appeasing the fears in those around them. Although the intentions of many may be good it cannot be ignored that psychiatric medication for children and teens has become big business supported by equally big marketing campaigns.

Three articles that may provide you with more insights in that regard:
[*] Schizophrenia Risk Factors Identified in Teens
[*] Psychosis Prevention Program Gets Press
[*] Suicide Risk Tests for Teens Debated

By the way, the doctors have just put him on Clozapine. Does anyone have any experience with a person who's on this medication?

That seems an unusual first line of attack. You may want to ask the doctors why that specific drug was chosen. Clozapine is usually a drug used as a last resort. According to epocrates.com clozapine is restricted to use with severe schizophrenia in those who have been treatment resistant to other anti-psychotic medications.

Some of the risks of clozapine include reduced white blood cells (Agranulocytosis) seizures, fatal myocarditis, cardiac failure, tardive dsykinesia and diabetes. According to this report from the FDA, clozapine was associated with 7,665 deaths between 1998 and 2005.

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Clozapine (sold as Clozaril, Leponex, Fazaclo, Froidir; Gen-Clozapine in Canada, Klozapol in Poland) was the first of the atypical antipsychotics to be developed. It was approved by the United States Food and Drug Administration (FDA) in 1989 and is the only FDA-approved medication indicated for treatment-resistant schizophrenia and for reducing the risk of suicidal behaviour in patients with schizophrenia.[dubious – discuss]

Clozapine has been shown to be superior in efficacy in treating schizophrenia. Were it not for its side effects it would be first line treatment; however the rare but potentially lethal side effects of agranulocytosis and myocarditis relegate it to third-line use. Furthermore it may rarely lower seizure threshold, cause leukopenia, cause hepatic dysfunction, weight gain and be associated with type II diabetes. More common side effects are predominantly anticholinergic in nature, with dry mouth, sedation and constipation. It is also a strong antagonist at different subtypes of adrenergic, cholinergic, histaminergic and serotonergic receptors.

<font color=red>Safer use of clozapine requires weekly blood monitoring for around five months followed by four weekly testing thereafter. Echocardiograms are recommended every 6 months to exclude cardiac damage.</font>

Source: Wikipedia: Clozapine


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Do you see why it's curious that clozapine might be the first anti-psychotic drug he was put on?

You may be able to find more information in the Drug Questions forum or through a good search engine. Do be aware that of all the medications out there, anti-psychotics carry some very significant and very risky side effects. It's worth the time and trouble of investigating what those are.

My continued best wishes that you're able to find the answers that will help your fiance and his family.