The Catch 22 And Your Mentally Ill Teen

Parents of children with mental illness have it hard, really hard.  Diagnosing, treating and managing a mental illness in a youg child is one of the most difficult responsibilities a parent can encounter.  Parents and families are thrown into a world of confusion, chaos and often despair.  Unraveling what you have is a daunting task.  These disorders of the brain are often met with much comorbidity but are also very dimensional each on their own.  Over time many of the presentations change and it could take years to see what you are truly dealing with.  With maturity of communication and self awareness some of these children eventually are able to participate in targeting the origin of the symptoms and become collaborative in their treatment.

For some, despite all efforts, the teen years pass by in a blurred flurry of  disregulation, outbursts, suicidal thoughts or attempts, self harm, dangerous or promiscuous behaviors, treatment resistant mania, psychotic features,  phobias, panic attacks, impulsive or reckless actions and most significantly unbearable pain. 

Multiple hospitalizations are not uncommon.  Multiple psychiatrists, therapists and residential treatment programs are not uncommon.  Navigating a children’s mental healthcare system that is broken leaves these families is financial and emotional ruin.

Even parents who have been fortunate enough to find a treatment to manage the disorder often find as the teen becomes more independent that noncompliance can undo years of progress.  As the child reaches his latter teen years, noncompliance with medications and therapies becomes a source of concern.  

In addition, teens that may have had minor levels of impairment with depression or anxiety find as the pressures of impending independence and often the use of street drugs or alcohol come into play, the disorders worsen dramatically leaving parents scrambling for control.  Instead of now dealing with trying to manage a mental illness they are now in the world of duel diagnosis and the walls are closing in on them.  

Some parents simply cannot take the pressure.  They are hopeless and as I mentioned earlier, are trying to fix a child or teen with a broken system.  The years of abuse by the teen, the years of chronic stress, worry and exhaustion take hold and they throw their hands in the air and give up.  Many of these teens wind up in the hands of the state and in state run facilities, it is a horrific situation for all.

“The mental-health-care ‘system’ in America is a broken system,” says Michael Fitzpatrick, executive director of the National Alliance on Mental Illness (NAMI). “The system was already in crisis, and has become even less accessible over the last three years as state budgets for mental health—psychiatric beds [in hospitals], counseling, and other services—have been cut by $2 billion. States have eliminated 4,000 in-patient psychiatric beds.” NAMI’s Katrina Gay adds, “In many cases you can’t even get an evaluation for two to three months—and that’s assuming you know how to get one in the first place.”

Some parents hope and pray as the teen matures they will outgrow the behaviors.  They put their faith in the day that the teen will finally break down and accept the help they need.   As they wait for that day they take every measure to keep the teen safe, walk on egg shells to keep the peace, construct a life around the devastation and often need to forgo expectations of limit setting, curfews and any remnant of a normal life.  These are good parents.  These are parents that like the rest of us do not have $75,000 to $100,000 a year to place their teen in a safe quality private therapeutic residential treatment program.   These are the parents that have tried to find help for their mentally ill child and tween using their health insurance coverage only to find very short term and ineffective programs available. These are parents that unknowingly are on the brink of a situation that will shake them to the core.  The situation they hoped and prayed maturity of age would resolve…. The loss of parental control and the age of majority.

The age of majority is the threshold of adulthood as it is conceptualized  in law.  The age of majority or the age a child is considered an adult varies by state and country.  In the US the age is usually 18. It is the chronological moment when minors cease to legally be considered children and assume control over their persons, actions, and decisions, thereby terminating the legal control and legal responsibilities of their parents or guardian over and for them. The word majority here refers to having greater years and being of full age; it is opposed to minority, the state of being a minor. The law in a given jurisdiction may never actually use the term "age of majority" and the term thereby refers to a collection of laws bestowing the status of adulthood. The age of majority is a legally fixed age, concept, or statutory principle, which may differ depending on the jurisdiction, and may not necessarily correspond to actual mental or physical maturity of an individual. It is the age a person is allowed to enter into a legal contract and control who has access to their medical and legal information.

In the event of an emergency hospitalization this can be very difficult for parents trying to get information on the reason and plan of treatment for their older teen.

The time to make decisions for your child is now gone without legal action and a court decision of continued guardianship must be obtained if the now adult is unwilling to have a parent participate.  Often the treating psychiatrist can persuade the adult child to accept help from parents but due to instability or destroyed relationships due to the disorders they cannot.

Parents are often put in a very difficult position when seeking information about a loved one with mental illness who is being treated by a mental health provider. Legally adult children with mental illness have the right to decide with whom their clinical information can be shared, and many times this is difficult for parents to understand when they genuinely want to help their child in his or her recovery and yet are told they cannot receive any information about him or her. However, in most circumstances (not all) providers are legally obligated to honor the wishes of a patient who withholds permission to make disclosures to family members.

There are limited cases of how a parent can receive information without consent.  The Director of a State operated psychiatric center is required by law to inform the parents of an involuntary-status patient of the fact that their relative has been involuntarily hospitalized, and must further advise the family where the relative has been hospitalized.This disclosure remains permissible under HIPAA because it is required by New York State Mental Hygiene Law.  Without express objection by the patient (who must be informed ahead of time) or compelling evidence that it would be counter-therapeutic, the family of a voluntary-status patient may be informed of the fact that their child has been hospitalized and where he/she is. In this case, information can also be obtained from the parent in order to obtain facts about the patient that are necessary for his/her treatment.

Even when parents are unable to obtain permission to receive information about their relative, this does not always mean they are barred by confidentiality laws from participating in treatment planning for the patient. In fact, unless it is plainly contraindicated, the New York State Mental Hygiene Law not only allows but requires the involvement of an authorized representative of the patient (which can include parents) in treatment planning, because it is presumed that such involvement has important therapeutic benefits. When done in such a way as to not compromise or reveal information that should be kept confidential, parens involvement can be accomplished without obtaining the express permission of the child and without violating confidentiality. For example, staff could discuss the programs that are available, privileges, family visits, legal status, and plans for discharge. Also, if not clinically contraindicated and appropriate, staff could share information provided by the parents with the patient, such as relaying messages of support.   Being in a psychiatric hospital is not pleasant, it can be very traumatizing and often teens soon seek the support of parents and allow them participate.  As hard as it is for parents for the teen it is absolutely devastating.

Having your 18 year old or legally adult child sign a HIPPA consent release or legal documentation such as a health care proxy giving parents access to information and decision making power for them is essential and can in some cases ward off a lot of problems.  In the event the now adult child will not allow information to be shared or will not agree to hospitalization to stabilize parents are often forced to take legal action to regain control in the capacity of a guardian or conservator.

What is the difference between a Guardian and Conservator?

A Guardian acts in behalf of the disabled person in personal matters. If appointed under the Mental Health Code, a guardian may also manage all of the disabled person's finances and property. In those cases of disability where the Mental Health Code does not apply, a conservator will be appointed to be responsible for such person's financial affairs. If both a guardian and a conservator are necessary, they need not be the same person. The judge must decide whether or not the person in question has a mental, physical or legal limitation which requires the judge to appoint a guardian to make decisions concerning the person's health and personal life or appoint a conservator to make responsible decisions concerning management of property and money.

A good resource for understanding the guardianship law and procedure is here http://www.zalkinlaw.com/pdf/guide_to_guardianships.pdf

Hoping, wishing and praying are wonderful, it keeps the faith and gives us some peace but realistically, if you have a severely mentally ill child.  If your depressed or mentally ill teen child is a risk to themselves or others, plan ahead.  Speak with the treating physician about their upcoming age of majority and or your lawyer about estate planning to ensure care for your adult child should you not be here and also discuss your options in the event of a period of severe mental instability.   Being informed is the best way to deal with the situation should it arise.

Any parent with a child with a mental illness knows being proactive is everything.  There is no more important proactive step you can take with your teen than to ensure their safety in the event they are not capable of making life saving decisions. 

Potpourri

Potpourri, I have always loved that word. The word congers up wonderful thoughts of bountiful fragrances, a palette of beautiful colors and a feeling of tranquility. It brings back memories of my grandmothers house with little aromatic bowls that gave her home its signature scent. It is a wonderful word.

The word potpourri has several definitions. The first, as I mentioned, is an aromatic mixture of dried herbs, spices and flowers. It also, in present day use, describes a miscellaneous collection or medley. The etymology of the word is French pot pourri, literally, rotten pot dated back to 1749.

When using the word Potpourri in reference to the child with a mental illness it takes on a whole new meaning. Professionals use the term "co-morbidity". I think I like "potpourri" better. Co-morbidity is the term used for multiple disorders. It is "literally a rotten pot".

Comorbidity makes for high rates of misdiagnosis among these children. It is rare that you find a child with just one disorder. Tourette Syndrome, OCD, ADD, PDD, Autism, Depression, Bipolar disorder the list goes on and on. Often times these children have one or more additional disorders which not only makes the diagnostics more difficult, but the treatment pure trial and error.

Adding to the confusion are the subgroups within the disorder. An example: A child with Tourette syndrome with severe exacerbation of tics or ocd symptoms after a strep or viral illness would be considered for a diagnosis of PANDAS or PITANDS as their subgroup. A test to identify the D8/17 marker would be performed. Treatment would be initiated. Seems simple, but it is not. There are subgroups within even this subgroup. Example: some children with PANDAS or PITANDS have different presentations. There is a subgroup that only have exacerbations after viral illness and others only after bacterial. Some respond to antibiotic treatment and some do not. On the autistic spectrum, there are some children who while with fever have significantly reduced symptoms. Dr Andrew Zimmerman at John Hopkins has done studies on these children and its relationship to the release of cytokines. Some of these children respond to augmentin - a preparation of amoxicillin and the potassium salt of clavulanic acid - rather than its base component amoxicillin alone,others do not. It is an eclectic puzzle. A potpourri.

Treating the child with multiple disorders, a potpourri, is a daunting task. Sifting through the symptoms to label the disorder is sometimes futile. It is understandably necessary for insurance coding but often times serves no purpose. Treating the symptoms is key. Looking at the child as a whole instead of a diagnosis, I feel, often times serves the child better. We are all complicated creatures but the child with a mental illness is like a convoluted bowl of emotional potpourri.

The Life Unexpected - The one you were meant to have

As little girls we played house and created a world with the perfect home, husband and child. Pretending to be a mom was a world with aprons, easy bake ovens, high heel shoes and pretty red lipstick. We knew this to be true, we saw it everywhere. It was on our televisions everyday. Donna Reed, Leave it to Beaver, Make room for Daddy even I love Lucy had moms with an idyllic charm that captured our imaginations.

As teenagers we rebelled. We were not going to be the idyllic housewife with pearls around our necks and children at our feet. We had new role models now. Mary Tyler Moore, Julia, That Girl and Charlies Angels transformed our beliefs. We dreamt of our careers and friendships and our lives as modern women.

As young ladies we became educated, got our first jobs, met the men of our dreams and felt the excitement and power of our first independence. We were empowered by the women on Cagney and Lacey, Knots Landing and Dynasty. The strength of these women changed our view of life and how we knew our life would be.

The men of our dreams became our husbands our partners our lovers. Maturity brought us to a balance of knowing that we could, if we chose, incorporate all the wonderful role models that had been set before us and have it all. We could wear that apron, advance in our careers, be strong formidable women, have that baby on our hip and do it all while wearing our best pair of stilettos. It was all laid out for us. It was the life we expected.

As woman and mothers we came to the stark realization that not unlike the fairy tales of our earliest memories, there are twists and turns and unexpected tribulations.

For some women life has given them pretty much what they expected. They seem to effortlessly walk through life and are truly content. For others, they are given the unexpected. They are given a child with a disability. They are given a heavy heart, not by the child, but by the illness or disorder that plagues them. These women feel limited in their choices, they feel they cannot have it all and feel a sense of loss for their happily ever after ending.

The woman of a child with a disability has been given the life unexpected.

Along with the unexpected can come the expected. If what we expected of ourselves as little girls, young ladies and women was to become nurturing, educated, independent, strong and supportive - then mothers of children with disabilities have not only met but far exceeded those expectations.

My father once told me "Expect nothing and you will never be disappointed". Seemed a bit harsh even a bit ridiculous. "Without expectations there are no goals" I replied. Looking back, I think I missed the point.

Perhaps the one thing never taught to be expected was to have a purpose. Maybe in some way having a true purpose in life - to be truly needed - may not be the life expected but the life you were meant to have.

The Dream Of Independence

I was honored to have Amalia Starr as our guest this week on The Coffee Klatch.  Amalia speaks and advocates passionately about the right and journey to independence for people with Autism.  Parental fear for the ability of their children to live independent lives can be overwhelming.   These fears can inhibit their child’s chance for a productive and independent life.  The sleepless nights worrying about who will care for their child once they are gone is universal among virtually every parent I speak with. The message I got from this interview is that parents need to overcome their anxieties and foster independence.  This amazing woman has now started the Autism Independence Foundation which will help families and young adults with autism lead productive lives with a community of support.

Elise, one of the hosts of The Coffee Klatch who writes beautifully about her journey raising two sons with Aspergers Syndrome a form of Autism. wrote a blog post that truly upholds the message from that interview.  Elise writes of her first year college son’s evaluation with a recommendation for future studies and career direction.  Clearly what was interpreted from the evaluation and what is in Elise’ mind and heart are two completely different things.  The title of this post is “Dreams” http://t.co/pxn4hed   Her son dreams of a career in law, the evaluation reportedly finds that not to be a viable option and alternate recommendations are made. 

I often think about the reality of the situation that many parents are in.  I think about the endless efforts and complete dedication that parents tirelessly devote to their children.  I think about, very often, are we being realistic?  Are we deluding ourselves to believe that our children will take everything we have spent decades teaching them and apply it to create an independent, productive and most importantly, happy life. 

Constructing realistic goals for special needs children is essential.  Reality based decisions need to be made on level of impairment and acquired life skills, of this there is no doubt.  Setting unattainable goals for our children will only lead to disappointment and failure but regression as well.  Are we setting them up for failure?  Are our expectations too high? Are we wasting our time?

Time will tell.   Time will not only tell if a mothers heart and soul can prove more accurate than a scientifically researched evaluation report, but if there truly is any way of calculating determination.  I am not only referring to the determination of the parent but of the child or young adult as well.  How can courage, capability and human motivation be so easily measured?

The word dream has many definitions.  The ones I find most important are these:

A strongly desired goal or purpose

Something that fully satisfies a wish

Something notable for its beauty, excellence, or enjoyable quality

A visionary creation of the imagination

What is a life without a dream? What is a life without desired goals, purpose, wishes, beauty, enjoyment and visionary creations?  There is another definition of a dream: A state of mind marked by abstraction or release from reality.  Fair enough, but where would be today without the abstraction of release from reality?  What incredible advances would have never come to pass without these unrealistic dreams and visions for the future?

Who is anyone to take the dreams of these children and disregard decades of over coming adversity?  Who is anyone to take the dreams of these parents that devoted their lives to these children and in one fifteen minute conversation project the future?

These women are turning their fears and anxieties into determination.  They are well aware of the importance of balancing reality and dreams.  They are fully aware of the limitations as well as the competencies of their children. They are not allowing their children’s futures to be predestined.  As did the mother of Dr Temple Grandin, they are not letting autism define their children.   Their futures and their dreams are yet to unfold and no one can take that away from them. 

Mental Illness - Its Not All In Your Head

Many people diagnosed with mental illnesses seek the help of

psychiatrists and other mental health care providers. It seems

the obvious treatment. What many people with depression,

anxiety and phobias, do not do, is seek out consultations to

find a possible medical cause for their symptoms.

There are many endocrine,neurological and cardiac diseases

that present symptoms of depression, anxiety and even

intermittent bouts of rage. Proper treatment of these disorders

can reduce and often times resolve the psychiatric symptoms.

Some patients will benefit from both psychiatric and medical

interventions. This is not to say that every person or child with a

mental illness is misdiagnosed, but many are.

The endocrine system, is a complex group of glands. These

glands make hormones which help to control activities in

your body. Along with growth, metabolism,reproduction and

development, hormones control the way you respond to your

surroundings. Diseases that alter the hypothalamic

-pituitary-axis may produce anxiety-like states. It important

to differentiate between medically induced and primary

anxiety disorders. Treatment with psychotropic medications

alone may not significantly improve the emotional symptoms

and may, in some cases, contribute to the hormonal

imbalances.

 Anxiety frequently occurs in endocrine patients with adrenal

dysfunction, Cushing's Disease, Carcinoid syndrome,

hyperparathyroidism, pseudohyperparathyroidism, hyperglycemia,

hyperinsulinemia, pancreatic tumors, pheochromocytoma and

thyroid diseases including hyperthyroidism, hypothyroidism

and thyroiditis. These diseases can be the organic basis for

an anxiety disorder and with proper diagnosis and

treatment can improve the quality of life of many

anxiety sufferers.

Psychoneuroendocrinology: The Scientific Basis of Clinical Practice

Polycystic Ovarian Syndrome is another very common

endocrine disorder which, in a large percentage of patients,

causes anxiety and depressive states. PCOS is caused by

irregular levels of estrogen, progesterone and testosterone.

It is estimated that 1 in 10 women have PCOS. Women with

PCOS may suffer from acne, excessive hair growth, loss of

hair, infertility, loss of menses, diabetes and weight gain.

Some data reports that almost 80% of these woman

suffer from anxiety, depression and other mood disorders.

Treatment with birth control pills as well as medications to

regulate insulin along with proper diet and exercise can

significantly improve the physical and emotional

symptoms of this syndrome.

Along the way you may have what is referred to as an

incidental finding. These unanticipated findings in the

course of testing or medical care can hold they key to

some anxious states. An incidentaloma is a tumor (-oma)

found by coincidence (incidental) without clinical

symptoms or suspicion. In our case it was a pituitary tumor,

a microadenoma. Cushings Syndrome -an endocrine disease

known to cause anxiety and phobic states -is suspected, as well

as Polycystic Ovarian Syndrome.

Although I have primarily focused on the endocrine -

anxiety connection, the list of diseases, disorders, syndromes,

and medications that can contribute to or cause anxiety and

depression is significant.

Treating depressive and anxiety disorders, in some cases,

needs to be a joint effort with a team of psychiatric as well

as specializing physicians working in harmony.

It has been my experience as a parent of a child with a

severe anxiety disorder,that what you see is not always what

you get. Proper diagnosis is the key. Finding the origin of a

mental illness is often like finding a needle in a haystack.

It took seven years and four endocrinologists before the

proper treatment was initiated, a lot of time lost.

Article: http://www.aolhealth.com/condition-center/chronic-pain/autoimmune-diseases-symptoms?icid=main|main|dl3|link5|http%3A%2F%2Fwww.aolhealth.com%2Fcondition-center%2Fchronic-pain%2Fautoimmune-diseases-symptoms

References:

http://www.drrichardhall.com/anxiety.htm

The Silence is Deafening

The organic basis of anxiety disorders in children and adolescents, this has become my focus.

I have spent a lot of time reading, researching and interviewing on this subject.

A few months ago I was approached about contributing to an advocacy book for special needs children. When I first decided to take this project on I had no idea what to expect. I had no idea what direction it would take me in or what if anything I would contribute.

It started with a few articles I had written that were read and picked up by bloggers and special needs websites. Soon, I began meeting a lot of people that were very passionate about these children and the struggles of their families. They are an eclectic group with different perspectives and theories on the causes of emotional disorders in children. Some have directed their focus on the environmental impact such as food additives, pollution and poor diet and exercise. Others have focused on vaccines and their role in autism. Videos games, music videos and present day stress is considered in learning disabilities. The genetic component is universally accepted. All have done their research and have educated themselves and others on the possible cause of this dysregulation in children. I believe there is validity in all.

I remain steadfast in my belief that some, not all, of these children's disorders are secondary to a primary medical condition. I began networking in many different venues to seek out parents, caregivers, nurses, adults who had been diagnosed with anxiety or depression as children as well as mental healthcare providers. The response was overwhelming. Within the first week I received over 80 responses to my request for people to be interviewed. I have spent weeks emailing and screening the responses.

To my surprise, I have had a tremendous response from psychologists, psychiatrists and otherhealthcare professionals. The internet has been an amazing tool for them to share their findings, research articles, case studies and opinions with me. Daily communication through text messaging and social media forums has been invaluable.

What became a striking similarity to me was the fact that none of the parents or adults I have been in communication with were given a thorough medical evaluation before being diagnosed and treated. A routine check-up and often times a blood panel to check liver and kidney function was performed but nothing further. Although a neurological evaluation was sometimes recommended, not one of the people I have spoken with were referred for an endocrine evaluation. It is important to add that the majority of people I have spoken with have either Cushing's Syndrome, Polycystic Ovarian Syndrome or another endocrine disorder. One out of every ten women has PCOS. Eighty percent of woman with PCOS have now or had as a child, some form of anxiety or depression. That is a very large population.

A week ago I decided to ask the mental healthcare providers I have been communicating with to let me know what type of endocrine testing they have recommended for the girls they treat for anxiety related illnesses.

I have not received one response.

Sometimes silence is deafening.

The Isolation of Families With Mental Illness

I can't think of anything more painful or more heart wrenching than that of the day to day life of a parent of a child with a serious mental illness. This is not to diminish the pain of parents of children with medical illnesses or of parents who have lost a child, but it is different. The isolation is palpable. The acceptance and sympathy is not universal. There is still, in this day and age, shame and the perception of failure. Yes, there are wonderful support groups and caring and knowledgeable doctors, but at the end of the day parents of children with mental illness are alone. Marriages are tested, siblings are adversely affected and families are held hostage by the disorders. Life becomes a constant calendar of doctor, psychiatrist and therapy appointments. Many families find themselves in financial ruin.

It seems there is always one step forward and two steps back. There is the medication roller coaster which once on, seems impossible to get off. There is the guilt and sleepless nights worrying if the decision to medicate is the right one and what the side effects may be, not only now, but in the future.

Here is an article posted today in the Los Angeles Times

Parents Cope With Schizophrenic Child

Mentioned in this article is the lack of services available for these children and their parents. Respite care is not offered, long term hospitalization is not offered and many specializing psychiatrists do not take insurance. It truly is a sad state of affairs when our healthcare system cannot accommodate these children and their families.

Having a child with a mental illness is a challenging and difficult experience. It takes a strong and special parent to deal with the daily uncertainty.

Being the parent of a child with a mental illness can also be the most rewarding and life altering. Little successes become major triumphs. Priorities become clear. Parents develop a bond that most spouses will never know. There is true understanding of unconditional love. And when the war is won, there is no better victory.

The road for these families is long but the reward at the end is great.

Medical Historian Key Role in Parenting A Special Needs Child

When I worked at the hospital, I was repeatedly told that the H & P (history and physical) was key to proper diagnosis and treatment. Having an accurate and up to date medical history can be the difference between life and death in an emergency room situation. A National Electronic Medical Records Database is essential to ensuring quality health care and should be part of our new healthcare plan.

Being the best medical historian you can be for your special needs child is paramount.

Having a child with special needs often creates a busy and stressful environment conducive to forgetting important information which is key to proper diagnosis and treatment. Keeping a journal and charting are two good ways to ensure that your child's history is correct.

Another important consideration in keeping detailed accurate records is the unlikely event of the absence of the primary caregiver.

Parents do not have to wait for a formal diagnosis to begin keeping a record of physical and emotional abnormalities. Journaling symptoms to discuss with your pediatrician or mental healthcare provider does not need to be specifically formatted. It can be as simple as jotting down observations and dates in a plain notebook or calender or keeping a journal on your PC. In the latter, I would recommend printing out hard copies for your file in the event of a computer crash.

Once a formal diagnosis is made, I feel it important to make a weekly (or during times of medication trials, daily) entry to document your child's progress or regression. As most parents of a special needs child are aware, symptoms and behaviors wax and wane and can soon be forgotten. I cannot stress enough the importance of daily documenting during times of medication trials. These are very hard times for the child as well as the caregiver. Recording the medication, form (brand or generic), dosage and times given, as well as any side effects is crucial. Adjustments are often made and it is key to have a point of reference.

As your child's disorder progresses changes are inevitably going to have to be made. Sometimes the change may be in the choice of treating physician or in the addition of one. Here is where the history is most important, this is where the H & P, as you give it, will decide treatment.

Charting is very popular and useful. Psychiatrists and therapists treating school age children will give forms for your child's teacher to fill out and return. The information is on a scale basis and requests specific information such as attention span, mood, social ability, grades as well as other important information. Always keep a copy for your file.

Keeping an accurate and up to date file for your child will make your life easier and alleviate one of the many stresses of doctor visits. Be sure to get copies of all reports, blood work, scans and other diagnostic testing for your personal file.

Remember, independence is not far away, your child will eventually grow up and move out.  Having a history of medications that were effective and those that caused intolerable side effects will be helpful as they begin to maintain their own mental health management.

You can find sample forms, logs and other record keeping ideas online.

Keep it simple, but get it done. It is key to parenting the special needs child.