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Author Topic: depression in our kids  (Read 559 times)
livednlearned
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« on: April 16, 2015, 07:07:58 PM »

S13 is seeing a psychiatrist who is treating him for depression. Watching S13 struggle as a child made me realize something was wrong, maybe with the environment, maybe his dad, maybe S13, maybe me, maybe all of it. I could not get N/BPDx on the same page to try and help S13, and things unraveled quickly. When S13 was 9, I packed our bags and we moved out.

I've written before in other places how I wanted to learn how to raise an emotionally resilient child, and to do that, had to learn what emotional resilience even meant. I'm still learning.

Over the years, I have harbored fears that S13 might be genetically predisposed to developing a PD like his dad. I read Blaise Aguirre's book about BPD and adolescence, and in it he says that BPD is 60% genetic, and 40% an invalidating environment. I took that to heart and learned what I could about creating a validating environment. It has helped a lot.

Still, S13 struggles with depression and anxiety. Today, I read an journal article about how researchers are learning that depression is often a combination of a genetic predisposition plus a traumatic childhood event, or abusive childhood.

This is from the article, "The participants who were shown to have limited gene function implied in both BDNF (brain-derived neurotrophic factor, a protein-coding gene) and serotonin transmission were extra-sensitive to the damaging effects of child abuse — whether the abuse was psychological, physical or sexual. In other words, this particular lack of gene activity mixed with an abusive history can result in an increased risk for suffering from depression."

There is a questionnaire (below) that people can take.

Excerpt
1. Before your 18th birthday, did a parent or other adult in the household often or very often swear at your, put you down, or humiliate you? OR act in a way that made you afraid that you might be physically hurt?

2. Before your 18th birthday, did a parent or other adult in the household often or very often push, grab, slap, or throw something at you? OR ever hit you so hard that you had marks or were injured?

3. Before your 18th birthday, did an adult or person at least five year older than you ever touch or fondle you or have you touch their body in a sexual way? OR attempt or actually have oral, anal, or vaginal intercourse with you?

4. Before your 18th birthday, did you often or very often feel that no one in your family loved you or thought you were important or special? OR your family didn’t look out for each other, feel close to each other, or support each other?

5. Before your 18th birthday, did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? OR your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Before your 18th birthday, was a biological parent ever lost to you through divorce, abandonment, or other reason?

7. Before your 18th birthday, was your mother or stepmother often or very often pushed, grabbed, slapped or had something thrown at her? OR sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? OR ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

8. Before your 18th birthday, did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

9. Before your 18th birthday, was a household member depressed or mentally ill, or did a household member attempt suicide?

10. Before your 18th birthday, did a household member go to prison?

"Elevated ACE scores have been shown to significantly increase the risk of alcoholism, chronic obstructive pulmonary disease (COPD), depression, fetal death, illicit drug use, ischemic heart disease (IHD), liver disease, risk for intimate partner violence, multiple sexual partners, sexually transmitted diseases, smoking, suicide attempts, unintended pregnancies, early initiation of smoking, early initiation of sexual activity, and adolescent pregnancy, according to the Centers for Disease Control and Prevention (CDC)."

Anyone else have kids who are struggling with depression? How are you dealing with the depression? Have you found anything helpful in your own healing, or in theirs, that you would be willing to share here?
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scraps66
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« Reply #1 on: April 17, 2015, 01:14:51 PM »

Thanks for posting this as I am dealing with this and an emotionally challenged S10 and how his significantly dysregulated mother has affected him.  This week he was suspended for several outbursts in one day including yelling at a lunch monitor, hitting a child because S10 claimed he was HIT playing tag (he was tagged, not hit, he doesn't know the difference), kicking, punching and yelling at teachers, principal, and guidance counselor.  Stomping on his aids foot.

In response, mother has casually notified school that she is concerned with the "cuts and scrapes" on S10s arms.  There ere two "marks" one of which was barely discernible.  The teachers had marks on themselves too.  She just won't get it.
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« Reply #2 on: April 17, 2015, 02:29:23 PM »

Do you worry that your son might be developing BPD? Or have a genetic predisposition toward it?

My son was diagnosed with ODD when he was 9, although it was literally weeks after we moved out, away from N/BPDx. We also discovered he needed glasses at the same time, and in the psycho-educational assessment, N/BPDx's scores indicated a lot more problems with our son's behavior than I believed to be true.

So challenging to try and sort this all out. I'm sorry you're having trouble with your S10. My son was the same way -- he could not tell the difference between what was really happening (like the tagging/hitting example you give -- that exact thing has happened to S13 when he was 9), and what was going on.
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« Reply #3 on: April 17, 2015, 06:03:39 PM »

My SS14 has had over half of the items happen to him.

He's emotionally immature, very introspective.  I don't see depression, but we do want to help him with his social anxiety.  However, I will mention this to his counselor as food for thought.  Poor kids, they've been through so much already.
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« Reply #4 on: April 17, 2015, 09:31:22 PM »

My SS14 has had over half of the items happen to him.

He's emotionally immature, very introspective.  I don't see depression, but we do want to help him with his social anxiety.  However, I will mention this to his counselor as food for thought.  Poor kids, they've been through so much already.

My son's T said that depression is one side of the coin, anxiety is the other. He doesn't see anxiety very often on its own, almost always there is depression there.

S13 also has social anxiety. I don't understand it, to be honest. Kids like him, he has a good sense of humor, is good looking, although a bit nerdy  Smiling (click to insert in post) and yet he is gripped with anxiety. He would rather hang out at home with me on the weekends, or spend time on the computer.
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« Reply #5 on: April 17, 2015, 10:28:07 PM »

My SS14 has had over half of the items happen to him.

He's emotionally immature, very introspective.  I don't see depression, but we do want to help him with his social anxiety.  However, I will mention this to his counselor as food for thought.  Poor kids, they've been through so much already.

My son's T said that depression is one side of the coin, anxiety is the other. He doesn't see anxiety very often on its own, almost always there is depression there.

S13 also has social anxiety. I don't understand it, to be honest. Kids like him, he has a good sense of humor, is good looking, although a bit nerdy  Smiling (click to insert in post) and yet he is gripped with anxiety. He would rather hang out at home with me on the weekends, or spend time on the computer.

Do you think he may being bullied in school? Kids can be like pack animals and pick up on things... .
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« Reply #6 on: April 18, 2015, 06:46:18 AM »

I've come to realize, uneducated guess, that my S10s outbursts are more or less outcroppings of anxiety.  This week was PSSA testing in PA and I believe that he had developed this coping skill of his outbursts getting him out of certain things that may be uncomfortable.  Days at school that are unstructured and/or out of the norm tend to be challenging.  Halloween is always a crap shoot. The chaos in the school the day of is tough for him.  This has been pretty consistent.  Surprise, has BP similar traits are not seen by his uBPD/NPD mother.  .She doesn't see the anxiety.

This week with him getting suspended, I'm now seeing the depression.  Sullen, reserved and despondent after spending a day with his grand parents.  Even his mother had a difficult time getting a reaction out of him as she pleaded for his acknowledgement while he sat in the car.  She repeated frantically, "Hi S10!  Hi S10!"

I believe the worst thing for these children, aside from being a witness to abuse, is the emotionally needy mother.  She preys on him constantly, puts him in her conflict subtly but certainly, and in so doing puts him in a constant of invalidation.

I can also see now there are tactile sensory issues.  Playing tag.  Whenever he is tagged he claims he is being hit.  This is also the case when I try to wrestle with him.  He almost immediately starts screaming and withdrawing claiming "it hurts."  So this along with all his other emotions is something that he doesn't know how to "feel."

And just like uBPD/NPD mother, Dr. Jekyl Mr. Hyde, he is fine 30 minutes post outburst.

   
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« Reply #7 on: April 18, 2015, 08:37:13 AM »

scrapps -- could the tactile stuff be sensory processing disorder? Sometimes called sensory integration dysfunction. If your son is ADHD or Asperger's, then there is a chance he struggles with SPD issues. My son has this, although it is mild and he is learning to cope with it. When my T suggested SPD, it was like unlocking a code. Suddenly all kinds of things suddenly made sense. For him, being touched without warning is very unsettling, almost shocks him. He experiences things as pain that don't seem painful. He won't wear long pants or underwear, no shirts with colors, no tags. Has a hard time with buttons, tying shoe laces. Do any of those sound familiar?

I've had to coach S13 to advocate for himself to deal with this stuff, otherwise he becomes emotionally overloaded. He sits near the door so he can get up first and leave, which helps him avoid being bumped and jostled.

Your theory about what makes your son act out sounds right -- if he is trying to manage other types of stress, and no one is listening to him or knows how to help him understand what's going on, and things around him feel chaotic, he will reach a boiling point and spill over. Sometimes I would pick my son up and he just seemed exhausted from trying to manage things all day, and that was in elementary school. When his T and I explained SPD to him, he seemed to feel relief, like someone understood what it was like for him.

I remember reading one book on SPD and the author made a connection with BPD as well. Wish I could remember which book. 

@Turkish -- S13 has friends and isn't being bullied. The guidance counselor did a covert investigation and even S13 confirmed that he just doesn't like being touched, and that it "feels like bullying." Mostly, I think he doesn't really know how to assert himself in a healthy way. He becomes aloof and guarded, and sort of self-isolates himself.
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« Reply #8 on: April 18, 2015, 12:22:58 PM »

S13 also has social anxiety. I don't understand it, to be honest. Kids like him, he has a good sense of humor, is good looking, although a bit nerdy  Smiling (click to insert in post) and yet he is gripped with anxiety. He would rather hang out at home with me on the weekends, or spend time on the computer.

You are describing my son too when he was younger (above).  He had an alcoholic dad and a mom that went into depression when he was in middle school.  I was able to mitigate his dad's shortcomings for a long time but the last 4 years of my marriage I was unable to function very well... .right when my son was entering puberty... .my timing could not have been worse.  His dad and I divorced the end of his sophomore year of High School.

My son is now 21 and feels stuck and frustrated because of his social anxiety and he has a naturally introverted personality.  He also struggles because he has no desire to "party" like most 21 year olds... .he wants nothing to do with alcohol.  So not only does he have social anxiety issues he is also outside the norm because of his personal choice is to stay away from the typical social scenes of kids his age. So he struggles with anxiety and depression. 

He just got started with therapy (3rd session today!) and is actively participating in helping himself... .I'm very proud of him.  Eating out is very difficult for him and he had an assignment to give it a try, with permission from his therapist to leave at anytime.  He picked a place where we get take out (so he knows and likes the food) but we ate in.  He picked a table in a corner were no one would "watch him eat" and got through his meal but decided to take dessert home with him. He has also set up an appointment to visit a Buddhist Center near us... .trying something new, investigating something he is interested in and a good place to meet new people.  So therapy where he can talk about things with a professional and my son's own desire are moving him forward.  I can't wait to see where it goes.
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« Reply #9 on: April 19, 2015, 03:36:21 AM »

scrapps -- could the tactile stuff be sensory processing disorder? Sometimes called sensory integration dysfunction. If your son is ADHD or Asperger's, then there is a chance he struggles with SPD issues. My son has this, although it is mild and he is learning to cope with it. When my T suggested SPD, it was like unlocking a code. Suddenly all kinds of things suddenly made sense. For him, being touched without warning is very unsettling, almost shocks him. He experiences things as pain that don't seem painful. He won't wear long pants or underwear, no shirts with colors, no tags. Has a hard time with buttons, tying shoe laces. Do any of those sound familiar?

Your theory about what makes your son act out sounds right -- if he is trying to manage other types of stress, and no one is listening to him or knows how to help him understand what's going on, and things around him feel chaotic, he will reach a boiling point and spill over. Sometimes I would pick my son up and he just seemed exhausted from trying to manage things all day, and that was in elementary school. When his T and I explained SPD to him, he seemed to feel relief, like someone understood what it was like for him.

This part is interesting. S10 was originally diagnosed with ODD.  Mother didn't "like" this diagnosis so went and got her own diagnosis, HFA/Asperger's.  She's held onto this diagnosis as "hers" and defends "her diagnosis." This week we are getting a re-evaluation for his wraparound services, he is currently diagnosed with "312.9 unspecified disruptive, impulse-control, and conduct disorder, r/o anxiety disorder."  Mother claims this is not "correct" and that he is on the spectrum.

My take, mother puts many of her own expectations on S10 that have him in a constant state of conflict.  She likes the Asperger's because it likely is more genetic than a result of the toxic environment she made around him when he was little.  So it sort of insulates her from any accountability of his behavior.  When in fact all of his behaviors have been modeled for him, by his mother.

Anyway, through all of this we have been told that ADHD is also a possibility. I try not to be hung up on the diagnoses but make sure that the observed behaviors are made known.  But, maybe I should be a little more hung up on the diagnoses from what's presented in this thread.
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« Reply #10 on: April 19, 2015, 08:41:28 AM »

Panda, I imagine it will be the same for my son, that he'll avoid partying as he gets older, and that will put him on the outside of social opportunities because he won't want to be around alcohol. Because he is so sensitive to food (due to the SPD, I am guessing), I cannot imagine he will like alcohol, not to mention the trauma he experienced having an alcoholic dad. My T encouraged me to have a beer every now and then, or glass of wine, in front of S13, to try and normalize the behavior. S13 was pretty upset, and every now and then he'll make a comment about me having beer in the fridge. T didn't want S13 to engage in black/white thinking about alcohol since it's such a big part of social life, and there are many people who can drink it sensibly.

Did your S seek out therapy on his own? Either way, whether at your insistence or not, that's a big deal that he would take care of himself and seek out a professional. There is a relatively new type of therapy -- metacognitive therapy -- that psychiatrists and psychologists are very excited about for treating anxiety. Apparently there have been three waves in the history of psychiatry, and "metacognitive" is this last wave. It is based on CBT and then therapists use mindfulness techniques and approaches on top. This is what my son is doing. From what I can gather, the point is to accept the anxious, depressed thoughts, and to not judge them, or try to control them. Instead, the point is to acknowledge them, and then move on, sticking with whatever the activity is. S13's therapist doesn't describe what he's doing with S13 because my son has a tendency to find fault with everything once he knows what it is or what it's called. S13 doesn't like solutions, he likes problems  

Scrapps, I went through a diagnosis war with my ex too. I think it's natural to be so mad at the other parent we don't even want to tolerate what they're suggesting. Not that her diagnosis is right. Just that it can be hard to hear anything coming from them when it has to do with the kids. When my son first got glasses, N/BPDx had a lot to offer and I ignored it all, and it turned out to all be insightful and accurate. I don't wear glasses, and let S13 pick out what he wanted, and $300 later, it was the wrong pair.  

I link ODD (my son was dx'd with this too) to severely impaired parent-child relationships. No doctor has ever said that, it's just my explanation.  Smiling (click to insert in post)

When I began my validation campaign with S13, a lot of those behaviors started to subside. When I discovered the SPD stuff, and began talking to S13 about it, that's when he finally felt truly understood, and saw that other kids were like him, that he wasn't the only one, someone was actually listening. I was flat out excited because so much of it fit.

S13 is learning to advocate for himself, which is hard -- he's not naturally a very assertive person. I got the school counselor involved, a great guy, and now a very intuitive psychiatrist, plus S13 is in social skills class. It's taking a whole village! I do see signs that things are changing.

Still, on Friday the power cord for his computer fried. The replacement won't be here until Tuesday at the earliest. He fell into a dark depression last night, just lying on his bed staring at the ceiling. Barely talking.  :'(  He doesn't want to get out of bed this morning, and when I offer up ideas about what we could do today, he shoots them all down.

I'm trying to be patient, hoping he will be able to work through this stuff with the support he has all around him  :'(

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« Reply #11 on: April 20, 2015, 11:31:38 AM »

www.aspergerexperts.com/go/the-sensory-funnel-why-some-fail-and-some-succeed/

This is a link my ex sent to me.  She is infatuated with the Asperger's diagnosis and will not waiver because it was HER diagnosis.  I won't have the timewasting argument with her and it is possible that children have pieces of lots of different diagnoses.  Heck the BP parents do!

On the other hand, in my case, the bit about the sensory issues and addressing those first to allow the child to be more open in addressing more complex issues I think is very valid for my S10.

I also agree with the above that "validating" is a very important thing for a child that spends any time around a BP parent.  Particularly where there is enmeshment and parentification as those children are caught having the unhealthy obligation of taking up the BP parents position and meeting expectations that may not be realistically achievable.  I see this in S10 all the time and he's programmed to appease his mother at all costs.   
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« Reply #12 on: April 20, 2015, 11:57:15 AM »

It sounds like with your ex, too, she is trying to win at the diagnosis game. Instead of working with you and the wraparound support to provide what he needs. Even with ASD, which I have heard is that it's so broad that it almost has more variety than the entire population of non-ASD people. So you have to approach treatment like a scientist to see what works, what doesn't work. The ASD guy who is talking in the link you shared confirms what has worked with my son. Just having someone recognize how painful it is for him to be touched -- that it feels like fight or flight -- that alone was a game changer. That kid desperately needed to learn that someone else knew what he was experiencing, believed him, and was willing to help him figure out better ways of managing the sensory overload.

My son is in a social skills class with three other kids, 2 are ASD. The sensory processing stuff is what connects them -- they all struggle with flooding in one way or another.

In elementary school, S13 nailed another kid in the chest with a pencil. My ex was working against me to try and get an IEP or 504, and that one act helped turn things around, as awful as it was. Fortunately, the other kid was wearing a heavy coat and his skin wasn't punctured. The school put together a whole system of support so that when S13 (9 at the time) felt his tank filling, he could go to the family specialist and cool down. He did that about 5-6 times. They also stopped insisting that he sit facing forward and let him sit in the back where he could wriggle, and one of his teachers let him wander in the back, as long as he didn't touch anything, and he had to agree to stop walking when she spoke his name. She realized he was paying attention to her every word. Being understood like that helped him manage.

A couple of times he hit overload in elementary school, and I would get a call. The first time, we left the school and walked and didn't even talk about what happened. After about 30 min of walking, he would just start talking about what was going on, and then I would suggest we go back and let them know he was ok, that he needed to decompress, and he had some ideas about what he could do next time he felt overwhelmed like that. No guilt, no shame, no punishment. He did have to talk to the family specialist and come up with some solutions for how he would handle things next time.

Even so, with these small gains, S13 still struggles with depression. I think it is very isolating to be managing all this sensory input in a school setting that isn't designed to help kids cope.

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« Reply #13 on: April 20, 2015, 06:21:43 PM »

Interesting conversation, I hadn't been back since Friday.

My DH and I went to SS14's counselor by ourselves on Saturday to make a game plan for the next phase of therapy.  We've dealt with the elephant in the room, his uBPDm, and the counselor let us know that he told her he had asserted some boundaries with his mom.  This, combined with a check of his phone and FB to confirm there hasn't been a lot of contact, encouraged us to start focusing on helping him with his social anxiety and social skills.  Not that we won't see things crop up, but right now he's doing well managing his relationship with her (she lives two states away).

The counselor had previously told us that SS14 presented as an abused child.  We've moved our way up to "just" neglected.  So that's positive.  When I mentioned that I originally thought he may be on the spectrum, she agreed that some of his behaviors do present that way, but more from neglect and not learning how to interact normally - given that he's the middle child, and introverted to begin with.  He's very bright, and does well at school - we see the "flooding" and subsequent "shut down" at home only.  Another positive, and we have learned how to approach him when this may be an issue, i.e. losing video game privileges.  Not that the world will learn how to deal with him, but he doesn't seem to have that problem with others - just the people he knows best and feels most comfortable around.

I also wonder now if there's some depression, even though it's not obvious, because he's lonely?  To that end, the counselor encouraged a social skills class (thanks for that idea and your follow up LnL!), along with some speech therapy and summer opportunities as a junior camp counselor or helper at Bible school for younger kids.  SS14 is immature and lacks confidence, so we hope that by helping with younger kids who will look up to him, he will gain more confidence in his own abilities.

I'm thankful that because he's the middle child, uBPDm hasn't focused her diagnostic talents on him.  That's reserved for his younger half sister - autistic and bipolar from what she tells him.  Sigh . . . that poor girl.

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« Reply #14 on: April 20, 2015, 08:31:39 PM »

Excerpt
Did your S seek out therapy on his own? Either way, whether at your insistence or not, that's a big deal that he would take care of himself and seek out a professional.



I think my son and I came to the conclusion that therapy would be helpful together.  He has talked about being lonely and sad for awhile.  I would suggest somethings then I wouldn't hear anything for awhile and then it would crop up again and I'd suggest something else and we went on this way for awhile but things remained the same.  After going around that merry-go-round a few times I realized he was truly stuck.  At the same time he was looking around the internet and found "social anxiety" and he felt this was his issue. 

I have an "Employee Assistance Program" at work that I can get 8 free therapy visits through so my son an I started looking for a therapist in our area that participated in my EAP, who also took our insurance so we could continue on if needed and someone my son was comfortable with.

My son tells me what he wants to about therapy so I'm getting pieces of information.  He took the Briggs-Meyer Personality Test, he's had some "assignments" that are nudging him out of his comfort zone and he says his situation is all my fault   I told him I'm sure some of it was my fault and I will work on my issues and he could work on his.  I'm not owning the guilt he's flinging but I will own my history and my actions.

His latest assignment is to do something that makes him standout and analyze the reactions of other people.  I thought this was a very good idea.  Pushes him not to hide under the radar but to interact with people and it puts his focus on them and not on what's going in his own head.

He's got a goal and is motivated so I am optimistic about his issues improving.
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« Reply #15 on: April 21, 2015, 01:16:38 PM »

This depression thing is hard to crack.

We've set things up with the psychiatrist so that S13 has the whole hour with him. If I need to talk to the T, then I make an appointment separately. I've made one for next Tuesday.

So S13 came out of his appointment yesterday and said, "Tell T about xyz story." It was a funny thing that happened when we were driving to the appointment, no big deal. I mentioned it to the T.

Then S13 said he was going down to the car. T and I are sitting in the waiting room together, so the T began talking. He said he and S13 are very in sync, the same sense of humor, get along well. He also said S13 is so guarded, and uses humor to deflect his attempts to get close and discuss things of importance. He said it's almost like S13 disassociates. He was concerned.

I knew I had a whole appointment next week with T, and didn't want to keep talking since it was almost 7pm and we had talked for a half hour. So that's where we left things.

But I feel ... . like maybe I am somehow responsible. Not guilty, but responsible. I use humor, and S13 and I joke around. Maybe because I am not sure how to handle the dark feelings S13 is experiencing? I went through the darkness and largely processed it out of sight of S13, and it was hairy. I grew up in a home where we never discussed our feelings, and don't even know what is appropriate. It's so strange being a tiny family of two, opposite genders. I have validation down pat, but I don't really know how to press gently on the sore spots. That's my takeaway from talking to the T, that S13 has sore spots and doesn't even know how to discuss them, or what they are. He just keeps skittering away, not understanding what's happening.

As a result he is a bit of an island emotionally. Such a great kid, so likeable, intelligent, all the things that helps a person get through life favorably, at least in somewhat superficial ways. He's so guarded, though. To the world, to people who like and love him, who care about him.

Maybe I am tiptoeing around him, I don't know.  :'(
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Breathe.
Panda39
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Gender: Female
What is your sexual orientation: Straight
Who in your life has "personality" issues: Romantic partner’s ex
Relationship status: SO and I have been together 9 years and have just moved in together this summer.
Posts: 3462



« Reply #16 on: April 21, 2015, 07:34:50 PM »

Excerpt
I grew up in a home where we never discussed our feelings, and don't even know what is appropriate. It's so strange being a tiny family of two, opposite genders. I have validation down pat, but I don't really know how to press gently on the sore spots. That's my takeaway from talking to the T, that S13 has sore spots and doesn't even know how to discuss them, or what they are. He just keeps skittering away, not understanding what's happening.

Have you asked the opinion of your SO?  I have found my SO has had some insights about boy-man stuff that I just didn't see. (Funny thing is my son has insight into my SO too). I'm not saying your SO needs to parent your son but he is an outside observer. 

My ex really didn't teach my son much about being a boy/man.  I suggested cub scouts, I taught my son to throw a football, taught him to drive, and helped him get his first job.  I have talked to him about dating and sex but I'm sure getting that information from a man "whose been there" would have been more helpful.  As much as I can teach him all those things I am still coming at it from a woman's/mom's perspective. 

Did the sex of your son's T play a part in your selection of him?  I was originally suggesting male therapists to my son but due to other factors he ended up choosing a woman.

The good thing is that you recognize that maybe you don't have all the answers and are seeking other perspectives giving you and your son additional approaches and options.
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