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|Saturday, December 7th, 2013|
And this is not a meme post, and it is still 1 AM and I should be in bed, but I have to write this anyway because I just finished Ancillary Justice
today and if I do not publicly recommend it RIGHT AWAY then I am going to spend all my time for the next week buttonholing people and recommending it to them individually. To be fair I will probably do that anyway, but at least this way I can pretend that I'm lessening the impulse by getting it out here first.
So the narrator and protagonist of Ancillary Justice
is Justice of Toren,
a warship of the Radchaai empire. Justice of Toren
consists of a vast artifical intelligence deployed across hundreds of ancillary units. She's stationed at Ors, officially the last planet that will ever be annexed by the empire, which is changing A LOT of its policies lately - and Justice of Toren
and Lieutenant Awn, one of her favorite officers, are about to get caught in the crossfire of that.
Twenty years later, all that's left of Justice of Toren
is the unit One Esk Nineteen. Instead of a vast linked consciousness, she has a single human body. Instead of her favorite lieutenant, she has a confused and unpleasant time-displaced drug addict she found dying in the snow, who coincidentally used to be one of her least
favorite lieutenants before a wacky twist of fate sent said unpleasant lieutenant into a suspended animation pod for a thousand years. And instead of a calm sureness of purpose and commands to follow, she has a seething anger the size of -- well, a spaceship -- and a very strong need to make a choice, the kind of choice that will matter.
If you've seen this book recced before, you have probably seen people talk about how it does things with gender and language and class and colonialism thoughtfully and well, and all of this is one hundred percent true. PLEASE READ IT FOR ALL THOSE THINGS.
You may also have seen qian
's post about the amazing id factor
of SPACESHIP WITH FEELINGS. I agree, but I would like to add what is to me a really important extra id factor, which is that she is a REALLY JUDGY spaceship with JUDGY feelings. This delights my heart and soul! I love every single conversation along these lines:
ONE ESK: *makes mild comment*
OTHER PERSON: oh no u mad
ONE ESK: ...I am very sure my face did not make an expression of any kind
OTHER PERSON: no, but still, you're JUDGING ME! I can tell!
Actually, this may seem like a strange comparison, but there are ways in which One Esk reminds me of Anthy Himemiya. Partly this is because of the way people treat her when she's a ship. Partly it is the passive aggression and the divided loyalties and the calm, simmering resentment. OF COURSE I LOVE HER.
And I love, too, that is not striving for humanity, this is not that kind of story; there are many things she's striving for, but humanity is not one of them. Late in the book, various people try to convince her that she is human, and she's like "...no...you have a fundamental misunderstanding of me..." WHICH IS ALSO GREAT. It is not necessary to be human to have feelings or agency!( People who have read the book already, click here!Collapse )This entry is cross-posted at Livejournal from http://skygiants.dreamwidth.org/352931.html. Please feel free to comment here or there! There are currently comments on Dreamwidth.
So technically I am an hour late on rymenhild
's December meme request
to fanwank Kage Baker's Company novels in such a way as to preserve the awesome and jettison the OMGWTFBBQ, but given that I went straight from work to a six-hour car ride to DC I hope I will be forgiven!
Okay, so the Company novels. What you need to understand about the Company books is that I discovered the first book, In the Garden of Iden
, probably about a year after it was published in 1997. I was thirteen and fell head over heels for Mendoza, misanthropic teen cyborg botanist in Elizabeth England, and her doomed and tragic romance with a brilliant heretic, and her equally doomed and tragic semi-father-daughter-relationship with the cyborg who created her, and Kage Baker's dark and hilarious blend of incredibly well-researched historical fiction and deeply cynical science fiction dystopia populated with SO MANY SAD FASCINATING CYBORGS. I devoured each new book as it came out! I fell in love with every single side character introduced! I was more than happy to let Kage Baker spend forty pages describing a bunch of cyborgs MST3K-ing D.W. Griffith's Intolerance
; that kind of thing was EXACTLY WHAT I WAS HERE FOR.
In fact, it is not an exaggeration to say that Kage Baker and her massive nerdouts about film history are a significant part of the reason why I am right now a moving image archivist. I referenced these books in my entrance essay to grad school -- and to be clear, this was after
the last couple books came out; I was at that point under no illusions. But there is no way for me to shake how important the Company books are to me and how many feelings I am ALWAYS GOING TO HAVE ABOUT THEM.
But . . . the last couple books. Oh, the disappointing and quite frankly horrifying aspects of the last couple books.
OH, MY OVERPOWERING DESIRE TO FEED EDWARD ALTON BELL-FAIRFAX, VICTORIAN DOUCHEBAG, TO THE CROCODILES.
So how would I
fanwank fix the series? Well, I could write out a detailed and thoughtful treatment that took into account all the threads of the plot, but that would probably require me to reread the last book, which to be honest I have mostly blocked out of my mind except for everything involving Lewis and Princess Tiana Parakeet and immortal cyborg William Randolph Hearst. So right now, at 1 AM after a very long car ride, my diagnosis is pretty simple:
- MENDOZA FEEDS EDWARD ALTON BELL-FAIRFAX, VICTORIAN DOUCHEBAG, TO THE CROCODILES ROUND ABOUT THE MACHINE'S CHILD
, AND EVERYTHING IS BETTER
(And then think of all the things a Mendoza liberated from the awful warping factor of Edward Alton Bell-Fairfax could do! She could go rekindle her friendship with Nan! She could plot revolution with Latif and Suleyman! She could sort out her relationship with Joseph! Hell, she could go hang out and shoot the breeze with Juan Bautista and his thirty pet birds and THAT WOULD MAKE FOR AN INFINITELY BETTER AND MORE REWARDING STORY than any plotline she had in the last two books.)This entry is cross-posted at Livejournal from http://skygiants.dreamwidth.org/352632.html. Please feel free to comment here or there! There are currently comments on Dreamwidth.
|Friday, December 6th, 2013|
Spent thirty minutes in a fruitless google trying to discover when the desu-masu verb form ending began in spoken Japanese. Then spent another thirty minutes reading a fascinating if frustrating text version of An Historical Grammar of Japanese. (Fascinating because it's the classical stuff I learned twenty-five years ago and never got straight even then; frustrating because text versions don't reproduce kanji.) If Edo yakuza speech in Mito Komon is at all historically accurate, which one doubts, then -masu starts pretty early on. Maybe by Bakumatsu it might be as it is today.
But I *still* don't think, Mr Gibson, that one would effect an introduction in the 1850s in exactly the same language one would use a hundred and fifty years later. It feels nowhere near polite enough, though I'm damned if I know what you'd say instead. That super-polite level that I only heard now and again, from older women talking about CEOs, maybe. Or maybe it's a level that disappeared with the war and I've never heard it at all.
|Helping Andi pack
My friend Andi (WINOLJ/DW) is moving in about a week, and has asked for friends to help pack. I figured hey, this would be useful and I'd get to spend some time with her, so I emailed her. After some back-and-forth about schedules and such, we agreed on this morning.
I got to Andi's (current) apartment a little before ten, and we talked in between her taking necessary phone calls. It turns out the sudoku app I downloaded a few days ago is handy for that sort of situation, because it's distracting and 100% interruptable: unlike a book, I'm not tempted to finish my paragraph, or worried about losing the thread. So we talked, about the move and the rest of our lives and random other stuff, and eventually I realized that I was overdue for lunch. Around then, Andi's friend Astrid called, and Andi said yes, please come over, we're having a lot of fun here but not actually getting anything done. So the two of us went to a pho place for lunch, and Astrid met us afterward, and proceeded to demonstrate her packing and carrying skills. I did some useful stuff, wrapping some tchotchkes and putting books in boxes and stuff, and Andi put things into categories: what to keep and what to sell or donate, and then the "keep" is classified by whether it will be needed the night she moves in, sometime relatively soon, or enough into the future that it can go into a storage unit.
Andi and I both ran out of steam a little after four, and I headed for the bus. The trip home was pretty straightforward, but also another example of my suspicion that a lot of people in this area don't know how to ride a bus. Specifically, they won't move to the back to make room as more people board, even if the driver asks. (This means that I have a good chance of a seat on a crowded 358 because people are too busy clumping in front to notice that the space in back includes available seats.)
I will call that a productive day, though I suspect not much practical would have happened without Astrid's involvement.
Cross-posted from Dreamwidth (http://redbird.dreamwidth.org/1409678.html
), where there are
comments. I welcome comments here or there (OpenID and "anonymous" are fine if you don't have a DW account).
We Will All Go Down Together: A Novel in Stories About the Five-Family Coven
is, officially, done. First draft, obviously; 176,000 words plus, rounded down. 37,000 of which, it turns out, is "Helpless." That's what happens when you set every character you have on a collision course, I guess. Anyhow, 'tis done.
Now comes the truly fun part, for which I'm really glad to have help--reformatting, looking at where best to cut, trying to figure out if the Scot/Fae accents slip far too much from story to story, etcetera. I think this thing is gonna be a serious beast in terms of continuity, but at this point, I don't much care; I stayed up all night getting its ass kicked, so I'm going to bed early, and I'm going to sleep as long as possible. Tomorrow I have choir dress rehearsal, then Cal's music lesson, then putting up the tree; Sunday is the choir's Winter Show, after which I must plunge head-first into a bunch of other shit: introductions, essays, two potential short stories, two blurbs. My heart will go on.
Okay, then. One extremely lady-heavy book, off the pile. One to go, starting January.
Falling over.This entry was originally posted at http://handful-ofdust.dreamwidth.org/513198.html. Please comment either here or there using OpenID.
|I could not love thee, Alley Cat, so much, loved I not Borderlands more...
Mmm, 24th St. Butchers and groceries and bookshops and coffeeshops and taquerias, hipsters and Hispanics all shuffled in together; and then Valencia, which - let's be honest - is pretty much hipster all the way, organic froyo and single-gear cycleshops. And now I'm in Borderlands, which is more or less home to me; I have my table in the window, and I'm set for the afternoon.
If I had my druthers, I would so live in the Mission.
Tragically, I am in fact drutherless in this regard, for want of a million dollars or so. Hey-ho. But I'm here now, which is niceness enough; and I'm meeting m'wife later and we're going for dinner with friends; and meantime I am not short of work to do, nor of the impetus to do it.
I have decided to declare this PeBoFiPe, or Pebofipe for easier typing: which as any fule will recognise must stand for Personal Book(s) Finishing Period. Far be it from me to call on the rest of any nation to get its act together and see stuff done; this applies strictly to my own self and none other. Before Xmas, I want to have my two currently contracted books settled and gone (that's Story Road
, the collection of short stories for Lethe Press, and Being Small
, the novel(la) for Per Aspera). And then comes the new year, and the drive to see Kipling finished with Mars. He's an old man; he needs to get home and see Carrie...
Finished with regular classes at Avery Point: the rule is that you have to have a meeting when your final exam is scheduled--for me that's Friday the 13th--but they don't have to write the exam in the 2-hour time. So I gave out the question weeks ago, and handed out the exhaustive (and exhausting) instructions at Thursday's last class meeting. I included everything except "And don't put beans in your ears!" (so I guess I should be expecting some students on 13 December who can't hear me because of the beans in their ears). At the official exam time, I've scheduled a free-for-all discussion and a party. Those who participate in the discussion get extra class participation credit. Those who don't, don't--no penalty. Of course, I know what will happen: those who already have "A" class participation grades will be brilliant. Those who could use the extra credit will not volunteer. But I'm really looking forward to the experience. Not sure what their favorite treats would be, so I'll bring a range.
I'm already scheduled to teach the same Brit Lit I class next Fall semester. I even have my days and times. I'm hoping that the word of mouth will be good and won't scare off potential students.
|To Do: School: DONE!
Sort of. I still have a paper and a half left to write. And I won't officially graduate (and so have to continue paying fees) for another six months, during which I have to attend one hour every other week of case discussion, due to the traineeship situation.
But in terms of classes, as of yesterday at 10:00 PM, I am officially DONE!Crossposted to http://rachelmanija.dreamwidth.org/1126700.html. Comment here or there.
I am considering dividing the story I thought could be contained by a single novel, Cherry Bomb
over two novels. I'm two thirds through the latter, and it's becoming obvious it's a much bigger story. If I do this, if my publisher is agreeable, it would add a fourth
Quinn novel, Ruby Red
. It would have to be written after Dinosaurs of Mars
, The Good, The Bad, and the Bird
(the next Dancy series), and at least the first half of Beneath the Wide Carnivorous Sky
I have a phone conference with my editor at Penguin on Monday to discuss this, and I should be able to tell you more Monday evening or Tuesday.
Aunt Beast Current Mood: okay
Work is being really full. Really really full, to the extent that neither the Real Science project, nor the major project I inherited in spring and really don't like, have had much of my time over the past couple of weeks, because urgent things keep cropping up and taking a day or half a day to be dealt with. At least I appear to have headed off one of my colleagues' "why don't you rename everything through the whole database to make this thing of mine slightly easier" bright idea without starting an argument. We have a Real Science result which may be interestingly significant or may just represent some circular logic hidden in the conceptualisation, which is a recurrent fear with working on this level of abstraction.marylace
's visit continues lots of fun. We had belated birthday dinner for papersky
in Reuben's on Tuesday with Z and A, I got to share a hot spinach and cheese dip and a mushroom skillet and that was lovely, played Apples to Apples some with cyberneticnomad
and E Wednesday which was good for a more tired than usual rysmiel
(I slept poorly the previous night due to being anxious about being late for a supposedly important early morning meeting) and had dinner in Azuma yesterday evening with alixsin
which was as usual utterly excellent. Also I have done about half of my Christmas cards. Had an odd bad mood early yesterday, combination of feeling surrounded with stuff to do and fear that there's other stuff I should be doing if I knew what it was and I really should know what it is, but the soothing atmosphere of Azuma and the good company helped that lift pretty much entirely. Planning to write tonight should also help lift the feeling surrounded by stuff to do.
We have only 5 eggs left! I shall have to bake judiciously!
(I won't do anything that requires me to separate eggs, because I don't want to mess anything up by accidentally breaking a yolk.)You can comment here or at the Dreamwidth crosspost. comments at Dreamwidth.
|"Alone in the darkness, darkness of light."
Rainy today, but still warmish.
Yesterday, I finished the
fourth chapter of Cherry Bomb
. I wish there were anything at all interesting to say about writing the 1,332 words I wrote yesterday.
Indeed, I'm fairly certain that, other than marking the completion of a chapter of a novel I'm very grateful to be more than half done with, there's no particular need for an entry today.
Sixes and Sevens,
Aunt Beast Current Mood: blah
We're snowed in! :D
And here is a small flock of juncoes (I counted 5 at one point, although only 2 are visible here) that's hopping around beneath the bird feeder. When I get dressed, I'm going to refill the feeder and scatter some seed on the ground for them.You can comment here or at the Dreamwidth crosspost. comments at Dreamwidth.
I've always suspected that when people say that they hate the shaky cam in The Hunger Games
, part of what they mean isn't shaky-cam shots, but the editing. Because the editing of The Hunger Games
. Cuts come a little sooner or a little later than you expect. You get wide landscape shots when you expect close-ups. The rhythm is odd, off-kilter. Things feel disjunctive, disorienting. It feels like Katniss's stride, long but careful; like her wary hunter's attention, her broad background awareness and abrupt microfocus. It feels like the entire movie is made to the rhythm of Katniss ducking through a rip in a chain-link fence. Arguably, movies are always made to the rhythm of human breath, but most movies are made to the breathing of a person at rest, or in conversation, or in a sprint. The Hunger Games
is made to the rhythm of a cross-country runner, the finish line nowhere in sight; a runner breathing extra deep but not extra fast, clear-headed.
It makes the movie feel odd. Isolated, internal, personal.
I miss that in Catching Fire
. This isn't to say that I dislike Catching Fire
, because I like it a lot. But the editing is more standard, more commercial; invisible, because what you're used to is invisible. And it's not bad
. (Clearly, a lot of people think it is, in fact, better.) But it's less weird, and I miss the weirdness.
|Mandela and Xanana
Among the many good things Mandela did, he advocated for the release of Timorese freedom-fighter Xanana Gusmão from prison:
Mandela not only called for the release of Xanana Gusmao, but also insisted on meeting with the latter – and got his way […] Soeharto at first refused Mandela’s request to meet Xanana with the question ‘Why do you want to meet him? He is only a common criminal.’ When Mandela responded by saying ‘that is exactly what they said about me for 25 years,’ Soeharto promptly and magnanimously responded by arranging for Xanana to be brought from prison to the State Guest House for an intimate dinner with Mandela.
--Jamsheed Marker, East Timor: A Memoir of the Negotiations for Independence, quoted in Aboeprijadi Santoso, “Mandela, Indonesia and the liberation of Timor Leste,” Jakarta Post, 22 July 2013
|Thursday, December 5th, 2013|
|A lecture by Zadie Smith: Why Write?
Zadie Smith (author of White Teeth
and other novels) gave a guest lecture today at the nearby university, and she said some extremely gratifying things—gratifying because they're things I feel but don't hear said much, about writing. The thing I underlined and circled most enthusiastically in my notes was this:
Writing lets you have the one thing that society offers in theory and obliterates in practice: self-determination. When I write, I escape [hard-and-fast roles as wife, mother, teacher, writer, black woman, British citizen]. My solid self disperses. I can be everyone in fiction. Writing is a de-selfing activity.
I can be everyone, in fiction. That
is a huge part of why I write. To live these other, different lives. I don’t think of it so much as a de-selfing activity but more as a way of discovering or expressing other selves, but maybe that’s just because I’m borglike in the number of other lives and selves I’d like to incorporate into me.
She also talked about writing as a craft, of being an artisan, of thinking of it like chairmaking. She said writing is saying, “I saw this thing—can I make you see it?”( She said. . . Collapse )
It was a wonderful talk.
|Year’s Best SF 18, edited by David Hartwell
Review copy provided by Tor.
This was a really solid Year’s Best collection. Of course there were stories in it I didn’t finish, or didn’t bother to reread, because that happens in pretty much every anthology ever: part of the point of anthologies is that not everything has to be to everybody’s taste for it to be worth the time and paper. But there were far fewer of that type of story than average, and more stories that I felt were worth mentioning in the good way.
I sometimes find Gene Wolfe’s characters frustratingly vague and distant. “Dormanna” is an exception, and it manages to have a child protagonist without being a teddy bear killing story. I like imaginary friends, that may be part of it. I also like complex friends, part real and part imaginary, and I think the titular Dormanna qualifies.
I am a sucker for alien stories, and Eleanor Arnason’s “Holmes Sherlock: A Hwarhath Mystery” is no exception, even though I am generally not a sucker for Holmesiana. But this isn’t Holmesiana, or at least not as I have encountered its worst excesses. Holmes is not a character in this story, but rather a character in stories read by the protagonist of this story. I love alien-perspective stories, and every time I encounter the Hwarhath, I think, “Oh yes, I like them, I should go find more of these.”
I can see where Naomi Kritzer’s “Liberty’s Daughter” would appeal to a very broad spectrum of SF readers, because it’s very like a lot of the SF people who are writing now read as teenagers, but with…how do I say this politely…it’s not with 75% less assholery. It’s with instances of assholery recognized and tagged as such, within the spectrum of human behavior. The seasteads are exactly the kind of varied extrapolative near future cultures I want to see more of in fiction.
In “Waves,” Ken Liu took a conflict that could easily have filled another SF short story and portrayed its outcome (I won’t say resolution) in a few pages, moving on to more and greater extrapolations across time, space, species, and family. One of my favorite of Liu’s so far, he portrays different gigantic life choices, and how they can separate–and reunite–family members.
Finally, “The North Revena Ladies Literary Society” by Catherine H. Shaffer is probably the least overtly SF of my favorite stories of this volume. It’s a spy action story that does SFnal things, but the SF aspects of them come in later. I just wrote out what it could be a crossover of and then realized that my analogy would be a spoiler for the story, so instead: SF spy ladies, hurrah!
| For the 5th on the December meme
asked me to write about placentas.
Here is what you need to know about placentas: one time three or four years ago Shati came to visit me. The plan was to spend the whole weekend watching Ugly Betty.
Instead we spent about 20% of the weekend watching Ugly Betty
, 30% of the weekend detailing elaborate and implausible crossovers between Angel
and Ugly Betty
(I can't remember how any of them went but THEY WERE GREAT and way better than Angel
sans Ugly Betty
crossover), 10% of the weekend drinking margaritas, and 40% of the weekend shrieking incomprehensible bad jokes about placentas. The reasons for this are lost in the sands of time. What are placentas? We just don't know. (We do, actually, know. But Shati refuses to believe that we do.)This entry is cross-posted at Livejournal from http://skygiants.dreamwidth.org/352499.html. Please feel free to comment here or there! There are currently comments on Dreamwidth.
|The day's work
The bulk of today, and the half of yesterday too, I spent fixing up an OCR'd scan of an old story, for the collection incipient from Lethe Press. Only 8.5K words, and yes: I could have typed it clean in half the time, given the mess it was. But scanned it we had, and fix it I was going to, and so I did. With occasional, inevitable tweaks: theoretically I might well believe that stories should be reprinted as they originally appeared, to speak to the author-of-the-moment rather than being revised to speak to the author-of-now; in actuality, I can't help fiddling. Just a little, just a semicolon elided into a full stop here, a comma smitten there. The occasional twitch of a word, or the balance of a sentence; almost all to do with sound and rhythm, almost never meaning. I think that's legit.
What's interesting, though, is what endures. The scan muddled so much so deeply that I had to keep referring back to the original for words, for runs of words, for whole missing phrases; the story was written long enough ago that I barely remembered the shape of it, certainly none of the language; and yet most of those gaps I could have filled in without recourse to the printed copy, and got them right almost every time. Voice is inherent, I guess. If I start a sentence thuswise, more likely than not it's going to wind hereabouts and end up over there. Much is implicit, and much is common; much is apparently inevitable. Who knew?
|What's a good med for ADHD?
A non-clinical colleague asked me that recently, “What are some good meds for ADHD?” Her child was taking one and had some improvement in symptoms but also some side effects. She was wondering if they should consider a switch.
I answered, “They’re all good. And they’re all lousy.”
That isn’t quite true. There are some less-good medications out there, or that used to be out there. I wouldn’t prescribe Cylert, for example. It worked for ADHD OK but it also caused liver damage. I think it’s off the market now so I couldn’t prescribe it even if I wanted to. I can still name my two students from the late 90s who took Cylert. It came up recently in a talk I attended about pharmacology, much to my surprise. And there are some medications out there that are occasionally used for ADHD that are less-good for ADHD than the ones typically used, such as Wellbutrin and the ‘triptyline family. That’s why they are only used occasionally, when all else has failed or when everything else is contraindicated for some reason. There are also poor medication decisions. I’ve seen children who can’t swallow pills prescribed medications that must be swallowed whole, or prescribed halves of medications that can’t be swallowed whole.
But overall, the medications which are on-label for use with ADHD are well studied, are effective against placebo in sufficiently large studies, and are safe for use in recommended dosages.
There are a lot of medications out there approved for ADHD. There’s the methylphenidate family, which includes, Ritalin and its generic methylphenidate, Concerta, Metadate and Ritalin LA, which are long-acting preparations, Daytrana, which is methylphenidate in a skin patch, Methyln and Quillivant, which are short and long-acting liquid preparations respectively, and Focalin (regular and XR) which is basically a right handed Ritalin molecule, on the somewhat substantiated theory that right handed Ritalin causes all the improvement and left handed Ritalin causes all the side effects. Then there’s the amphetamine family, which includes Adderall and its generic, mixed amphetamine salts, both of which come in short and long acting forms, Dexedrine, in long and short acting forms, which is the right handed half of the mixed salts, and Vyvanse, which converts to a long-acting Adderall in the body. There are also two blood pressure medicines approved for ADHD, either alone or in conjunction with a stimulant, guanfacine and clonidine, that mainly help with hyperactivity and impulsivity rather than focus. Guanfacine comes in short acting and long acting versions called Tenex and Intuniv. Clonidine comes in a short acting generic, long acting Kapvay, and a skin patch. And last, there’s Strattera, a non-stimulant which is built a lot like an antidepressant or antianxiety molecule, and mainly works on inattentive ADHD.
I’ve prescribed all of them except Methlyn and Quillivant, and I’ve only prescribed Kapvay once, too recently to have feedback.
With that exception, there is no medication for ADHD that I have prescribed that hasn’t worked for some of my patients. This includes kids with just ADHD, kids with ADHD and anxiety, kids with ADHD and autism, kids with hyperkinesis and developmental delays and other kids who have symptoms of hyperactivity, impulsivity or inattention. I have kids who are no longer being sent regularly to the principal’s office or being suspended. I have kids who are no longer hitting on the playground. I have kids who were able to return to aftercare, or resume speech or occupational therapy. I have kids who are able to go to regular ed classrooms for part of the day who couldn’t before due to behavior. I have kids whose therapists asked their mother “did you give him smart pills this morning?” before being told anything had changed. I have kids who sat and watched a movie for 30 minutes, which is 6x longer than they previously would sit and watch a movie. I have kids whose grades went from Fs to Bs. I have kids whose parents greet my “how did the [whatever] go?” question with “We love it!”
There are also a lot of kids who have had more subtle improvement, but who report better focus in class, whose parents and teachers report some improved attention or reduced impulsivity. Kids who no longer get badly side tracked getting dressed in the morning. Kids who don’t struggle with homework for nearly as long.
However, there is no medication for ADHD that I have prescribed for which I have not seen a child have a spectacularly poor response. I’ve had kids who never hit before take one dose and smack their teacher. This includes kids on Tenex, which isn’t reported to do such things, as well as Ritalin, which is. I’ve had kids get so sleepy they called the on-call doctor and needed a blood pressure check. I’ve had kids get way too sad, withdrawn, hide under the tables. I’ve had kids get much more anxious and bite the skin around their nails or pick at their arms. I’ve had kids get significantly more hyper. One mother descriptively told me the medicine “Vice Versa-ed.” These reactions are more likely in kids who also have autism or other brain differences, but I have seen them in otherwise typically developing kids with ADHD as well.
There are also kids who have had less striking side effects that still led to discontinuation, such as poor appetite, whinyness, sleepiness, sadness or stomachaches. And there are some kids who didn’t seem to show any improvement after increasing to the maximum recommended dose.
So they’re all good. And they’re all lousy.
And having a bad side effect to a medication, even a really really bad side effect to a medication, doesn’t mean the medication is bad, objectively, or even that the medication had been a bad choice for that particular patient in the first place.
Someday, perhaps someday soon, we will likely have a blood test that can predict who would do well with what medication. There are studies already looking for biomarkers that seem to correlate with response to stimulants, antidepressants, atypical antipsychotics.
But right now, the best we have when making a decision are our studies, the FDA approval list, insurance coverage, family preference and clinical judgment. In other words, informed, joint decision making and a best guess.
There are reasons to start with an alpha agonist, clonidine or guanfacine. The side effect profile is reassuring. Some feel they are less likely to cause side effects in children who are younger, and/or autistic. They may be less likely to worsen mood or behavior, although I’ve had more patients than would be expected start Tenex and start hitting. They can be used in the afternoon without affecting sleep, for kids who are just as hyperactive and impulsive after school as they were in school. They can even be given at night, in slightly higher doses, to help with sleep in children with sleep problems, so we can sometimes get away with one medication instead of two. They are less likely to increase heart rate or blood pressure, in children with known heart problems. There isn’t abuse potential, for children living in a household where there may be a high risk of diversion of a stimulant. They can be called-in, and written for 3 months at a time. There is less need for lunch-time dosing at school, although that is less of a concern now with the advent of long-acting stimulants. They also don’t have the bad reputation that sometimes comes along with Ritalin. Sometimes I use Tenex as a “starter medication,” knowing that a stimulant is likely in the future but hoping to buy a year or so of brain development so the stimulant is more likely to work.
There are even a few times I’ve started with Strattera. For an older kid who is mostly inattentive and has some anxiety, and who has symptoms at home as well as school, it makes sense to try a once-daily medication that gives 24 hour coverage. Sometimes it's worked.
Mostly, I start with a stimulant. They are better studied, over decades in some cases. They work better, when they work, especially on focus. They are less likely to cause sleepiness. They work quickly. They can be taken some days and not other days, for example not taken on weekends, without the risk of withdrawal or rebound symptoms if a dose is missed.
And usually the stimulant I try first is methylphenidate, absent compelling reasons to the contrary. Compelling reasons to the contrary include, but are not limited to, insurance coverage, attending telling me otherwise, parent requesting not to use “Ritalin” for whatever reason, or a close relative with a history of doing poorly on a methylphenidate product and well on an amphetamine product. We don’t have that blood test yet, but there does seem to be some medical folklore to support this practice. I routinely use short acting Ritalin in younger kids, longer acting Concerta in older kids who can swallow pills whole, a longer acting Ritalin that can be opened up and sprinkled onto food in older kids who can’t swallow pills. Sometimes I start with Focalin in an anxious kid, since Focalin isn’t supposed to make anxiety worse, even though it sometimes does.
And I give my new-medication spiel. I give administration directions that Strattera, Intuniv, Kapvay and Concerta HAVE to be swallowed whole and can’t be cut in half or crushed. I recommend giving the first dose on a weekend rather than a school day, even if ultimately the family is not going to use the medication on weekends. I give titration directions for starting at a low dose, often so low that my psychiatrist colleagues would call homeopathic, and increasing over the next few weeks. I explain the state and federal laws about stimulants, so that I can’t call in a prescription if they run out, and about watching appetite. I reassure that the media coverage of dangerous heart symptoms were found to not be a risk in large studies of children without heart problems or family history of certain heart problems. We make plans to bring the child back for a weight and blood pressure check. I explain about the risk of rebound hypertension if an alpha agonist is stopped suddenly, and warn about daytime sleepiness. We make plans to bring the child back for a blood pressure check. I talk about side effects of stomachache for Strattera, as well as the rare but dangerous liver damage symptoms, and make plans for a recheck. Strattera rechecks are usually 6-8 weeks out, rather than a month out, because it can take time to build up levels and take effect.
And then, whatever the medication, I tell them, “any medicine that can affect the brain in ways we like has the potential to affect the brain in ways we don’t like.” There may be an increase in aggression or anxiety, exactly the symptoms we are trying to avoid. If that’s the case, try giving it a few days because anyone can have one bad day. But if, even after one dose, you are thinking, “that’s not my kid,” stop the medicine and call us. I’m not expecting a bad reaction, but they do happen and I want my families to call me if they do, rather than either stop the medication or keep giving it and not let us know until the follow-up visit. Because sometimes the kid who went bezerk on Ritalin would do great if I mail them a substitute prescription for Adderall instead. Having a bad response means you had bad luck, not a bad med.
A psychiatrist I know tells families that they will run out of patience before she runs out of meds.
Because they all work, often enough to get through the studies, and often enough for us to have positive clinical experiences.
They’re all good. And they’re all lousy.
Is that why we call it practicing medicine?
I'm sort of hoping for a snow day* tomorrow because I've got a pantry full of baking ingredients that need to be used. And I'm signed up for the Metafilter Cookie Exchange so I'll have three people to send cookies to.
* Make that "ice day" as it's North Texas and we tend to get ice storms instead of snow shutting down workplaces.You can comment here or at the Dreamwidth crosspost. comments at Dreamwidth.
|The exposition must flow
I finished reading Dune
today. I've never been sorrier I committed time to a book. Holy smokes, that was the most boring novel I've ever made myself sit through. I had such high hopes! So many people whose opinions I respect love Dune
. All I can think is that the movie is more entertaining than the book, and they've merged the two in their imaginations. What the hell do people see in Dune
that's made it a classic? Many a time before, I'd started to read it and bogged down near the end of Part 1 because the only interesting things (the gom jabbar, the death of Duke Leto) were over, and now it was all a bunch of stuffy people spouting exposition about what-all had happened and might happen later. This time around, I plowed on in hopes it would get better, but it's. all. like. that. Everybody speculates and rambles a lot, and Paul Atreides is smug.
Serious question, I will listen if anyone wants to tell me the answer: what makes people enjoy Dune
? I thought, if nothing else, I'd like the villains, but Baron Harkonnen is wasted on the plot. He sits around and twirls his mustaches and essentially goes, "Hee hee, ain't I rotten?" through 300+ pages. In the denouement, there were a few moments I liked. Creepy child Alia spends two pages onstage and is the most memorable character in the book. But it wasn't enough to justify a big thick book.