April 30, 2009


When I applied to medical school, I kept getting asked the same bunch of interview questions. One of them was what I might do if I didn't become a doctor. My usual response was that I'd like to be a kindergarten teacher. Mostly, I was told that this was not a response they usually heard. The interviewers heard a lot, they told me, of applicants saying that they would become research scientists and selfless public health workers. I, on the other hand, thought it would be fun to play circle games. I got in despite this—or maybe because of it. I have great respect for teachers, and appreciate the work they do.

So when Henry came into my office because of a problem noted by his kindergarten teacher, I took it seriously. His mother said that she was told he had pinkeye, which was well known to be extremely contagious, and he would not be permitted back to school until it was better.

Pink Eye is a disease which can only be diagnosed by kindergarten and preschool teachers. It does not appear in the index of, for example, The Manual of Ocular Diagnosis and Therapy (6th edition).

There are many reasons an eye could be red. Eye infections of all kinds can make an eye red. Though this is often called conjunctivitis, there are many different types of infection that can make an eye look red. Mostly, we get these infections from touching our eyes with our hands. It’s a natural thing to do and trying to keep kids from rubbing their eyes is not a worthwhile or achievable goal. Our tears wash over our eyes continuously, rinsing away bacteria and dust from the air. The tear ducts drain into the nose, which is why people blow their nose when they’re crying.

In babies, these tiny tear ducts can get blocked. They are so small that the twists and turns they take on their way to the nose just don’t allow the free flow of tears. When they back up, the dust particles and dead cells and bacteria will clump up and make for a goopy eye. Usually, a clean moist cloth is all that’s needed to clear away the debris. For any symptoms beyond that, I like to see the baby and make sure. Blocked tear ducts often clear up as the baby gets bigger. If they don’t, a specialist can help.

Allergies are also a reason an eye could be red, but why just one eye? Usually, allergies affect both eyes.

Of course, he could have something in his eye, irritating it and hurting or itching.

Henry had a pink eye, which was crusted with dried stuff. He said it didn’t hurt, didn’t itch. It was a little pink yesterday, and pinker today. When he woke up, it was glued shut. Just his right eye was affected. He wasn’t sick and wasn’t injured.

For his eye infection, he got some drops that didn’t sting and took away the goop and redness within about a day.

Kids his age do all kinds of wacky and unsanitary things. But short of rubbing somebody else’s eyeball, these typical ‘pinkeye’ infections are not more contagious and not more serious than any other minor illness.

I am often asked when a preschooler is not contagious and can return to school. Honestly, I’m not sure I know a preschooler who isn’t contagious. At least with a red eye, I can clear up the teacher’s concern and get the kid back to school.

April 29, 2009

Alan's Tears

Babies can’t tell what’s wrong with them, so it takes careful detective work, experience, skill and intuition to figure out if there’s a problem and where the problem is. They cry because it’s one of the main ways they have to communicate. Usually, that process is the hardest part from the doctor’s point of view. For many common problems, we have studied and have figured out what the best treatments are.

But Alan just turned 11. Though he’ll use a word or two with gentle prodding by his parents, he has almost no language. He understands a lot, we think, but exactly how much isn’t clear. It’s often difficult to get him in the car, and though he likes me, his parents and I try to handle as much as we can over the phone.

His father called, and told me that for the past several months, he’s been crying. At first it was just when he was at school, for a few minutes. Then it was at home also. Gradually, this behavior had increased to several times a day, for up to 30 minutes or more. He’d slump onto the floor and weep. When he did this, his facial expression was sad. His father said that initially he was very concerned that something bad was happening at school, whether someone was being mean to him or something was going on that the child didn’t like. But that didn’t lead anywhere after a lot of questions and meetings with teachers. It was only after that path had been exhausted that the father called me, wondering if Alan was in pain somehow.

One of my UC Berkeley students was observing the day that Alan came in with his parents. I examined him as much as I could, and found nothing physically to be concerned about. He was very interested in (and affectionate with) my student, and she was a good sport in letting him try to sit on her lap and climb on her back.

Alan’s parents explained that these bouts of crying seem to come without provocation, and without a pattern of time of day. He doesn’t hold his head or his stomach when they’re going on. Just talking about it made the parents and me sad. Was there some kind of bullying or abuse? Did he have migraines? They said that his teachers were very loving and there was no one at school that he used to warm up to but now does not. He still liked going to school. And it meant a lot to me that the expression on his face during these episodes was one of sadness.

After an hour of asking detailed questions, the most likely interpretation was that he was, in fact, depressed.

In fact, there’s some reason to believe that people with autism suffer at least as much as everybody else. Studies of those with autism spectrum disorders (with generally much less severe deficits than Alan) show they have higher rates of anxiety and depression than their peers. And those who are more socially isolated also have higher rates of depression. (By the way, it also seems to be true the other way around--depressed kids seem to have weaker social skills, more isolation, than their peers who aren’t depressed. Are social skills the product of the same gene that regulates depression? Or are depressed people just no longer interested in socialization? Or is it that people with poor social skills, being more isolated, end up feeling depressed about their isolation?)

At the big-picture level, an objective look at Alan’s life as an 11-year-old with severe autism is sobering. He has great difficulty making himself understood, and is not given a large number of choices to make. He really doesn’t have peer friends, though he has a team of loving adults he does care for. He is indeed isolated.

As I’ve said before, my job is occasionally to make a diagnosis and initiate treatment. But it is always to try and relieve suffering. I had no way to know for sure what was making Alan sad. But only a little empathy was needed to glimpse life from his point of view. I started him on an antidepressant.

April 27, 2009

Swine Flu

The Centers for Disease Control is one branch of the government that works superbly. They are the most authoritative source on this planet for all news of epidemics and new diseases. There is no physician or expert who knows more than they do. All the major news organizations get their information from them, and you should too. The Swine Flu page is where you can find the best and most up-to-date information. It's updated at least once a day. Don't be sold on something from the alarmist salesperson at the alternative-medicine pharmacy. Trust yourself and get the straight story from the CDC. They have no hidden agenda and aren't trying to sell you anything.

This map shows the extent of flu cases in California. The California Department of Public Health also has a website that is very helpful, especially with links to local resources. Contra Costa County's web page has updated information on school closings and other newly-implemented rules. Alameda County has a web page that isn't as well organized, but has a lot of helpful links.

Back to the blog.

April 24, 2009

Autistic Boy Seeks Extravagant Chocolate

Attacking a child's personal space is never a good way to get him to cooperate. So taking a lot of time to let a child, especially an autistic child, get comfortable can be valuable. It also gives him the opportunity to assess the comfort of his parents. The less verbal the child is, the more essential it is to take the time to observe his self-directed behavior.

Today I met Robert for the first time. His parents said he had a few words sometimes, but mostly doesn't speak. Purposefully, I spent about an hour getting a history from his parents as he and his sister explored my office and found my toys. I noticed a few important things. He looked for and found toys on his own. We kept an eye on him, but my office is reasonably kid-safe and he didn't wander randomly. He was very happy with a couple of the interactive toys, generally intended for younger kids. They're fun when you haven't tried them before, and his sister played with them too. As the minutes dragged on, and the grown-ups talked about interventions and techniques and help organizations, he kept himself occupied and smiling, sometimes laughing. Even when his sister took a toy that he was playing with, he didn't lose his cool but found another toy or somehow got the original toy back from her.

She told me that she was worried about the future, and wanted him to be happy and enjoy all that life could offer. She shared a few anecdotes about him.

His mother said that one day, Robert came upon her eating a chocolate truffle. He gestured to her in a way that unambiguously meant that he wanted one. She said, 'if you find me a picture of one of these, I'll give you one.' He thoroughly searched his picture books, and found a photograph of a chocolate chip. Showing this to his mother, he got the truffle.

I didn't know what the future would bring, of course, and I couldn't guess how much language he will eventually acquire. But I believed, and I told her, that there were a couple of signs that made me optimistic. First, he was generally happy. It's hard to make someone happy who isn't. We have very helpful antidepressants which can, for some, relieve despair. But the medication doesn't induce happiness. A joyful, playful, happy child who delights in his world has something I would wish on everyone.

And the truffle story said a lot. I broke down the story for her. Many kids on the autistic spectrum have very inflexible ways of thinking. If you ask them to bring you the book from your table, they won't bring you the book if it's next to the table. If you ask them to say 'hello,' they might say the word but not to the person to be greeted. This is a type of concrete thinking. So it's very creative, intelligent, abstract thinking that can make a conceptual leap from truffle to chocolate chip. The story is more than evidence of abstract thinking. He also had to make a plan. His mother didn't tell him what to do. She gave him a sort of hypothetical situation. All by himself, he first decided on a goal he wanted to achieve (getting the truffle). Then he had to figure out how to reach that goal. He decided to call his mother's bluff. He used the resources at his disposal (books) and skills he was comfortable using. When faced with objective failure (he never did find a photo of a truffle), he didn't give up or become frustrated. He either had faith in the flexibility of his mother or faith in his own nonverbal negotiation skills. He found a picture that was as close as he could find, brought this over to his mother, and received his prize.

As the complexities of our lives and social interactions increase, abstract thinking and goal-oriented strategic planning become critical life skills. He had some of these critical skills already. The story also told me that his hearing was probably OK, that his auditory processing was pretty good, and that nobody should be eating chocolate around him unless they were prepared to share. I liked him.

April 21, 2009

Video Violence

In school the day after watching an episode of the popular TV show Kung-Fu, my friends and I would play-fight with all sorts of made-up kicks and chops. None of the kicks ever connected, and nobody ever got hurt. None of us knew any martial arts. It was the early 1970's, and within a few years, Bruce Lee movies and martial arts would become part of our culture. Did our exposure to the TV show increase our violent behavior? In some ways yes, we definitely played in imitation of the fights we saw. But none of us were newly aggressive or violent.

I just finished reading a provocative study in The Journal of Pediatrics. The researchers carefully examined 25 studies published between 1998 and 2008, which looked at the public health effects of exposure to media violence. Most of the studies they looked at (16) were with children, but there were 11 with adult subjects. Most of the studies showed that the more exposure a person had, the more violent behaviors they had.

But they found several interesting things. It turns out that many different measures of violent behavior were used. Some of the measures had never been validated scientifically, and some weren't measures of actual behaviors at all. Some used statistical analysis to see if those with violent behaviors watched more violent video. But did they choose this content because they already had violent tendencies, or did the exposure cause the violent thoughts? And will a child act on aggressive thoughts? Will the exposure to violence cause more violence in our communities?

They wanted to know how many of these studies examined directly-measured real-world violent behavior, such as a crime or hurting another person, and how many used another measure of aggression that would be more difficult to confirm. Some of the studies used ratings from teachers or even peers--these have been shown to have the least credibility in predicting actual violent behavior.

Interestingly, they found that the studies with the poorest measures of violent behavior showed the strongest relationship between violence and media exposure. Those using more certain measures of violence showed a much weaker relationship. Overall, the relationship was very weak.

Another study looked at published studies specifically examining violent behaviors, rather than surveys or questionnaires. They found that there was no general relationship between exposure to media violence and aggressive or criminal behavior.

The American Academy of Pediatrics, and several other official groups, have fully embraced the need to restrict a child's exposure to violent media. In a practical sense, this is increasingly difficult. Because of the internet, a lot of objectionable material is easily available. And because of a child's natural inclinations (see my post on Forbidden Fruit), they will have the innate interest in seeking out some of this content.

But I wonder if it really changes them. The two studies I cite in this post don't support the thinking that seeing violent media will somehow transform our children into violent people. Video games are more popular than ever, and some are shockingly violent. Some are played by children much younger than their rating would imply. But there doesn't seem to be evidence that these kids are more likely to become criminals.

Lack of harm, however, isn't the same as proof of a benefit. Even if I buy the conclusion that violence in the media isn't as harmful as it's currently made out to be, that doesn't mean I think it's a good thing. What would be best, I think, is if the kid would put down the video game and go outside to play some basketball, or ride their bicycle (with a helmet).

April 18, 2009

The Bridgeport Paradox: Black and White in the Delivery Room

Connecticut is one of the richest states in the United States. Most of its many wealthy people live on the 'Gold Coast' which is within commuting distance to New York City and is along the shore of Long Island Sound. The richest county in Connecticut is Fairfield county, where low-density communities are filled with some of the most expensive private homes in America.

There are no major hospitals in these affluent towns, owing to their low population density. So when the rich and famous need a hospital, they go to the nearest major medical center, Bridgeport Hospital.

Bridgeport is an island of poverty in this sea of wealth. A booming 19th-century industrial town, it gradually ran out of most manufacturing jobs decades ago. It has double the state's average rate of people living in poverty, and triple the rate of the poorest poor—people living at less than 50% of the poverty rate.

When I did my required training rotation through Obstetrics, I was assigned to Bridgeport Hospital. It's a big urban medical center, with a busy Labor & Delivery ward. Almost all of the Obstetricians in the area had luxurious private offices located in the adjoining wealthy communities, where they served an exclusive clientèle, mostly white. For deliveries, however, even the fancy doctors used the great facilities at Bridgeport (in private rooms). Some of these doctors in private practice, along with the doctors on staff at the hospital, also worked with the patients from Bridgeport, mostly women of color. Most of these patients didn't have private insurance, and sometimes didn't have insurance at all. These patients often had less prenatal care, and less access to medical care in general for any of their other medical needs. Many had complex social issues associated with poverty which complicated their care.

In this context, I expected that the wealthy, private-paying patients with their private physicians would somehow get better treatment and have an easier time. For many types of medical problems, this seems generally to be the case, and I expected it at Bridgeport Hospital, where the stark contrasts in patient resources are dramatic.

The experience of my first day has remained deeply etched in my memory. I was told to wait at the nurse's station of the obstetrics ward. The screaming started within minutes of my arrival. It was the most disturbing sound I had ever heard. Clearly screaming in severe pain, the halls were filled with this sound which came from behind a closed door. I was new there, but I asked the nurse sitting next to me, who was browsing through a catalog for scrubs with cartoon characters, if we should go in there and help. She was very kind and explained that the obstetrician was already in the room and the woman had said that she didn't want any interference or medication. Within a couple of hours of this, a new patient was wheeled in to another private delivery room. With her was her husband, her doctor, and her personal secretary. After getting settled, the personal secretary left the room and sat in the waiting area. A second source of intense and disturbing screaming started coming from this room, too. Now there were two.

Before lunch, an ambulance brought in one of the local women, and the nurse sitting next to me dropped her catalog (by now she had moved on to a shoe catalog), and prodded me to come along. I didn't do anything at my first delivery, but I watched a very skilled doctor give this woman an epidural anesthetic. A couple of hours went by before she had her baby, which is about the most fabulous thing a person could witness. She pushed and was awake and happy when the delivery nurse put her new baby into her arms.

I don't know what happened in those private rooms, as I was never invited in. But this experience was repeated nearly every day I was there. I asked one of the obstetricians about it. She told me that many of her private patients refused all medications and wanted what she called the 'full experience' of childbirth and motherhood. She said this wasn't often the case with the inner-city mothers she treated in the hospital. She never really thought about it, and tried to give her patients what they requested.

So much suffering, both medical and otherwise, falls heaviest on the poor. What I witnessed was counter-intuitive: the rich were enduring unspeakable pain, and the poor were not. I'm not an obstetrician, but I do look upon my job as trying to ease suffering if I can. Were the poor women getting better advice than money could buy? Maybe they just had more common sense.

April 15, 2009

A Mother's Concern: Forgetful and 15

Claire is 15, and she’s been a patient of mine for a couple of years. She’s very bright and has always been healthy. When I’ve seen her, she always asked articulate questions with an adult vocabulary. She never seemed conformist with high-school fashion or makeup. She seemed comfortable with me, though she generally avoided eye contact.

Her mom had just read my post about girls with ADHD, and telephoned. She said that her daughter was getting poor grades in school despite high aptitude. She often forgot her homework assignments and forgot to hand in the assignments she did. Her written work seemed randomly put together, with one idea not flowing naturally into the next.

Although this pattern had been noticed since she began elementary school, she has never been in trouble, and her excellent reading was always thought of as a major educational advantage.

Could this be ADHD, especially the inattentive type often found—and often missed—in girls? She seemed to meet some of the common criteria: performance notably below her potential, forgetfulness, disorganization, and her teachers often found her not paying attention. But that lack of eye contact and awkwardness in following and participating in a conversation could be symptoms of what is currently called Nonverbal Learning Disability, which is considered an Autistic Spectrum Disorder.

While these were possible, I wanted to be sure not to miss important other possibilities in this teenager. At her age, I’m particularly concerned about depression. Social isolation, bullying, harassment of some sort at school could be an issue. Is there an eating disorder? Is she hurting herself in some other way? Was there a boy the parents didn’t know about? What about alcohol or drug use?

I posed all of these questions to Claire's mother. She thought all were unlikely. They had a warm, open relationship and she didn’t think the child would hide much. Though teenagers can have very private lives as they try to find an identity independent from their parents, I thought the most important factor was the long history of behavior, observed very early in her school career. Even Claire joked with her friends about her being ‘spacey.’

Her mother wanted to know how to approach her.

Be completely open with her. Parents who aren’t usually find themselves defending their omissions or deceptions. This can have serious consequences for the credibility of the parent and the relationship with the teenager.

Tell her:
  • You read the post online, and show it to her.
  • We spoke on the phone and this plan was my idea.
  • I want to see her, to ask her opinion and to ask her screening questions.
  • I want to initiate a formal evaluation.
  • I will give questionnaires to her current and former teachers, but only to the teachers she likes.
  • Questionnaires will also go to her parents.
  • She will get a questionnaire so that she knows what questions are being asked and so she can evaluate herself.
  • She will be included in every part of the process. No decisions of any kind will be made without her.
  • All of the process, including that the evaluation is happening at all, will be completely confidential. It will not be a topic for conversation at the family dinner table, or with her siblings or friends.

It’s a mistake to assume that the teenagers who aren’t crying out for help don’t want help or wouldn’t accept help if offered. I don’t know yet if any of this will happen, or what the results will be. I’ll keep you posted.

The photograph above is by Paul Strand. It was taken in 1953.

April 12, 2009

ADHD: Girls

When Chloe's mother brought her into my office, she didn't know what was wrong. She told me that her 10-year-old was doing very poorly in school. She seemed to get along with everyone very well, but didn't have many friends. When her mother sat with her while doing homework, it didn't seem to be too hard for her, and she appeared to know and understand everything required. But reports from her teacher were that she wasn't doing a lot of the classwork and she almost never turned in her homework. Chloe always liked talking to me and her mother asked if I could try to figure out what was going on.

I asked a lot of questions about social changes in Chloe's life, but there hadn't been any. She continued to be well medically, and was growing fine. Chloe herself said that she wanted to do better in school but didn't know how. She denied having difficulty with reading, or writing, or math, or social studies. She didn't know why she didn't hand in her homework, but was aware of many days when her teacher asked for homework but she either didn't know there was homework or didn't know what the assignment was. She has also sometimes been surprised by tests in class she didn't know or forgot were coming. She never got in trouble in class. Her teacher said she would often be caught daydreaming. I asked how long this had been going on. Her mother said all year. I asked about last year and the year before that. After some thought, her mother said that these were all comments she had heard before, even in kindergarten.

Only a few years ago medical authorities taught that about 4 or 5 boys had ADHD for every girl. This was undisputed, and confirmed by the general experience of elementary school teachers everywhere. Almost always, it was the boys who got in trouble both in and out of the classroom. These days, most books will say that it's twice as many boys than girls.

Is ADHD truly more common in boys? Or do boys force us to give them the diagnosis twice as often because of their behavior? Perhaps because boys with ADHD are more often singled out for their disruptive actions in the classroom, they are more likely to get sent to the principal's office, more likely to have their parents called by the teacher, more likely to get taken to the doctor, and thus more likely to get diagnosed with ADHD. So maybe ADHD isn't twice as likely in boys, it's twice as likely to get diagnosed in boys. (I have mixed feelings about this. Is the overdiagnosis of ADHD in boys because it's more likely or are boys unfairly singled out by our elementary school methods and institutions?)

Luckily, there are really smart scientists like Stephen Hinshaw at the University of California, Berkeley. He and his colleagues have been following and researching girls with ADHD for more than a decade. What they have found suggests that it's probably close to equally likely in girls as boys, but that many more girls never get diagnosed. Those that do, get recognized much later, sometimes in late elementary school or even when they are teenagers. Those that never get diagnosed, never get treated. Since there's good evidence of the effectiveness of treatment, some girls really have a tough time. For all girls with ADHD, they often have continuing difficulty both socially and academically, and have a much more difficult adolescence.

When I received the reports from Chloe's current and prior-year teachers (I have them fill out questionnaires), it was clear that Chloe had ADHD, Inattentive type without hyperactivity. I urged mom to consider medication, which has been shown to be very effective and safe, but she didn't. We'll try some behavioral therapy, I guess. While it avoids medication, it is significantly less likely to be effective by itself.

Many boys are brought to me for evaluation of ADHD. Usually they are 4-8 years old or so, just starting their school years. Where are the girls? How many have been missed? The words used to describe the behavior of boys who are referred are almost always negative: disruptive or out-of-control, for example. For girls, the words are not so scary: daydreaming, forgetful. I wonder if this is influenced by our different expectations for girls. Maybe because the words we get from teachers describing the girls aren't so alarming, we don't rush to take action.

Studies show that early patterns of school failure are a real warning sign. Early intervention for problems like ADHD or learning disabilities are often very effective and help the child all through school. Girls with ADHD have continuing social and academic problems, are more likely to drop out, have more substance use problems, eating disorders, and depression. Isn't that worth preventing if we can?

The photograph is by Jim Steinhardt, and is from the 1940's.

April 11, 2009

ADHD: Does ADHD exist?

I am sometimes asked if ADHD is a real disease. There are good reasons for questioning.

Medicine doesn't always get it right, and there's no reason to believe that the way we currently think of certain diseases is the way they will be diagnosed and treated a few years from now. I picked 3 examples. It wasn't until 1974 that the American Psychiatric Association announced that homosexuality wasn't a mental illness. They made this decision by a vote. Until 1982, generations of people were told that their ulcers were because of their 'Type A' personalities, anger issues, or stress. There was a body of research supporting this. It was shown to be complete nonsense, needless to say, when the bacterial infection that causes stomach ulcers was found by Australian scientists. My favorite is the long medical history of 'hysteria' in women and its curious treatment. I read a fabulous book about it, bought lots of copies, and sent one to everyone I knew (knew well, anyway).

ADHD has a long history. In 1902, a group of children, all boys, were described to be unusually impulsive, overactive, attention impaired, and accident prone. This particular group was also defiant, dishonest, and aggressive. We'd probably define them as Oppositional-Defiant. There was an epidemic of encephalitis in 1917-18, which left some affected children with these symptoms. So doctors at the time reasoned that the behavior issues were a result of brain damage. As more children with these problems were identified, and most were found to have no history of illness or injury, and most were of normal intelligence, it acquired the name of 'minimal brain dysfunction.' By the 1960's, 'hyperactive child syndrome' was defined. Just a few years ago, the group of diagnoses were divided up so that we could distinguish kids who were mostly hyperactive from those who had attention problems.

What became of those 'spirited' children, mostly boys, in the past? Before there was mandatory education, there was plenty for a child who wanted to keep moving to do on the farm. While some tasks required careful attention, it's not hard to imagine a kid doing a wide range of tasks to keep him interested or major tasks under careful supervision. Girls who daydreamed might never have been the most productive makers of needlepoint samplers, but there were many jobs for them to do, too. I believe that the conformist model of education which requires long hours of sitting quietly at a desk is exactly the kind of environment which will accentuate the symptoms of ADHD and call affected children to our attention, maybe even for treatment.

I do not believe, however, that ADHD is simply a cultural issue, and if our children were allowed an unstructured childhood, they wouldn't have the problem. In an unstructured environment, the natural inclinations of kids with ADHD would lead to their unsustained learning of anything in particular, and failure to acquire necessary knowledge and skills. The lives of truly ADHD children are filled with dysfunction in all areas of life--school, social interactions, relationships with parents and siblings.

Should we avoid medication by getting these children out of the school setting? This ignores the intellectual potential of the child, which is unrelated to their attention issues. In fact, medication for this problem has been used for about 50 years and has been well studied. It's one of the surest treatments we have for any kind of medical problem. Stimulant treatment shows clear success when done carefully and with good monitoring. Parents are sometimes afraid of the potential for substance abuse, but teens who aren't treated have significantly higher rates of substance abuse than those who are treated. And if you're reading this, you've probably successfully finished quite a bit of school. Statistics show that those who fail at school have a very hard time in our society. So maybe the strategy should be to help every child do as well as they possibly can do, and try to keep them advancing in school as far as they can go.

Next Post: ADHD in girls.

The photograph above is from about 1932, by Dorothea Lange, taken for the Farm Services Administration. Sorry, but it's the only photograph I had of kids on a farm.

April 10, 2009

ADHD: Is ADHD Inherited?

About two weeks ago, a couple expecting their first child asked me an intriguing question as they interviewed me for the opportunity to be their pediatrician. They asked if ADHD was inherited. They were concerned because the father had been diagnosed as a child and took medication for many years. The scientific answer is clear. Yes, there is pretty good evidence that from studies of twins and epidemiologic studies of parents and children that if a parent had been diagnosed with ADHD, there was a much greater chance that the child will have ADHD.

ADHD is widely studied, and there are many things known about it. We know that children diagnosed with ADHD but untreated or ineffectively treated have much more problems in school than those whose ADHD is effectively treated. We know that teenagers with ADHD who are untreated have much higher rates of substance abuse problems than those whose ADHD is treated (yes, treated with speed-like medication). There’s a higher rate of ADHD in children raised in households without a father and in which the mother practices inconsistent, unstructured, discipline.

I started to assemble some of these facts. How would the adult with ADHD, untreated, parent a normal child? I'm guessing that there would be a lot of impulsive decisions, inconsistent discipline, and failed relationships. Growing up in a household with a parent with untreated ADHD is likely to make worse any existing problems in the child. It would make an anxious child more anxious, a depressed child more depressed. If the child had some behavior issues, these will become more of a problem with this kind of unstructured household and impulsive, distracted parenting. So a kid with some mild ADHD symptoms--and most normal kids have some (and most normal college students)--might act out enough to get in trouble at school. The impulsive parent might perceive some of these normal behaviors as impossible to manage. Now that the child is having trouble in school and at home, they might cross the diagnostic threshold and meet the official qualifications for ADHD.

Studies have shown that if you smoke, it's more likely that your children will smoke. Is smoking genetically inherited? Kids naturally follow the model behaviors of their parents, even the behaviors we don't want them to copy. But just maybe, children inherit some subtle feature of brain chemistry which responds powerfully to nicotine. So is smoking inherited? I'm not sure what that means.

Some parents with anxiety can't help but share their fears with their children. Won't this make their kids anxious? If the child has a little bit of anxiety of their own, will this make it worse? Does this mean the child inherited anxiety from the parent?

Is ADHD inherited? By studies that have been done on genetics and brain function, yes. But I suspect it is less often inherited when the affected parent has been effectively treated.

There's a couple of general parenting lessons here. First, you are not your parents. The things they did that didn't work for you as a child probably won't work on your own children. But most importantly, every child needs consistency and structure. The more disorganized and unstructured they are, the more valuable a structured environment and consistent parenting will be for them.

Next Post: Does ADHD exist?

April 9, 2009

ADHD: A Berkeley lecture -- Adult ADHD

A couple of years ago, I was giving a lecture at Wheeler Hall, a 600-seat auditorium at the University of California, Berkeley. The Interdepartmental Studies course drew hundreds of undergraduates who were in many different majors, with many pre-meds and public health students.

I opened with a test. Paraphrased from several websites I found on Adult ADHD, all of which promised help or cure with a purchase of nutritional supplements, vitamins, medication from Canada, or a service such as counseling or self-help or spinal manipulation. I asked the students if:

  • They find their mind wandering from tasks that are uninteresting or difficult
  • They have trouble keeping focused on written material that’s not very interesting even if it’s important they know it
  • They sometimes find it hard to stay focused on group conversations
  • They find it difficult to complete long tasks when there are many shorter tasks competing for their attention
  • They think they have the potential to accomplish much more than they do
  • They sometimes notice a lot of time has gone by and they haven’t finished what they thought they would, and don’t know where the time went

I requested a show of hands, which showed an overwhelming majority of the students in the room to have, by these criteria, adult ADHD.

Next I turned to presumed therapy for their presumed ADHD. How many, I wondered, would be willing to take something that improved concentration and alertness, and might make them feel a little less tired. A main side effect of this class of drug was appetite suppression and even weight loss. I didn’t want to embarrass anybody or ask any of the students to reveal their pre-lecture psychological diagnoses. So I didn’t ask how many actually were taking prescription ADHD medication. I did show a slide listing the many substances that have many of the same effects on brain chemistry. These include coffee, tea, and Coca Cola. A majority of the students admitted to self-medicating with some form of stimulant.

Do we all have ADHD? Surely many or most of us use mild stimulants to help with alertness and concentration.

The official diagnostic criteria for the diagnosis of ADHD include a long checklist of predictable symptoms covering impulsivity, inattention, distractedness, and so on. But it’s not enough to have the required number of symptoms, even if they are severe.

In my experience, the single most important factor in the diagnosis of ADHD is, “There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.” (From the American Psychiatric Association.)

A few years ago I saw an interview on TV featuring the CEO of an airline. He said that he had ADHD and thus had a continuing struggle. He also noted his long happy marriage, and successful children. Where, I wondered, was the significant impairment? He didn’t say if he was taking medication, but if he was, why was he taking it? Though there may have been some students in my lecture who had been diagnosed and were in treatment at that time, those who met the criteria I gave them from the internet site on adult ADHD were not significantly impaired. They were almost all extremely successful students in a demanding program at an elite university.

I am often called upon to evaluate a child for ADHD. They usually do have symptoms that have brought them to the attention of their teachers or parents who have sent them on to me. But the smarter kids (and, I believe, the smarter adults), develop compensatory skills which can be very effective. They concentrate on things they’re good at and avoid those that are particularly difficult. Don't we all try to do that? Maybe they go into more creative, less structured fields. Maybe they successfully negotiate for certain types of flexibility from the teacher. Maybe they need to run their own business. Maybe they need to be CEO of an airline.

Next Post: Is ADHD inherited?

The sampler above is in my office. Sorry about the fuzzy photo, but it was taken through glass. The verse reads, "When I was young I little thought/That learning was so dearly bought/But by experience I do find/That it is not gained by an idle mind." Of course, it's easy for her to look back wistfully to when she was young, since she was 8 when she did this.

April 7, 2009

Eight is Enough -- All the king's horses and all the king's men

What do you do when you can't fix what's broken? My patients--and my readers--know that I take a practical approach.

There wasn't any way for me to repair the relationship between his mother and father. Maybe it will work out someday, maybe not. I couldn't force his father to call or visit. Indeed, this is just the way Max saw the situation. His family was broken and couldn't be repaired; his father was gone forever. Nobody ever asked him what he thought about it. This is why when you're 8, what happens seems inevitable.

Max was depressed. He had a lot of the same symptoms of depression that adults get. He was sad, cried sometimes without provocation, had disturbed sleep and eating, lost interest in the things he used to enjoy, and was more distant with his friends. Even so, I was optimistic. He hadn't always been like this, it's just been the last few months. Technically speaking, this was a reactive depression, a problem adjusting to new circumstances. But I couldn't sit back and watch this child suffer while waiting for things to happen—like his father calling, or his parents getting back together. That's the perspective of an 8-year-old.

I could help this child by sharing with him some of my power as a grown up. I also respected him in a way he wasn't used to. Rather than telling him what to do, or talking to his mother with or without him in the room, I suggested some positive actions he could take. First, I gave him permission to call his father, and asked him if he'd be willing to call every Monday, Wednesday, and Friday. He liked this idea and his mom said it was OK with her. I told his mom not to dial and not to remind him. This was completely Max's responsibility and he could do it alone. I made it clear that his dad might not pick up the phone or might be busy, but told him that he should leave a message every time he called. It gradually came to him that this might not bring his dad back. “What if he still doesn't call?” he asked. I told him that he could go shopping for postcards and that a couple of times a week, he would send his dad a postcard with a note on it, or a picture.

I had met his dad several times over the years, and knew this man loved his children. If getting a lonely message from your 8-year-old three times a week didn't melt his heart, I'm not sure I could come up with something better.

But here's the key step: moving the child from passive to active. This is a repeating pattern in my parenting advice. Taking a child, especially at this developmental age, and empowering them to take control of at least part of their lives, to give them tools that can leverage the influence they never knew they had. I knew that I didn't have the power to repair what was broken from the child's perspective—his family. But I did have the ability to fix his sense of helplessness, and push away the inevitability of the world.

I also had the ability to try and relieve the sense of sadness. We'll try a little medication, too.

Coming up: a series of posts on ADHD.

April 6, 2009

Eight is Enough

When you're eight, the world is full of inevitability. Your parents go someplace, and you are dragged along. Your teacher assigns homework, and it has to be done. It feels like everyone in the world has some kind of authority over you. Don't they know you have your own plans? Your own agenda for things that have to get done? Your own idea of what is most important?

Max came into my office with his mother. He gave me a hug hello but wasn't smiling. His mother told me that he said he wasn't feeling well and wanted to see me. She said that he wanted to stay home from school for the last few days, but couldn't say just what was wrong. She made him go to school, but wanted him to see me on Saturday. I went through the usual review of his symptoms with them, but he denied headaches and stomach aches and everything else. I asked if he had pain in his toes. I asked if he had pain in his feet, ankles, knees, legs, and so on up to his eyes. Finally, I asked, “does your hair hurt?”. This usually causes a pause to think and then a smile. He paused and his eyes started to tear up. His mother started to tear up. I started to tear up.

Luckily, my office is equipped with the latest in medical technology and there were tissues enough for all.

His mother flatly related that his father had moved out several months ago, and had just moved in with somebody else. His father hadn't seen Max for about a month. He stopped calling a few days ago. After saying this, his mother told me that she didn't know what was wrong with Max, that she was worried about him, she asked him what was wrong but that he won't talk to her. She wondered aloud if he would talk to me. She didn't ask either of us, but as she said this, she arose and said that she'd wait outside the room.

“Max,” I said, “do you miss your dad?” He nodded tearfully. “Does it make you sad that you don't see him?” At this point, the perceptive reader sees where this is going and I can't claim it was particularly insightful of me to see it at the time. The fact that his mother seemed genuinely in the dark about it was remarkable. Even though he was eight, I asked screening questions I typically ask dejected teens. Did he think about hurting himself? Did he think about running away? Finally, I asked him if I could tell his mom about what we talked about and about what he said. He said that was OK, and I invited her in.

Though mom was made sad by what I relayed to her, she was relieved that he opened up about it. Max was visibly relieved that mom now knew.

Max's younger sister was acting out a little more in kindergarten, but had not taken it so hard in an obvious way. But 8-year-olds can see the world in a bigger picture, and in this case as something that was broken forever. Preschoolers just want more time with mommy, and it's OK if she's shopping as long as they get to come along. Teenagers get to stay home alone.

Max told me that it made him sad to think that his family isn't the family he had when he was little. He said that he thought he would have that family forever and now it's gone. This made him cry a lot. Again, we took advantage of tissue technology. His perspective is an important one for parents in every situation to be aware of. To him, everything in the grown-up world is fixed for eternity. Until it's not, and then it's shattered. As adults, it's typically from about this age that emerge some of our most troubling memories of the relationship of our parents or the circumstances of our childhoods.

Next Post: Trying to help Max.

The photo from my collection is by Walker Evans and was taken during The Depression.

April 4, 2009

Postpartum Depression: A father's comment -- strategy for relief

My job, as I see it, is to make a child’s life better if I can. The comment that this father emailed to me about a blog post gave me a glimpse into the first days of their lives as new parents. So I tried to break this situation down into problems that I could solve.

First, the wrist. This was my first target because it was the easiest. With sleep deprivation, small but persistent annoyances can appear as giant and impenetrable problems. They can be the spark that starts big fires. I brought the parents into my office and found the right kind of splint on my computer. I gave them the printout and told them to buy it that same day. Mom was to wear it all the time, except when showering or sleeping. The thick aluminum bar in the splint would prevent the wrist from flexing, allowing the tendons to heal on their own.

Then, the breastfeeding. The father said in his comment, “…we keep telling ourselves the benefits the baby will receive from breastfeeding will far out way [sic] a strictly formula diet.” Maybe it’s heresy, but breastfeeding may be best for the baby, but by how big a margin? Will one bottle of formula a day (maybe less than 10% of the baby's total nutrition) make a real difference? There's an interesting article on this from The Atlantic magazine, which poses this question. My priority is clear: what’s best for the baby? Breastfeeding dogma, which is powerful here in Berkeley, would have us believe that there is no other way. I saw an alternative path that I’ve used before.
  • First, I need to relieve some of the relentless pressure on this first-time mother. By giving her permission to feed the baby pumped breastmilk or even a couple of ounces of formula once a day, I might be able to absolve her of some of her performance anxiety. She’d worry less about the baby not getting enough and worry less about her own inadequacy. And skipping a direct feeding might give her a needed relief for her soreness.
  • Second, I needed to find a way for her to get help she could have confidence in. This would also take some pressure off.
  • Third, dad needed to be involved. He needed the opportunity to shoulder some of the burden his wife had been under alone. He also deserved an opportunity to step into his baby’s life.

Every night, they were to give the baby one bottle feeding. Dad would do this feeding by himself, so mom could sleep. True, it would be in the middle of the night. But dad would have this precious time for just him and his baby, in which he was meeting all the baby’s needs and the needs of his wife, too.

I saw this family again about a week later in the office, though I had called and spoken to them on the phone several times in the intervening week. Everything was better. They were still tired, but mom’s mood had brightened a lot and dad was now king of the night-time feeding. When I asked how things were going, mom told me a lot but when she was done, dad had a lot to add about the baby’s expressions and actions and feeding behavior and sleep pattern. He really knew.

Postpartum depression, and perhaps depression in general, seems sometimes to blind us to paths leading out of the dark places in which we sometimes find ourselves.

Next Post: Do 8-year-olds get depressed?

April 3, 2009

Postpartum Depression: A father's comment--observed

A father’s Comment, observed.

In my last post was the comment of a new father. This story has many elements in common with a lot of the cases of postpartum depression that I have seen. The mother isn't overtly depressed, and wouldn't identify herself as depressed. Dad says that he is, but is quick to say how happy he is. But when I read this, I don't get a happy feeling. I think most readers will hear the tone of sadness throughout the comment. Professionally speaking, I don't think things are going all that great for these parents and I don't fully believe that either one of them are really happy with the situation.

Can I relieve some of this suffering? Does it have to be this way?

Her Mood:
When I received this comment, I called the family and asked them to come in to the office. The baby was doing fine, which enabled me to focus on the parents. Just as hinted at in the father's comment, mother was at the same time territorial about the baby's care and yet feeling overwhelmingly pressured to do everything herself. I started with the usual, ‘How are things going?’ She said everything was going fine, and she felt good. But every time I asked about something specific, it was a different story. Mom used a lot of tissues during the visit.

For this mother, as she saw it, nothing was going the way it should. Breastfeeding was very painful, and she had been told it wouldn’t be. She was very afraid that the baby wasn’t getting enough, even though his weight gain was good. To her, he always seemed hungry after nursing because he continued to want to suck. She couldn’t stand his screams. The baby was telling the world that what she was producing, what she was doing, just wasn’t good enough.

Dad’s Mood:
She didn't think the father could do a lot of the tasks she did, but never asked him for help or showed him what she wanted. She never let him help, and was angry at him for not helping. He felt like an outsider looking in, saddened by his isolation and by his own helplessness.

The Wrist:
The mother felt bad enough without the excruciating pain in her wrists. Every time she went to pick up the baby, she felt that she was destined to wince in pain. She didn't know who to tell about this problem, but I'm glad the father told me. She had something called nursemaid's wrist. (Important note: this has nothing whatever to do with nursemaid's elbow.) It's an overuse injury that you get from picking up babies all the time. The fix is rest. What I told her to get was a wrist splint with a metal bar in it for stiffness. All the wraps and elastic things won't help. The wrist has to be immobilized for the inflamed tendons to heal.

It’s tough enough to keep your spirits up when you’re in pain. But she told me that her wrist pain made her feel bad. She explained that every time the baby cried, she dreaded having to pick him up, as if he were causing her pain. She felt terribly guilty about these feelings and knew it wasn’t the baby’s fault—it was her fault.

As an aside, this brings up once again a philosophical problem with medical care. I'm the baby's doctor and the baby was doing OK. Should I mind my own business about everything else? Hint: what do you think?

Next Post: A strategy

April 2, 2009

Postpartum Depression: A father's comment

Shortly after posting New Mother, Breastfeeding I received a comment online. The original comment had a lot of names in it, which I have removed. I am posting the comment with permission.

Hey Dr. Wolffe,

[Our son] was born Jan 18th, which makes him just eight weeks old today. You've been seeing his mother since his second week or or so. His mother will be in with him on Tuesday I believe. We were so thankful for gaining you as [his] pediatrician.

Now for the topic of discussion. my wife still struggles daily with breast feeding. We've had many a discussion, and for the most part I try to back off and let her handle it. Their her breasts, not mine. Her mothers made comments about her sister not having the same troubles. She's had problems with engorgement, so on and so forth. But, everything is getting better from day to day as well. He screams at the top of his lungs when he's hungry. My wife still gets up at all hours of the night. We hardly sleep together since she's up so much. We've had lots of help over the past few weeks from her mom and sister. During the first couple of weeks my mother was here helping out with what she could. Every now and then I see the PPD monster climb out, but after a little bit of rest and noticeable improvement with the baby, PPD settles down. I am the husband, and I feel a little depressed from time to time. I'm not to worried about it since overall, I am happier than I've been in years. Marriage and fatherhood have been great for me. Now if we can just keep ironing out all the wrinkles that come along with being new parents.
My wife's number one complaint is pain from him tugging on her breasts.
#2 is her sore wrists. He's getting heavy fast. Heck I'm twice her size and he strains my wrists too.

For her first complaint, I've asked her to continue to go to breast feeding class, so they can help her master the technique. I notice sometimes her posture and technique of latching don't go hand in hand with what I watched her being taught at Alta Bates [Hospital]. I tried to point these things out, but it mainly causes arguments.

I have sat with her and helped with the entire process. I do admit, she's getting better, and the baby's feeding better. In the evening I don't think she's producing so much milk, so a couple of times we have supplemented formula to give him a full belly. This takes care of the crying.
Her sore wrists don't seem to be getting any better yet. I have purchased her several different athletic supports (splints) to help out, but they aren't working too well. I've asked her to ice, but I've never seen her actually do it or heard her say she has. Being an wrestler in high school, college, and post college, I can attest to ice being the miracle drug for joint pain, bursitis, strains, sprains. Icing twenty minutes on and ten minute ice massage are uncomfortable at first, but they works.

Today we went out to REI in Berkeley, and ended up cutting our trip short as she was having too much pain in her wrist to breast feed him in the car. I realize this is uncomfortable, so I encouraged her to put a pillow or something in the car so she can feed him comfortable. We went home.

I was very pleased this afternoon to get him to take a pacifier for about twenty minutes. He did well. I can see smoother sailing ahead for all.

So for all concerned, we keep telling ourselves the benefits the baby will receive from breastfeeding will far out way a strictly formula diet.

Next Post: My response and follow up