May 12, 2009

ADHD: Claire 3--Unexpected Insight

A couple of weeks ago, I gave Claire and her parents questionnaires to fill out. I asked Claire herself to fill one out, and there were separate questionnaires for her teachers, too. The questionnaires were developed and tested by some smart people at Vanderbilt University, and have been adopted as the standard assessment of ADHD by the American Academy of Pediatrics and the National Initiative for Children’s Healthcare Quality. They are designed to distinguish those with the inattentive type of ADHD from those with hyperactivity. They also sneak in a few screening questions for other issues. All the questions need to be rated from “Never” (0) to “Very Often” (3).

Surprisingly, the teachers and parents didn’t really score the questions about inattention too highly. An example might be, “Has difficulty keeping attention to what needs to be done.”

But Claire herself rated as “Very Often” the statement, “Is self-conscious or easily embarrassed.” The statements, “Is fearful, anxious, or worried,” and “Is afraid to try new things for fear of making mistakes” were also rated highly by Claire, her parents and her teachers.

When I scored the Vanderbilt forms, an unanticipated pattern emerged. She did have some attention issues. These were right on the margin of meeting the official diagnostic criteria for ADHD—Inattentive Type. She did have some sort of issue with paying attention. But there was a loud and clear signal about anxiety. So I sent her mom some anxiety-specific questionnaires, and once again asked Claire and her parents to fill these out.

When they were returned, an anxiety problem was clearly identified. Claire and her parents had noticed that she was often worried and often worried about what people thought of her. At least some of the behaviors that her teachers noticed in class, such as never participating in class discussions or volunteering answers, were because she was afraid, not because she was distracted.

Parents are often concerned about ADHD medication. Part of being a careful prescriber, of course, is having judgment and experience in the use of medication. And part is being disciplined about it. I have no a priori problem with prescribing medication where I believe the benefits outweigh the risks. A couple of months ago I wrote about a boy whose life at school and at home, and his social interactions even with his friends, was very difficult when he wasn’t taking his meds. But an advantage of seeing so many kids with ADHD and managing so many medications is knowing that stimulant medications, in some people, can make anxiety worse. In those with an anxiety disorder, the medications are often less effective.

When the screening questionnaires were designed, it was essential to screen for anxiety and depression. A depressed child might be sitting at the back of the class uninterested in the topic of the moment, might avoid social interactions, might forget assignments and not care about exams. This child, too, won’t benefit from ADHD medications yet acutely needs our help. If the child is very worried about what others think, she won’t speak up in class. She might ‘forget’ homework or other tasks if she’s afraid of what they indicate about her and her understanding of the material. So though girls with ADHD are often not diagnosed at all, it’s important to keep an open mind as we look for the underlying problem.

Next Post in Claire's story: I meet with the family.

The photograph is from my collection and is by Alfred Stieglitz.

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