May 18, 2009

ADHD: Claire 4--Breaking the news

As difficult as it might be to tell parents that I know what’s wrong with their child, is often much more difficult to present a complicated interaction of several different problems. In Claire’s case, because she was older, there was the additional issue of telling her directly.

I believed she had an anxiety disorder. She might or might not have an attention problem. It’s conceivable she could have a subtle learning issue. I asked her parents to come to the office with her so I could lay it all out for them.

Because of a busy schedule, Claire could join us only after we had started. I scheduled 90 minutes for the conference. I showed the parents the Vanderbilt ADHD questionnaires that I had received and explained my scoring and interpretation. I showed them the anxiety questionnaires.

There were a few key pieces of information I thought were extremely important. First, Claire’s reaction when her mother told her about my plan to look into these problems. This suggested that she knew we had hit upon something important to her, and she was relieved about it. Second, the high scores that she herself gave for some of the statements on the anxiety questionnaires (“I am a worrier;” “I feel worried about things that have already happened;” “People tell me that I worry too much.”)

The anxiety-specific screening tools allow me to be more specific about what could be going on. Claire and her parents indicated that she didn’t have significant separation anxiety or somatic symptoms such as headaches or stomach aches. But she seemed to have generalized anxiety and social anxiety, and she’s anxious about going to school for many reasons.

Just informing this family about what I’ve discovered isn’t very helpful without some plan to deal with it.

A therapist might help, and anxiety disorders are often helped by cognitive behavioral therapy. This kind of therapy helps the patient be aware of the thoughts and feelings that are a problem for them. Once aware of these thoughts, they are taught techniques to get these thoughts under control. Though often effective with bright, cooperative people like Claire, this takes practice and time to learn.

When I was in my last year of medical school, my research work with pain control for cancer patients helped me win a brief fellowship for a training course run by the New England Society of Clinical Hypnosis. Though the workshop I attended taught the use of hypnosis with adult patients, it’s something I sometimes use with children. I suggested to Claire and her parents that she might benefit from some relaxation techniques, and some guided imagery whether through meditation or self-hypnosis (which I could help her with) could be helpful when she was in a stressful situation.

Aerobic exercise can also be helpful for mood disorders including anxiety and depression. If she could find something she liked, it could be therapeutic for her.

An anti-anxiety antidepressant medication could be very helpful. Its big advantage is that it might work right away to help relieve some of the worst symptoms and make her feel better, so she’d have an easier time making some of these other changes.

But none of these ideas, even if they help her, will give her the skills she will need for life. So we would still need to change the way she organizes her day and her assignments and her life. I suggested getting at least a week’s worth of assignments at a time from each teacher, and immediately entering those assignments onto an online calendar. That way, she’d never lose them and could check them from anywhere—and so could her parents.

This is a new concept for this teenager and her family. More updates to come.

The photograph is from my collection and is by Richard Avedon.

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