December 4, 2009

Looks Like an Attention Problem: Part 1

The official diagnostic criteria for ADHD require that symptoms start before age 7.  In boys, particularly the hyperactive ones, they usually show up in my office while still in elementary school.

So I was skeptical when I met Franklin, 15 years old and brought at his own request for an ADHD evaluation.  Most kids don’t think there’s something ‘wrong’ with them.  Parents are reluctant to think this too, and most don’t want to think that their child might benefit from medication.  So in the context of both patients and parents reluctant to get this diagnosis, I couldn’t help but wonder if this teenager had a substance problem.

Indeed, his mother admitted that he had been requesting this evaluation since 7th grade, but his grades had been good and his mother couldn’t imagine that something could be wrong.

But I have to admit he looked the part.  Rail-thin, and constantly in motion.  When his knee stopped moving, his fingers would tap.  He fidgeted constantly in his chair.  I asked about what his classroom work was like and found the same classic answers.  He could do the work, but often forgot that there was an assignment, forgot to hand in assignments he did, and never knew when there was going to be a test.  His mother bought him an organizer.  Then another and another as he lost them in series.  When asked about a family history, she took the opportunity to  tell me that his younger sibling had no such troubles, and excelled in school.

In his favor, he hasn’t been a conduct problem.  He wasn’t constantly being sent to the principal’s office.  I sent them home with questionnaires for parents, teachers, and Franklin.  But before they left, I told his mother that I wanted to talk with him privately.

As fidgety in private as he was with his mother in the room, he told me that he was frustrated by attention issues.  He wanted to do his homework, but every time he sat down to do it, he’d end up in another part of the room, doing something else—within just a few minutes.  But the more he described the attention issues, the more his voice changed, and his face changed.  I asked him about depression symptoms, and he paused.  He thought he was depressed.  I asked if he thought about suicide.  He said he did, but didn’t everybody?

The questionnaires came back with a clear concentration of attention problems.  When I asked them about his attention symptoms, they clearly did start long before he was 7.

Though I think ADHD is too casually diagnosed and managed too haphazardly, it has been treated and studied for decades.  So there are really good data showing that careful medication improves just about everything.  Unmedicated teens with ADHD have higher rates of dropping out of school, substance abuse, suicide, failed relationships, teen pregnancy, and many more interactions with the criminal justice system.  So for the right person, in the hands of the right doctor, these medications are life-changing and are extremely effective.  Franklin’s core attention symptoms were so focal that I thought he would really benefit from a medicine that addressed these symptoms directly.

But I told him directly that the fact that he had been able to get by in school so far made me very optimistic that we’d figure out the attention part at some point.  But at this moment, I was most concerned about his depression.  I told him that I wanted to treat that first, and when the depression was under better control, I’d focus on the attention.  With his permission, I explained the plan to his mother.  He looked tremendously relieved.

In Franklin’s case, his attention symptoms were quite specific.  He was impulsive, forgetful, disorganized, hyperactive, and unfocused.  It would have been easy to treat this directly, and probably would have helped him feel better.  But I was worried about him, and that makes all the difference.

Depression, unlike Franklin’s attention problem, is not a focal problem.  It’s a pervasive stain that taints all the aspects of a persons life.  When you’re depressed, things planned for a couple of weeks in the future just don’t matter.  So they lose their importance.  If you don’t think that your life is going anywhere in 5 years, what possible meaning could the test in school have for you?  Why would your homework matter?  And if your class lapses even momentarily into boredom, paying attention to anything else seems like a perfectly logical choice.  As depression gets more severe, this time horizon gets closer.  When it doesn’t matter what happens that day or that hour, there’s not much that will motivate you to organize a whole semester of assignments.

I prescribed an antidepressant, which fortunately took effect within days.  If his mood stabilizes, I’ll start him on an attention medication.

The photograph at top is a portrait by Felix Nadar, the finest French portrait photographer of the 19th century.  It's of his son.  Except, perhaps, for his clothing, it is certainly a completely modern photograph.  It is in my collection, and used to belong to Andre Jammes.

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Please let me know what you think. Do you know a child or situation like this?