February 26, 2010

A First-Grade ADHD Story

bart_simpson_s01e02_I-will-not-waste-chalk There was no secret about Sean. when Mr. Dickson took over the first-grade class after the original teacher had to leave for an operation, she had told him a little bit about every student. So he knew what to expect about Sean.

And so did his mother. She telephoned me in tears about 3 weeks after Miss Maclean left and Mr. Dickson took over. Sean was saying he was sick every morning, didn’t want to go to school At the same time, Mr. Dickson had called her about every other day, complaining about Sean’s behavior. He wasn’t getting into fights, wasn’t hurting anything or anybody, but was spending a lot of the time joking with his friends, making silly noises when the teacher’s back was turned, making silly drawings, writing silly notes, and basically just being silly.  He is very fidgety, and never sat still on his chair.  This was, if anything, getting worse. It was becoming a real management problem for Mr. Dickson in the classroom. During the most recent phone call from him, he suggested that Sean might benefit from ADHD medication and urged an ADHD evaluation, as he put it, ‘ASAP.’

Sean’s mother, perhaps feeling a little defensive, asked Dickson why he thought it might be that for the first half of the school year she had not received a single phone call about her son, but since he took over, she’s had at least 10. Maybe, she suggested, he was not doing something that Maclean had been doing, or wasn’t doing something she used to do.

I asked her some neutral but important questions. Was he doing his assignments? Was he handing them in? How did he do on quizzes? How did he get along with the other students? Did he get in trouble during recess when he was running around outside? Were any of his standardized test scores available? She told me that he was popular and had lots of friends, all his assignments were up to date and he seemed to breeze through his homework, which seems completely unchallenging to him. His standardized test scores put him fully a grade-level ahead of where he was. when mom asked him why he talks in class, and why he gets in trouble, he says that he’s bored.

She told his teacher, Mr. Dickson, that Sean says he’s bored. He responded that there was no way to manage a classroom full of first-graders if some students were off doing stuff on their own. He went on to note that Sean seemed particularly unimpressed by the loss of certain privileges in the classroom. He asked for advice on how to ‘control’ him until he starts taking ADHD medication. This was all quite upsetting for Sean’s mom, so she telephoned me.

I have been Sean’s doctor since he was born. I have been the doctor of Sean’s 3 older siblings since they were born. I have been to his home many times for house calls. His family is intact and loving, but with 3 older siblings, there’s no point in getting too attached to any particular toys or objects--the whole concept of ownership has to be flexible.  At home, all the kids play with all the toys. For Sean in particular, who has never been a materialistic kid, this weak attachment to things makes them poor tools for discipline. His parents have mentioned to me that taking away his access to any particular toy just isn’t an effective way for them to get their point across.

Having been the doctor for him and his siblings for many years, and coincidentally having some expertise in ADHD and child behavior, I didn’t hesitate bringing these issues up to his parents when they became obvious in my office some years ago. I asked his mom if she thought he was more active that his 3 siblings. I already knew that he interrupted a lot, couldn’t sit still, seemed always to be in motion. So I don’t think that mom was insulted, exactly, when Dickson brought up ADHD. I had brought it up to her years earlier. But I thought she was right to mention that this wasn’t a problem until the new teacher showed up.

So I thought Sean was a little hyperactive, had some impulse control issues, was often interrupting and talkative. That does indeed sound like ADHD. But he had some important compensatory skills. He was very intelligent, and had excellent reading ability, a good vocabulary, and could speak in a surprisingly articulate way. He was also funny and warm and the only people he had occasional fights with were his siblings. Because of these positive traits, he had friends at school and did well in his schoolwork. Sure, he had an attention-deficit. He had hyperactivity. (That’s ‘ADH’ if you’re keeping track.) But the ‘D’ for disorder didn’t really start until the new teacher started.

As I have written before, this is an essential part of the diagnosis. Just because you might have every other trait associated with ADHD doesn’t mean you need to be on medication for it. If, on the other hand, your life is crumbling, is it because of the ADHD or something else going on in your life?  Maybe a new teacher in the middle of the year?

Among the most important skills for a doctor is listening. There was one important person I had not heard from yet.

Sean could not sit still. He made good eye contact when he was speaking to me, but not as good when I was speaking to him. When we were talking, he had no problem staying on his chair.  His answers to my questions were completely focused and appropriate.  But he was a little fidgety. When I asked him why things were different with Mr. Dickson--something he said that no one else had asked him--he told me. He said that Miss Maclean had let him get up from his chair and go to the back of the room and work on stuff when he got bored. Mr. Dickson not only doesn’t allow that, but enforces infractions of his classroom rules by taking things and privileges away from Sean. According to Sean, this doesn’t make him angry, it just confuses him. He didn’t understand why his teacher would take away stuff that he didn’t really care about. It’s true he joked around a lot in class, and he knows that he’s not supposed to, but class is so boring for him when he often has nothing to do. He usually finished his classwork early and it was hard for him to sit with nothing to do as he waited for the rest of the class to catch up. He got in trouble for getting up out of his seat, for looking for something to keep himself busy. He repeated the definition to me, together with his conclusion. “I don’t like being bored.”

Who does?  In the next post, I propose an intervention.

February 23, 2010

Ethical Dilemma: Do the right thing or keep the patient?

Robert is one of my troubled teenagers.  To him, his parents seem outrageously restrictive and inflexible.  No particularly innovative insight is needed to recall the times in ones life when parents seem less like a tugboat, pushing and pulling us ahead, and more like an anchor, holding us behind.  He came to me for an ADHD evaluation, in the course of which I noticed his itchiness, and thought he should get some allergy testing.

For most of his 15 years, his family moved every few years as dictated by his father’s diplomatic career.  Now stationed here, his European parents have lived all over the world.  They had just begun a stay in Thailand when Robert was born.  He was scrawny then (as he is now) and became jaundiced.  I have written previously about jaundice in a newborn.  Though his parents didn’t remember the levels in his blood, they were told that his jaundice was quite serious and that the baby needed a blood transfusion.

The idea behind transfusion for this problem is simple enough.  If we take out the blood that’s packed with bilirubin--the natural breakdown product of hemoglobin that can build up in the blood--and replace it with blood without bilirubin, then it’s much less likely that bilirubin will get deposited in the baby’s brain.  It’s the treatment of last resort, and his mother was told that it was necessary at the time.  This is 15 years ago, remember, and technology has improved since then.  Even so, I’m not experienced enough in international medical practices to know the level of vigilance used to screen donated blood in most of the world.

When I proposed doing some blood tests for allergies, given his history of itchiness and runny nose, his mother asked if I could do a test for Hepatitis.  She told me about the tranfusion in Thailand, and I added the blood test to the laboratory order form.  His test result indicated that he had been immunized against Hepatitis A and B.  The test was ambiguous for Hepatitis C.  I looked up his specific test result, and the references I looked at said that he should get a follow-up test or two to be sure he didn’t have it.   This didn’t seem ominous to me, just something that needed to be done to be thorough.

I called his parents to discuss the tests, and mailed them copies of the test results and a printout of the reference interpretation that indicated the necessity of another test.  I tried not to make a big deal out of it--but I was clear about what needed to be done.  I asked his mom if she wanted me to mail her another lab form or if she’d pick one up in the office.  She said it would have to wait.  She explained that it would have to wait until we do another round of allergy or other blood tests.

She asked me not to tell him about the test.

Huh?  It’s not like the lab sucked a half-dozen tubes of blood out of his arm without him knowing about it.  She told me that he doesn’t know anything about the transfusions, the jaundice.  Somehow, she said, it never came up.  I was confused--wasn’t he there when I filled out the lab form?  Where was he when his mother told me the story about the jaundice?  I couldn’t remember.  During the long visit, he got up to go to the bathroom.  Was that when she told me the story about him as a baby in Thailand?  She never told me not to tell him anything, and I just assumed….

I was silent for a long time on the phone, and she asked if I was still there.  I do not withhold anything from my teenage patients.  Already struggling with trust issues (parents usually try to convince their teenagers that sex is lousy and nobody should think about it), I have found that the only dependable way to establish trust with a teenager is to be 100% open with them all the time.  If they want to keep something from their parents, I try to use my best judgment to support them or to explain why I disagree and push them to do the right thing.  I am always very clear about the secrets I cannot keep, such as those making me fear for the child’s safety.  It doesn’t work the other way around:  when I am occasionally asked by a parent to keep something from the teenager, I just say no.

Many times, for example, I have been asked by a parent to test a child for drug use.  I tell them that if they want to find out if their kid is using drugs, ask the child directly.  Perhaps surprisingly, many teens will be quite honest about it.  If they aren’t, the parent might want to try another tactic.  But I am the child’s physician, not parole officer.  [There are circumstances, most of which occur in emergency rooms, in which a drug test is sometimes done without consent.  That’s true for adults, too, by the way.]  I have never tested a competent teenager for anything without telling them about it.  I felt manipulated by the mother.

I told her that I thought this was a bad idea.  If he had hepatitis and she (and I) knew about it, surely she would tell him.  She agreed with this but noted that if he didn’t, why should he have to worry about it?  There’s usually only a few days between lab test and result, I pointed out.  That didn’t seem like a lot of worry. 

I looked at it a different way.  If he didn’t have the disease, yet found out that we had tested him for it, the trust I had built with him would be gone, and could never be re-established.  And the trust of his parents would be a mess.  I told his mother that this was a dangerous plan from the point of view of her relationship with her son.  She said that he was already unhappy, and didn’t think he could handle the anxiety.  That upset me.  Many studies on adults clearly show that the paternalistic witholding of bad news is universally counterproductive.  Paradoxically, it increases patient anxiety (we tend to fear worse scenarios than the actual bad scenario), and damages the relationship between patient and whoever it is who was supposed to be telling them the truth.  Often that’s a doctor, but it might be a family member.  So her assumptions about how this bright, sensitive teenager would take the news either way was simply misinformed.  Inevitability is the elephant in this room.  Even if I don’t tell him, he’s going to find out.  Maybe not today, not tomorrow, but someday he will.  And when he does, she may lose him over this.  Who is she really protecting?  His delicate sensibilities or her denial of a lifelong lie that she would now have to confess to her teenager?

Getting to the point, I am  screw ed.  If I take it upon myself to tell him, she’ll fire me and the damage to the relationship that his mother fears will come about.  If I don’t tell him, I am facilitating this lie and being bullied into doing the wrong thing.  And when he does find out, I’ve lost him just the same.

I did my best to convince her to have a heart-to-heart with this nice boy and apologize profusely for her mistake.  With the troubled kids I see, they get themselves into this same situation all the time.  They don’t do the big project for their least-favorite class, but say they did it, thinking that they will catch up in a few days.  Then it’s a week overdue, then a month, then suddenly mom and dad get a call about summer school.  Maybe we’ve all been there, maybe there’s a MasterCard with our name on it about which this all seems hauntingly resonant.  It’s the human condition, and I was sympathetic to her situation.  But I was angry about being pulled into it unawares.  I was tricked.  How can I trust her in the future?  How can her son?

Now what do I do?

Please comment and let me know what you think I should do.

February 19, 2010

The Coming Wave: ADHD

wave hokusai Currently, to get an ADHD diagnosis you need more that just a problem paying attention.  You also need this problem to be causing problems in your life.  I have discussed this many times in the context of many cases.  I’ve described a couple of times giving a ‘test’ for ADHD to a lecture hall at UC Berkeley filled with overworked premeds, and how most of them qualified for the diagnosis by that test.

I read an article about planned changes in the criteria for diagnosing ADHD.  The article quotes Dr. David Shaffer of  Columbia University saying
“We really separated ourselves from the rest of medicine by saying you couldn’t have a disorder unless you were impaired.  We all know that there are some people who persist with a very active and unimpaired life even though they have very severe illness.”
He explained that the current way of making the diagnosis was not consistent with the way most other diseases are managed.

He’s right, of course.  There are, perhaps, millions of adults in this country with Type 2 adult-onset diabetes.  It means that their blood sugar gets abnormally high when they eat sugary things, and simple starches like bread.  But for many of these people, they can control their sugars with a disciplined diet, weight-loss, and exercise.  Certainly, they still have the disease.  No doctor would say they are cured.  But they have no symptoms, and get through their daily lives without incident.  Another common diagnosis is asthma.  You can have it, but have no symptoms for years and only under certain circumstances.  And who would claim that someone who is in a wheelchair and clearly cannot walk is therefore somehow ‘impaired.’

Impairment is relative, of course.  Some of us can’t reach a high shelf, and others can’t see what’s on it.  But human ingenuity being what it is, we mostly can get by despite our inabilities.

I am asked to evaluate many kids with genuine attention problems.  If they are intelligent and creative, and perhaps if their focusing problem isn’t too awfully severe, they develop compensatory skills.  Maybe they can recall what the teacher was saying even while looking elsewhere.  Maybe by making lists of things to do, they keep from falling behind.  Maybe by bringing a carton of pencils brought from home and left in class they will never be without one.

pen-horizThis is a picture of the pen that I have carried and used every day for about 3 or 4 years.   Pretty nice, huh?  I used to lose pens constantly.  Then I received a really nice pen as a gift.  I didn’t use it for a long time.  Since I lost pens all the time, sometimes after a single use, I didn’t want to risk it.  Am I absent-minded?  A close friend convinced me that life is indeed short, and that I should use the pen.  At first, I was obsessive about it.  But I use it so often that it didn’t take long for me to stop thinking about it.  I have not lost it in years.  Am I absent-minded?  Maybe those cheap pens just couldn’t afford the writing-utensil-LoJack part of my brain, which was there all along when it was important enough.

Yet I worry a lot about this particular change (not officially coming for a couple of years, I think).  I have chronicled many cases of kids who clearly aren’t paying attention like they should.

So what?

I don’t think paying attention matters.  Quote me on that.

I have heard parents complain about it, and seen teachers reduce a kid’s grade because of it.  If they fidget in their chair, does it matter?  As I deconstruct ADHD, it’s not the same as having diabetes or asthma. 

As with most of our inner lives, as with our homes, the problems which require fixing are the ones that interact with the outside world.  You want to live in a messy, dirty house?  I don’t think anybody would care as long as you showed up to work on time and did good work.  It may be distracting for the teacher to see a student chronically staring out the window or doodling in her notebook.  But the rubber doesn’t hit the road at all if the homework gets handed in on time and well done, if the projects and exams are good.

This is an issue familiar to the Human Resources manager at your company.  Good management and good morale are based on clear goals and criteria for success.  If you achieve those goals, you should be rewarded.  Notwithstanding legal issues, if the manager doesn’t like the way you look or dress or stare out the window, tough luck.  Even so, we work and interface with others, so nobody gets a free ride in an office or school setting with general hygiene issues, or being disruptive in some way.  That hurts others, thus requiring guidance if not intervention.

In the case of Kyle’s ADHD, I got the impression that the insidious annoyance of a tapping pencil was what pushed his mother to seek out professional help for him.  But when it got right down to it, he was doing as well as he was willing to do.

It may be with best intentions that you encourage your child to start work on the big project earlier than the night before.  And I would support you if this pattern had an impact on the outcome.  But what is it, exactly, that you want?  Do you want your child to get good grades?  Then decide what you mean by that and let them go after it, always with the offer of help and support and suggestions.  If you want your child to stop staring out the window, close the shades.

Here’s what will happen when the impairment criterion is removed:  everybody will have ADHD.  Everybody normal, that is.  [Boy, I don’t use that word much!]  Think about who, until about age 15 or so (or maybe 90), is not fidgety and distractible when having to sit still and do repeated tasks without interruption, pay no attention to their friends and classmates who are not so attentive, who focus on the teacher with laser-like intensity and who sit quietly during any pauses.  Picture these kids from when you were in school.

Say a parent brought such a child to me, as many have over the years, and told me that they’re doing well in class but eat lunch alone, that they don’t have a best friend, that they aren’t part of a group.  Luckily, the same general group of academic experts helped to categorize these kids some years ago as having autistic spectrum disorders.  Normal intellect, normal communication ability, but weak in social intuition, inept in social skills, maybe thought of as ‘different’ by their peers.  Recall, however, that the creative and technology industries are filled with distractible, interrupting, socially inept people.  They are warm, loving, and have sometimes done quite well for themselves.

Maybe you are ‘on the spectrum’, maybe you have an attention deficit.  But when this change comes, the number of kids so identified will explode, and we will see a massive hunt for the culprit.  Vaccines?

February 16, 2010

The Knowledgeable and Empowered Parent

raphaellas help note 1-16-10 Last night I went over to the home of a couple of my patients to drop something off.  The dad greeted me at the door and said that his daughter had something for me.  The 7-year-old gave me the picture above.  Impressed as I was, I asked her why she chose this subject.  “Because we were really sick!  You could have made us feel better.”  But I didn’t know anything about it.  Her parents had never called.

Much of what I write about could be called parenting.  Hopefully, the cases I describe are instructive in some way.  It’s logical that a first-time parent will learn more new information than a more experienced parent, who have seen and experienced so much.

Indeed, part of my Slow Medicine practice model (described in parts 1, and 2) is taking the time not just to engage with the child but also the parents.  I want to make the parents feel like an essential part of the health apparatus applied to their child.  In what I call the ‘factory model’ of medical care currently being practiced, patients are nameless widgets whose crucial function is to be passively processed as quickly as possible.  Above all, they can’t be allowed to slow the velocity of throughput.  I want to take the time to explain things to parents, describe my approach to the problem and what the options are as I see them.

Over time, however, I have discovered an unexpected aspect of this method.  Empowered families feel empowered.  Strangely, this hadn’t occurred to me right away.  I did realize that from the payer’s point of view (the insurance company), it was an absurd and obvious false economy to push patients to be seen as quickly as possible.  Though it might cut insurance expenses this month or this quarter, over time each patient would have to come in again and again for their one or several problems.  Teaching them to manage their own care better will save both patient and insurer a lot of real money.  Keeping patients out of ERs would save even more.  This post, however, isn’t about the counterproductive financial incentives of our dysfunctional system, and the ways it doesn’t work.  This post is about the system I came up with, and how it does work.  I want to be up-front about the economics, however, and get that out of the way.  Like every primary-care physician, I am paid per visit.  No visit means no pay.  It may be true that if you give a man a fish you feed him for a day but if you teach him to fish you feed him for a lifetime.  Still, it seems strange to run a fish store with a tuition-free fishing academy.

(As an aside, when I was in Business School a few decades ago, piecework was considered so obsolete and ineffective a model of employee compensation that it wasn’t really covered.  I couldn’t have guessed that one day I’d be living the dream.)

In The Telephone Paradox, I note my experience of changing people’s behavior just by answering the phone.  Not so much but what I say, but just by picking up.  As parents came to believe that they really could reach me directly at any time, nights or holidays, they actually called less.  They came to see that since they could always call if the child got worse, they could wait and see for a moment.  Given the opportunity, many of those sick children did get better on their own, and so the parent never actually called the doctor.

My practice is populated by a very diverse group of families.  Many of the nurses at the nearby hospital bring their children to me, along with many of the physicians.  They all know lots of things that I don’t know.  As the parents in non-medical fields become more educated and empowered, by me and by their own experience, they too make a lot of their own treatment and diagnostic decisions.

‘This is what I wanted!’ I sometimes have to remind myself.  A group of smart, independent-thinking, empowered parents who can handle a lot of routine medical issues.

The problem is, they don’t come to the office.  When the children get sick, these parents are rightly self-assured that they can handle it.  They were carefully instructed by me about the method and purpose of treatment, and what to watch for.  Besides, they know they can call me at any time.  I’ll always see their child the same day, even if it’s at night or I have to come to their home.

As it turns out, I’m not sure this is really ideal.  I worry about parents being a little too confident, and missing some important aspect of the child’s condition.

I also worry more about missing patterns of illness that I might pick up over time, by seeing when or how often certain symptoms were happening.  In the case of Tammy, her horrible rash kept appearing on Mondays, a day after visiting grandma.  There are many medical problems that are identified by pattern-matching, and like a pixelated picture, more data produces a clearer image. 
Surprisingly often, I see a child in the office with the following dialog.
“It’s nice to see you.  How have things been going?”
“Great,” says the parent.  “She’s been really healthy.”
“I’m glad to hear it.  So what brings you in today?
“Well, she’s been coughing a lot at night.”
“For how many nights?”
“I don’t know exactly.  Maybe 4 or 5 months.”
There are important, unspoken—and mostly unstudied—aspects to medical care and the doctor-patient interaction.  Her parents may have been right in deciding that they knew how to handle the illness and I wouldn’t have changed anything.  But for children (and this is true for many people of all ages), going to the doctor helps to make them feel better.  I think it’s one of the reasons that people sometimes complain when the doctor never examined them or listened to their heart, even if they are there for an unrelated problem.  I think there’s a real therapeutic value in physical touch and just listening attentively to the patient’s complaint.  So although her parents may have been precisely right about the appropriate therapeutic intervention, and maybe I couldn’t have made the child get better sooner.  But they didn’t see that maybe I could have made her feel better sooner.

Perhaps this is why doctors and nurses bring their kids to me.  I may not know more, but I’m the doctor, and that gives them permission to be mom and dad.

February 12, 2010

Honesty vs.. Hope: An Ethical Dilemma

Lupus pilum mutat, non mentem

At our last visit, Franklin spoke to me in private.  “Will it get better?” he asked

“Will what get better?”

“My parents.”  His parents had recently been suggesting to him that his antidepressant medication cost should come out of his allowance and if he were more like his two younger brothers, star athletes and students, he would be costing them a lot less.  He needed to get away from them any way he could.  He played X-Box video games.  Given his ADHD, this was the perfect escape, and would hold his attention for hours.  But this bothered his parents quite a bit.  They didn’t feel like they were being responsible parents if they let him play video games for hour after hour.  So they decided that he was to play no more than 1 hour.

Most parenting authorities would agree with this restriction, I think.  I, too, think that it’s reasonable for parents to restrict the amount of time a kid is playing video games.  It’s reasonable to limit the time to 1 hour. 

But I know something else:  it’s completely arbitrary.  Yes, there are studies that show that increased screen time is correlated with obesity, social dysfunction, and other problems.  But at what duration do those problems suddenly occur?  Nobody knows or has looked at that.  Is 15 minutes safe?  What about 120 minutes?  Because I believe television is a drug, how much of a dose will cause some effect, and what dose will cause trouble?  Franklin may not have been familiar with the research in this field, but he know in his gut that the 1-hour limit was arbitrary, and that his parent picked it out of thin air.  He also knew that he was unnaturally thin, didn’t snack, got plenty of exercise, and that whatever social problems he had weren’t caused by his screen time.  His parents made another mistake.  They insisted that he reduce his video game time by hours.  They didn’t offer him any alternative ways to spend those hours.  He was doing well in his classes, and keeping up with his assignments.

When he spoke to me in private, he told of many little remarks made by his parents.  They weren’t directed at him, they weren’t meant to hurt his feelings.  They weren’t insults or denigrating.  They were, however, part of the family lexicon.  He recalled this statements in precise detail, and I don’t doubt him at all.  Sometimes they came when a parent was talking on the phone to a friend or relative, sometimes it was a statement between the parents, and sometimes it was something said sotto voce to one of his younger siblings.  Franklin heard them all, and he knew what they meant.  ‘We can’t go because Franklin….’  ‘Why can’t Franklin be more like you?  You never cause us any trouble.’

Families have a jargon all their own.  Big companies have this, the military has this.  Sometime restaurants do, too:  Adam and Eve on a raft famously meant poached eggs on toast.  And wreck ‘em was added if you wanted scrambled.  When his brothers fought, sometimes one would call the other Franklin; a parent would smirk.

So he asked me one of the hardest questions I have been asked.  He asked if it would get better.  The easy way out would have been to say one truth, ‘I don’t know.’  I can’t predict the future, so I would have fallen back on that dependable standard.  But he wasn’t really asking me for a prediction, such as the dates and times for the coming apocalypse, for example.  Just as so many parents do, he was asking my professional opinion.  Based on my training and experience, my intelligence and intuition, what did I really think?  Would it get better?

This is an ethical problem, too.  Do I make him feel better or do I tell him the whole truth as I know it, not just a statement that happens to be an accurate ‘I don’t know?’  When I ask my own doctors if something will get better and they say they don’t know, is this the whole truth?

I knew a more substantial truth than ‘I don’t know.’  I knew from my own life and from the families I have known since childhood, from the families of my parents’ friends in their retirement community.  And I knew from the children I have seen grow from babies to high school students.  Most parents have told me that their teenagers ‘were the same way’ when they were infants, maybe easily frustrated or easy to comfort, restless or relaxed.  In this way, personalities can be surprisingly stable.

In Franklin’s life, I had become about the only person he opened up to.  It was a great privilege and he deserved more than facile answers.  I told him once that I would always be honest with him.  I said, “No, I don’t think it will get much better.”  I don’t know if this was what he wanted to hear.  If I had sounded upbeat and tried to assure him that it was going to get better, would he have believed me?  How long would he give that prediction to unfold if it didn’t get better?  I suspect he expected the easy answer, ‘I don’t know.’ 
Though this was my best professional assessment, rolled into a single No, it wasn’t the whole truth, either.  Dealing with some of the most difficult kids, I can say confidently that even when we can’t change the difficult child, we can change how we understand them and deal with them in ways that make those interactions much less frustrating.  This increasingly educated and empathic approach often helps a lot in reducing the number and intensity of explosions.  In Franklin’s case, I found myself with a type of role reversal.  I told him what I often tell parents of particularly problematic kids.  Pick your battles carefully.  If you know that something will provoke an explosion, then whose fault is it when the inevitable happens?  Change your expectations of them, and that will cause you to change your expectations for yourself.  Be the grown-up.

I reviewed with him the situations most likely to cause battles.  I asked him the same questions I ask parents of difficult children.  What was your last fight about?  Did you win?  If you did, was it worth it?  Did the child learn a lesson and now won’t do that ever again?  (The answer is always no, by the way.)  Do you feel good about it?  Does the child feel good about you because of it?  I ask the same follow-up questions if they didn’t win the fight.  If it wasn’t worth it, if nothing was learned or gained by it, would you like to do it again?  If not, then don’t fight about it.  It takes two to make an argument.  Be the grown-up, be the first to walk away and say you’re sorry.  You may lose a fight but gain a child.

In Franklin's case, I counseled him to play the grown-up.  I suggested that he try to predict what the battles will be about, and decide carefully if they will be worth it.  I'm hoping that just having a plan will empower him and help to stabilize his relationship with his parents.

The Latin proverb at the top of the page means The wolf changes his coat, not his disposition.  Readers need only look as far as their own aging parents.  Are they very different from when you were a kid?  Do they treat you or talk to you so much differently?

February 9, 2010

Kyle’s ADHD, Part 2

pencil tapping on-paperAt our meeting, Kyle was, at first, reserved. He wasn't angry at me, I don't think. Nor at his mom, exactly. But he wasn't happy with her for bringing him or having to have this conversation with a doctor. Clearly, this is something that his mother had brought up with him before and he had made his feelings on it clear to her.

I describe meeting Kyle, 13, in the last post. His mother was frustrated with him for underperforming his capabilities at school. His standardized test scores were generally much higher than his grades. While not in serious trouble, he had a lot of detention last semester for talking in class and lapses of attention. These lapses included failing to hand in some assignments, forgetting work and exams, and not paying attention in class. By all accounts, however, he was generally well liked by students and teachers.

Especially when doing homework, as the effort dragged out, his mother would watch him stare into space, tapping his pencil and leg in complicated rhythms.

She assembled data on his attention issues from teachers, from his father and from herself. She also secured for him some tutoring which focused on organization and study skills.

I clarified my position to him as soon as I asked his mom out of the room. I told him that I would tell him exactly what I thought, and that I would tell him first whatever I was going to tell his mom so that there would be no surprises.

What I learned when she wasn't in the room was apparent in the teacher comments. He didn't pay attention in class like he should, and was often socializing. He admitted not handing in some assignments, saying that he kind of lost track of them, not that he had real difficulty doing them. None of his teachers mentioned the pencil-tapping. He said he never really did that in school, it was just at home during the tedious homework time. He also pointed out that in the last couple of weeks he had been engaged in an after-school program, during which he nearly always finishes his homework. He doesn't socialize so much there pencil-verticalbecause most of the other students aren't in his class or aren't even in his grade. And they want to get their homework done, too. For these reasons, he felt that his problems were largely solved.

As promised, I told him the truth. According to the teacher and parent questionnaires, he met the arithmetic criteria for an ADHD diagnosis. His mother, he and I agreed, would probably like me to say that he had it and needed treatment. But there was no way I was going even to suggest treating him when he didn't think there was a problem. And I didn't want to suggest to his mother that it was necessary if I didn't believe it and that would only increase the amount of conflict between him and his mother.

But I didn't want to lie to his mother, either. So when she returned, I told her that Kyle definitely does have some traits in common with people who have ADHD—as we all do. He meets the numerical criteria according to the questionnaires that were answered about a month earlier. But I explained that many intelligent people with short attention spans and occasionally annoying habits have other skills that help them compensate for these weaknesses.  In Kyle’s case, he has now gone a full two weeks without a missing assignment or detention. He’s getting homework done after school, before he gets home. That alone will cure him of most of his school underperformance as well as the dreaded pencil tapping.  (Which seemed to bug mom more than anyone else.  In the previous post, I included a video of a high-school student whose peers appreciated his talent.)

Yet this was clearly an optimistic scenario given what has been going on earlier in the school year. The compromise I struck with Kyle in private was that he would agree to return in 6 weeks and revisit the issue. If his optimism were justified, he’d still be current with his homework and assignments and not spending time in detention. His grades wouldn’t have been lowered by penalties for missing and late assignments. If somehow things didn’t turn out the way he was anticipating, he might have to admit there’s a problem. His mother appeared pleased with this plan (I haven’t spoken to her in the few days since the visit, however). Kyle seemed OK with it, and I think he knew it was about as good a deal as he was likely to get.

Does he have ADHD? In some ways, yes. Last semester, definitely.  But if you have a problem that’s fixable with the diligent use of a day planner and some coaching, do you need medication? Should you get a diagnostic label?

Off the record, just between us (I didn’t tell him or his mom any of this), I have a different take on this. I don’t know if it’s right or not, and I only met this mother twice and the boy only once. I think it’s mostly his age and developmental stage, mentally and physically. I think 7th and 8th grades are difficult transition years. The teachers try really hard, but the boys are discovering more interesting distractions. Yes, the obvious. But also new and confusing rules of social standing. (For boys, the only typical constant is sports. Those few boys of nearly any age who are good athletes often have a natural peer group and image among their peers that is reasonably stable.) Kyle was like the majority of boys, perhaps. Searching for a place among his group, finding his people. This is also the age when aspiring to be part of the wrong group can be ominous. But that wasn’t him. The highest priority for him is his friends that will be his companions into adulthood, at least for this part of the journey. Bright as he was, he was still developmentally-stuck in concrete thinking that prevents him from seeing that the homework for 7th-grade History—that would only take him a half-hour and he should just get done, for goodness sake—will be dust under his feet long before he forgets the beloved friends he got in trouble with. When he told his mother that listening in class just wasn’t that important to him, she was shocked…but he might be right.

February 5, 2010

Charity, Haiti, and The Teachable Moment

ScreenHunter_02 Jan. 27 22.57

We all think of ourselves as generous.  Obviously, that can’t be right because we definitely think of some people we know as not being generous at all.  From their point of view, however, I’ll bet they would say they are very generous (as generous as they feel they can afford to be).  People who are more giving, in their view, aren’t more generous, they are simply foolish or misguided.  So an empathic perspective is that we each give what we feel we can.  We know there are those who give much more of themselves, and those who give much less.  I hope most people aren’t too judgmental about this, but I think we all tend to label people when we perceive a mismatch between what some people appear to have and what they appear to give.  We are unforgiving of those who seem to have a lot yet give little, and impressed by those who seem to have little yet give a lot.

Research in early child development has rid us of the antiquated idea that all babies are born as a blank slate, equal in capacity but either blessed or limited by their nurturing situations.  Let’s face it, some people are really good at math and some people find it really hard.  But this skill or weakness isn’t destiny.  With some sympathetic tutoring and lots of patience and practice, even the math-phobic can get through high school.

But how can parents teach important things that they themselves were never taught?  How can children learn concepts that don’t come in workbooks or sets of DVDs or in listings for tutors?

Empathy isn’t a course you can sign up for.  It’s a way of looking at other people and trying to imagine what it would be like to be them.  This is a teachable skill.  Empathy is a particularly human ability, and those that don’t show much of it are not well liked.  We are born with our brain chemistry wired for a particularly great amount of it, or maybe a lesser amount in some people.  Some have an intuitive skill and some don’t.  I’ve seen this in children:  some find it easy to sense a playmate’s feelings, and some seem oblivious.  Can we teach it?

Teaching children feelings is much more complex than teaching them behaviors or factual knowledge.  Each child is different in how their experiences affect their own feelings.  For this reason, talking to them about what they should feel is likely to be fruitless.  If they don’t feel sorry for the crying child in the park, your telling them they should will just be confusing, inexplicable, frustrating, or insulting.  If they do feel they way you think they should, then your telling them about it is simply unproductive.  It’s great to try and help your children get a vocabulary that helps them express their feelings verbally, so talking about feelings is an important exercise to do with your child, whether the feelings are strong or mild.

But how can we get them to see what they don’t?  How do we teach them to open their hearts?

Since I suspect we each believe ourselves to be appropriately generous—open handed but not profligate—I also suspect we want to instill these values in our children.  As with most behaviors, what we tell our children is mostly irrelevant and what we force them to do largely backfires.  So forcing them to give part of their allowance to some charity—no matter how worthy—when we don’t show them our paychecks and how much we are giving, is preying on their arithmetic naivite.  What happens when they get to high school and find out that you weren’t giving 20% to the poor, it was more like $20?  You will have created yet another reason that you can never undo for them to avoid calling you or visiting when you’re 70.  I wonder if, at that age, you’ll be thinking it was worth the money you saved.

To those not naturally inclined, we teach math through gentle encouragement, positive feedback, and practice.  And perhaps most effectively, through real-life examples.

The important aspects of life are there every day, all around us in our lives.  They might not lend themselves to school books, but they are everywhere.  If you want to teach your child something really difficult, like altruism or charity, master the teachable moment.

A teachable moment is defined (by me) as an important event that gets your child’s attention without direction from you.  It could be when he comes to you in the park and tells you that a child is crying.  It could be when she asks you where Haiti is.  Once the teachable moment is brought to you, it’s up to you what to do with it.  You can certainly show her where Haiti is on a map.  You could look it up online together and map its leading agricultural products by topography.  To me, that’s a teachable moment squandered.

She’s asking about Haiti because she hears about it on the news.  Maybe she’s seen some pictures.  Her words might be asking where it is, but she’s really asking why it’s important, why it’s on TV, why people are talking about it.  Tell her—she deserves to know, and will continue to come to you for these important questions.

ScreenHunter_03 Jan. 27 22.57
Here’s what I did.  I took some of the ties out of the top shelf in my closet.  Over the years, I have received many as gifts that for one reason or another I was never going to wear.  I hope I was always gracious about the generosity, but I knew I would never wear them.  The Garfield tie above..well, that’s obvious.  The Save the Children tie was nice, but not useful as a prop when I examine a preschooler.  I sold them on eBay, and designated 100% of the proceeds to go to Medecins Sans Frontières, an amazing group that was already on the ground in Haiti.  I donated the ties and the shipping and the fees for listing the items.  Anything people paid would go to MSF in Haiti.  They sold really well!  I’m also selling a camera lens I’ll never use.  Haiti needs whatever it will bring more than my closet needs a lens.

When your child asks you about Haiti, tell them that you want to help and ask her if she wants to help, too.  What does she have on her shelf or closet that she can give up?  She must make her own decision!  And she has to see you do it, too.  If you’ve never sold anything on eBay, now’s the time.  This is a real teachable moment, and it will make a lifetime impression on her to see you take a photo of the stuff and then write the listing.  It doesn’t matter if you only get a dollar.  The lesson isn’t about how much, it’s about identifying the feelings, then taking action.  There aren’t too many more important lessons than working with your child to make the world just a tiny bit better.  That’s incredibly empowering for a child, who often feels unable to change the world around her.  Besides, we both know how long that stuff has been in your closet.

February 2, 2010

The Tapping Teenager -- Part 1 of Kyle's ADHD case

While I nodded, nearly napping, suddenly there came a tapping,
As of someone gently rapping, rapping at my chamber door.

                                                                            --Edgar Allan Poe, from The Raven

I was asked to give a lecture at the local University about child mental health.  It’s a big topic and so I limited it to just a couple of examples that I thought would be interesting to the large class of undergraduates.  It was a big course of about 500 students.  I gave them a test.  Taken from an internet site directed at those adults who think they might have ADHD, it asked, I think, only about 10 questions.  Each was generally like this:  When you’re tired, do you find yourself reading the same paragraph over and over again?  I asked the students to keep track of their score as they answered the questions.  According to the directions of the site, I told them that if their score met a certain threshold score, they did, in fact, have ‘adult’ ADHD.  When I asked for a show of hands (realizing this was a clear violation of their medical confidentiality), at least 80% of the students achieved the diagnosis. 

They didn’t all have ADHD.  They were college students—staying up too late, too much coursework, too many deadlines, not enough structure, romantic entanglements, part-time jobs, and so on.

ADHD stands for Attention Deficit Hyperactivity Disorder.  In my experience, it’s easy to find and focus on the attention deficit and the hyperactivity.  When people are tired and have to do some reading, they will read the same paragraph over and over.  It’s how our brains work—or don’t—when we’re tired.  When we’re worried about something or depressed about something, we probably don’t have our best listening skills or make our most well-thought-out decisions.  So it’s normal for everyone to have an attention deficit in certain situations or at certain times.

For this reason, making the diagnosis of ADHD, for me, isn’t about an attention deficit or hyperactivity.  It’s about disorder

A worried mother called me about her 13-year-old son, Kyle, and wanted me to evaluate him.  I suggested that the family come in to talk to me and tell me what prompted this.  She said she wanted to come in alone first.

This is a bit of a red flag for me.  It often means that this parent feels strongly but another parent doesn’t.  Maybe the child in question doesn’t want to be seen about this.  If that’s the case, it could be because they don’t realize there is a problem or that they don’t want to help their parent do anything about it.  Either way, it’s tough on the doctor, the parent, and the child himself.

She came in and gave me all the appropriate questionnaires and supporting documents—school evaluations, standardized tests, and so on.  I took them from her and told her it might take me a week or so to get through them all.  But she summarized the problem and her concern.  She said that on most school nights he would spend a long time doing homework—sometimes more than 3 hours.  He wasn’t really getting that much homework, since he had the opportunity to do most or all of it after school.  It bothered her most that whenever she would check on him, he was staring off into space, tapping his pencil on the table.  Gradually, she observed him more systematically.  She thought that he appeared to be spending a great deal more time tapping his pencil or shaking his leg than on the homework.  This must be a problem because who would want to sit there and look around when he could, if he finished his work, doing something fun?  To me, it certainly sounded like it could be an attention problem.  She said that he had not been doing well in a couple of courses because of assignments not turned in, and that some of his teachers have mentioned to her that they often see him staring into space.  The child himself asked her if he might have ADHD.  She said that some people could find the constant tapping infuriating.

When I scored the questionnaires, he did meet the minimum score to diagnose ADHD, but just barely.  The comments by his teachers were consistent, and repeated again and again that he is casual about homework, prepares poorly, spends a lot of classroom time socializing, and is clearly not paying attention much in class.  I made sure to have a prescription pad available when he came in.

He didn’t want to come to see me—or any other doctor—about this.  His grades at mid-year were:  one C, one A, and a few B’s and B-‘s.  This was also a flag for me.  Where is the disorder?  True, his standardized test results suggested that he should be able to do better than this, but I thought this was pretty good for somebody who chronically got penalized for turning in homework late or who messed up on obviously unstudied quiz material.  I asked him about this, and he said that he consistently got A’s on important and bigger exams.  He was often graded down for not paying attention in class.  As I always do, I asked him questions about depression (he wasn’t), anxiety (wasn’t worried), substance use (didn’t), and why he thought that his mom thought this was such a problem.  He didn’t know.   During our conversation, he answered all my questions appropriately.  He was polite and seemed articulate and bright, though he didn’t volunteer anything not asked about.  He said that his parents had hired an ‘organization tutor’ to help him with some study skills.  This helped him a lot, he felt, and he was no longer behind on assignments.  He believed that whatever the old issues were, they were behind him.

He certainly didn’t think this was a problem or that there was anything wrong with him.  That was one of the reasons why he didn’t want to see me.  The other reason was that it was Friday night, and he could have been out with his friends.

I told him explicitly that he seemed nice enough, but we both knew how concerned his mother was, and I had to come up with some sort of conclusion acceptable to her.  He agreed in principle, and I outlined what I planned to tell her.  I cleared with him first everything I planned to say to her.

That will be the post after next.