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?

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