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.

1 comment:

  1. I like your approach very much, Dr. Nadoolman.

    The way I see it, you've involving Kyle in the process and doing a bit of "motivational interviewing." This is a great technique for adults with ADHD, too, who aren't so keenly self-observant and might have defensive denial around their symptoms. It helps to draw their attention to the problematic behaviors and take "ownership" of them.

    If Kyle does have ADHD, he might be able to keep up the "new and improved" behavior for a while, but when the novelty fades, that's another story. As I'm sure you know.

    So, at that point, he'll have data that he did "try harder" and while it worked for a while, the motivation just diminishes over time. (The same happens with adults who have untreated ADHD, of course.)

    Your approach is infinitely more effective over time, IMHO, than a top-down ADHD diagnosis and treatment.

    I do still worry about the dad, though. If he has ADHD, it'd be so much better for Kyle if the dad got on board.

    Gina Pera, author
    Is It You, Me, or Adult A.D.D.?


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