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.

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