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?

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.

Alan's Tears

Babies can’t tell what’s wrong with them, so it takes careful detective work, experience, skill and intuition to figure out if there’s a problem and where the problem is. They cry because it’s one of the main ways they have to communicate. Usually, that process is the hardest part from the doctor’s point of view. For many common problems, we have studied and have figured out what the best treatments are.

But Alan just turned 11. Though he’ll use a word or two with gentle prodding by his parents, he has almost no language. He understands a lot, we think, but exactly how much isn’t clear. It’s often difficult to get him in the car, and though he likes me, his parents and I try to handle as much as we can over the phone.

His father called, and told me that for the past several months, he’s been crying. At first it was just when he was at school, for a few minutes. Then it was at home also. Gradually, this behavior had increased to several times a day, for up to 30 minutes or more. He’d slump onto the floor and weep. When he did this, his facial expression was sad. His father said that initially he was very concerned that something bad was happening at school, whether someone was being mean to him or something was going on that the child didn’t like. But that didn’t lead anywhere after a lot of questions and meetings with teachers. It was only after that path had been exhausted that the father called me, wondering if Alan was in pain somehow.

One of my UC Berkeley students was observing the day that Alan came in with his parents. I examined him as much as I could, and found nothing physically to be concerned about. He was very interested in (and affectionate with) my student, and she was a good sport in letting him try to sit on her lap and climb on her back.

Alan’s parents explained that these bouts of crying seem to come without provocation, and without a pattern of time of day. He doesn’t hold his head or his stomach when they’re going on. Just talking about it made the parents and me sad. Was there some kind of bullying or abuse? Did he have migraines? They said that his teachers were very loving and there was no one at school that he used to warm up to but now does not. He still liked going to school. And it meant a lot to me that the expression on his face during these episodes was one of sadness.

After an hour of asking detailed questions, the most likely interpretation was that he was, in fact, depressed.

In fact, there’s some reason to believe that people with autism suffer at least as much as everybody else. Studies of those with autism spectrum disorders (with generally much less severe deficits than Alan) show they have higher rates of anxiety and depression than their peers. And those who are more socially isolated also have higher rates of depression. (By the way, it also seems to be true the other way around--depressed kids seem to have weaker social skills, more isolation, than their peers who aren’t depressed. Are social skills the product of the same gene that regulates depression? Or are depressed people just no longer interested in socialization? Or is it that people with poor social skills, being more isolated, end up feeling depressed about their isolation?)

At the big-picture level, an objective look at Alan’s life as an 11-year-old with severe autism is sobering. He has great difficulty making himself understood, and is not given a large number of choices to make. He really doesn’t have peer friends, though he has a team of loving adults he does care for. He is indeed isolated.

As I’ve said before, my job is occasionally to make a diagnosis and initiate treatment. But it is always to try and relieve suffering. I had no way to know for sure what was making Alan sad. But only a little empathy was needed to glimpse life from his point of view. I started him on an antidepressant.

Please see my urgent post on Swine Flu.

Eight is Enough -- All the king's horses and all the king's men

What do you do when you can't fix what's broken? My patients--and my readers--know that I take a practical approach.

There wasn't any way for me to repair the relationship between his mother and father. Maybe it will work out someday, maybe not. I couldn't force his father to call or visit. Indeed, this is just the way Max saw the situation. His family was broken and couldn't be repaired; his father was gone forever. Nobody ever asked him what he thought about it. This is why when you're 8, what happens seems inevitable.

Max was depressed. He had a lot of the same symptoms of depression that adults get. He was sad, cried sometimes without provocation, had disturbed sleep and eating, lost interest in the things he used to enjoy, and was more distant with his friends. Even so, I was optimistic. He hadn't always been like this, it's just been the last few months. Technically speaking, this was a reactive depression, a problem adjusting to new circumstances. But I couldn't sit back and watch this child suffer while waiting for things to happen—like his father calling, or his parents getting back together. That's the perspective of an 8-year-old.

I could help this child by sharing with him some of my power as a grown up. I also respected him in a way he wasn't used to. Rather than telling him what to do, or talking to his mother with or without him in the room, I suggested some positive actions he could take. First, I gave him permission to call his father, and asked him if he'd be willing to call every Monday, Wednesday, and Friday. He liked this idea and his mom said it was OK with her. I told his mom not to dial and not to remind him. This was completely Max's responsibility and he could do it alone. I made it clear that his dad might not pick up the phone or might be busy, but told him that he should leave a message every time he called. It gradually came to him that this might not bring his dad back. “What if he still doesn't call?” he asked. I told him that he could go shopping for postcards and that a couple of times a week, he would send his dad a postcard with a note on it, or a picture.

I had met his dad several times over the years, and knew this man loved his children. If getting a lonely message from your 8-year-old three times a week didn't melt his heart, I'm not sure I could come up with something better.

But here's the key step: moving the child from passive to active. This is a repeating pattern in my parenting advice. Taking a child, especially at this developmental age, and empowering them to take control of at least part of their lives, to give them tools that can leverage the influence they never knew they had. I knew that I didn't have the power to repair what was broken from the child's perspective—his family. But I did have the ability to fix his sense of helplessness, and push away the inevitability of the world.

I also had the ability to try and relieve the sense of sadness. We'll try a little medication, too.



Coming up: a series of posts on ADHD.

Eight is Enough

When you're eight, the world is full of inevitability. Your parents go someplace, and you are dragged along. Your teacher assigns homework, and it has to be done. It feels like everyone in the world has some kind of authority over you. Don't they know you have your own plans? Your own agenda for things that have to get done? Your own idea of what is most important?

Max came into my office with his mother. He gave me a hug hello but wasn't smiling. His mother told me that he said he wasn't feeling well and wanted to see me. She said that he wanted to stay home from school for the last few days, but couldn't say just what was wrong. She made him go to school, but wanted him to see me on Saturday. I went through the usual review of his symptoms with them, but he denied headaches and stomach aches and everything else. I asked if he had pain in his toes. I asked if he had pain in his feet, ankles, knees, legs, and so on up to his eyes. Finally, I asked, “does your hair hurt?”. This usually causes a pause to think and then a smile. He paused and his eyes started to tear up. His mother started to tear up. I started to tear up.

Luckily, my office is equipped with the latest in medical technology and there were tissues enough for all.

His mother flatly related that his father had moved out several months ago, and had just moved in with somebody else. His father hadn't seen Max for about a month. He stopped calling a few days ago. After saying this, his mother told me that she didn't know what was wrong with Max, that she was worried about him, she asked him what was wrong but that he won't talk to her. She wondered aloud if he would talk to me. She didn't ask either of us, but as she said this, she arose and said that she'd wait outside the room.

“Max,” I said, “do you miss your dad?” He nodded tearfully. “Does it make you sad that you don't see him?” At this point, the perceptive reader sees where this is going and I can't claim it was particularly insightful of me to see it at the time. The fact that his mother seemed genuinely in the dark about it was remarkable. Even though he was eight, I asked screening questions I typically ask dejected teens. Did he think about hurting himself? Did he think about running away? Finally, I asked him if I could tell his mom about what we talked about and about what he said. He said that was OK, and I invited her in.

Though mom was made sad by what I relayed to her, she was relieved that he opened up about it. Max was visibly relieved that mom now knew.

Max's younger sister was acting out a little more in kindergarten, but had not taken it so hard in an obvious way. But 8-year-olds can see the world in a bigger picture, and in this case as something that was broken forever. Preschoolers just want more time with mommy, and it's OK if she's shopping as long as they get to come along. Teenagers get to stay home alone.

Max told me that it made him sad to think that his family isn't the family he had when he was little. He said that he thought he would have that family forever and now it's gone. This made him cry a lot. Again, we took advantage of tissue technology. His perspective is an important one for parents in every situation to be aware of. To him, everything in the grown-up world is fixed for eternity. Until it's not, and then it's shattered. As adults, it's typically from about this age that emerge some of our most troubling memories of the relationship of our parents or the circumstances of our childhoods.

Next Post: Trying to help Max.


The photo from my collection is by Walker Evans and was taken during The Depression.