Sean’s ADHD, Part 4: Sticks and Stones

In my many posts about ADHD, and many other kinds of behavior issues as well, I have described cases in which a lot of the things a kid did looked just like the kind of things that a kid with ADHD would do. (It is for this reason, I suspect, that so many kids get diagnosed with ADHD and get prescribed medication.) Sometimes another doctor will send the child to me because they have ‘failed’ treatment with standard ADHD medication. Careful, patient, and thorough investigation often shows me that the child’s attention problem is actually caused by unappreciated anxiety, unseen depression, itchy skin or itchy eyes, a vision or hearing problem, or a bully.

Some aspects of attention are driven from within us. In order to accomplish any task, we have to shut out sensory inputs from the world. There are many medical studies that show fairly conclusively that multitasking is a simple delusion. We don’t really focus on driving and talking on the phone and sipping our coffee all at the same time. We actually do them in sequence, one after another. Because we’re not spending a visible amount of time on one before moving on to another, the sequence is invisible and it gives the illusion of simultaneous action. In every waking moment, we multitask in the same way. We walk and talk, we look where we’re going, we keep our pants from falling down. (When people get impaired in some way, they stumble.)

In Sean’s case, I thought he clearly had some attention and hyperactivity issues. He will have to learn to restrain some of his impulses in certain situations--such as a classroom. He also needs to be respectful of teachers, even if they aren’t the best. But when I asked him about bullies, he denied this problem. Now I realize that I hadn’t considered the possibility that the bully could be his teacher.

His mom asked him if what the other parent wrote in the email was true. He confirmed all of it.

Even without physical violence, this is abuse. Sean didn’t know or understand that a teacher could be wrong, or could do something wrong. So when Mr. Dickson called him a ‘rotten child,’ he didn’t take it as an insult. He understood it to be a professional assessment, like a B+ grade, or advice that he needed to practice his arithmetic. Since he now understood himself to be a rotten child, he realized that this new identity afforded him a freedom from behavior boundaries that he had not had before.

The rhyme about sticks and stones is simply a lie. It is irresponsible to teach it to your child as a defense. It is curious to me that parents will teach this to their children as if they believed it to be true. Given, part of being an adult is knowing when not to respond to hostility or an insult, when to simply keep your feelings to yourself, when to appear noncommittal when you really do have strong feelings. Most people, maybe everyone, has lost friends, relationships, jobs and many other important things because of words. Believe as we do in freedom of speech, there is no freedom from feeling hurt by speech. If your son struggles in school, and a sibling called him stupid, what would you do? Would you teach him about sticks and stones? Is that doing your job? I’ll come back to this.

When a teacher, and especially a parent, gives a negative assessment of the way a child is, a scar is made.

There are 2 important points here. If your kid messes up, you don’t have to go through some self-effacing nonsense--just tell them how it is. It’s OK to tell them they are wrong, that they must never play with daddy’s drafting equipment, that they are not allowed into the street without holding a grown-up’s hand. You must never tell them that they are stupid, unattractive, incompetent, or that they speak funny. Never tell them that they are rotten kids—save this one for your toast at their weddings. Never even hint that you wish they weren’t born, or wish they were more like one of their siblings or cousins.

In a work environment, there’s a big difference between hearing an assessment that you need to improve the way you organize the files and hearing that you are disorganized. One is a skill you need to improve, and can try to improve. The other is a label that is permanently attached to you.

The second point is how you deal with the bullies in your child’s life.

In the movies, the caring father teaches the child boxing or martial arts, so that when threatened, the on-screen David can beat up a schoolyard Goliath, humiliating him or her and inducing a catharsis in the ticket-buyer powerful enough to provoke tears. While I have often admired the positive impact on a child when they study martial arts, for example, real life never, ever has worked like this even once. If there’s a child threatening your kid, physically or emotionally, are you going to sign the kid up for lessons? How many years will that take? And then when the bully gets the desired reaction, and your kid finally explodes with the righteous justice of any number of action movies, who will be suspended from school? What will the lesson be about fairness and right and wrong? When the bully is an authority figure, who does the child have who could compete with that? Who is more powerful than a teacher or a school principal who tells your kid that he is some kind of delinquent? Only you can fill this role.

It could indeed make the child’s school life more uncomfortable if you intervene on your child’s behalf. But that child will be with you long after this school term is a bad memory. Step up to the plate on the child’s side, and they will remember it for decades. If you don’t, they will remember just as long. Don’t measure your success by whether the child gets a new teacher, or is being sent to the principal’s office. Your success is in your relationship with your children, who have acquired the secure knowledge that you’re always there for them, you’re always going to stand by them against the bullies of the world.

Sean’s ADHD? Part 3: Dark Times in 1st Grade

Sean is a 1^st-grader who is bright and active and distractible. He’s also funny and talkative. Consistently finishing his classroom work before the rest of the class, he has been viewed as a behavior problem by his teacher. Even in my office, he is more fidgety than most kids his age. But I couldn’t get around the fact that for the first half of the term, he had a different teacher, with whom he never got in trouble. He didn’t sit quietly, exactly. The previous teacher gave him stuff to do to keep him occupied instead of bored. So even though I thought he might indeed have ADHD, I wasn’t ready to medicate him before figuring out why this became a problem as soon as the new teacher, Mr. Dickson, took over.

I re-evaluated Sean and he was just as before: fidgety, happy, talkative. But he never left the chair during a long discussion, and to each of my questions he responded with a full and articulate answer. As promised in Sean’s ADHD Part 2, I wrote a letter to the teacher. Here’s what I wrote:

Dear Mr. Dickson:

Sean’s parents asked me to evaluate their son, and to write you about some of my assessment. He’s a great kid and I enjoyed the time I spent with him.

As you know, Sean has been struggling somewhat in school. His distractibility, talking out of turn, and occasional disrespect have been issues for him. 

There’s no question that he’s an active child, with some of the motor traits of hyperactivity. He is also a bright child, who clearly understands and retains a lot of the academic material presented to him. It’s important to note that he is not uninterested in school work, and is curious and motivated to learn new things.

He has been disrespectful and sometimes even disobedient. Even so, he absolutely does not meet any of the diagnostic criteria for any disorder characterized by oppositionality, defiance, or conduct problems.

Though his hyperkineticism is longstanding, this has not caused problems for him until a recent change in his classroom situation. Thus even though he might be hyperactive when compared to most children his age, this hyperactivity does not mean that he has ADHD requiring medical treatment. In cases such as his, a behavioral approach will often result in the best outcome.

Sean has said that he is sometimes bored in class. He should be taken at his word. He is not very responsive to negative consequences, so these are of marginal value and might serve to frustrate him. A more effective approach would be to channel his energy in productive ways. If he’s done with his class work, for example, he should be able to access a ‘Bored Bag’ containing 4-5 quiet activities that he can do alone. It would be helpful if he chooses these activities from many choices given to him. 

From what Sean has told me, these might include:

• Some extra or more advanced math problems;
• Headphones and a recorded book;
• Coloring;
• Books.

It is essential that he be able to access these materials without permission, so he doesn’t interrupt you or the class. Ideally, he would also have the freedom to get out of his seat and walk quietly over to another spot, where he could work on some other task. I think he will be relieved to have this freedom.
These recommendations do not imply that he should be allowed to be disrespectful of teachers or disruptive to the class. Before starting this with him, you and his parents should meet with Sean and come up with a set of written rules. They don’t need to be extensive, but they need to be written. They should be simple and specific. For example, ‘you must not have a bad attitude’ is vague and difficult for a child his age to understand. ‘No talking during class,’ is something more likely to be understood. Taking away, as punishment, access to this Bored Bag or to recess—during which he gets to redirect some of that excess motor energy—would be particularly counterproductive. Those are the things that will keep him focused and motivated in the classroom. Try to enlist his help. If he’s fidgety and wanting to get out of his chair, there is no enforcement mechanism that will stop this. He doesn’t do it by choice and it not easy for him to control. Making a rule about him sitting still is setting him up to fail. If this is an issue, ask him to get up and do something helpful, then praise him for it. In this way, he will feel appreciated and not trapped.

There are certain things that ADHD medication can and cannot do. It can help some children sustain their attention, but it won’t do this if they have finished their work and are required to sit still with nothing to do. Indeed, none of us can do that.

Sean is a warm and kind child with a good sense of humor. He needs our help to plan what to do when he’s ‘bored’ and he needs the tools to work with that plan.

Please feel free to call me with your questions.

Only a day or two after mailing the letter, I received a forwarded email from Sean’s mother. She was active in the school, and received this note from a parent of one of Sean’s classmates.

Hello everyone,
I am sending this message because my son has reported to me some very disturbing comments that have been made to some of our children in the classroom.  I have not had an opportunity to speak with Mr. Dickson directly nor have I had the chance to inform the principal of this report because I was just made aware of this tonight. However, if these statements were directed to my child I would be very concerned! 

My son has reported to me that he (Mr. Dickson) told one child (Alice) that kids who talk too much in another country have their "tongues cut out". He said he told the child this because she was talking.    He also reported to me that he told one of the girls to sit her "fat butt" on the chair today when she was attempting to pick up her papers and color pencils off the ground.  He also told me that he often refers to two other boys (directly) as "rotten children" (Sean and Michael).  I am totally shocked that this man would speak to our kids like this!

I do not believe that this is a constructive way to reprimand children but it is a sure way to make them develop low self-esteem.

I am certainly not sending my child to school to be verbally abused by an adult.  I will be at the school bright and early Monday to speak with the principal about this.  The last thing we need is someone belittling our children.  Please speak with your children to confirm this. 

It is our responsibility to make sure that our children receive a good education in an environment that is conducive for them.

Suddenly, the pieces of this story started to fit together really well. More in the next post.

A First-Grade ADHD Story, Part 2

When parents ask me about ‘discipline’ they are generally thinking of ‘punishment.’ Though they might feel very uncomfortable with the concept, they associate a child’s naughty behavior with a supposed need to have the child associate their impulsive or destructive actions with some kind of negative consequence. The way I see it, this is very close to an eye for an eye metaphor of proportional response. If your kindergartener is jumping on the bed, that would presumably require a different consequence than if you found him at a pool table in a bar having just lost your next mortgage payment to a particularly unkempt-looking group of motorcycle enthusiasts with tattoos that seem somehow less decorative than meant to convey some kind of threatening message.

My patient Sean, a bright first-grader who is bored and distractible in class, is a thorn in his teacher’s side. He’s not difficult, exactly. He’s polite and helpful and isn’t a problem student. But every time the teacher turns his back, giggling erupts and it usually seems centered on Sean. His homework is usually 100% and he does well on both in-class tests and standardized tests. But the teacher doesn’t know how to punish him. Every time he takes away a thing or a privilege, it just doesn’t seem to matter to Sean.

Sean’s mother knows this, of course. In their crowded house with Sean and his 3 older siblings, the kids have learned that becoming too attached to specific things like toys is a setup for frustration and disappointment as ownership gets vague very quickly amongst the children.

There are children, just as there are adults, who are particularly attached to specific things. In helping a child establish a sleep ritual, for example, I often recommend finding a transition object--like a teddy bear or doll--which can provide some comfort and help the child relax. I bring this up at this time because it is one of the deep errors parents sometimes make when they are angry. If you must punish your child, temporarily take something away. Never take away the one thing that gives them comfort. When you do that, you leave them helpless against the world, which at that moment is you.

Just like many parents struggling with discipline, Sean’s teacher was blinded by the fog of action and consequence. Here’s a medical example. A person in an emergency room says that they have chest pain. Should they get some pain killer? The right answer is that it depends. The first thing we try to do is find the cause of the pain or problem and deal directly with that.

Parents (and teachers) often try a discipline method that doesn’t appear to work. The kid either ignores the discipline, or it doesn’t have any impact on the behavior they want to change. Under these circumstances, it’s a mistake to do more of what’s not working. In my line of work, if I try some sort of medication or treatment and it’s not helping, should I just give more of it? Maybe I should change the treatment.

Sean’s teacher tried taking stuff away from Sean, but Sean wasn’t attached to material things and this didn’t work. So his teacher took more stuff away. This just appeared as wacky to Sean, who was amused by his bare desk. His teacher felt that he had no other options but to place more and more restrictions on the child. These didn’t really control his talking in class. Without even a piece of paper or pencil at his desk, Sean had nothing to do except talk with his classmates. This appeared to Mr. Dickson as overtly defiant, requiring ever more intensive punishments and restrictions.

I haven’t spoken directly to the teacher, but it certainly seems that it was much easier for the teacher to escalate the situation than it was to try and figure out why it was happening.

I’m not proposing that you even try to do some kind of forensic psychological analysis when one of your kids smacks the other. A simple NO HITTING! will do. But if it keeps happening, it is absolutely your responsibility to figure out why. Besides, it will only increase your frustration with the child and the child’s frustration with you when you keep pouring on more of whatever it is that isn’t helpful.

What about ADHD medication? It might help some of Sean’s symptoms of distractibility and impulsiveness, as well as what looks to be a short attention span. But I just couldn’t get past the idea that he was doing great until this teacher showed up, and suddenly he needs psychoactive medication. As my readers know, I have no philosophical problem with trying to help a child with medication, if it’s appropriate. But if Sean’s ADHD was well managed by non-pharmaceutical intervention, maybe we should try that first.

So I came up with the following plan, for his mother to review with the teacher.

1. Stop punishing him in ways that are not effective.
2. If he says he’s bored, and his rapid and excellent schoolwork suggests he might be bored, and he’s acting like a kid who’s bored, consider the possibility that he is, in fact, bored.
3. Like the tree branch that bends with the wind, find a way to support his attention. For him, I have invented #4.
4. The Bored Bag
   a. Let Sean pick out not one but at least 3 or 4 or 5 projects that can be worked on quietly and by himself. Give him plenty of choices.
   b. He can work on these without permission.
   c. When he is bored, he can get materials out of his Bored Bag and work on them by himself.
   d. Avoid projects with many pieces or requiring power tools.
   e. Some choices could be reading or drawing something or looking something up or writing about something or working on problems that the rest of the class doesn’t get to do yet.
5. Sean’s doctor will write a letter stating, pretty much, the above. I will write that I have evaluated him, and suggest that in his particular case, the best remedy for his distractibility is likely to be distraction. Hopefully, the Bored Bag will allow this to occur without disrupting the class.

A First-Grade ADHD Story

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.

The Coming Wave: ADHD

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.

This 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?

Kyle’s ADHD, Part 2

At 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 because 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 7^th and 8^th 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 7^th-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.

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.

Looks Like an Attention Problem: Part 2

Like many kids brought to me because of an attention problem, Franklin turned out to be a more complex case.

I found out about his depression.  Not by being so empathic.  I found out because I took the time to ask him.  There were several important reasons for treating his depression first, before the ADHD that had been obvious to him and to me.  Depression pervades every aspect of life.  Until it’s gone, or at least improved, he wasn’t going to have the motivation needed to stay compliant with medication or new organization techniques.  And there was no point in trying to help him improve his school work if his suicidal thinking made school seem unimportant to him.  Through these and other mechanisms, depression itself reduces attention span, interferes with restful sleep, and weakens our most important supportive relationships.  Of course, I was deeply concerned about his safety above all. 

Dr. Wolffe’s Rule #11:  The Parent Unawareness Rule
Just because parents don’t know about it, doesn’t mean it’s not important to the child.

This rule applies to many of the hidden corners of every child’s life.  The bullying at school that will only get worse if a parent is told.  Maybe it’s the teacher who just doesn’t like you and singles you out.  Maybe it’s the coach who makes everyone else laugh at you.  Maybe it’s the popular girl who thinks you’re pathetic for even trying to speak to her.

In Franklin’s case, this is a serious rule.  Just because his parents were unaware of the severity—or maybe even the existence—of his depression, didn’t mean that it wasn’t the dominant issue in this child’s life at the moment.  This was clear when we first talked about it by the relief in his voice and on his face.  Somebody else—me—finally knew.  He was relieved when I told him I wanted to treat him for depression and that the treatment might help.  He was relieved, too, when I told him I wanted to tell his mother.

That was more than 2 months ago.  Since then, his depression has lifted, and he’s getting along better with everyone. 

I started him on a conventional stimulant medication designed for ADHD.  It made him feel sick and feel like his thinking was slowed, somehow.  I reduced the dose, but it still gave him stomach aches.

There are good things and bad things about the enormous number of psychopharmacological choices for a physician to make when treating common problems like ADHD (at least 13 or so different medications) or depression (at least 30).  With so many different available medications, there’s a good chance that one or several of them might work well for a patient without too many side effects.  On the other hand, with so many choices, it sometimes takes a lot of patience and trial-and-error to find the best fit for any particular person.  So if we try a medication for a chronic problem, and it doesn’t work, there’s still a reasonable chance that something else will work.  But if each medication requires at least a week or two or three, going through 20 medications could result in a year of suffering both from the original problem and a series of unwanted side effects.

I changed the medicine Franklin was on, and prescribed the lowest dose that is manufactured.  I prescribed exactly 2 pills.  If they didn’t upset his stomach or cause anything else, I’d write another prescription for 2 pills at the next-higher dose.  Franklin was willing to stick with it because of the dramatic change he saw from the effective treatment of his depression.  With this very cautious approach, we found something that helped his ADHD.  His mother seemed surprised when she told me that he went from all Fs to all As in 2 weeks.  He made up all the delinquent or missing assignments for every course.  This case, clearly, is a success.

But there’s something that I can’t treat, medicate, or fix.  In the previous post about Franklin, I noted that at our first meeting his mother said that his various problems weren’t in the family.  His two younger brothers were academic and athletic stars, she told me, and never caused problems at home.  Franklin heard her tell me this.  I watched him look defeated.  His mother didn’t see it, since she was talking to me.

Though his mother, an obviously very bright and caring person, was relieved and pleased by the improvement in her son’s depression, I’m not sure how much she shared with Franklin that she was happy he felt better.  When they returned to discuss the ADHD treatment, his mom continued to focus on his school failure.  At the most recent visit, it was clear that for her, a key criterion of successful treatment was the improvement in his grades.

It made me a little sad for Franklin that his parents openly compared him unfavorably to his younger siblings.  How did this make him feel about himself?  How did it make him feel about his parents?  How did it make his siblings feel about him?  And how did this make him feel about school?  These feelings probably contributed to his depression.  And it made me a little sad to think that he has been living in a crisis of hopelessness for at least a couple of years and the problem only got the attention it deserved because his grades were low.  Thank goodness he didn’t do anything really desperate.

Regular readers know that I don't think school grades are unimportant.  It's certainly true that those who excel at schoolwork can have certain doors open to them.  And when parents convey the message that school isn't important, children don't think it's important either.  But keep in mind that school performance is a measure of school performance, and doesn't say much about who that child really is.  So please don't let the school's opinion influence your opinion of your child.  The kid will thank you for it.

I don’t think this glass is half empty.  Eight weeks or so ago, I met a suicidal teenager failing all his courses.  Now he’s doing great, feeling great, and he’s back in the embrace of his parents.  Certainly, that’s success in my line of work.

But I still keep in mind Rule #11.




The photograph at top was taken by Alexander Leventon, and is from my collection.  It was probably taken prior to 1921 but it was printed, most likely, in the early 1920s after he had moved to the United States.  He was concertmaster of the Rochester Philharmonic from 1923 to 1944.

Visit to The Other Parent

We have the technology. At holiday time in particular, when school is out for a substantial amount of time, many of the children of divorced parents get to spend some quality time with the other parent.

A stepmother expressed her worry about this.  She said that  Luke, 13, is very excited about spending the holidays with his mom, who lives an airplane ride away.  She said that Luke has often said how much he misses her.  Despite this, however, she also notes that his mother doesn’t call, doesn’t write, doesn’t email.  His mom is not involved in his life.

Life at 13 is difficult.  On the one hand, kids this age can smell and taste the benefits of adulthood.  If we would let them, they’d drive.  So they see attractive things on the horizon that they believe they are perfectly capable of doing.  But they can’t quite figure out how to get from here to there.  They have no idea that to become a doctor (I get this question a lot), you actually have to spend a lot of time in classrooms and do a lot of homework.  Another problem that nearly all 13-year-olds share is concrete thinking.  You tell her to call if she gets out of school late.  She doesn’t call, it’s 8pm, and you have the police out looking for her when she walks in the door and asks what all the fuss is about.  ‘Why didn’t you call?’ you ask in the calmest tone you can pretend.  She answers that she was supposed to call if school got out late.  It didn’t.  She left school right on time, then went shopping with a friend.  She followed your directions to the letter.  But she missed the forest because all she could see was the one tree.  This kind of thinking leads to parental frustration and these younger teens thinking that their parents don’t understand them at all.  Maybe they’re right.

As the child gets to this point, like a scenic overlook where they can see adulthood in the distance (but hopefully not with those awful binocular machines that always steal your 25¢  and never work right),they try to distance themselves from their parents and move closer to their peers.  This is a normal developmental stage, but it’s hard on the parents who can feel that they are losing the child.  If the parents hold on tighter, I usually see a much worse outcome in the long run.  You can’t hold back the tide, either of the ocean or of your child’s independence.  If you try, the end result is typically resentful and rebellious children who may or may not talk to you after they leave your household.  They will be independent whether or not you try to restrain them.  Why not make it work for the two of you?

Luke has concrete thinking.  So I worry that it has not occurred to him that something is wrong with this picture.  His mother isn’t in contact with him.  You, dear reader, are either a mother or have met one at some point in your life.  Does that sound right to you?  I don’t know if the problem is the mother’s alone (illness of some kind, including mental illness; substance use; shame or economics (can’t afford to call or visit, can’t write a letter, is embarrassed by meager circumstances compared with ex-spouse)), or if the father has explicitly or in some subtle way discouraged contact perhaps by intercepting letters or restricting phone use.  No matter what the reason, there’s a serious problem here.  Whatever Luke thinks life with mom--even for just a couple of weeks--is going to be like, he’s wrong.

This is the advice I gave.  We’ll see, after the holidays, what actually happened.

I suggested that his dad and stepmother give Luke a cell phone before he goes.  (If you think this is too indulgent, maybe you can find a fat bearded guy in a red suit to give it to him.)  This is really important.  It gives him a way to call you without using his mother’s phone, and without asking her permission.  It also gives you a place to call every day without leaving a message on her answering machine, without having her accuse you of interfering.  Most importantly, CALL HIM EVERY DAY.  Don’t call multiple times, don’t ask the minutia of what he did with mom as if to second-guess all of her decisions and plans.  (If that’s your goal, get help.)  The purpose is to tell him every day that you’re thinking of him, that you miss him, that you love him.  Don’t ask him anything.  Not even one question.  You are just calling to tell him that short message, not ask anything of him, nor interfere with his relationship with his mother.  He may say he doesn’t want you to call every day.  You might want to do it anyway.

Luke is one of my patients with ADD.  So I had further advice for his stepmother.  Get a second, prepaid cell phone.  Write down the serial number and all the numbers inside the phone, and the activation instructions that came with the phone.  Then, James Bond-like, sew this brand new but nonworking cell phone into the lining of his suitcase.  Ideally, without his knowledge.  Then, after he loses the phone you gave him, he will have one right there.  All he needs to do is call you, get the activation instructions, and turn it on.  Maybe you can even do it remotely.  He’s going to lose the phone you gave him.  So get over it now, be prepared with the online tools or toll-free number to turn off the lost phone.  Don’t blame him for it!  How can you blame him from something you knew was going to happen by reading this very paragraph?  You, dear reader, have been served.

OK, for those of you a little more domestically challenged, maybe you don’t have to sew it in the lining.  But sneak it in the bottom of his bag.

I know that once he’s got a cell phone, it will be tempting for him to use all the available airtime texting his friends.  Get a plan with expensive texts and tell him you will take the cost out of his allowance.  Or turn off the text function altogether.  As the owner of the phone, you can turn this feature on again if you need it by phoning the cellular company.

Do NOT tell him to call you at all.  If he wants to, he will.  If you want him to, he won’t.  If you force him to, he’ll resent doing it.  If you don’t want to follow my advice to call him every day with a quick ‘I miss you’ message, don’t tell him you will call him every day.  Never, ever, tell children this age you will do something that you don’t actually do.  They will remember it for the rest of their lives.  More on this later.

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.

Claire 6: Tastes Like Chicken

They came into the office in the late afternoon. I turned off the phones in the office (though callers could still leave messages). I directed Claire to the most comfortable chair, and her mom sat next to her. Claire was in the office to be taught some relaxation techniques. On the one hand, I thought that helping her get through her anxiety would allow her to focus better. On the other hand, she really did have a problem with paying attention. So I didn't know if the technique I was going to use—which requires you to focus very intensely—was going to work for her. I asked if she had any questions before we begin. She asked if I were going to turn her into a chicken. “Yes,” I said.

I had her put her arms out in front of her. She pulled up while I tried to push them down. I told her to remember that feeling of tension in her muscles. She followed my direction beautifully and slowly reduced the force of her arms; I adjusted my pressure to match. I asked her to close her eyes.

I asked when her school year ended. How did she sleep last night? What did she have for lunch? Was lunch good? Does she usually eat that for lunch? Is she hungry right now? I asked her to think about what lunch tasted like. Every flavor in every different thing she had for lunch. After I asked, she said she felt relaxed.

I told her to tense up her toes like she did with her arms when I was pushing against them. Then slowly relax them. Then her ankles and her calf muscles and her thighs and her hips...all the way up to her neck.

She was going in to a warm pool, not too hot, just perfectly warm and comfortable. She dips her toes in to test it and it's nice and warm. So she steps slowly into the pool. At first, the warmth is just on her toes and the soles of her feet, and then the tops of her feet and then her ankles, and then...the pool is up to her shoulders, and then, nice and warm, up to her neck muscles. The warmth is helping all her muscles be relaxed. She is feeling very relaxed. She can feel this way whenever she wants. All she has to do is think of the warm pool on the soles of her feet and then slowly going all around her body making her feel comfortable and relaxed and taking all her tension away. I told her to count to five with me and then she would open her eyes feeling very rested.

I had been completely focused on Claire, who sat quietly with eyes closed on the comfortable chair across from me. Speaking continuously without a pause takes practice and strong focus. So I had forgotten completely about her mom, who was sitting on a chair next to her, yet totally out of my attention. Apparently, she had been doing everything I had been asking Claire to do. When she spoke first, it was unexpected. “Wow. I feel great.” Within a few minutes, Claire did too. She had been an excellent subject, and I think she was in a nice trance-like state.

This kind of hypnosis, guided imagery, focused relaxation, or whatever, has several practical uses. For Claire, I wanted to get at two specific anxiety symptoms that she was having trouble with. Often, she said, she'd have trouble falling asleep because thoughts would rush around in her head while she was in bed with the light off. She managed this by reading, but that just kept her up later. And she had a lot of anxiety-provoking tasks in school which made her perform, she knew, far below her capabilities.

I told her she could do this herself, and no one needed to know. When she was in bed, I suggested that she not try to ignore the rushing thoughts, but to think about each one and make a list of them in her mind. Stop them from rushing and get a leash on those thoughts. Then keep the list in her mind while she thought about the soles of her feet just touching the surface of that warm pool, then the tops of her feet....

I called the next day to make an appointment for lesson 2. Claire said that she felt great and had done it herself. I said that I hoped she didn't mind acting like a chicken. She didn't.

Next in Claire's story: teaching her self-hypnosis

Jeremy--Teacher says he doesn't pay attention

Jeremy’s mother called me today and said that his school requested an ADHD evaluation because he wasn’t paying attention. He just turned 10, and was struggling in school.

Several years ago, his mother told me that his school wanted to ‘retain’ him, which used to be called getting left back when I was a child. At that time, I told her in clear terms what I thought of ‘retention,’ which is a common suggestion for elementary school kids. This will be a topic of its own series of posts. I suggested she request an IEP, which I attended with her. They didn’t retain him, and he was given some special help in a couple of subjects. Since that time, he has kept up with his grade until now.

Jeremy has never been in trouble. He’s kind and polite to everyone. But there’s something different about him. When he speaks, the words make sense but the rhythm of his speech is off. Often, he will sound a little like a computer speaking, with flat intonation that masks emotional content. This speech issue is just one aspect of some social difficulties. He likes most other kids, but seems to have a lot of trouble reading and reacting to them in a typical way. He does have a breaking point, where frustration and loneliness make him sad and upset. He is a bully magnet.

He also has never been given a diagnosis. His parents can’t afford several thousand dollars to get him tested for all kinds of learning disabilities, and he might have some. The school and school district (and state, for that matter) have no money and are cutting some of these special ed and tutorial programs.

His teacher told mom that he couldn’t concentrate in class and he has requested being allowed to sit in the hall and do his required work in a more quiet environment. The teacher took this as oppositional and sent him to detention, where he had never been before. That afternoon, he told his mom that he loved detention since it was really quiet and he could really focus on his schoolwork. He accomplished several days of homework assignments in 1 hour of detention, completely without direction or supervision.

A picture was emerging. I asked more questions about all kinds of sensory input. Mom said that he was indeed sensitive to ambient noise and found it hard to concentrate in noisy environments. He also was very sensitive to smells, tastes, and the textures of his clothes. He was always cautious about people touching him.

So I could see that he did have an attention problem. But it sure didn’t smell like ADHD to me. He had no attention problem at home or anywhere else except for the classroom. He didn’t have this problem last year, with the teacher who adored him. He didn’t have it in my office, where he would sit and look through a book as his mother and I talked. People who have ADHD have it everywhere they go. They have it on weekends and weekdays, at school, at home, at work, in their conversations and their personal relationships.

I had suspected a diagnosis for Jeremy for years, but what good would a label do for him? I decided to broach this topic with his mother.

I told her about the things I had noticed: the speech issue, the social stuff, the sensory sensitivities. These all could be minor features of autism. But clearly, there were many features of severe autism he didn’t have. He spoke appropriately for his age. He didn’t seem to have any hand-flapping or other repetitive movements, and he was definitely interested in making connections with others. This was an autistic spectrum disorder. There just aren’t enough specific diagnoses to fit everybody on the autistic spectrum. The official ones are Autistic Disorder and Asperger’s Disorder. He didn’t have either of these. Everybody else, pretty much, gets lumped into Pervasive Developmental Disorder--Not Otherwise Specified.

The reason I brought this up with his mother was the result of a 2004 California Law called the Individuals with Disabilities Education Improvement Act [IDEA]. (Other states also have special education laws, and this link has links to the laws in other states.) If a child is diagnosed with dyslexia, for example, the school may get them reading help, if the school can afford it. But the law is explicit for the diagnosis of Autism--the state must provide the needed services. It's possible that if he were diagnosed with autism, that might open up opportunities for him to receive services his family might not afford. But will teachers expect less of him? Will he expect less from himself?

I hate assigning labels. They pigeonhole our children in ways that are convenient only for the industrial institutional system of education and the cultural biases of limited expectations. I am truly fortunate to have learned from and worked with creative teachers, fabulous professors, and brilliant colleagues with inept social skills, inarticulate conversation, or quirky nonconformist interests. Maybe they, too, met the criteria for PDD-NOS. I'm sure that the list of Nobel Prize winners includes a lot of people with these traits.

My Swine Flu post.

Claire 5: The Medication Paradox

About a week after starting medication, I called Claire's mother to check on any progress or side effects. Her mom is a very intelligent and perceptive well-educated woman. I respected her opinion.

“I don't think the medicine is doing anything,” she said. “Claire seems exactly the same.” I told her I was glad there weren't any obvious side effects. “I just don't think it has any effect on her,” her mother said helpfully. It was still early, I said, and suggested she continue the medication for the moment, which her mother was willing to do.

At the moment, it is very hard or impossible to predict which medicine will work best—or work at all—in which person. This is especially true for psychoactive medications. But it's pretty common for people to know that they act or feel differently when they are taking certain drugs, even if they aren't prescribed for their psychiatric effects. Prednisone, for example, is a medicine used for inflammation and asthma that often makes people act in surprising ways. Birth-control pills can have this effect. It was disappointing but not shocking that my first choice for a prescription was not doing what I thought it might. Still, I wanted to be thorough.

“Is she getting her homework done?” I asked. Her mother said that she hadn't been getting any reports of assignments not handed in. “But is she remembering the assignments?” To this, her mother said that Claire had started to use an online calendar for her assignments so she hasn't forgotten any yet. “How about exams. When are they coming up?” Her mom said that she had a history quiz and did well and hadn't mentioned it beforehand. Without my asking, her mother added that Claire probably just wasn't very worried about it. And so our conversation went. I asked about how she was getting along with her classmates and her siblings. I asked how her motivation was in general, if she had shown any interest in new things, if she was worried about her friends or how she looked or how she was doing in school.

There were a lot of changes, all improvements, all pretty small and hard to notice by themselves. I pointed this out tho her mom, who had to pause for a moment. All the changes occurred around the same time, a couple of days after she came to my office. The only thing that changed was the start of medication.

It was a revelation to Claire's mother that maybe the medication was helping—a lot, as it turns out. Yet she had been convinced that it was doing nothing at all.

Although this post is another true chapter in Claire's story, it is an experience I have had dozens of times. What is the ideal psychologically-effective medication? I think it's something that helps patients with the things they struggle with, but leaves them feeling and appearing just the same to themselves and those around them, with every ability unchanged. When a medicine isn't working, the targeted problems don't improve. When there are side effects, the specific problems might improve, but new problems arise (such as sleepiness, for example, or inability to sleep).

Claire herself had been equally convinced that the medicine was ineffective. She felt the same, she said. It was true, she acknowledged, that her assignments were getting remembered and done and that she studied for and wasn't too worried about that history test. But that wasn't because of the medicine, she told me. It was hard for her to remember the way she was even 2 weeks before, and how worried she was about everything. She wasn't very worried right now, and she felt that's the way it has always been.

This is a very serious problem for people who take medicine to control a chronic problem, such as asthma or depression. They start taking a very effective medication, which really works to control their symptoms. After a while without the problem symptoms, they get to feeling that the problem is gone so they no longer need the medication. They stop the medication and the problem returns.

With ADHD, the kids often get brought to me when they have been getting into trouble at school. With good therapy, they do well in school. But when they do well with medication, they get the feeling that they don't need the medication. When they stop, and start getting into trouble again, they will find specific explanations that don't include the fact that they stopped their medication.

There is, I believe, a medication paradox. If you take your medication, then you feel like you don't need it. If you don't take it, you will need it.

Next post in Claire's story: I make her believe she is a chicken.





The photograph at the top is from my collection and is by Emmet Gowin.

ADHD: Claire 4--Breaking the news

As difficult as it might be to tell parents that I know what’s wrong with their child, is often much more difficult to present a complicated interaction of several different problems. In Claire’s case, because she was older, there was the additional issue of telling her directly.

I believed she had an anxiety disorder. She might or might not have an attention problem. It’s conceivable she could have a subtle learning issue. I asked her parents to come to the office with her so I could lay it all out for them.

Because of a busy schedule, Claire could join us only after we had started. I scheduled 90 minutes for the conference. I showed the parents the Vanderbilt ADHD questionnaires that I had received and explained my scoring and interpretation. I showed them the anxiety questionnaires.

There were a few key pieces of information I thought were extremely important. First, Claire’s reaction when her mother told her about my plan to look into these problems. This suggested that she knew we had hit upon something important to her, and she was relieved about it. Second, the high scores that she herself gave for some of the statements on the anxiety questionnaires (“I am a worrier;” “I feel worried about things that have already happened;” “People tell me that I worry too much.”)

The anxiety-specific screening tools allow me to be more specific about what could be going on. Claire and her parents indicated that she didn’t have significant separation anxiety or somatic symptoms such as headaches or stomach aches. But she seemed to have generalized anxiety and social anxiety, and she’s anxious about going to school for many reasons.

Just informing this family about what I’ve discovered isn’t very helpful without some plan to deal with it.

A therapist might help, and anxiety disorders are often helped by cognitive behavioral therapy. This kind of therapy helps the patient be aware of the thoughts and feelings that are a problem for them. Once aware of these thoughts, they are taught techniques to get these thoughts under control. Though often effective with bright, cooperative people like Claire, this takes practice and time to learn.

When I was in my last year of medical school, my research work with pain control for cancer patients helped me win a brief fellowship for a training course run by the New England Society of Clinical Hypnosis. Though the workshop I attended taught the use of hypnosis with adult patients, it’s something I sometimes use with children. I suggested to Claire and her parents that she might benefit from some relaxation techniques, and some guided imagery whether through meditation or self-hypnosis (which I could help her with) could be helpful when she was in a stressful situation.

Aerobic exercise can also be helpful for mood disorders including anxiety and depression. If she could find something she liked, it could be therapeutic for her.

An anti-anxiety antidepressant medication could be very helpful. Its big advantage is that it might work right away to help relieve some of the worst symptoms and make her feel better, so she’d have an easier time making some of these other changes.

But none of these ideas, even if they help her, will give her the skills she will need for life. So we would still need to change the way she organizes her day and her assignments and her life. I suggested getting at least a week’s worth of assignments at a time from each teacher, and immediately entering those assignments onto an online calendar. That way, she’d never lose them and could check them from anywhere—and so could her parents.

This is a new concept for this teenager and her family. More updates to come.


The photograph is from my collection and is by Richard Avedon.

ADHD: Claire 3--Unexpected Insight

A couple of weeks ago, I gave Claire and her parents questionnaires to fill out. I asked Claire herself to fill one out, and there were separate questionnaires for her teachers, too. The questionnaires were developed and tested by some smart people at Vanderbilt University, and have been adopted as the standard assessment of ADHD by the American Academy of Pediatrics and the National Initiative for Children’s Healthcare Quality. They are designed to distinguish those with the inattentive type of ADHD from those with hyperactivity. They also sneak in a few screening questions for other issues. All the questions need to be rated from “Never” (0) to “Very Often” (3).

Surprisingly, the teachers and parents didn’t really score the questions about inattention too highly. An example might be, “Has difficulty keeping attention to what needs to be done.”

But Claire herself rated as “Very Often” the statement, “Is self-conscious or easily embarrassed.” The statements, “Is fearful, anxious, or worried,” and “Is afraid to try new things for fear of making mistakes” were also rated highly by Claire, her parents and her teachers.

When I scored the Vanderbilt forms, an unanticipated pattern emerged. She did have some attention issues. These were right on the margin of meeting the official diagnostic criteria for ADHD—Inattentive Type. She did have some sort of issue with paying attention. But there was a loud and clear signal about anxiety. So I sent her mom some anxiety-specific questionnaires, and once again asked Claire and her parents to fill these out.

When they were returned, an anxiety problem was clearly identified. Claire and her parents had noticed that she was often worried and often worried about what people thought of her. At least some of the behaviors that her teachers noticed in class, such as never participating in class discussions or volunteering answers, were because she was afraid, not because she was distracted.

Parents are often concerned about ADHD medication. Part of being a careful prescriber, of course, is having judgment and experience in the use of medication. And part is being disciplined about it. I have no a priori problem with prescribing medication where I believe the benefits outweigh the risks. A couple of months ago I wrote about a boy whose life at school and at home, and his social interactions even with his friends, was very difficult when he wasn’t taking his meds. But an advantage of seeing so many kids with ADHD and managing so many medications is knowing that stimulant medications, in some people, can make anxiety worse. In those with an anxiety disorder, the medications are often less effective.

When the screening questionnaires were designed, it was essential to screen for anxiety and depression. A depressed child might be sitting at the back of the class uninterested in the topic of the moment, might avoid social interactions, might forget assignments and not care about exams. This child, too, won’t benefit from ADHD medications yet acutely needs our help. If the child is very worried about what others think, she won’t speak up in class. She might ‘forget’ homework or other tasks if she’s afraid of what they indicate about her and her understanding of the material. So though girls with ADHD are often not diagnosed at all, it’s important to keep an open mind as we look for the underlying problem.

Next Post in Claire's story: I meet with the family.


The photograph is from my collection and is by Alfred Stieglitz.