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?

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.

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.

ADHD: Claire 2--Looking for the ADHD diagnosis

Did Claire have ADHD? She was forgetful, distracted, and had trouble paying attention. After her mother and I agreed on a plan, her mother had to tell her about it. Smartly, she waited for the right opportunity—in the car.

The car is often the perfect place for a serious topic. It’s isolated so you have privacy. No one will interrupt and siblings are not around. There’s physical closeness but there’s no chance of forced prolonged eye contact, so the passing outside world is a helpful relief valve.

Claire’s mother reported following my script closely. She said that she had seen my blog story about girls with ADHD and wondered about Claire. She outlined some of the features of ADHD in girls that often get missed. She talked it over with me on the telephone, and I suggested a formal evaluation, including input from parents, teachers, and Claire herself.

Claire’s eyes started to tear. Her mother didn’t expect this reaction, and asked her what was wrong.

She said that she was incredibly relieved that maybe there was a reason for her being the way she is, and that it wasn’t her fault.

She had been well aware of being ‘spacey’ and disorganized, and she didn’t like it. But both from herself and everyone around her—friends, family, teachers—she kept getting reinforcing feedback that supported the idea that this was just who she was, as unchangeable as her height or her voice. Unlike most of the evaluations I do for kids who are much younger, this one is a crucial new part of this teenager’s identity. We will all have to walk very carefully.

Once through the initial suggestion, Claire was excited about the prospect. I don’t think she liked the idea of ADHD, exactly, but she genuinely liked the plan to figure out what the issues might be.

A therapist, who had not noticed a particular problem when talking to Claire, suggested neuropsychological testing. This is an expensive and detailed group of tests in which every aspect of her learning and understanding is carefully analyzed. It’s the essential tool for figuring out exactly what a kid’s learning disability is. But Claire was a voracious reader who read for pleasure, so it’s unlikely she’s got a reading disability. She’s not great at math, though. But her attention problems are in all her classes, not just math. In addition, a child being tested for hours has to be able to keep focused on the exam tasks. So in general, I try to get an attention issue under control before having kids do this kind of testing.

I sent questionnaires to Claire and her parents, and separate questionnaires for her teachers.

I often feel uncomfortable bringing up a new diagnosis to a parent. It’s hard to tell someone that their child has asthma or eczema or pneumonia. But almost always, this news is met with some sense of relief by the parent. They knew something was wrong, which is why they brought the child into my office and complained of a cough for 2 months or a rash that didn’t go away. Nobody’s happy about it. But now it has a name, and things with names can be discussed, can be treated, can be joked about, and can be looked up on the internet.

Much more to this story as it unfolds....


The photograph above is from my collection and is by Lewis Carroll.