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.

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 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.