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.

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

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

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

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

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

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

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

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



Coming up: a series of posts on ADHD.

Eight is Enough

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

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

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

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

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

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

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

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

Next Post: Trying to help Max.


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