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.

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?

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.

Transition Issues -- A Definition

Pretty much every week, I’m in an airplane.  At this point, I have flown so often that nearly everything is routine about it.  Those of us who board earlier in the process are already sitting as the rest of the passengers walk on.  Nearly everybody is using this time to talk on their cellphone, text messages, or do something technological until the plane takes off, when all electronics must be shut off.  So it was not unusual that the guy across the aisle from me was chatting breezily on his blackberry phone in a foreign language as the plane filled up.  I heard the big door shut and sealed by the flight attendant, who announced that all electronics must be turned off.  They walked up and down the aisle.  Politely, they reminded a few of the passengers that they had to finish using their laptops or phones.  The big jet was being backed out of the gate.  One of them tapped him on the shoulder and gestured, with a smile, to his phone.  He nodded his head in cooperation as he continued to talk on the phone.  The plane started to taxi to the runway.  Both flight attendants approached the man and told him verbally that he must shut off the phone.  He kept talking but nodded his understanding.  They walked away, as the plane got closer to the end of the runway.  The plane stopped.  Both pilot and co-pilot, in uniform, emerged from the cockpit and came to the man.  He saw them, smiled and held up his index finger, as if to say ‘I’ll be with you in  a minute.’  One of the officers said, “In 15 seconds we will have you removed from this aircraft by Federal marshalls.  You will be taken to Federal detention.  You are committing a crime and will have a criminal record.”  The man, showing an unexpected facility with languages, seemed suddenly to understand English.  He abruptly said into the phone, “I gotta go,” and turned off the device.

Ask any parent about getting their child to turn off the video mid-story and wash their hands for dinner.  Sometimes they wish they had a couple of Federal marshalls to call.

This is the first essay of several on transition issues, techniques, and objects.  I hope some readers find these ideas helpful.

Transitions are the times of overlap between what we are doing and what we are doing next. 

This is my own definition, so it doesn’t appear just this way in parenting books.  But I think it applies throughout our lives.  In babies, it could be transition between being awake and being asleep, or maybe between being held and being put down into the crib.  For preschoolers, it might be the transition between one activity and another, say coloring vs. playing with blocks.  In school, there are transitions between classroom work and lunch, lunch and active play, then back to class.  By high school, it may be all about just getting off the phone.

Being able to navigate successful transitions is a life skill.  Our frequent flyer, for example, nearly spent a night in jail.  There’s an important balance to be struck between being bad at this and being too good at it.

Many children are brought to me for evaluation of what is thought to be an attention problem.  (Because I do this very carefully, I often find other issues. )  Other children are brought in for behavioral advice because every transition results in a tantrum.

Being able to pay attention is also a key life skill.  It enables us to listen to a story, to follow crucial directions, and to fall in love.  Even if it didn’t help us get through school, it would be important in establishing human relationships and stalking prey on the savannah.

But it’s also important, and little studied I think, to be able to break off our attention when appropriate.  Otherwise, we might end up on the No-Fly List.

There’s something about certain activities, I believe, that interferes with the normal balance of transition controls in the brain for certain children.  For some, video games tap into something very primal.  There aren’t many activities that a child can do for so many hours that they ignore bodily functions.  There’s a clue about autistic spectrum disorders here, by the way.  Some children with ASDs will continue to do a repetitive activity until they fall asleep exhausted, or are distracted or stopped by somebody.  Maybe it’s making a sound, maybe it’s not so benign.  Decades ago, some of these were assigned the unfortunate categorization of self-stimulatory behaviors. 

Max was brought to me because his mother didn’t know what to do.  In kindergarten, he did fine with the class activities and didn’t get in trouble.  In school, he could transition between circle games and coloring and learning to write his name just as well as everybody else in the class.  He was not a behavior problem.  At home, however, it was a different story.  No matter what he was doing--playing with blocks, playing with his robot people, or looking through picture books of trucks--his mother couldn’t pull him away.  She’d plead with him to come to dinner, bargain with him to get into the bath, but he always said words that were the equivalent of holding up an index finger as if to say, ‘I’ll be with you in a minute.’  When she was more assertive, a long and unpleasant tantrum exploded.

Max was not, in my professional opinion, developmentally abnormal, attention-challenged, or emotionally unstable.

It was hard for him to give up a fun activity.  Because of his normal developmental stage, it was almost impossible for him to envision himself in a future situation, even if that future was only 15 or 30 minutes away.  So even when his next activity would be even more fun, he could never appreciate it.  So there was never an incentive to stop what he was doing and move on.

For the record, he was brought to me with his mother complaining that he was constipated.  It was only after I asked lots of questions that the whole story emerged.  He focused so intensely on whatever he was doing that he never wanted to stop, even for brief bathroom breaks.  After a while of ignoring the feeling that he had to go, he no longer felt that he had to go.  This led to a spiral of holding it in until it turned to concrete.

The first step would be helping him get to a less intensely-focused state, in which he'd be less and less invested in his current activity and more ready for the next.  I suggested a gentle reminder at 20-minutes.  Mom could tap him on the shoulder and let him know that a change was coming.  As expected, he would nod his head or indicate he understood but otherwise show no indication that he would comply.  Then again at 10-minutes, but this time with a little more discussion.  At 4 or 5 minutes, he should be told to shut off the video.  He won't, but he also won't be surprised when it happens.  Maybe he won't like the transition, but at least he'll be prepared for it.

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.