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.

Monsters: Part 3

The Monster Whisperer

In Monsters:  Part 2, my medical colleague, a very smart adult physician whose office is across the hall from mine, burst in and asked for a urgent medical consultation, assuming I had expertise beyond his own.  He asked me what he can tell his distraught patient to help her get rid of her child's witches.

I didn’t think her child was afraid of the fact that there are witches. She’s not afraid of their power to do things by magic.  She’s not afraid of their malicious motives or the scary way they look or dress or of their scary henchpeople or flying monkeys.  I thought that gentle questioning of the child, while never doubting her belief in witches, would probably reveal that she’s afraid they will come into her room when she’s asleep, and work their bad intentions there.  (I would use this opportunity to point out that it is the child’s concrete thinking that doesn’t usually consider that a witch with magic powers could cast an evil spell from afar, without warning.  In Snow White, why couldn't the evil queen just wave a wand over in her palace, and do her mischief from there?  Despite her apparent powers, she had to get Snow White to take a physical bite of a tangible apple.)  As in Monsters:  Part 1, with the child so afraid of a toilet monster, this child was keenly aware of when she was most corporeally vulnerable.

How can we help?  If we tell them that their belief system is sheer nonsense, we alienate them and make them feel worse.  If we sympathize with them and agree that witches are a constant threat, they might continue to trust us, yet their fear is reinforced and we have confirmed that there is a dangerous broomstick-riding predator somewhere above us just waiting for the right opportunity to strike.  Keep watching the skies!

Our problem is that the child's fear is magical, but we are limited by our physical reality.  Or are we?

• If her specific fear is of a witch entering her room, she might benefit from a meticulous bedtime ritual of closing and locking her windows at bedtime.  If it’s hot and her window must stay open, how about getting a special witch screen that fits the opening?  The openings in a window screen are very small and no witch could fit through.  Or maybe witches can’t fit through those window safety bars that you are going to install to protect your child. (Maybe you should be doing that anyway.)

• Consider a special witch treatment or repellent that is not toxic once dry but is especially specific and new to the child.  My favorite for witches and related hazards is witch hazel, a pre-19th-century remedy for many things with a distinctive smell.  Because it is not in widespread use these days, it might not be easy to find.  But it sounds like a logical product.  So an exhaustive hunt for it with the child in tow will have that much more of a chance of effective pest extermination.  As you go from pharmacy to pharmacy, don’t look on the shelf!  Since the child can’t read, it is not helpful when you tell her that you looked and there’s no witch hazel there.  How can the child be confident of that?  Make a point of asking a manager—always with the child right there—if they carry witch hazel and if not, where you might be able to get it.   Maybe it can be used to seal the joints around the windows and doors.

These aren’t tricks.  I will repeat that lying to your child is never, ever a good idea.  Are these lies?  Is my approach dishonest?  Yes, in spirit it is dishonest, because you don’t, in fact, believe in witches or in the monster du jour.  But these anxieties and beliefs are a normal developmental phase.  I often discuss concrete thinking and the ways a parent has to anticipate and deal with a concrete thinker.  I have also discussed in previous posts the gradual development of abstract thinking as a mark of adulthood.  The kind of thinking that gives rise to this kind of childhood anxiety is called magical thinking.

With magical thinking, there does need to be some sort of a link between observations or events, but it doesn’t have to be rational from the point of view of an adult.  Let’s say your child takes a bath every day just about the time that daddy gets home from work.  One night, dad has to work late.  At bedtime, your child snuggles with you and asks to take a bath.  This seems odd to you, but slow iterative questions determine that he believes that if he takes a bath, daddy will come home.

So my empathic approach, as always, directs our technique to take its cue from the child.  This brings up...

5.  Dr. Wolffe’s Thinking Rule:
Concrete thinkers need concrete actions.  Magical thinkers need magical actions. 

There is no intervention for supernatural issues except for supernatural interventions.  If you wanted to help someone suffering from demonic possession, would you call a surgeon?  Of course not.  You’d look for an exorcist.  How do we accomplish this for the supernatural conflicts experienced by young children, when we might not be experts in the field—and probably can’t easily find an expert.  Think about it...who is an expert on toilet monsters or witches? Maybe we all have enough knowledge for the job we need to do.

All of us, by the way, are a soup of all kinds of thinking.  My bank just changed the way ATM deposits are done.  I asked a bank officer about this, and she helpfully showed me how to drop the deposit into the night deposit slot.  I told her I’d rather change banks—it was intolerable for me to drop an envelope of checks or cash into a blind slot without any sort of record or receipt.  It wasn’t that I didn’t trust them, it was just my need for concrete security.  (Ronald Reagan said, "Trust but verify.")  Now that the holidays are over, do you feel comfortable telling your kid all you really know about Santa Claus?  And what do you do when you are cornered by somebody at a social gathering who insists on convincing you that every English word of the Bible is the literal word of God, despite your knowledge of it being compiled by a committee in London at the turn of the 17th century?  I have met plenty of scientists who follow a religion.  Does understanding the universe convince us that there is no God or that there must be a God?  Whichever we believe, no amount of moot-court argument will change a person’s faith in their belief system.

I’m not lying when I tell preschoolers that I can see an elephant in their ears.  It makes them laugh.  Even if I say I see a dinosaur or a crocodile, they still, mostly, laugh.  They aren’t worried about it because they know, within their magical belief system, that the only elephants that could be in their ears would have to be very tiny ones and they wouldn’t hurt.  Maybe they just acknowledge the elephant I see the same way they would play along with one of their younger peers, and are being indulgent with me because I’m obviously not as mature as they are.  That, indeed, is rational insight.

Monsters: Part 2

The doctor from the office across the hall from me burst into my office. “Do you have a minute?” he asked when he saw me walking between exam rooms. He’s a very nice, very smart physician who treats adults. When he’s in the office, he wears a long, starched white exam coat.

“I have a very distraught woman in my office. She hasn’t slept in 3 days.” I felt bad for the woman, but the expression on my face must have conveyed my curiosity about how, exactly, he thought I might help. “She’s in the office right now waiting for me.” I suspect I must have looked increasingly unhelpful with this new urgency. “Can you tell me, really quickly, how you get rid of witches?”

One evening in the early 1980's, I was having dinner in New York's Theater District at a lovely restaurant named Barbetta.  Margaret Hamilton, pictured above (not, however, as she appeared that evening in the restaurant), came in with a couple of companions and was seated at the next table.  I wanted to tell her how great I thought she was, but it felt awkward to interrupt her dinner, and I didn't.  It didn't seem like anybody else in the restaurant noticed her.  It isn't well known that she started her working life as a kindergarten teacher, and was known to be particularly good with children.  She once was a guest on Mr. Rogers' Neighborhood, and explained that she wasn't really a witch.  She just played one as an actress. If children were frightened by this character, would her appeal help?

He explained that the woman’s 5-year-old daughter had been unable to sleep for 2 or 3 nights since a play date with a friend. When I asked, he didn’t have a lot of the important details. He didn’t know if they had watched a video intended for an older sibling, or seen a TV show, or just been told a scary story by somebody. My approach, as usual, is from an empathic direction, in which the child guides the response.
In this blog, I don’t usually discuss religion. I think parenting is about universal truths about children and childhood that transcend most cultural and religious variations. Think about religion, in your personal experience. Has anyone ever tried to convert you? Have you ever tried to point out the rational inconsistencies in your own or somebody else’s religion? Generally, this is an unproductive tactic. When someone sees the Virgin Mary in a reflection from the glass of an office building, often a flock of believers come to the miraculous spot. Yet plenty of others either can’t pick out the particular shape or just don’t think it’s a supernatural event. Whatever your religious beliefs, I can suggest certain things that you either believe or you don’t. For these matters of faith, it’s hard to imagine even the most cogent and scientifically-supported argument will dissuade you from your belief. I could be writing, for example, about UFOs. Some people believe that the US government has aliens (unclear if they might be considered legal or illegal aliens) in top-secret storage hidden in Area 51. This is the reason, I suspect, that new religions have such a hard time catching on. You have to convince people that their cherished belief system is wrong, and then convince them that yours is right. How well do you think it would work if you said something along the lines of Your religion is ridiculous. There’s no such thing as a god like the one you believe in? It doesn’t work with adults. Being dismissive of someone’s beliefs is not an effective way to get them to give up those beliefs. We all know this, and it’s why the socially adept among us try not to get into discussions about religious belief at friendly dinner parties.

If this approach wouldn’t work with you, why would you think it would work with a child?

In Monsters: Part 1, I described a child who believed that monsters lived in toilets, and were a serious threat to her safety. Her fear, however bizarre and irrational it appeared to be, was having a material impact on her quality of life. Modern life just doesn’t go as smoothly when you're afraid to use a toilet. Though this was genuinely frightening to her, she started to cry after her mother told her that her monsters did not exist and that she was immature for thinking so. She was hurt that her mother didn’t believe her. She felt bad that her mother didn’t think of her as a big girl. And she felt isolated and abandoned and especially scared now that her mom, basically, told her that as far as the monster threat went, she was on her own. Can you imagine abandoning a preschooler?  Imagine how it feels to her.  That’s why my solution wasn’t attempting to dismiss the potency of her fear. The solution did not require her to give up her belief. Instead, it empowers her to overcome the anxiety-provoking aspects of this fear.

I knew the doctor across the hall didn’t have answers to many of my questions. So I gave him some general guidelines for the distraught mother.

1.  Don’t discount her fear.  This gives her messages you aren’t trying to give.  To her, it appears that either you don’t care about her suffering, or you are unable to help her, or maybe you just aren’t listening.  When you tell your terrified child that there’s no such thing as monsters or witches, you do not silence these demons.  You simply drive them underground*. Often, these children will open up to me about these threats in private, but not in the presence of the unsupportive parent.

2.  Find out concrete things about the problem, and what it is that she is actually afraid of.  This knowledge about the fear is what will give you the tools to help her manage it. Most kids, for example, are not particularly anxious about the existence of ghosts or aliens or monsters of any particular kind.  They accept these as a part of the natural world.

Why is it that kids aren’t afraid of dinosaurs?  When they go to the Natural History museum and see the giant skeletons, it’s clear they understand that these things were really big.  They see the teeth, maybe they ask a guide about it and are told that yes, they could eat a child in one bite.  The gentlest little angels wear pajamas with depictions of Tyrannosaurs in particularly aggressive and threatening poses.  So why no nightmares about this, when they know the script so well?

It’s because dinosaurs aren’t part of their belief system.  Go ahead and ask a 5-year-old.  They won’t tell you about von Baer’s theory about the recapitulation of phylogeny by ontogeny, and they won’t know Lyell from Lamarck, but before they can read they know the word extinct.

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* In 1895, H.G. Wells published his story The Time Machine in which creatures called Morlocks lived underground.  There they keep the machinery working that supports the care-free life of the surface-dwellers.  In exchange for providing this labor, the people that live in the sunshine regularly march off to feed themselves to the CHUDS.

Television Rules and Concrete Thinking

A parent recently asked me for advice about TV.  She said that they had just moved, and in the past few weeks, it’s been blissful living out of boxes with the TV not yet unpacked or hooked up.  They aren’t fighting with their 6th-grader about limits on viewing time, and all the things that go with it.  Her 12-year-old keeps asking about the television, however, and her husband is going to try to set everything up over the weekend.  What should she do?

She’s not particularly afraid of the content of what her son watches.  He’s a smart, nice kid who does well in school.  She’s more concerned about the hours he can spend doing nothing else.  She is not looking forward to the inevitable fights about limits on screen time, limits on times that he can watch, limits on TV when his homework isn’t yet done, and so on.

One issue is his age.  At 12, kids do a lot of concrete thinking (see Visit to The Other Parent).  That means that vague rules about priorities (homework is more important than television) are not as effective as concrete rules (no television until math homework due the following day is done).  So the rules have to use this inflexible way of looking at the world.  And they can’t be made up as you go along.  To the child (and to me) that will see capricious, arbitrary, punitive.  So the best way to make rules might be collaboratively, with the child actively involved.  Have a family meeting on the night before you unpack the box.  At the meeting, ask him what he wants and what he thinks you want.  Then ask what he thinks you’ll settle for.  You might be surprised at how realistic he is.  So I don’t anticipate a big fight when the rules are put to paper.  The same concrete thinking reduces his capacity to project scenarios ahead in which he would very much be interested in nagging you for an exception to the rules.  So fights over TV tend to arise at the time of the child’s temptation (when they want to watch something or play a video game, but their homework isn’t done or there’s some other commitment).  These conflicts don’t usually occur in the drafting session, when the rules--though worded concretely and specifically--require abstract thinking to foresee their application.  From a business negotiation point of view, this gives you an advantage in the formulation of the rules.  If you don’t do this, and let it go until his TV show is on and his big project is due tomorrow, he will have the advantage in the negotiation.  Even though it might not end well for him, there could be a considerable amount of bad feelings all around.  Keep the language simple, keep it to one side of one page.  Frame it, under glass.

  In Emergency, Break Glass.

 

Oh, one more tip for concrete-thinkers:  rules are made to be kept, not broken.  He’s having friends over?  It’s Christmas?  The math homework still has to get done.  You can use his concrete thinking for his advantage and yours, by collaborating on (not imposing) some specific rules.  But those same concrete interpretations of the rules will conclude from every exception that arises that the rules are flexible with your mood/your whim/your schedule.  In other words, there are no rules at all.  Consistency is credibility in concrete thinking.

A lot of parents find rules easy to make and hard to keep.  They figure they are grown-ups and get to do what they want.  Well, in most ways, that’s completely true.  Do what you want.  But now that you’re a grown-up, you should know that there are consequences for your choices, and you should be able to anticipate most of these.

So in the example I’ve been mentioning, he is not allowed to watch TV until the math homework due the following day is done.  OK, he did it.  (How do you know?  Are you aware of his assignments?  Have you asked the teacher if he’s behind on turning homework in?  Does he need help with math?)  So, according to the rules, he’s allowed to watch TV for, let’s say, an hour.  But he still hasn’t cleaned up his room, and you asked him to do that a week ago.  Do you tell him he can’t watch TV?

Assuming you come up with some TV rules that you both agree to, have him sign the paper.  It’s probably the first contract of his life.  Every contract has a term.  (We know how long a marriage contract, for example, is supposed to last.)  So put an end date on the rules, and agree to revise them at the end of the term or some other natural date.  You have to sign the paper too.  When you do, know that this is not a parenting idea.  It’s your credibility with your kid.  Sure the rules may appear to be about him and his TV privileges.  But they require you to comply also.  Your enforcement tool is your power to disconnect the television.  His enforcement tool is his power to distrust you forever and not speak to you for the last 50 years of your life, keep your grandchildren from you, and make you pay for college tuition—for your therapist’s kid.   Do you really want to play chicken?

It never ceases to amaze me that the most insightful parents lose sight of this basic truth.  I’ll ask them about the things their parents did that most bothered them (and might bother them still).  They—you—remember these actions vividly, even 20 or 40 years later.  So why is it such a mystery when your kid is bothered by you doing it?

So can he watch TV or not?  Stay tuned.

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.