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.

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.

A Mother's Concern: Forgetful and 15

Claire is 15, and she’s been a patient of mine for a couple of years. She’s very bright and has always been healthy. When I’ve seen her, she always asked articulate questions with an adult vocabulary. She never seemed conformist with high-school fashion or makeup. She seemed comfortable with me, though she generally avoided eye contact.

Her mom had just read my post about girls with ADHD, and telephoned. She said that her daughter was getting poor grades in school despite high aptitude. She often forgot her homework assignments and forgot to hand in the assignments she did. Her written work seemed randomly put together, with one idea not flowing naturally into the next.

Although this pattern had been noticed since she began elementary school, she has never been in trouble, and her excellent reading was always thought of as a major educational advantage.

Could this be ADHD, especially the inattentive type often found—and often missed—in girls? She seemed to meet some of the common criteria: performance notably below her potential, forgetfulness, disorganization, and her teachers often found her not paying attention. But that lack of eye contact and awkwardness in following and participating in a conversation could be symptoms of what is currently called Nonverbal Learning Disability, which is considered an Autistic Spectrum Disorder.

While these were possible, I wanted to be sure not to miss important other possibilities in this teenager. At her age, I’m particularly concerned about depression. Social isolation, bullying, harassment of some sort at school could be an issue. Is there an eating disorder? Is she hurting herself in some other way? Was there a boy the parents didn’t know about? What about alcohol or drug use?

I posed all of these questions to Claire's mother. She thought all were unlikely. They had a warm, open relationship and she didn’t think the child would hide much. Though teenagers can have very private lives as they try to find an identity independent from their parents, I thought the most important factor was the long history of behavior, observed very early in her school career. Even Claire joked with her friends about her being ‘spacey.’

Her mother wanted to know how to approach her.

Be completely open with her. Parents who aren’t usually find themselves defending their omissions or deceptions. This can have serious consequences for the credibility of the parent and the relationship with the teenager.

Tell her:

• You read the post online, and show it to her.
• We spoke on the phone and this plan was my idea.
• I want to see her, to ask her opinion and to ask her screening questions.
• I want to initiate a formal evaluation.
• I will give questionnaires to her current and former teachers, but only to the teachers she likes.
• Questionnaires will also go to her parents.
• She will get a questionnaire so that she knows what questions are being asked and so she can evaluate herself.
• She will be included in every part of the process. No decisions of any kind will be made without her.
• All of the process, including that the evaluation is happening at all, will be completely confidential. It will not be a topic for conversation at the family dinner table, or with her siblings or friends.

It’s a mistake to assume that the teenagers who aren’t crying out for help don’t want help or wouldn’t accept help if offered. I don’t know yet if any of this will happen, or what the results will be. I’ll keep you posted.


The photograph above is by Paul Strand. It was taken in 1953.