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.

ADHD: A Berkeley lecture -- Adult ADHD

A couple of years ago, I was giving a lecture at Wheeler Hall, a 600-seat auditorium at the University of California, Berkeley. The Interdepartmental Studies course drew hundreds of undergraduates who were in many different majors, with many pre-meds and public health students.

I opened with a test. Paraphrased from several websites I found on Adult ADHD, all of which promised help or cure with a purchase of nutritional supplements, vitamins, medication from Canada, or a service such as counseling or self-help or spinal manipulation. I asked the students if:

• They find their mind wandering from tasks that are uninteresting or difficult
• They have trouble keeping focused on written material that’s not very interesting even if it’s important they know it
• They sometimes find it hard to stay focused on group conversations
• They find it difficult to complete long tasks when there are many shorter tasks competing for their attention
• They think they have the potential to accomplish much more than they do
• They sometimes notice a lot of time has gone by and they haven’t finished what they thought they would, and don’t know where the time went

I requested a show of hands, which showed an overwhelming majority of the students in the room to have, by these criteria, adult ADHD.

Next I turned to presumed therapy for their presumed ADHD. How many, I wondered, would be willing to take something that improved concentration and alertness, and might make them feel a little less tired. A main side effect of this class of drug was appetite suppression and even weight loss. I didn’t want to embarrass anybody or ask any of the students to reveal their pre-lecture psychological diagnoses. So I didn’t ask how many actually were taking prescription ADHD medication. I did show a slide listing the many substances that have many of the same effects on brain chemistry. These include coffee, tea, and Coca Cola. A majority of the students admitted to self-medicating with some form of stimulant.

Do we all have ADHD? Surely many or most of us use mild stimulants to help with alertness and concentration.

The official diagnostic criteria for the diagnosis of ADHD include a long checklist of predictable symptoms covering impulsivity, inattention, distractedness, and so on. But it’s not enough to have the required number of symptoms, even if they are severe.

In my experience, the single most important factor in the diagnosis of ADHD is, “There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.” (From the American Psychiatric Association.)

A few years ago I saw an interview on TV featuring the CEO of an airline. He said that he had ADHD and thus had a continuing struggle. He also noted his long happy marriage, and successful children. Where, I wondered, was the significant impairment? He didn’t say if he was taking medication, but if he was, why was he taking it? Though there may have been some students in my lecture who had been diagnosed and were in treatment at that time, those who met the criteria I gave them from the internet site on adult ADHD were not significantly impaired. They were almost all extremely successful students in a demanding program at an elite university.

I am often called upon to evaluate a child for ADHD. They usually do have symptoms that have brought them to the attention of their teachers or parents who have sent them on to me. But the smarter kids (and, I believe, the smarter adults), develop compensatory skills which can be very effective. They concentrate on things they’re good at and avoid those that are particularly difficult. Don't we all try to do that? Maybe they go into more creative, less structured fields. Maybe they successfully negotiate for certain types of flexibility from the teacher. Maybe they need to run their own business. Maybe they need to be CEO of an airline.

Next Post: Is ADHD inherited?

The sampler above is in my office. Sorry about the fuzzy photo, but it was taken through glass. The verse reads, "When I was young I little thought/That learning was so dearly bought/But by experience I do find/That it is not gained by an idle mind." Of course, it's easy for her to look back wistfully to when she was young, since she was 8 when she did this.