Wednesday, October 23, 2013


      The best practical example of the interplay of external and internal stimuli and response is to think of the ADHD child in the school setting.  We, along with the teacher (and believe it or not the child himself) would like him to stay in their seat, listen carefully, and not talk loudly to his neighbors or suddenly blurt out the often wrong answers.  At school our child lives in a real “outside” world that causes problems for his “inside” world sensitive and reactive personality.  The unpredictable day-to-day changes in his environment or in himself cause the seemingly inexplicable variation we see in his performance.
      For instance, there are days when all the noisy boys are absent from class, the teacher is in a good mood and is teaching a subject that the child loves (such as dinosaurs or gladiators).  Perhaps the lesson involves hands-on activities such as building a volcano or feeding Christians to the lions and rewards right answers with a handful of fake molten lava (just kidding – although you know he would love it!) or more likely plastic golden coins.  They have a wonderful day and often outperform his classmates in creativity, enthusiasm and leadership.  
          The next day, however, all the noisy boys are back, a student or substitute teacher who is unfamiliar with the routines and student personalities  is wading for the first time through a difficult math or social studies unit in a monotone lecture (“What is the capital of Djibouti?  Anyone? Anyone?....”), They may not have been warned that our child should sit in the front row, rather than the window.  As fate would have it the window is open and there is a class at recess playing basketball, tag and kickball. And now his world if filled with swirling images and sounds, random thoughts and new ideas, tangents and intangibles but the lecture is unheard, notes forgotten and homework assignments missed completely.  The other children have similar difficulties paying attention because of these distractions, but nowhere near the degree of impairment for our ADHD child. 
     Although we are only too well aware of this situation, reviewing it now can help us understand why the hallmark of ADHD is variability. It seems strange that at times they can demonstrate laser-like focus on certain topics (like video games) yet drive us crazy at the kitchen table trying to complete a simple fill-in-the-blank worksheet.  That is very different from our earlier medical example of strep throat.  Although the symptoms of fever and pain may worsen or improve over days, the patient is not totally healthy one minute and deathly ill the next.  But this inconsistency is classic for ADHD.
          Obviously our best chance to get our child on track will require adjustments to both inside and outside worlds.

Thursday, August 22, 2013


Our child with school difficulties has two essential characteristics: an exquisite sensitivity to their environment (both external and internal) and a corresponding over enthusiastic reaction to those stimuli.  Some experts believe their primary difficulty is a drive to actively seek more and more stimulating situations. They are acutely aware of what is happening around them as well as inside of them and they react quickly and strongly. They leap before they look. They are like lightning rods that instead of harmlessly conducting their white hot energy safely away into the ground instead send it back to the sky and at innocent bystanders leaving unintentional destruction and conflagration.
      We try to minimize the external stimuli by choosing a teacher who is flexible but fair, provides a consistent routine with clear rules and expectations, and immediate rewards coupled with appropriate consequences.  The teacher may sit him in front of the class, give a good deal of eye contact and tap on his desk when he is distracted. She may give him special responsibilities to keep him moving and reward his good behavior.
           At home we try to supervise his interactions with siblings and other children, provide constant discipline from both parents, and avoid wild birthday parties, violent loud cartoons or video games. Tea at his elderly great-aunt’s apartment is not going to happen.  We have seen what over stimulation can do and want to prevent the problem before it starts.  As my mother-in-law states it “You just have to nip it in the bud”.  Good advice but it is hard to catch them (if you can).
     The internal component is somewhat more difficult to get at but has the potential for greater success. We can’t completely control their outside world but we can help them learn how to manage their inner attention, hyperactivity, and impulsivity. We want our child to be less immature, to think carefully, take their time, remember to slow down and finish the job and be kind especially to small animals and stressed parents.  Psychiatrists call this process “internalization”.  As people grow older they eventually come to accept the values and customs of their culture. They become more civilized.  This is the hope and prayer of every parent.
           And so we teach our children well to behave and make the right decision. We reinforce the good behaviors by rewards and give the opposite with natural consequences.  Despite our best efforts some of our children seem to take a lot longer to learn these lessons even though they provide the multiple learning opportunities time and time again.  The frustration level for us rises quickly as the same sad scenes get replayed over and over again with diminishing returns but increasing anger, tears and guilt.
          Improvement depends on addressing both internal and external issues. My patient with a fever might lower his temperature and feel better sitting in an air-conditioned room, drinking cool water, wearing light pajamas next to a giant fan. He might finally make it to 98.6 degrees if I add some Tylenol as well. The combination of inside and outside strategies can get us back to “normal”.
          Goals to measure of therapeutic success in child with ADHD are more difficult to define. We don’t have a thermometer for that, but we have some ideas for next time.

Wednesday, July 17, 2013

HYPERACTIVE AND INNATTENIVE: Speeding without a map in sunglasses

     Because ADHD is classified as a behavioral diagnosis we will need to identify the three essential characteristics of ADHD; Hyperactivity, inattention, and impulsivity. Not all of these criteria need to be present at the same time, although it is probably impossible to really have ADHD you have a normal attention span.  The diagnosis also requires that these characteristics be seen from an early age (even before delivery some mother say!), present in multiple settings (at least at home and school but often at church, scouts, dance, basketball practice, birthday parties and grandmother’s house), different from their peers (usually longer lasting and severe), and causing impairment. These behaviors sadly create havoc in both academic and social arenas.
     Hyperactivity is exactly what it sounds like.  These kids are on the go, bouncing off the walls, swinging from the chandeliers, “as if driven by a motor (see American Psychiatric Association DSM IV criteria for full descriptions).  The energizer bunny is their team mascot.  They just keep going and going and going and going.  On a positive note even extreme hyperactivity tends to decrease with age.  Over time the physical component slows down as the brain matures, particularly in the area called the basal ganglia.  Fidgeting and other fine motor activity, however, often continues unabated throughout life.  Their keys are jangling, gum is clicking, and toes are tapping even when they are trying to sit as still as possible and doing their best to listen to you.  These children are like cars whose accelerators are stuck racing down the hill towards the cliff while they fiddle with the satellite radio.
     ADHD carries in the name the hallmark of inattention or distractibility.  This may include vigilance, freedom from distractibility, processing speed, working memory or even motivation. Neuropsychological tests can help to measure these qualities which have their origin in the chemical processes of the brain. The scientific research in this area will deserve its own discussion in the future.  Dr Joel T. Nigg presents a comprehensive discussion of this topic in his book “What Causes ADHD?” 
   The brain based defect actually appears to be in the control or modulation of attention.  It is obvious that at times children with ADHD concentrate so completely on some things, particularly those that interest or challenge them, that their problem seems more like selective or over–attention. It is not that they cannot pay attention, but more that they pay attention to everything: the sounds of the refrigerator or overhead lights, the TV downstairs, the pattern or the floor or even their own thoughts. The problem is not distraction but more one of  attraction to whatever they can see, hear, feel or smell. They live in a world of overstimulation and over-reaction.
          The impulsivity associated with ADHD (leaping before they look) includes difficulty with sequential memory or emotional mood swings.  More on this next time.

Monday, June 3, 2013


      One example of this attention dysregulation that deserve special comment is the fascination that boys often have for video games.  One of the reasons they can play for hours is because the Nintendo demands interaction on many levels.  There is a colorful, rapid-paced animation, loud sound effects and dramatic theme music, multiple buttons and levers requiring fine motor coordination while possibly receiving jolting vibrations from the controller itself.  Add to all this a mysterious quest with seemingly endless trails and worlds to discover while being constantly rewarded with objects or new skills or weapons and the allure of games makes perfect sense.
           As we know too well, the real world is often confusing to children with ADHD and their best efforts are not rewarded.  The problem is that these games are not the real world and probably do little to prepare children for our twin goals of academic and social success.  They are addicting to us as well because our child is finally quiet and is not irritating his sister, running around the room or loudly refusing to do his homework.  As the game system develop better graphics and unlimited capability through internet connections the addiction potential multiples and more and more time and energy may be devoted to them. 
          We need to teach our children moderation in all their activities whether it be TV watching, eating, practicing or playing sports or other activities such as dance or gymnastics , or going to church or playing video games.  It may be true that the games increase fine motor coordination or self-esteem because of the “expertise” they develop but it is surely a small gain at a huge price.  There is evidence that despite their devotion to their “DS” those children with ADHD score lower than their peers because they still have deficits in attention, distractibility and impulsivity.  Let the games begin but control them with reason and let them end just as frequently.
     It is helpful to think of distractibility as a mental rather than physical hyperactivity.  It seems that these minds of these children are working just as fast as their bodies.  Thoughts come and go with blazing speed and travel on “to boldly go where no man has gone before”.  They make a thousand journeys of one step but never arrive anywhere.  They multitask but never achieve anything.  It is difficult for them to screen things out or ignore the noise around them then to focus and complete the task at hand. 
          The problem is not that they cannot pay attention, but that they pay attention to everything. They listen to the sounds outside the door, the buses going buy, the overhead lights humming or air-conditioning, the patterns in the floor and their own thoughts.  One mother recently told me that her only chance with her son was to hold his head in both hands, come down to eye level with him and slowly repeat one phrase at a time.  Even then he would take off with a new idea or observation that seemed very important to him but had little to do with the job that needed to be done.  I thought had finally reached my son when he kept the eye contact going after my heartfelt instruction but was brought back to earth when he said “Do you know I can see myself in your glasses especially when your eyes get so big when you yell?”  So much for my parenting techniques.  We want to speak the truth in love but don’t know the specifics on how to do it.

Friday, May 10, 2013


The mother of my new 7 y/o patient confided to me that she simply did not believe the complaints her daughter’s 2nd grade teacher had about her classroom behavior until she decided to see for herself. The following is her verbatim list of what her daughter did over one three hour afternoon, including lunch and music class. (By the way, her teacher later commented that this had been one of her “better days”.)
  • Smacked papers hung in hallway (when her teacher got onto her, she said she didn’t do it)
  • Played with egg from desk (it was a part of a project) – 2x
  • Played with hair bow
  • Up to pencil sharpener – 3x
  • Feet not on floor – 10x
  • Dropped pencil – 3x
  • Put jacket on – 2x
  • Took jacket off – 3x
  • Not paying attention – 9x
  • Looked at book instead of listening
  • Wrote on chair and desk
  • Stood up – 18x
  • Tattled
  • Clapping hands
  • Shoes not on feet – 4x
  • Did not raise hand when teacher asked who was not allowed
  • Fingers in mouth – 3x
  • Laughing
  • Saying random words (“hun”, “mom”, “oww”) at inappropriate times
  • Skipping to the pencil sharpener
  • Asked to go to the bathroom – 3x
  • Dropped book
  • Talked out of turn – 7x
  • Dancing at desk
  • Raised hand to tell a story after teacher said “No more stories”
  • Didn’t put lunchbox up
  • Looked at reading test while teacher explained block project
  • Scooted seat across floor
  • Didn’t know what area and perimeter was even though teacher explained it 3x
  • Hitting and playing with Cameron
  • Didn’t clap to show she was paying attention
In Music Class
  • Whistling – 4x
  • Singing while the teacher was talking
  • Hit a boy
  • Hands in mouth
  • Hair in mouth
  • Yelled at boy to sit down
  • Rude to teacher (about teacher’s voice)
  • Singing after told to be quiet
  • Shouted out answer without raising hand – 3x
  • Did not sing
  • Scooted seat – 2x
  • Shoes not on foot – 3x
  • Stood up – 6x
  • Kicking feet up
  • Did not stand when told too
  • Clap hands
  • Played with friends shoe
  • Tattled
  • Sung too loud – almost to the point of screaming.
It is funny and sad and scary all at the same time. We want to keep her spark, but prevent her wildfire from spreading out of control. The only way to help her get all this under control is for parents to recruit a 3 person team of teacher-counselor-doctor to come up with treatment plans that the family coordinates for success in grades and relationships.  More on that process to follow.

Monday, April 29, 2013


During the World Cup soccer matches, a goal would always set off wild celebrations on the field and in the stands. All the team effort to kick, run, defend and block paid off in scoring a goal, increasing the likelihood of winning the game and ultimately the winner’s trophy. Setting goals is also important for parents if they expect to solve their ADHD child’s problems. We as parents basically want our children to consistently reach their best potential in school, relationships, and self esteem. Keeping these goals in mind is an important problem-solving strategy to help clarify the problem and direct the treatment.
When I see a new patient my last question for the parent is “What is your main concern?” Almost everyone correctly takes a moment to think carefully before they answer. If they have difficultly putting their thoughts into words I ask more specifically about their goals for their child or what behaviors they would like to change. I write this on the front of their chart to remind us on every visit of what our team is trying to accomplish.
I recently had a mother give me this list concerning her son. It is a heartfelt summary of the hopes we all have for our ADHD children.
1.    To know and help with what is really wrong with him, even if it is autism
2.    To sit down at a meal at home or in a restaurant with him and have him eat without arguing
3.    For him to feel safe and know he is loved
4.    For him to be able to make friends his own age
5.    For him to do well in school – academic and behavior
6.    For him to be able to sleep without nightmares or getting up so many times through the night
7.    To have one day without him misbehaving
8.    For him to listen and understand what I’m trying to explain to him
The path to successful treatment of ADHD starts when the family can begin to clearly and truthfully describe their expectations of a brighter future. The next step is to put a parent team of experts together that can work to reach that magical moment of rejoicing and screaming “GOOOAAALLL!”

Wednesday, April 17, 2013

DIAGNOSING ADHD: Looking for Distractibility, Hyperactivity and Impulsivity that are “Significantly Different” from their Peers AND Cause Impairment.

This inconvenient variability of symptoms noted in our last blog also makes it difficult to determine if the behaviors see are different from our child’s age and sex-matched classmates.  In a scientific study this would be the control or healthy comparison group.  We know from experience that all five year boys often behave differently from each other and even more remarkably from five year old girls.  Even the same child, especially our ADHD, child reacts differently from day to day or even hour to hour.  The strep throat in our febrile patient acts much more reasonably by maintaining the high temperature, sore throat, headache and stomach ache symptoms so that the diagnosis can be made and treatment begun. Persistence, severity and impairment have accomplished their mission.  But not so with ADHD.
           Furthermore we parents have a limited perspective on comparative behaviors of children.  We have only one (thankfully) 5 year old ADHD boy at home, not 10 or 20 (can you imagine?).  Our frame of reference is severely limited to my other children or less well known cousins, nephews or acquaintances. Experienced teachers, however, have spent long hours with boys and girls of the same age often for many years in different settings.  They are reliable observers who may agree that all the boys in their class are a little rowdy and restless but seem to be settling down nicely as the year goes by. These boys are responding to the teachers instruction as well as the examples and unstated expectations of their classmates to follow the rules – sit in your seat, raise your hand, stay in line, no hitting or calling names. They are becoming civilized.
           To our surprise and dismay the teacher may call us for a conference in November, or worse March, to tell us that our child   is different from his peers.  He is not at the expected level of academic success or social skills and in danger of retention. After our initial, defensive mechanism reflex of denial (not my son!) has gone we begin recognize and accept in our heart of hearts the accuracy of their assessment.  These are our exceptional children who are by definition both generally and specifically different from their peers. The most discouraging part is that we also know they have great but unrealized potential.
     The last historical criteria for judging behaviors characteristic of ADHD answers the question “So what?”.  The type of symptoms present is irrelevant unless it causes harm or impairs your child in some way. After all this is America, the land of the free.  Everyone is allowed to be themselves because everyone has different unique characteristics.  We vigorously celebrate this diversity because it has made us strong.  From a religious standpoint we are taught in church that the body of believers is made up of heads, hearts, feet and hands all working in harmony with gifts differing.  Some of us can sit still longer than others, some of us tend to listen better and react quicker, some are louder and more persistent, some are on the go from morning to night, some need to be told over and over and still don’t seem to ever get it.  But it is not a problem, a disorder or diagnosis until it hurts, the pain in failing grades and failing relationships.
          Parents understand this because is the reason they have come to my office. They have finally reached the end of their rope, a point where the pain is so great they have to take action.  This is how we all make decisions about when to seek medical assistance.  If I awaken with a slight sore throat but feel pretty good after a shower, some breakfast and a couple of Tylenol, I am grabbing my briefcase and keys and soldiering on to work.  But if I can hardly swallow and my head is killing me and I feel hot and cold at the same time I am instead pitifully pleading with my wife to drive me to the Emergency Room as fast as possible. I am in distress and pro-actively am seeking relief.

Next Blog: Turning Pain into Gain (transforming impairments into goals)

Wednesday, April 3, 2013


We are taking up again the idea of using information from parent, child, and teacher (our medical history) to build a case for the diagnosis of ADHD. Since there are no physical for drugs or laboratory test available to prove the diagnosis, we must rely on descriptions of the core behaviors of ADHD: (1) Hyperactivity (2) distractibility and (3) impulsiveness – verbal, physical, and emotional.
            The diagnosis of ADHD cannot be made unless the following conditions of those three behaviors are met:
1.   Occur over a long period of time
2.   Occur in more than one setting
3.   Significantly differ from their same age and sex peers, and
4.   Cause impairment or hurt the child                        
     Recently I saw a 9 year old girl in 2nd grade that was identified in kindergarten by her teacher with short attention span and exquisitely sensitive temperament.  She cried more easily than her classmates and seemed lost in the classroom for much of the day’s activities. Her mother agreed with the teacher’s opinions. A difference in her behavior was noted by her parents when compared to her younger brother at 6 months old and she was 2 years old. Mothers sometimes will describe the child as very active even before delivery.  They have always been on the go, driven as if by a motor, impulsive, slow to listen or remember, quick to respond and emotionally susceptible. If the child’s behavior has only recently developed it is much less likely that the cause is an inherited genetic trait or behavioral style.  Environmental circumstances such as a different teacher, new school or changes at home such as a death in the family, a new baby, divorce, a move or money problems are more likely the culprits for the worsening behavior.  Circumstances not personality have dictated the course.
     Secondly the characteristics need to be seen in more than one setting to solidify the diagnosis. The children act this way not only in the classroom setting but at home and day care, with the grandparents or babysitter, at church and Sunday School, while shopping, at the ball field, McDonalds, or a birthday party, in the car or even in (or out of) bed.  There is an unpredictable quality to their behaviors as well.  One day they may be as close to perfect as humanly possible and the next day transform into an unrecognizable monsters in the same setting with the same persons.
             At other times we may be able to predict the results of an explosive equation if the additive factors can be calculated.  If he is tired or has missed a meal, cramped up in the car for a long drive to Grandma’s party at her house full of expensive, breakable and accessible knick-knacks, and is instructed to play quietly with his evil young stepsister, we know it is only a matter of time before the inevitable screams, tears and blood happens.  The actions are related to the environment, the level of supervision and the personalities involved. Problems are often magnified if the situation is unstructured, the rules imprecise and inconsistently enforced and the child’s feelings ignored or injured.  There is some evidence that if the surroundings are not particular stimulating to these sensitive and responsive children, they will explore until they discover something interesting that keeps their attention. This extreme sensitivity to their environment and rapid, intense response of the child with ADHD creates the unpredictability that is the hallmark of the disorder.  They are consistently inconsistent all the time.

Thursday, March 7, 2013


      We will use “school and/or behavioral problems” as our chief complaint. Notice we intentionally keep the definition broad to avoid over-focusing on one cause resulting in missing other correct diagnoses.
          After seeing 5 or 6 children with fevers caused by throat swab positive strep I might be tempted to conclude that all the children with fevers I will see today will have strep and that it would obviously save time, effort, expense and pain to skip my three-step (history, physical, and lab) diagnostic process and simply start giving penicillin to everyone.  It is even easier to make this jump because we have a wonderfully effective treatment for strep and are looking for opportunities to apply it.  When one has a hammer everything begins to look like a nail. But this approach would result in over-treating the majority of children with simple viral illness and, much more seriously, missing the rare but potentially treatable case of meningitis or septicemia. 
      The most effective way for me to proceed is to define the problem at my best level of understanding.  When I enter the room with my chart in hand describing an 8 year old with a high fever of sudden onset, who I find is crying with a sore throat and lying very still on the exam table, I am already leaning towards the diagnosis of strep while trying to keep an open mind about other realistic possibilities.  All medical students are taught to develop a “differential diagnosis” to consider all the potential reasons for their patient’s symptoms.  This analogy to shifting gears is helpful in reminding us to drive ahead logically towards our diagnosis based on what we know or don’t know.  Often the facts that do not seem to fit correctly in our diagnosis might be crucial to lead us in the right direction.  We must guard against our natural tendency to sweep contradicting facts under the carpet when they do not fit into our system of understanding.  We are all guilty of that at some point.
      We now need to further clarify the initial chief complaint by asking the parents and child (and eventually the teacher) for more specifics. The parents have already written on my history form the reason they have scheduled an appointment and the results they hope to achieve.  Most often they are looking for improving for their child is grades and behaviors but also for reducing the frustration they feel in not being able to help their child.  When a child has an illness, particularly one in which the cause is unclear, the parents automatically assume it is their fault.  In the case of strep they are sure the infection was caused by letting the child go outside without a coat, forgetting their vitamins or allowing them stay up to watch a special movie.  Often there are other relatives (mother-in-laws or ex-spouses) who are quick to step in and agree with the parent’s self-assessment of blame.  In reality the source of strep is most often the classmate the child sits next to not mother (or father) failure. Similar family dynamics are associated with school problems where feelings of guilt are added to long-standing confusion and aggravation.
          The lists of chief complaints that I see include: failing to stay in a seat, not finishing school work, forgetting to hand in assignments, impulsive actions, irritability, emotional labiality, poor social skills (no friends), deteriorating relationships with parents or siblings, falling grades and lack of self-esteem.  Although it is discouraging to contemplate such a list, facing and describing the situation is the first shaky step towards correcting the problem.  The treatment phase will require transforming these concerns into goals which can then lead to a successful outcome.
      We will need to review how to obtain accurate and complete information (history) in a timely and efficient fashion. This is the ultimate goal of every medical encounter.  Next time we will begin with the four characteristics of the behaviors we must gather from our history that are essential for establishing the diagnosis for ADHD and other coexisting conditions.