GOOAAALLLSSS!!!!

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!”

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)

MAKING THE RIGHT DIAGNOSIS: CRITICAL BEHAVIORS

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 2^nd 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.