THE ADHD PERSONALITY: SENSITIVE AND STUBBORN

        Children with ADHD often are very emotionally sensitive and impulsive.  They get their feelings hurt easily and wear their heart on their sleeves. They are upset by things that are said, the way they are treated, the tone or volume of the voice we use and specific remarks that teachers or friends often innocently make. Because of their lack of attention to social situations they are especially vulnerable to the unkindness of others.

           Who of us has not spent sad times drying their tears, listening to their sad stories and reassuring them against the thoughtlessness of friends and family?   These experiences develop in them a deep empathy for other children and even adults who are going through tough times.  They often have exceptional insight into the problems of others who are drawn to them for their consolation and advice. 

          Traveling through the trials of life on an emotional roller coaster is difficult.  They are pulled off the straight and narrow King’s Highway of The Pilgrim’s Progress not only by every sound they hear or thought they consider but every harsh word or unfair action that they experience.  Clearly they will need to build some emotional toughness. My son hates it when I tell him to get a thicker skin.

       Along with this sensitivity they also have perhaps the worst possible combination character trait – they are stubborn. Here is where many parents automatically begin to nod their heads in rueful agreement and recognition. Psychiatrists call this unholy union “Oppositional Defiant Disorder” but I prefer the more descriptive terms of sensitive and stubborn personality. These children have very strong feelings about what they want and do not want to do and they are happy to strongly express their opinions in no uncertain terms to anyone who questions them. 

     This combination of characteristics (which are completely separate from the additional diagnoses of ADHD or learning differences) are challenging to everyone around the child, but once we get past our frustration we begin to see their extraordinary qualities.  They not only have highly original ideas but the drive to start (but not always finish) their plans.  We appreciate their creativity and sense of purpose. Stubborn people should be more positively defined as determined and persistent.  They strive to complete the work they are interested in and can often find a way regardless of what anyone says.  The idea that no one believes they can accomplish the impossible motivates them like nothing else.       

          Because stubbornness is essential to faith, we find many examples in the Bible.  Jacob wrestled an angel and Abraham had every intention of following through on Jehovah’s command to sacrifice Isaac on the altar.  The determination of Job to not blindly accept the false critical comfort of his “friends” was rewarded by the voice from the whirlwind.  The hard-heartedness of Jonah in refusing to go to Nineveh or the Israelites questioning everything God asked of them changed their lives.  Hard lessons may be necessary but ultimately rewarding.

          Sensitive but stubborn children achieve may not their best in grades, relationships with family and friends, or self-esteem.   Invariably when school and relationships sour, frustration leads to determination to not do their work or cooperate with the rules.   An attitude of disagreement or an atmosphere of resistance becomes more and more firmly ingrained and difficult to alter at home and at school.  It is not our wish to change their personality but rather recognize and redirected it in appropriate directions.  Relentless single-mindedness can be our friend if it is properly harnessed.  It sounds difficult and it is but it is not impossible.

ADHD AND THE “OUTSIDE” WORLD

      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.

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.

           

MAKING THE RIGHT ADHD DIAGNOSIS: Using the Chief Complaint

      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.

ADHD - Making the Diagnosis

We need to proceed to accurately describe the two major barriers obstructing our path from chief complaint of school and behavioral problems to valid diagnosis and effective treatment.

     The first barrier to diagnosis is the pitiful lack of hard scientific evidence.  There are currently no specific physical findings or laboratory tests that we can use to help us diagnosis any behavioral problem such as ADHD, depression, anxiety or obsessive compulsive disorder.  Our vaunted medical problem-solving system that should flow from history, physical and lab test to correct diagnosis fails us miserably.  This not to say that a complete physical examination including a neurological assessment should not be performed on every child with school problems.  Certainly there may be specific labs that we may want to obtain if the physical examination suggests disorders such as anemia, lead poisoning, hyperthyroidism or fetal alcohol syndrome, Such causes of “acquired” ADHD are for the most part very rare.  Medical research is daily adding to our knowledge concerning the genetics, neuroanatomy and physiology (structure and function of the brain) associated with ADHD.  Although it is encouraging and enlightening to discover evidence supporting the existence of a brain-based disorder, none of them separately or together can be used as a gold standard for the official stamp of approval for diagnosing ADHD.  The bad news for us all is that there is no test for ADHD.

     What to do?  Actually this is a dilemma that occurs more often in medicine than physicians would like to admit.  Life and death treatment decisions must sometimes be based on our best guesses at underlying causes when there is limited supportive physical or laboratory evidence.  Asthma, for example, is not diagnosed by any specific test or sign but rather on the history that the parent and child describe.  Our confidence in our diagnosis is increased if we are able to add findings of audible wheezes heard while listening to the lungs and flattened diaphragms or hyperinflated lungs seen on chest X ray films.  We fare better in the case of the strep throat because current technology provides a rapid, reliable test for the presence of the bacteria.   Not too long ago, however, we had to wait 24 to 48 hours for our bacterial colonies on the throat swab to grow on blood agar plates incubated at 100 degrees and show a zone of growth inhibition around the bacitracin discs to prove the presence of beta-hemolytic Group A strep.  Despite these limitations we were able to immediately correctly diagnose and treat patients for strep in the “old days”. We simply had to work harder.  Without the weight of the positive strep test to confirm the diagnosis we had to gather more information to tip the balance one way or the other.  We were forced to expand our history, increase our physical findings and augment our laboratory tests to be as certain as we could be before risking definitive treatment.

     The conscientious physician would ask a lot more questions after “Does your throat hurt?”.  For instance “Do you have a headache or stomach ache? (common with strep).  How about cold symptoms or cough? (rarely associated with strep). Have you ever had an illness like this before?  Do you know what strep feels like? Have there been strep infections in your class recently?  Has anyone else been ill at home? In the same way we would look for more positive evidence from our physical examination.  We would not simply note the red throat, but we would look more closely for white or yellow exudates on the tonsils, tiny red spots or petechial rash on the roof of the mouth or a strawberry appearance on the surface of the tongue, We would palpate the neck at the angle of the jaw for the presence of enlarged and tender lymph nodes.  We would check the abdomen to see if the liver and spleen were enlarged – signs more compatible with mononucleosis.  A severely ill child with strep-associated complication of rheumatic fever might have warm swollen joints, subcutaneous nodules on the arms, unusual choreioform movements of the extremities and a heart murmur.  And although we did not have the new rapid strep test , we could order stat some more general tests that are often positive in patients with bacterial infections such as a complete blood cell count (CBC) with differential white cell percentages, erythrocyte sedimentation rates or C-reactive protein levels. 

      None of these findings prove that strep is present and causing the illness but the weight of the evidence improves the odds in our favor.  Lawyers use this strategy of building a case when they defend their client or prosecute a defendant.  This painstaking process done in partnership with families is the only sure way to develop enough data to tip the diagnostic balance in our favor and lead us to effective therapy and successful future follow-up care.  We will use this approach to navigate around the two major barriers or roadblocks on our journey to solve our children’s school and behavioral problems. Those barriers of uncertainty and complexity will next on our agenda.

MAKING THE RIGHT DIAGNOSIS I: DEALING WITH UNCERTAINITY

Obviously starting with the correct diagnosis is critical for our medical-problem solving system to work. If I think you have a strep throat but you really have diabetes, we are both in a lot of trouble. Doctors understand here is always some degree of uncertainty in every patient. The only physician who knows the diagnosis without a doubt is the pathologist at the autopsy—absolutely sure about everything but way too late to help. In real life we need to come up with a way to reduce the uncertainty of the diagnosis of ADHD and school problems right now.

Physicians use evidence from the history, physical and lab test to build a case for the most likely diagnosis. If you say that your throat hurts, your tonsils are big and red, and your throat culture is positive, the probability that you have a strep throat is high. You will be given a prescription for penicillin with instructions to call back tomorrow to check for improvement or side effects. Our working diagnosis is like a three-legged stool that securely rests on history, physical and lab results. The problem with behavioral diagnoses such as ADHD is that there are no positive physical findings or test. There should be because we know that ADHD is more strongly inherited even than height. Research evidence is accumulating towards specific ADHD genetic patterns, MRI findings and neurotransmitter brain levels that someday will help us nail the diagnosis—but not yet.

Before we give up and throw away our shaky one-legged diagnosis stool, we need to consider how we might strength it. If we could expand the history to form a rock-solid post, it might be able to hold a circus elephant. The diagnosis of ADHD requires a complete history from the child or adolescent, the parent as well as the teacher. Specific behavior patterns need to be looked for and then compared to same-age children using standardized questionnaires.

It is possible to make the diagnosis of ADHD and start safe, effective educational, behavioral, and medical treatment. Parents can do this. Next up, dealing with complexity.

START ME UP - The ADHD Doctor (with a little help from the Rolling Stones)

  

January 2013 -A new year is the perfect time to for an introduction.

I have been a pediatrician for a while now and a husband and father to our 6 children who are rapidly growing up and leaving home.  They are good kids but half of them had problems in school and home with short attention spans and short fuses.  Their personalities and styles of learning and behavior were all very different but some were much more challenging than others in academic, social and spiritual arenas.

There is today an epidemic of children who are struggling at school.  They are constantly at odds with the system and are hopelessly unorganized.  They have trouble keeping friends.  At home there are constant arguments and physical fights with siblings.  There are addictions to video games or computer time, unfinished homework and bedtime battles.  The well-meaning but conflicting advice from relatives, friends and self styled know-it-all experts proves to be worthless.   Parents feel both guilty and powerless as they watch their cherished child spiral downward out of control.

These children defy categorization.  They don’t fit well into the school's definition of a good student – one who sits quietly, writes neatly, follows the rules, pays attention and memorizes facts to be correctly repeated on request.  They are instead bursting with energy and excitement.   They have a million new ideas and perspectives that they want to share with everyone loudly and immediately.  They notice incredible new details that most of us miss.  They are persistent, determined and passionate about their feeling and ideas.  They do not have a medical disorder - they are just a little different in a world that often doesn’t value their gifts.

Trending psychobabble, expensive leafy garden supplements and shallow religious formulations of tough love are no help. What parents really need is a comprehensive, practical approach that helps them understand how their child’s brain works.  The best solution is a parent-led team approach centered on the strengths of the child.

 My personal experiences and professional training eventually led me into a medical school practice which is limited to children and adolescents with school and behavior problems.  Over the years I have listened carefully and learned valuable lessons from the parents and children that I work with.  I know there is hope for these families.  Parents can find the answers to help their children achieve their best potential in grades and relationships. I see it every day.

I teach parents to use my medical problem solving strategy.  If it works for me for to manage a fever, it should work as well to help them take charge of their child's school and behavior problems.   We focus on defining the chief complaint and making accurate diagnoses by using information from history, physical and laboratory testing.  Next we develop a logical multidisciplinary treatment plan and evaluate the results by measuring risks and benefits.  Parents learn how to recruit and coordinate a team of experts in education, psychology and medicine for advice on learning disabilities, ADHD and emotional concerns.  All decisions, however, are completely in the hands of the family.

Our goal is for children to reach their full potential.  Everything we do should clear their path to consistently achieve their best capability in academics and relationships with their family, friends and themselves.  Their self-esteem, confidence and happiness are at stake.  We look forward to discovering how to make the diagnosis in our next installment. 

Thanks for reading and always remember:  Don't get distracted!