A DAY IN THE LIFE

The mother of my new 7 y/o patient confided to me that she simply did not believe the complaints her daughter’s 2^nd 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.

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 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 & Dropping Out

This is an article that was published in our local newspaper The Herald Dispatch on July 12, 2012.

A few years ago I had a 16 year old teenager come to my office for help with school problems. He had been retained in Kindergarten for “immaturity”, struggled through elementary school and repeated 6^th grade because of poor test scores and missing assignments. Although he was now only half-way through his freshman year in high school, his parents had been notified that he was in danger of failing again. All his grades were low and he was refusing to do his work and more than once slept at his desk. Recently, he had become argumentative with the teachers and other students and was often tardy or absent from class.

            His parents remarked that even as a young child he had always been “on the go” – “full force” they said. He often forgot the rules about staying in his seat, not talking and forgetting to raise his hand. He was a slow reader and did poorly on timed tests. In middle school his lack of organization resulted in zeros for lost papers and unexpected exams. Homework was a nightmare for everyone that could last for hours and might end in tears and threats. He was becoming very moody and was staying out later with unfamiliar and unwelcome friends. In the morning it was hard to wake him up and he would complain of being tired all day. He was thinking about dropping out of school and his parents were at the end of their rope.

            I was reminded of this patient and many others like him when I read an article in the Herald Dispatch describing a new initiative to reduce dropouts in Cabell County. A multi-disciplinary team of parents and professionals lead by Laura Gilliam and Sara Blevins of The United Way of River Cities was meeting regularly to address three basic concerns: attendance, behavior, and course performance. Although it is still unclear to me if I volunteered or was drafted, I was glad to join the Education Matters team.

            As a physician I have learned that children and adolescents with school problems usually have more than one diagnosis. They may have any combination of learning differences, emotional problems, family conflicts and Attention Deficit Hyperactivity Disorder (ADHD). Effective treatment requires finding all the diagnoses present and creating a team of education, behavior, social, and medical specialists that the family can use to help them get back on track. My expertise in ADHD is based on board certification in Neurodevelopment Disabilities and on-the-job training as a parent of two children with ADHD.  

            ADHD is a neurologic medical condition that may be present in up to 10 % of all children. The American Academy of Pediatrics has recently published evidence based guidelines for accurate diagnosis and treatment of the condition. More than 50% of children with ADHD continue through adolescence to have symptoms of hyperactivity, short attention span as well as physical, verbal, and emotional impulsivity. Children with ADHD also have an increased rate of learning disabilities causing them to struggle with reading, getting their thoughts on papers, and staying organized.    Deficits in social comprehension and problem-solving lead to difficulties making and keeping friends or maintaining good relationships with parents, teachers, and school personnel.

            Research has shown that high school students with ADHD when compared to their classmates generally have significantly lower GPAs, turn in a lower percentage of assignments and are more likely to be absent or tardy. A higher likelihood of grade retention and failure to graduate has also been documented in this group.  It is not surprising to discover that a study completed in 2011 found that the dropout rate of adolescents with ADHD was eight times greater than their age and sex matched peers.  Investigators noted that other factors independently contributing to dropping out included lower IQ, marijuana use, and decreased paternal interaction.

            What can be done to solve this complicated problem and help these teenagers? Studies across the country are showing that multi-disciplinary programs based at the local school and community level can be effective. Teachers and school administrators, agency and governmental representatives, counselors, mental health professionals, and physicians can work together to provide their special expertise. Parent leadership, however, is the key to success. North Carolina has developed a model protocol which provides the combination of education, behavioral, and medical treatment that allows these students to reach their full potential both academically and socially.

            There are happy endings. My patient’s parents obtained IQ testing for him through his school eventually resulting in an Individual Education Plan that maximized his educational strengths while providing needed modifications. Family counseling and a behavior modification system to reward correct decisions was implemented.  Medical therapy was added resulting in improved attention span and better grades. He graduated, went on to technical school, found a good job and a stable, loving relationship. 

            Education Matters, with the help and support of our community, is building a comprehensive program for these Cabell County students that can spread this kind of success to everyone.  This is an opportunity for all of us to lend a hand and get the dropout rate under control.

PLANS VS LISTS

I am a little tired of ADHD “numbers” articles. I mean the ones that list the “7 Secrets to Improve Your Child’s Attention”, “5 Ways to Eliminate Homework Problems”, and “32 Sure Fire Steps to Save Your Marriage” (that one seems to requires a little more work). Getting ADHD under control is just not that simple. What really is needed is a system, not a list.

            Of course, lists have a place when used to remind, prioritize, and teach us. For example, one for successful brain surgery might be:

1.    Get plenty of sleep the night before.

2.    Wear comfortable shoes.

3.    Make sure your scalpel is sharp.

They may be good rules, but we expect our neurosurgeon will also have the required knowledge, experience, skills, and clinical judgment to do the job correctly. Every professional from hairdresser to plumber to policeman has a reliable plan to deal with bad hair, clogged drains and criminals. Parents too need a problem-solving process to help their ADHD child consistently achieve their best potential in school, relationships, and self-esteem.

Years ago I was unexpectically given the responsibility to provide medical care for a large number of children who had ADHD and were in trouble at school. Although I had received excellent training in managing premature infants on ventilators and severely injured children in the Shock Trauma Unit, I had no idea what to do with this group. But what I discovered is that the medical problem-solving system I used to diagnosis and treat fever, pain, rash or whatever could work for ADHD as well. Although I realize this looks suspiciously like another list, I prefer to think of it as an algorithm or the sequence of steps that all doctors use to solve a problem.

1.    Describe the chief complaint (fever)

2.    Take a history (ask questions such as “Does your throat hurt?”)

3.    Do a physical exam (open your mouth and say “Ahh”)

4.    Perform a laboratory test (swab the throat and perform a rapid strep test)

5.    Make a working diagnosis (probable strep throat)

6.    Decide on best treatment ( usually penicillin)

7.    Evaluate the accuracy of your diagnosis and treatment (call the next day and ask about improvement or side effects)