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.

ADHD: THINKING OUTSIDE (& INSIDE) THE BOX

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.

LET THE GAMES BEGIN - ADHD and Videogames

      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.

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.