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.

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)

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!