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.

HYPERACTIVE AND INNATTENIVE: Speeding without a map in sunglasses

     Because ADHD is classified as a behavioral diagnosis we will need to identify the three essential characteristics of ADHD; Hyperactivity, inattention, and impulsivity. Not all of these criteria need to be present at the same time, although it is probably impossible to really have ADHD you have a normal attention span.  The diagnosis also requires that these characteristics be seen from an early age (even before delivery some mother say!), present in multiple settings (at least at home and school but often at church, scouts, dance, basketball practice, birthday parties and grandmother’s house), different from their peers (usually longer lasting and severe), and causing impairment. These behaviors sadly create havoc in both academic and social arenas.

     Hyperactivity is exactly what it sounds like.  These kids are on the go, bouncing off the walls, swinging from the chandeliers, “as if driven by a motor (see American Psychiatric Association DSM IV criteria for full descriptions).  The energizer bunny is their team mascot.  They just keep going and going and going and going.  On a positive note even extreme hyperactivity tends to decrease with age.  Over time the physical component slows down as the brain matures, particularly in the area called the basal ganglia.  Fidgeting and other fine motor activity, however, often continues unabated throughout life.  Their keys are jangling, gum is clicking, and toes are tapping even when they are trying to sit as still as possible and doing their best to listen to you.  These children are like cars whose accelerators are stuck racing down the hill towards the cliff while they fiddle with the satellite radio.

     ADHD carries in the name the hallmark of inattention or distractibility.  This may include vigilance, freedom from distractibility, processing speed, working memory or even motivation. Neuropsychological tests can help to measure these qualities which have their origin in the chemical processes of the brain. The scientific research in this area will deserve its own discussion in the future.  Dr Joel T. Nigg presents a comprehensive discussion of this topic in his book “What Causes ADHD?” 

   The brain based defect actually appears to be in the control or modulation of attention.  It is obvious that at times children with ADHD concentrate so completely on some things, particularly those that interest or challenge them, that their problem seems more like selective or over–attention. It is not that they cannot pay attention, but more that they pay attention to everything: the sounds of the refrigerator or overhead lights, the TV downstairs, the pattern or the floor or even their own thoughts. The problem is not distraction but more one of  attraction to whatever they can see, hear, feel or smell. They live in a world of overstimulation and over-reaction.

          The impulsivity associated with ADHD (leaping before they look) includes difficulty with sequential memory or emotional mood swings.  More on this next time.

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.

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.

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!