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.

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.