There is an old saying, “Be careful what you ask for”. This holds very true with the diagnoses of ADHD, but most parents haven’t even thought about it.
Let’s look at a case to explain my point. I have a hypothetical friend named Johnny. Johnny is 8 years old and he is not doing so well in school. His grades are starting to fall and his 2nd grade teacher has written notes to his Mom informing her that he is struggling to stay on task. He is easily distracted by the other kids and seems to “zone out” often. He frequently forgets to take his homework home and therefore doesn’t turn in his assignments. He gets in trouble for talking and blurting out answers and fidgets frequently with his hands.
Johnny’s teacher implied that he may have ADHD by sharing that he exhibits characteristics similar to her son who was diagnosed with ADHD when he was in 2nd grade. She said she put her son on medicine and it made a dramatic improvement in his ability to perform in school.
The last note from the teacher stated that Johnny was refusing to do his work and had to be sent to the principal’s office for disrupting the class.
Johnny’s Mom feared that someone would mention ADHD to her eventually because she had noticed similar behaviors at home; especially surrounding homework completion. She also noticed that he is very active and needs frequent reminders to get his chores done. He has also become defiant at home and is refusing to comply with directions.
Like most parents in the 21st Century, Johnny’s Mom went to Google to obtain more information about ADHD. She found several articles that described Johnny perfectly and was convinced that he did in fact have ADHD. After diagnosing her son via the internet, Johnny’s Mom scheduled an appointment with Johnny’s doctor. When she arrived for her 20-minute appointment, Johnny’s Mom delivered a textbook description of Johnny’s symptoms. It’s no wonder that after about 5 minutes of speaking to the doctor and completing a survey, Johnny was officially diagnosed with ADHD and started on a stimulant medication.
There is just one problem – Johnny’s ADHD was NOT causing his problems in school. His real issue is that he has a learning disability and a processing disorder which was completely overlooked. Johnny’s Mom was not careful about what she asked for and she got it. She had convinced herself that Johnny had ADHD and her story was so accurate that her doctor didn’t look for any associated conditions. It took one full year and 4 failed stimulants before other medical conditions were considered.
The 80/20 Rule
One of the issues that I have with ADHD is that everyone thinks they are a subject matter expert. I can’t tell you how many times I will be in Walmart and a clerk will inform me that the kid in line before me “must have ADHD”. Unbelievably, every person that is hyperactive or inattentive does not necessarily have ADHD. The other important point is the 80/20 rule – 20% of individuals with ADHD have uncomplicated ADHD that will improve with a medication and behavior modification but 80% of individuals with ADHD will have a co-existing condition. These conditions include learning disabilities and processing disorders; behavior problems like oppositional defiant disorder and conduct disorder; mood disorders like anxiety, depression and bipolar; and neurodevelopmental disorders like autism and Intellectual Disabilities. Unfortunately, because everyone thinks that they know ADHD often the other co-existing conditions can be missed and they may be the condition that is causing the most problems.
The Diagnostic Process
So how do you know if you or your child’s ADHD is in fact the problem? You must ensure that your symptoms have been thoroughly evaluated and assessed. The gold standard assessment for diagnosing ADHD is a survey, either the NICHQ Vanderbilt Assessment Scales or the Connors Rating Scales. This typically needs to be completed by the individual or parents for the home environment and then also a teacher for the school environment. If symptoms of inattention and/or hyperactivity exist in two separate environments and those behaviors cause academic or social problems then the diagnosis of ADHD is given. That is just the first part of the evaluation. The next part needs to consider the possible co-existing conditions. A comprehensive interview and review of past medical history, family history, educational and developmental history and a history of present concerns will highlight additional potential conditions that should be considered. The history will dictate which batteries of cognitive testing should be completed by a psychologist who will look at ADHD but also learning and processing issues. Lastly, there needs to be a behavioral assessment (which can also be completed by a psychologist or a counselor) looking specifically at mood disorders and behavior problems. If symptoms of autism are identified, then specific assessment for autism should be completed by the psychologist or developmental pediatrician.
With thorough and comprehensive assessment of ADHD and the potential co-existing conditions a specific treatment plan can be selected to ensure that support is provided to help you or your child reach your greatest potential academically, socially and in life.
Don’t forget to be careful what you ask for.
Autism Awareness Is More Than a Month
With the end of Autism Awareness month, I want to encourage everyone to continue to think about, support and encourage those individuals who have autism. Autism is about more than a month, it’s about a lifetime. If you or your child has autism it is something that you were born with. Despite what some might believe, you can’t catch autism from another individual or acquire it from immunizations or substances found in foods. Autism is a blessing and I don’t know about you, but my God doesn’t make mistakes. We all must learn more about autism and be more accepting of those characteristics that coalesce to create the spectrum. Everyone is different but because we cannot readily see and understand the differences that make up autism, we fear it. We fear it in ourselves, we fear it in our children and we fear it in our society. Move beyond the fear and celebrate what makes autism unique and powerful. When we can come to understand that everyone in this world has characteristics of the Autism Spectrum maybe we will reclassify it as a variant of normal. Those individuals diagnosed with autism have tremendous strengths but in exchange for those exceptional abilities they may have significant challenges to overcome. Never forget that you have a choice; you can either be crippled by your challenges or empowered by your strengths.
Choose to be Empowered!
One of my greatest frustrations as a physician who cares for individuals with Attention Deficit Hyperactivity Disorder (ADHD) is that everyone, and I mean EVERYONE, thinks that they can do my job. It’s amazing to me how often I hear from parents that they have come for an evaluation because their child’s teacher mentioned to them in a conference that their child might have ADHD. That one doesn’t bother me too much because I can appreciate that a teacher, who is struggling to impart wisdom to a child, is expressing their concern to a parent. But it doesn’t stop there, I’ll hear that the soccer coach said something, then it’s the choir director or the girl scout leader. My kids even think that they are experts, as if they gained a certain knowledge set by just being my off-spring. We’ll be out at the mall and they will lean over to me and say, “Mom, I think that kid up there has ADHD”. Really?!?
The reality is that inattention can be the result of many, many factors with ADHD only being one (and sometimes not even the most important one). I’ll use myself as an example. I have just completed a very intensive week of study at Babson College for their 10,000 Small Business Program. I am mentally drained and exhausted while sitting in the airport writing this blog. I know I’ve got to get this done because my deadline is tomorrow, but I find myself getting distracted every other minute by just about everything. Do I have ADHD because I’m struggling to stay focused to get this task done? The answer is NO! In fact, I have been tested and I know for sure that I don’t have ADHD. What I am right now is tired and being tired often looks like ADHD.
What about the boy in class who frequently puts his head down on the desk while the teacher is talking and writing on the board, does he have ADHD? Or the girl who always seems to be gazing out of the window or lost in thought. Does she have ADHD? If you asked five people to observe those two kids and tell you what they think is wrong, I guarantee you someone will say “ADHD”.
So why are we so quick in our culture to jump to ADHD? Since I haven’t done the research on this topic, I obviously can’t give you a definitive answer. But what I can tell you is that 11% of school-aged children in the United States have ADHD. That is a staggeringly high number. I believe the statistic, but what I don’t necessarily believe is that ADHD is causing problems for all those people. In fact, those individuals with a diagnosis of ADHD often have other conditions that can lead to inattention as well. ADHD’s “kissing cousins”, as I like to call them, include learning disabilities, autism, anxiety, depression, processing disorders, oppositional defiant disorder and obsessive compulsive disorder. Each of these issues can result in inattention. Each of these can lead to difficulty starting or completing a task as well as distractibility.
So how do you know what’s going on? My point is, just by looking, you can’t. Here’s the part that is most disturbing to me as a physician: a lot of parents won’t seek care for their child if they suspect ADHD because they don’t want their child on medication. Would their response be different if the teacher said, “I think your son may have a learning disability” or if the football coach said, “I think your child may be depressed”?
Here’s the take home message, you can’t look at someone who is not paying attention or having difficulty completing a task and determine from that 5-minute observation that they have ADHD. You can’t even observe them for 2 days, 2 weeks or even 2 months and know with certainty just based on that observation alone that they have ADHD. What you can observe and comment on is that their inattention is making it difficult for them to learn or get some tasks accomplished and that is what is most important.
I don’t want anyone to jump to an ill-informed conclusion and then allow the fear of ADHD to prevent them from obtaining real answers that could lead to real solutions. Inattention is an issue; it is one that we know how to thoroughly evaluate and support. Let us in the medical community handle this one. Don’t fear the outcome but embrace that there is a solution. Did you ever think that the girl who always seems to be gazing out of the window may be thinking about her grandmother who has Alzheimer’s and for the last couple of months doesn’t seem to recognize her. Or maybe the boy who is putting his head down on the desk is doing so because he has a visual issue that causes his eyes to hurt after he has read too much. In each case, they need to be evaluated but the treatment is much different. If you, the teacher, the coach, the choir director or even the store clerk expresses a concern, don’t hesitate to have your child evaluated. Only then will you be able to help.
Everybody thinks that if you are a doctor you must be really smart. In fact, that “M.D.” behind one’s name often instills a sense of confidence that intellectually, the physician must know what he or she is talking about. So here is the real deal, you should be confident in your physician’s abilities but not because you think they are smart, but because they have the drive, dedication and work ethic needed to complete the exuberate amount of education and training necessary to get where they are. Don’t make the assumption though that it was easy, and that physicians (and other higher level professionals) relied on just their intellect to make it through . . . speaking from personal experience, it was anything but easy.
After 18 years in practice, about a month ago I had a revelation that I wish I had had back in second grade. I realized that the educational system in this country falls prey to the old saying of “putting the cart before the horse.” Our system is set up to assume that all children learn the same way. Teachers are trained to teach kids using the top two learning styles (visual learning and auditory learning), with a little hands-on, kinesthetic work just to sweeten the pot. The thought is that by using two to three learning styles to teaching children, educators will capture the majority of the class and children will successfully understand the content. But think about this: there are eight (8) learning styles and out of those eight, there are some people who don’t use the visual or auditory learning as their primary way to learn.
So what does this mean? This means that some kids will struggle in school. Some kids may even fail just because they are not being taught in a manner in which their brain can adequately process the information and really learn. Understand that the way most school systems are set up in this country, it is not until these kids fail to perform to their expected capabilities that teachers and parents become concerned. But by then the damage has most likely already been done. I know that sounds dramatic, but have you thought about the consequences of failure? Low Self-Esteem. Depression. Anxiety. School Avoidance. Defiance. Those are all things that can be consequences of a child not being able to acquire the information they are supposed to, and have the innate ability to, learn.
Along with my revelation, I had an epiphany: We should seek to understand how a child learns before we even begin to try to teach them. I know that sounds like a reach, a little too idealistic but it really is possible. In fact, it’s quite easy, and simple, to get an idea of how your child may learn just by doing learning style surveys. You don’t have to go to a psychologist, developmental specialist, or doctor; these surveys can be found online! I will say, though, for parents who are interested in ensuring that there are absolutely no obstacles to your child’s learning, I would encourage obtaining baseline cognitive testing through a clinical psychologist. Unfortunately all that glitters isn’t gold and there is a catch: traditional health insurance companies don’t cover this type of testing unless there is proof that the testing is indicated for poor academic performance. But still, this doesn’t mean that you shouldn’t consider the testing. There are resources everywhere, you just have to figure out which ones are available to you.
One last thing: let’s not forget that learning occurs outside of the classroom as well. Kids aren’t born knowing how to tie their shoes, how to make their beds, or how to clean their rooms. Wouldn’t it be nice to know when your child requires hands-on demonstration (kinesthetic), written instructions (visual) or verbal cues (auditory) to learn these tasks the first time? Better yet, wouldn’t it be nice to know that turning off the television for a musical learner is actually counter-productive? Hmmm . . . something to think about.
Why not consider setting your child up for success before waiting for them to fail? Just a thought.
Recently, I was asked by a colleague if I would be willing to go into a local detention center to provide medication management for a young adult she was counseling. This young man had been in and out of the detention center several times previously. But this time, he expressed to my colleague that he was ready to do whatever was necessary so that he would not return to the facility once he got out. Prior to his detention, he had been given two diagnoses: Attention Deficit Hyperactivity Disorder (ADHD) and Bipolar Disorder. He and his mother had concerns about medication so he had never tried them. Now, he was ready to take whatever medication was necessary.
I gave my colleague the “green light” in regards to prescribing him medication. But I had one condition: both the young man and his mother had to make a commitment to understand the foundational issue for what was going on in his life and had to be willing to do the work to fix it. Medication is never the answer; it is only a tool.
In the end, logistic issues prevented me from working with this young man, but it did get me thinking. Can we identify at an early age which juveniles are going to get caught up in the prison cycle? If so, how do we prevent it? The answer to the first question is “yes” but the prevention piece is hard. Some of you may be familiar with the phenomenon known as the “School to Prison Pipeline.” The “pipeline” speaks to the funneling of students from the school house to the jail house, most often because of the zero tolerance policies employed by school systems (which developed after the 1999 Columbine High School massacre) and the overuse of undertrained school resource officers in the schools. Comparatively speaking, the “pipeline” is disproportionately full of Black and Hispanic students, as well as students with disabilities. These students funneled into the “school-to-prison” pipeline often find themselves suspended (and sometimes expelled) from school for non-violent (though sometimes violent) offenses. Eventually, they will find themselves in jail. Let’s put that into perspective:
These statistics got me thinking. If 68% of incarcerated males didn’t finish high school, we can either ignorantly believe that they didn’t want to be in school or maybe school was just too difficult. But for most students, school is an awesome place to be, if they don’t get excited about the actual learning, then the social aspects are usually significant enough to keep most students there. I’m a firm believer that any child who hates school to the point of avoidance has some underlying issue. Is ADHD enough? Personally, I don’t think so. If you have noticed, it seems like everybody who is not successful in school has ADHD. It is true that a lot of people have it, but you would be amazed at how many other conditions exist with ADHD. These conditions include learning disabilities, processing disorders, mood issues like anxiety, depression and bipolar disorder and let’s not forget the neurodevelopmental disorders like autism. Far too often, it is these other conditions that impact learning and success in school far more often than ADHD alone. A recent study published by the American Academy of Pediatrics in September 2015 showed that a diagnosis of ADHD can forestall a diagnosis of Autism by up to 3 years.
So, here is my premise. We should re-describe the phenomenon from School to Prison Pipeline to Preschool to Prison Pipeline. Why? Because many of these children present as early as age 4 with behavior problems, focus issues and resistance to the learning environment. I’m wondering if we did a better job of identifying, treating and supporting these youths at as early an age as possible could be impact the number of individuals to find themselves in the pipeline. Not only that, I am finding that there is a genetic component to many of these issues and if we can treat parents and other family members could we finally break a cycle?
Only time will tell but I and my staff are working diligently one patient at a time to ensure that we don’t contribute to the pipeline.
I hope I got you thinking . . .
I recently heard a wonderful quote by Nelson Mandela that read, “I never lose. I either win or I learn”. I thought that was profound. So much so that I considered adding the quote to my signature block (which I’m sure I will get around to one day).
It made me think about my own experiences. I frequently say that “failure is not an option.” In my mind, if I do fail that just means I have provided myself with an opportunity to do better next time. I guess it’s the same idea but Mr. Mandela said it better.
At my clinic, one point we always try to make after we tell a parent their child has been diagnosed with either ADHD or Autism is that neither diagnosis is a curse. In fact, both diagnoses are blessings. I continue to be impressed by the resilience of my patients to grow within each diagnosis and become a truly unique and phenomenal individual. After all, an individual with ADHD, Autism or any learning disability is born that way. They didn’t catch Autism from their friend, get it from an immunization or from the gluten or red dye in their food. A person with Autism or ADHD is just that: a person. They are just the way their God intended them to be. Last I checked, my God doesn’t make mistakes.
The only issue I see with these diagnoses is that you don’t know you have them. Your parents don’t know you have them and neither does your teacher or friends. Eventually, your behavior may change and even become undesirable as a result. That behavior change would be the clue that something is going on. Another problem is that sometimes folks don’t know what to make of these behaviors. I’ve heard everything imaginable. I’ve been told that a 6-year-old is still going through the “terrible twos” that the other kids are making him behave this way or the classic explanation is that “he’s a boy.” The key is, if your child is not acting like the majority of kids his age, whether that be less mature or more mature, he warrants evaluation.
Knowing what’s going on and putting a name to it can be a liberating experience, if for no other reason than now you as the parent have insight into why your child is thinking, saying or doing what they are. That’s when the Superhero training begins . . .
Are you a winner? The answer is a resounding “YES”.
Over the last couple of months bullying has been a theme that continues to recur for me. First, we have had the presidential campaign (SMH), then I have had several patients in my clinic that have either been bullied or are the bully, and now our new first lady will be taking up bullying as her primary cause. I’ve been thinking about writing a blog on bullying but couldn’t get motivated until yesterday. I was shooting an episode of UnCharted Territory when I got into a heated discussion with my guest off camera. My daughter, who serves as a camera person for the show, had had enough and said to me “Mom stop being a bully and be a buddy”. This would have caught me off guard but she frequently says this to me especially when my older daughter and I argue. I think the other people in the room were surprised by the comment and one even said, “your Mom’s not a bully, she was just stating the facts”.
This got me to thinking, am I a bully? Of course, I don’t think I am but what bully is willing to admit it. So here is the question, are bullies born or made? The answer is that bullies are made and believe it or not they are made at home. Bullying is a learned behavior. I always like to have a common point of reference when I write about a topic such as this so I typically go to Google and look up the definition. I was surprised that I didn’t like the first definition that popped up. In fact, I searched several definitions before I found one to be appropriate. What’s that about?!? Most of the definitions spoke to bullying specifically with students and children but adults get bullied, people can be bullied outside of school and even at the workplace. I really thought these definitions to be short sighted.
The definition that I found to be most helpful was from Pacer’s National Bullying Prevention Center. They defined bullying as “an intentional behavior that hurts, harms, or humiliates a student, either physically or emotionally, and can happen while at school, in the community, or online. Those bullying often have more social or physical ‘power’, while those targeted have difficulty stopping the behavior. The behavior is typically repeated, though it can be a one-time incident”. This website also stated the difference between Conflict and Bullying. “Conflict is a disagreement or argument in which both sides express their views. Bullying is negative behavior directed by someone exerting power and control over another person.” For the record, I am NOT a bully but I will strongly exert my views and opinions when challenged. I must make sure my daughter gets this right and stops mischaracterizing me (l0l). Anyway . . .
Back to my point, where do bullies learn to be bullies. After spending years taking care of special needs individuals, I really believe that bullying starts at home. Parents don’t see themselves as bullying (much like I don’t see myself as a bully) since their actions are not intentional but I’m wondering if their children perceive them as a bully. Let me break this down for you. Let’s say you have a child who has ADHD and has difficulty completing a multiple step task like “come down stairs, pick up your shoes and put them in the closet”. As a parent, we will ask our ADHD child over and over to do this and when they can’t get it accomplished what happens next? We get mad. We’re mad on several levels; one because we keep repeating ourselves, two because the task is not getting accomplished and three because we believe that they are blatantly disregarding us.Eventually this will lead to some form of punishment. We’ll turn off the TV (which is always the distraction), take away their favorite toy or banish them to their room. If they are lucky, we’ll just yell at them. For the child with ADHD, this cycle repeats frequently maybe to the point of them not believing that they can do anything correctly. As parents, we often don’t realize that we have asked too much of our ADHD child by putting more than one simple task together. Maybe we set them up for failure and didn’t realize it. In any event, over time are we not bullying our kids? Again, that is not our intention but is it the result?
It’s not just the ADHD child that gets bullied (unintentionally) at home. It’s the child with Autism and even the child with a learning disability who may not fully understand what is being asked of him or her simply because of how we have presented the task to them. A child with auditory processing may not quickly understand a task that is presented to them verbally because their brain may struggle with processing verbal cues.
What we have done is demonstrated bullying for our children. They have experienced firsthand what it feels like to be humiliated and to be powerless. Now they have a choice to either remain powerless and become the victim of continued bullying by classmates; find someone who they can exert their power over and bully; or because they know what bullying looks like they can choose to avoid it all together. What choice will your child make?
I hope I have given you something to think about. Don’t be a bully, be a buddy as my daughter says.