Synopsis of Treatment of ADD, Part 3

Driven To Distraction : Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood
by Edward M. Hallowell, M.D., John J. Ratey, M.D.

(Page 6 of 7)

"She liked the stories?" I asked.

"Oh, she loved them. I could calm her down almost anytime with a story. Not that she got upset very often."

"Could she add to the stories?" I. asked. "Make things up?" A crude assessment of imaginative and linguistic ability is the capacity to add on to a story line.

"She was better at listening," her mother said. "I could tell story after story and she would sit next to mc rocking and smiling. If I asked her a question, it would become clear some of the story had passed right by her. Because she was so faraway, I'd tell myself. But I didn't know what I meant by that. It was just a feeling I had."

"It sounds like you were well attuned to her," I said.

"But now I think she wasn't getting it at all. She did love to listen, though." Regret began to fill Mrs. McBride's voice. "Why didn't I get some help sooner?"

Joe McBride, a ruddy-faced man smartly dressed in a business suit and a muted purple and turquoise tie, put his arm around his wife as she started to cry. Sitting together on my office couch, they looked frightened and embarrassed. "What Polly means," Joe said, "is that we had no idea anything was wrong. Penny was a quiet little girl, that's all."

"I understand," I said. "Try to go easy on yourselves. You're obviously concerned parents. It was hard for you to come here at all. Let's sec if I can't make it worth your while."

Wearing a red wool sweater, jeans, and her slightly graying blond hair up in a bandanna, Polly looked like she'd come directly from a hike with her children. She was a casual contrast to her more packaged-for-the-public husband. "It's a bit of a shock to the system to hear your daughter needs to see a psychiatrist," she said, wiping her eyes not with the handkerchief her husband offered her but with the first knuckle of each hand.

As we began to get more history — and the key to making a diagnosis in this complicated field is through the story of the child's life, rather than through complicated tests — what emerged was a picture of an intelligent gift who had some language and attentional problems.

Problems in the development of language can occur at a number of levels and in a number of ways. One can have difficulty with input or with output. Input problems, or what are called receptive language problems, can affect both what you take in and what you are able to put out, because what you put out is dependent on what you were able to take in. Output problems, or what are called expressive language problems, can affect what you are able to write or speak as well as what you are able to conceptualize within your brain.

Although a full discussion of learning and language problems, including dyslexia, is well beyond the scope of this book, we cannot discuss ADD without some mention of language problems — and learning disabilities in general — since they so often coexist with ADD, each usually making the other worse. In addition, we will have to touch on other neurological problems that can mimic or exacerbate ADD, from the obvious, such as hearing impairment, nearsightedness, or a nerve problem that affects articulation, to the more subtle aphasias and memory problems and seizure disorders.

I asked Polly if Penny were late in learning to talk. Although developmental milestones, as these moments of specific achievement are referred to, are not etched in stone, they do give a quick reference point as to whether it is a developmental delay worth investigating. You also have to be sure you and the parent have the same definition of "early" or "late." Some parents consider their child late if he or she cannot recite Shakespeare by ten months, while others consider no language at all until age three just fine, if not a relief.

"Yes, she was," Polly said. "Her first words didn't come until about twenty-two months, and little sentences didn't come until she was three. Our pediatrician suggested that I read to her a lot and make up stories together. That's where the Faraway Stories came from."

"She liked them?" I asked.

"She loved them. That's what was so touching. Even though I knew she wasn't getting it all, she'd sit still and ask to hear more stories. And if I stopped in the middle, she'd pull on my ann and say, 'I want more!'"

"Could she play with words at all?" I asked.

"What do you mean?" Polly responded.

"You know, make rhymes, repeat rhymes, make up nonsense words —"

Polly, who was leaning forward eagerly, interrupted to answer. "She couldn't do rhymes exactly. But she made up words all the time. She couldn't think of the right word, so she'd make one up. Instead of saying we're going to the airport, she'd say we're going to the plane place. Or instead of birthday present, she'd say box-day thing."

"You remember these well," I said. "What would you do when she said them?"

"I would correct her. Shouldn't I have?"

"No, it doesn't matter at all. I'm just trying to get a sense of what this was like for her emotionally."

"She would say the new phrase I told her. I didn't want her to think she was stupid."

"Did you think she was stupid?" I asked.

"No, not at all," Polly said emphatically. "If I'd thought she was stupid, I probably wouldn't have corrected her so easily. But I knew she was smart and would want to get the right word. Plus, I thought her ability to improvise and make words up proved she was smart."

"You're right," I said. "It sounds like her problem was in finding the right word in her storage bin, so to speak. Or in finding the right storage bin. Or in remembering the word. Or in transporting the word from the storage bin to her mouth."

"This sounds pretty complicated," Polly said.

"Well, it is," I said. "But that's really good news that it's complicated, and that we know that it's complicated. Not so long ago we seemed to think all this was very simple. You were either smart or you were stupid. Oh, we had some ultra categories like genius and moron, but it was all based on a really simpleminded notion of intelligence. Smart versus stupid. And that was the basic ball game. But lately we've been finding out how complicated intelligence and learning really are. For example, Mel Levine, one of the great figures in the world of learning problems, talks about seven kinds of memory, and you can have a problem with any one of them that can interfere with learning. That's what I was referring to when I was talking about getting words out of the storage bins. I just wanted to think of some analogy. You get what I mean?"

"Yes, I do, and it's exciting," Polly said.

"What about in school?" I asked. "What happened then?"

"She fell behind in reading from the start," Joe said a little glumly.

"That's not quite true, honey," Polly said, gently containing her annoyance with his performance-appraisal approach. "She was more interested in books than any of the kids. She just couldn't comprehend them all. But she always wanted me to read to her and she still likes to hear the Faraway Stories even to this day."

"What about the daydreaming?" I asked.

Polly handed me a stack of papers. "These are teacher reports going back to first grade. You'll see they all say about the same thing. 'Tunes out.' 'Seems shy.' 'Can't pay attention without frequent reminders.' One of the teachers even wondered if she might be depressed, she seemed so quiet all the time. But it wasn't until this year that Becky Truesdale —"

"Who?" I interrupted.

"Becky Truesdale, her fifth-grade teacher. She was the first to bring up the possibility of ADD or a learning disorder. I have to admit I'd never even heard of ADD. I only knew about hyperactivity in boys. But Becky says girls can get it and sometimes there's no hyperactivity, just tuning out."

"Becky's right," I said. "Girls can have ADD as well as boys. Hyperactivity is the old name for the syndrome. More recently, the label ADD was invented to focus on the symptom of attention inconsistency these kids have. A lot of girls who have it never get diagnosed. Instead, they're just thought of as shy or quiet or even depressed, like Penny." In giving the McBrides an overview of the ADD syndrome, I stressed that ADD was often found in particularly creative, intuitive children. "Lots of kids who have ADD also have something else, something we don't have a name for, something good. They can be highly imaginative and empathic, closely attuned to the moods and thoughts of the people around them, even as they are missing most of the words that are being said. The key is to make the diagnosis early before these kids start getting stuck in school with all kinds of pejorative labels. With some help, they can really blossom."

I took a few minutes to read through the teacher comments which, as Polly had told me, were full of descriptions of absentmindedness or daydreaminess or unfinished work. The comments reminded me of a term Priscilla Vail uses in reference to children who don't quite fit any mold exactly: conundrum kids.

"Would you like to meet Penny?" Polly asked.

"Of course," I said. "But why don't I go to her. Often kids with ADD can focus very well in the one-on-one situation of the doctor's office. In here there is structure, and novelty, both of which drastically reduce ADD symptoms. Even the fear a child sometimes feels in a doctor's office can increase concentration, and so mask the ADD symptoms. That's why it can be so easy for a pediatrician to miss the diagnosis. The symptoms just aren't there in the office. In a classroom you get a truer picture. So may I visit?"

Polly and Joe McBride enthusiastically agreed and made arrangements with Becky Truesdale. Schools are usually quite receptive to this kind of visit. They are eager to share what they know. What they have to say is usually of great value.

I slipped quietly into the classroom during what looked like math period and took an empty chair along the bookshelves in one comer of the room. Another teacher who had guided me to the classroom pointed Penny out before she left. I watched her, trying not to stare. She was a cute little brown-haired girl with a ponytail, wearing a yellow dress and Nike sneakers. Her desk was where I'm sure she wanted it to be: at the back of the room, right next to a window.

Now I should put in a word here about windows and schools and ADD. One can easily get the idea from a school that it thinks windows are the devil's own work, placed in schoolrooms as a means of temptation, pure and simple. The good children look away from windows, while the bad cannot resist their transparent allure, free passage to the sky and trees and daydreams beyond.

About the Author

Edward M. Hallowell, M.D., is an instructor at Harvard Medical School and director of the Hallowell Center for Cognitive and Emotional Health in Sudbury, Massachusetts, an outpatient treatment center serving children and adults with a wide range of emotional and learning problems. He is the co-author of Driven to Distraction and the author of The Childhood Roots of Adult Happiness, and Worry, among other titles. He lives in Arlington, Massachusetts, with his wife and three children. He welcomes hearing from readers, and can be reached through his website at www.DrHallowell.com.

John J. Ratey, M.D., is an associate professor of psychiatry at Harvard Medical School. He has lectured extensively and published many articles on the topic of treating adults with ADD. Dr. Ratey is the author of A User's Guide to the Brain and the co-author of Driven to Distraction. He lives in Cambridge, Massachusetts, where he has a private practice.