Tears quickly welled up in her eyes and flowed in streams down her face. Her voice was choked with pain as she attempted to answer my questions regarding her school performance. Although I was asking routine questions typical for an ADHD (Attention-Deficit/Hyperactivity Disorder) evaluation, Kristen�s emotional response could not have been anticipated especially for a thirteen year old high school student. Kristen believed that her problems with broken concentration started in the fourth grade. She felt unable to control her wandering thoughts even when involved with casual conversations with others. Despite her difficulty listening to auditory instruction in the classroom, Kristen usually was too shy to ask for further explanation or additional help with her assigned work. As a result, her grades suffered as did her feelings of confidence as a student.
Kristen�s tears and painful description of her academic frustrations tugged seriously at my heart strings. It was pretty uncommon for me to hear a teenager speak so candidly and credibly about her attention problems. Kristen was convinced that she had ADHD. Yet, I was struck by the lack of supporting data in other areas of her life. Descriptions of her behavior by her parents and classroom teachers failed to identify Kristen with any notable attention deficits or distractibility. Kristen had almost completed elementary school before her teachers expressed initial concern about her inconsistent work performance. According to her parents, Kristen began to show homework avoidance just prior to the start of middle school. Neither her parents nor early classroom teachers had ever recognized that Kristen struggled with inattention or distractibility. Kristen�s early developmental history and family history were equally absent of any positive ADHD factors.
My interview with two of Kristen�s middle school teachers failed to reveal additional information that would support ADHD. Kristen was described as a student with weak academic skills. Her work effort in the classroom was inconsistent at best. Her interest and motivation to invest her best effort seemed to always decline at mid-year. She often would invest a more concerted effort at the end of the school year to improve her final grade. Yet her teachers never recognized Kristen as struggling specifically with inattention or distractibility in the classroom. However, her teachers did describe Kristen with weak comprehension and low quality performance that earned her low grades in English, Math, and Science.
Kristen was described as a typical teenager at home. She often needed reminders in order to complete her assigned chores. She showed a great deal of forgetfulness around personal responsibilities unless there was an immediate incentive available to her. It was not difficult for me to recognize her selective memory and convenient forgetting as typical teenage behavior.
After reviewing all of this past and current information, I felt it was impossible to identify Kristen with ADHD. Yet here she sat in front of me personally convinced that she had problems with attention. Emotionally distraught by this realization, Kristen saw herself as handicapped by ADHD. In her opinion, her difficulties with English and Math were less important concerns. I then realized how critical it would be for me to prioritize her attention weaknesses over her learning problems.
I offered two provisional diagnostic statements for Kristen that addressed her learning disabilities as well as attention deficits. I recommended that she receive a comprehensive educational assessment while starting a trial of stimulant medications. Although I could not offer a definitive diagnosis of ADHD, it was most important that I respond to Kristen�s unshakable belief concerning her impaired attention. Her self-diagnosed ADHD in combination with her learning weaknesses had already caused serious damage to her self-perception as a learner.
Kristin�s parents were given the chance to use a trial of stimulants for Kristin. Even though Kristen was convinced she was attention impaired, her parents were still concerned about using medications to help her. I was careful to outline my personal reservations about using medications for a child with only a provisional diagnosis of ADHD. In a myth dispelling statement, I clarified that most stimulant medications often will enhance a child�s attention and task engagement even when not diagnosed with ADHD. While I would never recommend giving medication to a non-ADHD child, a provisional ADHD diagnosis would allow us to be responsive to Kirsten�s convictions regarding her own attention impairments. In Kristen�s case, stimulant medications could easily offer some improved attention and concentration that may enhance her learning. Her improved attention would also allow for a more valid assessment of possible learning disabilities disrupting her performance. Although the use of medications should always be taken seriously and with recognition of associated risk factors, close monitoring of Kristen�s medication response would diminish our remaining concerns for this intervention.
In addition to the trial of stimulant medications, Kristen�s parents decided to ask the special education team at her high school to complete a learning assessment. In this way, achievement and cognitive testing could provide invaluable information on Kristen�s intellectual abilities as well as her learning style. If she should qualify for programming, Kristen would likely benefit from the additional academic support the school could provide her. The parents were also prepared to provide Kristen with private tutoring as necessary for the remainder of her high school years. Although Kristen�s career path promised many future challenges, her parents were comforted by the intervention plan that was formulated.
Seven days later, Kristen and her parents met with the pediatrician to review a selection of a stimulant medication. Although Kristen was slightly anxious starting a medication trial, she was substantially comforted by the hope of improved concentration and mental organization. The medication seemed to provide her with emotional reassurance and renewed optimism regarding her future academic efforts. Her parents also informed her of their intention to request a comprehensive educational assessment from her school�s special education team. If a learning disability were identified, Kristen would then qualify for individualized academic support. Even if a significant learning disability was not identified, it remained possible to recognize her attention weaknesses as a disruptive handicap qualifying her for additional academic support from special education.
Kristen�s story can teach an important lesson when considering the possibility of ADHD. In her case, there were many factors that failed to support this diagnosis. Yet her personal conviction regarding her impaired attention demanded to be factored into the ADHD equation. In this evaluation, I learned to listen more carefully to the self assessment provided by this older patient. Kristen was certainly well capable of accurately describing her personal experience, and her self report justified a provisional diagnosis of ADHD.
George Gallegos, Ph.D.
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The PDA is described in detail at youadditup.com youadditup.com At youADDitup, visitors will find a wealth of information on ADHD history, symptoms, and evaluation. An ADHD Library page offers a section of ADHD articles authored by Dr. Gallegos.