pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

Hyperactivity: The Boy or Girl – The Patient

January 15, 2017

Of the many children I’ve seen with this issue, let me introduce you to Terry. He is a real boy… well, a couple real boys and a girl actually so my example could be clearer and, of course, not break any confidentialities.

Telling you about a “combination” case this way will let me better show the diversities in how children can present their issues to those tasked with helping them through their developmental years.

Some come with issues very early on in life, others not till later. The latest I’ve personally seen diagnosed was a senior in high school “melting down” trying to get into a prestigious college. Some are identified by parents, others by teachers and still others not until behaviors bring the judicial system into play.

See if you can use the new diagnosis criteria I’ve mentioned in the previous posts to see if Terry actually has what is called: “Attention Deficit Hyperactive Disorder”—ADHD for short.

Meet Terry
A Diagnostic case study in “Hyperactivity” (ADHD)

Terry is a red-haired, light complected, caucasian boy who is twelve and in fifth grade. He lives with his natural mom, dad and younger sister in an average middle-classed suburban neighborhood. The problem is that, perhaps shortly after he turned 11, his school grades have fallen substantially.

He has begun avoiding school with claims that he is ill; and, when he does go to school, he is disruptive and often visits the school nurses office. At home, his parents are perplexed with his “meltdowns and tantrums” over trying to get him to complete his homework—or, actually, anything they want him to do which is time consuming or “cognitively demanding.”

The exception is playing “video games,” which he can do for hours on end. Other times, they say, he is amazingly forgetful like when sent to get ready for bed and they find him playing with his Lego’s or the cat which distracted him on the way.

According to them, Terry has always been an “outdoor type of kid.” Asking if he can help with weekend work on machines and engines, he forgets which tool his dad sent him for before he reaches the toolbox.

He came to the pediatrician for advice and assistance with the urging of his teachers and guidance counselor.

Evaluation

Visit One:
The very first thing a doctor learns to do is to become certain about WHY the patient is here. In this case WHO sees that Terry has a problem and HOW BAD do they think it is? It’s the teacher who started the ball rolling on Terry by quantifying his distractibility, short attention span, disruptiveness and hyperactivity; don’t the parents see the same thing?

Actually, both parents do see that Terry has been “active” since early age but mom thinks it’s worse than dad who has always told his wife: “He’s just active. So was I and I grew out of it. So will he.”

The second thing a smart doctor learns quickly is to bring everything out in the open right from the beginning. In other words the elephant in the room cannot hide in the corner. My challenge question to find out whether they disagree with the teacher is met with respectful re-thinking. “We can’t argue with anything they’ve said because we see the same thing and even though I haven’t seen it as a significant problem, he is failing in school and I’d like to help him around the things that I went through… if I can.” [What a truly great thing for a father to say! He could have dug in his heels to save face and persisted in denial.]

What we still don’t know yet is why the teacher is seeing an issue only now. Was it there earlier and overlooked or has something changed? We’ll get that information from the school with a release of information form; also a brand-new “eval” from anyone who regularly see’s him for more than a couple of hours in a day.

With just this short bit of discussion, Terry clearly was beginning to feel stress; after all, his “adequacy” was being discussed all around him. I can easily convince parents “I’m on everyone’s side” with a quick word in the hall; BUT, you can’t do that with kids.

Kids actually need to be shown you’re on their side; so, when I see this happening, I usually, unobtrusively move to make some kind of supportive contact with them. Without anyone really noticing, while I talked and gestured, I rolled my chair over to Terry’s side of the room—to face his parents with him, together.

Only his dad gave any notice of my move in position to where the body language was now “us” against “them”; and when Terry eventually mellowed enough to reflexively lean toward me, he noticed that too and gave me an acknowledging smile. [This guy was savvy! I now knew I could rely on him being an active participant in any therapy Terry needed.]

I quickly went down the past medical history form they had completed and discussed the high points letting Terry follow along and occasionally nod his agreement. Terry had no previous head injuries or significant medical conditions except “hay fever” for a few weeks in the fall, which always responded to antihistamines. They hadn’t noticed any similar problems with the cat (yet).

He reached all his developmental milestones within normal limits but seemed to walk and talk early—which began his habit of knocking things over, which he still holds to this day. “He jabbered all the time,” his mom added. “Still does,” his dad said, eliciting a chuckle from Terry.

General Exam: While he was getting undressed for his exam, his father remained in the room and I decided to step into the hall for a moment with his mother—actually, that’s how Terry chose to do it when I gave him the choice of whether he wanted his parents in the room or not.

That gave me the chance to ask her about any “family crises or emotional traumas” to which she replied there were none. [A welcome relief because often there are]

On general physical exam Terry was obviously nervous. He was well developed and nourished and an appropriately-sized 12-year-old. When I pointed out that he seemed nervous and asked him if he was worried about anything, he quickly responded “are you going to give me any tests?” That took me back a bit because usually kids want to know about shots.

I told him no I didn’t need any blood work today and he corrected me “are you going to make me read?” I smiled and said “not today, unless you want to.” After he smiled and visibly relaxed I did add that sometime I would really like to hear him read but we could do it in private.

I gave a running commentary, explaining some of the things I was looking for and either finding or not finding during his exam; and, at the same time, throwing in questions he could answer without me having made a “big deal” out of them.

His genitalia still were what is considered prepubescent Tanner I stage, but it was clear that puberty was imminent. I could tell that he had finally decided to trust me when I pointed out his rapidly approaching need to go shopping for new clothes; then offered to bet him “twenty-seven cents” that my next measurement in a couple months would give him “at least an inch” when he didn’t seem to agree.

Frankly, that did explain at least a portion of what was going on. Boys often have an episode of “the grumps” as they experience their very first testosterone “surge,” even though it’s only in the bloodstream and not yet showing on their bodies.

[I’ll comment here that it was refreshing to see the tête-à-tête between Terry and his parents. My gut was telling me there was more to this than was obvious but an intact parent-son relationship, despite all the difficulties, speaks volumes to being able to make great progress.]

Visit Two:
As usual, Terry was my last case of the day and the waiting room was now empty. I perused the information the school sent and the completed Connor’s forms before I entered the room to see essentially the same situation I saw at last visit. Everyone was staring at me and Terry was stressed.

Like I said before, I usually tackle things head on; so, ignoring his parents, I immediately moved my chair right next to Terry’s and softly said: “You look worried again. It’s alright if you tell me why.”

He resignedly looked at me and replied: “You’re going to make me read aren’t you.”

I thought for a moment then told him, “Come here Terry” and gently guided him directly in front of me. Kindly, but determined I continued, “let’s face our fears and get it over with right now so you can relax for the whole rest of the visit. Tell you what. I want to show you that what I’ve got for you to read will be over in only a minute and won’t be anywhere near as bad as right now you’re thinking it will be.”

Then I turned him around so we were both facing the corner of the room and gave a sign to his parents behind us to remain silent. “I don’t want you to read,” I told him as I held the card in front of him, “I just want you to tell me the words on the page as slowly as you want to.” [Only a short paragraph I wrote about a dog in pajamas doing math, written on a 3rd grade level. He complied but under stress.]

As he progressed one word at a time, his speech became a little stammered, his ears first turned slightly red then his face, then his arms. His stress reaction seemed greater than the difficulty he was having reading and I could see how it could become debilitating for him.

He did reverse some letters; and he did have some difficulty tracking; and probably, if he hadn’t been standing in front of me while I held the page he may have been all over the room, he fidgeted so much. But it was soon over.

I gave him a nudge to lean his back against me if he wanted and told him: “See. It’s over and you did great. Now close your eyes, take a deep breath and tell all your muscles to relax and stop making you miserable. No hurry. Turn around when you feel that you’re back to being ‘Happy Terry’ again—like you were last time.” It took him about a minute to slowly unclench and “melt” against me; then he turned around and weakly smiled through glistening eyes.

His eyes were looking over my shoulder to see his parents, both smiling. When he looked back at me I said “Welcome back Terry. I’m glad you stuck it out. You see your parents, why do you think they’re smiling?” “Cause it’s over,” he croaked, his voice breaking.

“No. I don’t think so,” I told him. “To me they look like they’re proud of you for doing something hard and sticking it out until it was done. Ask them and see what they say.” He did and he had a wonderful quick discussion with his dad.

[I have to break in again here and say that I told you about this for a bit of a selfish reason. It doesn’t happen often but once in awhile when you’re trying to help a child, you just do something without thinking that turns out to be exactly the right thing. When it does, you know it and it becomes forevermore an anchor you can use to remember why you do what you do. I helped him face what he needed to do for his life and taught a skill he could use when he needed to do it… and, showed both he and his parents a little “hope” for the quality of his future.]

Neurological Exam and Terry’s Interview:

His mom stepped into the hall while Terry got ready for a more detailed neurological exam looking for “soft signs” of developmental delay or injury; and as before, I followed her out for a moment. “Wow, I told her. That seems like a kid with something more than just difficulty reading. Do you know what might be causing so much stress?”

Then it was her turn to surprise me by revealing that they had hired a tutor at the first of the year who had been “quite stern” with him. Perhaps a bit more than stern, I thought to myself.

Terry was sitting on the exam table in his underwear and was looking as relaxed as I had seen him. I broke the ice while he was doing the “follow the light” and “my finger to your nose” tests by asking him how it felt to have his “reading” over with and how he felt about facing his fears. He had apparently decided he could talk to me and did so with good insight for a 12 year-old—low/moderate anxiety, coherent and finally with affect which was contextually congruent.

He showed a good sense of humor along with age-appropriate oral expression evidenced by his vocabulary and use of complex sentence structure. His short and long-term memory were intact.

He did have greater than normal difficulty with such tasks as: heel to shin tracing, rapid alternating hand and foot movements (i.e. tapping and flipping hands over and under); tandem walking; two point discrimination, discrimination with distraction, eye rolling and a few others.

He seemed to be right-eyed, right-handed and left-footed; so I checked again his gait, reflexes and lower limb strength and found what seemed to be a slight deficiency in his right foot so made a note for neuro referral and possible testing if it persisted over several visits.

All during the exam he answered fairly pointed questions and explained that he “always” becomes nauseous and feels “hot” when he has to read. [Now wasn’t the time to pursue this, so I didn’t; but will in future encounters]

He said he gets headaches when he has to do tasks requiring extended attention over time, especially “if they are boring.” And, he admitted to feeling “stupid” in school most of the time and taking his frustrations out on “the smart kids” by sabotaging their learning by disrupting them.

However, his “fun times” at school were when they did plays and he had no difficulty memorizing his lines; and band, where he has no trouble reading musical notes.

Putting It Together

Anecdotal teachers’ notes for the first 5 grades did report classroom disruption and need to be on the move; but, having the ability to meet academic demands, apparently without having to do any homework. Until, that is, this year; which is undoubtedly why all the “drama” started this year and not before.

The Connor’s evaluation forms scored “positive for ADHD” by both teachers and parents. Interestingly, more so by his mother than his father (who may have ADHD himself). He is unable to focus on tasks, abandons tasks initially started in favor of new ones and he often daydreams.

They had administered a Woodcock-Johnson achievement test showing him in the 37th percentile for reading and math, which they considered “was within the expectation of a child with an IQ score of 102.” They noted that Terry did much better on tests delivered in a one-on-one basis where there were focusing ques and no distractions.

In addition to their observations, I found that he didn’t meet criteria for any of the major psychoses associated with childhood or a conduct disorder and there is no significant family disruption. However, there has been an, as yet quantified, personal disruption which has given him an exaggerated stress response to public academic challenges and a low self-esteem.

Terry does not appear to have any physical or medical conditions which might mimic ADHD although he does exhibit the “soft-signs” often associated with the disorder—and there is that hint of a possible lower limb neurological issue.

My assessment agrees with his teachers and parents in that “he is generally a jovial and friendly child” and he is said to have a lot of friends. Teachers consider him “helpful” by being the “runner” for supplies and messages with great reliability. I didn’t find him to exhibit hypomania or any other symptom associated with mood or anxiety disorders.

He denies having “racing thoughts,” problems sleeping or “being afraid of anything” (although obviously he gets greatly stressed over reading and math, especially when others watch). At other times his emotional range mostly matches his circumstances and situation so the anxiety he does have is most likely the result and not the etiology of his indicated ADHD.

According to his counselor, his academic testing suggested that he does NOT have a learning disorder; but my findings make me believe the jury is still out on that. With the several neurological “soft sign” findings, it makes one wonder if being at the low range of achievement percentiles is really being consistent with an IQ in the “normal range” (which part I do believe). And then there’s that stress reaction to reading. That’s got to be figured into the plans going forward for sure.

Diagnosis

What is YOUR diagnosis. I’ve given you all the criteria we use. Do you agree? Terry is male, has seven of the possible symptoms for inattention and six for hyperactivity-impulsivity; and, has demonstrated them for more than six months in at least two documented locations. Additionally, there is clear evidence that his issues are negatively impacting his family, social and school life.

He does meet the criteria for ADHD (combined presentation) with, in my opinion, possible learning disabilities. An additional, but not etiologic, diagnosis may be “situational anxiety” or another stress syndrome; with the possibility of a, yet to be delineated, right lower limb neurological defect (possible CP?).

In any case, Terry is a great kid and I look forward to seeing him back after treatment has been started; which, as is the case in many instances, may serve to help delineate more accurately all the diagnoses we’ve got going. Which we will do in the next post in this series.