Monday, February 5, 2007

A Dennis the Menace Incarnation

Johnny is a six year-old boy who appears to have missed his calling for the leading role in the remake of “Dennis the Menace”. He is blond-haired with two teeth missing. When I introduce myself, he steps behind his mother allowing one eye to remain trained on me. He follows his mother and me into the office, sits quietly while his legs swing rather quickly under his chair. He tells me that he has no idea why he is here today (although mother swears they had a thirty minute talk about the visit on the trip to the office), but later relents to suggest that his mother wanted him to come here because he doesn’t “listen”. Mother subsequently describes a child history of significant inattention at home that includes not following instructions (ie., he may recall only one step in an instructional set), not attending when she calls him name and becoming overwhelmed in high stimulation (noise) conditions. Mother indicates that problems intensified when Johnny entered kindergarten. In addition, the teacher reports an increase in social withdrawal and limited peer interactions on the playground. However, mother suggests and the kindergarten teacher concurs that perhaps symptoms are due to immaturity. Mother reports that the situation deteriorates in first grade. Johnny is off-task when the teacher is talking, he turns and looks at the papers of other children, he cannot answer questions posed by the teacher, he looks puzzled during class sharing/discussions and he constantly draws or plays with small items in his desk. Mother reports that she took Johnny to see the family physician with a handful of checklists in which the Inattention boxes had been checked by the teacher. Do you know him? Classic ADD, right?

Mother reports that Johnny was started on Strattera (since its not a “stimulant”). After a month of no benefits, the medication is discontinued and replaced with a more potent psychostimulant (fill in the brand name). Mother reports that since taking the psychostimulant, Johnny is restless, has trouble falling asleep and appears to be more “fragile”. Mother indicates that the dose of the medication is increased since the physician suggests that perhaps his symptoms are intensifying in the school setting. Johnny reportedly responds with insomnia, crying, agitation and irritability. Johnny is seen by a counselor who discusses issues of low self esteem with mother. Mother reports feeling overwhelmed and anxious… she is failing her child. Which brings us to today’s clinic visit….

…findings of our comprehensive neuropsychological evaluation reveal that Johnny has a receptive language disorder. While statistics on the frequency or base rate of this disorder are unclear, research suggests that perhaps 4-8% of children with “classic ADD” symptoms may have receptive language disorders. For Johnny, the English language is like a second language (recall taking Spanish in high school?). He cannot decode speech sounds at the rate necessary for comprehension and, as result, he cannot follow instructional sets, cannot comprehend the discussion of the teacher and cannot decode the rapid-fire playground speech of his peers (with resulting social withdrawal). Reading, which is dependent upon integrating speech sounds with letters is labored for Johnny (and no fun) and, as a result, he learns words based on the visual configurations (which appears to reflect “impulsive” guessing). On the playground, Johnny retreats since he cannot keep pace with the conversation rate and slang of his peers.

Application of a symptom-based diagnosis (which Johnny fits all ADD criteria) resulted in termination of the search for the underlying cause with resulting delays in introduction of intervention strategies, social isolation, loss of self-confidence, dislike of reading, treatment using medications for a disorder that he did not “have” and counseling sessions after school. . The solution… demand evaluations that search for the underlying cause while ruling out other alternative or possible causes.

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