Time: A Marker for Change Part 2

OK… I was not dodging the first part of the last question (even though it may resonate with my life and I would probably feel better dodging it). “My child always did well in elementary school… but since about 5th or 6th grade, his performance has really deteriorated… he is disorganized, does everything at the last minute, makes repeated careless mistakes. I’ve been told that a lot of kids have difficulties at that age due to the transition into middle school along with the hormones kicking in. Is this just a maturity thing? Will it just get better with time?”

The first part… “is this just a maturity thing?”. The answer is most likely “yes”, “no” or “yes and no” (which philosophically-speaking should cover all states of the universe). Helpful? Let me expand. The collection of “coaching” functions including organization, planning, utilization of feedback to adapt responses (along with assumption of an “observer role” to perceive the world through the eyes of others, internalization of social rules and inhibition of lower level emotions), has been related to the frontal lobe. Studies indicate that this frontal lobe or “social” part of each of us shows a trend for progressive development or maturation throughout childhood. Existing social institutions (ala Erik Erikson) have evolved to mirror this maturation process. During the first few years of life, the frontal lobes play a very limited role…ergo the egocentric (“terrible”) under-socialized two year-old tramples social rules in service of self. At about age 3-4, children complete toilet training. Completion of toilet training reflects initiation of frontal lobe processing (and inhibition of lower level behaviors). At about 5-6 years of age, children start kindergarten. Initiation of formal schooling parallels a phase of rapid growth or maturation of the frontal lobes. At about age 12 years, children begin to change classes in school and manage social interactions independently. This time frame corresponds to a phase when the frontal lobe development has progressed beyond 50% development. This frontal lobe development also corresponds with reduced parental input (as the “external hard drive frontal lobes”). At about age 16 years, we (and other drivers) hope that the frontal lobe development has developed to at least about 85% to sustain executive driving skills and by age 21 years of age, frontal lobe processing should approximate the adult level or about 100%.

Children at age 12-13 years show very dramatic differences in rate of growth secondary to hormonally-drive growth spurts. As a result, children in this age range often show dramatic variations in the extent to which the frontal lobes are maturing. Children who are later maturing (with respect to the frontal lobes) often present with features of disorganization (ie., desk, backpack, outlines for writing, study notes, etc.), poor planning (ie., spur of the moment), failure to use feedback to adapt (ie., repeatedly make same mistakes), poor observer functions (ie., difficulties understanding how others may see the world, difficulties with peers, etc.) and limited control of basic emotions with resulting dramatic mood swings, irritability, acting out and rule violations. While “maturity” or growth results in changes, it is the quality of the environment (ie., parenting) that channels the growth into effective processing. Therefore, while maturity may result in positive changes, the positive changes are not a given unless the parents are able to establish and develop a good “frontal” lobe environment that includes: (a) high levels of organization (ie., desk, backpack, room, etc.), (b) high levels of planning (ie., schedule, daily planner, daily study times, etc.) and (c) consistent and predictable feedback (ie., require child to correct tests, study after tests to learn areas of weakness, well-defined rules and consequences, consistent and predictable consequences, etc.). Stability during this stage of instability is critical to positive growth.

Time: A Marker for Change

“My child always did well in elementary school… but since about 5th or 6th grade, his performance has really deteriorated… he is disorganized, does everything at the last minute, makes repeated careless mistakes. I’ve been told that a lot of kids have difficulties at that age due to the transition into middle school along with the hormones kicking in. Is this just a maturity thing? Will it just get better with time?” The last two questions posed by beleaguered parents take on the quality of a hopeful plea.

Last things first. “Will it get better with time?” Check out your garden… some weeds crop up. Will the weeds get better with time? How about the rusty fender on your car… will the rust go away over time? Unfortunately, nothing changes as a result of or due to time. Time is a marker for change, but time actually causes nothing. So, the belief (or perhaps wish) of parents that “time” will make things better is unfortunately not true. What actions you take across time, however, definitely have the potential to make things better. Unfortunately, some actions have the potential to have no effect and some actions have the potential to make things worse. Actions, like treatments, need to address the specific underlying problem or issue. Weeding the garden will enhance the quality of the garden, but has no known effect upon the rust in your car’s fender. Likewise, the actions of trimming away the rusty fender, sanding, painting, etc. may enhance our fender, the garden weeds tend to show limited effect (unless you pour the solvent on the weeds). Getting the point?! An effective intervention (or parental action) must address the underlying problem or issue. The solution… treatments, interventions or parental actions must begin with a comprehensive assessment of the problem and factors contributing to the problem.

My Child is Inattentive and Hyperactive

“My child is inattentive and hyperactive!” I hear this as a presenting complaint about two hundred times each year (from among our clinic’s 400 referrals each year). My first response (after my unspoken… “And?!?!… you had to have been told something about children and this behavior before becoming pregnant?”) is to tell parents that all children (and adults) are inattentive and hyperactive. The question is, “How much does the inattention (or hyperactivity) differ from the norm?”. Einstein aptly informed us that “all is relative” and that a behavior cannot be understood independent of the observer. A parent who exhibits significant symptoms of inattention and hyperactivity may perceive similar child symptoms as the norm. A parent who resides within a chaotic, unpredictable and inconsistent home environment may not recognize features of inattention as a problem. The symptoms defined as the “norm” in one home or “not a problem” in another home may be perceived as disruptive, disabling or catastrophic to the parent whose world corresponds to a Franklin Covey Day Planner. The central role played by the parent (observer) in the diagnostic process is obviously problematic since the presence of a diagnosis is potentially more dependent upon the parent than the child.

The solution to the dilemma introduced by observer bias is the use of standardized tests to assess processing capacities/abilities and deficits/impairments. Standardized tests are measures (or tests) that are presented to children (or adults) using a standardized (consistent, predictable, etc.) method with specific (standardized) instructions to maximize consistency among observers (testers). The diagnostic task is to identify whether the presenting symptoms/complaints (ie., inattention, hyperactivity, etc.) are part of the normal bell curve (within the norm for children the same age) or are outside of the normal bell curve relative to the child’s peers.

All human behavior or performances tend to be normally distributed such a low number of people exhibit a high level of performance, a low number of people exhibit a low level of performance and most people fall in the middle. As an example, a few people are very fast, a few people are very slow, but most people fall in the middle. A few people are very strong, a few people are very weak, but most people fall in the middle. Standardized tests are simply measures of behavior or performance and, as a result, performance on tests is normally distributed with a few children scoring high and low, and a large number of children scoring in the middle. Within the standardized testing method, observations obtained on a single child are compared to this normal bell curve. The task is to identify the extent to which the child’s behavior deviates from the norm. Definitions (often referred to as “cutoff scores”) regarding what constitutes abnormal behavior or the presence of a disorder differ. However, most clinicians tend to classify scores that deviate from the norm by over two standard deviations (ie., observed among less than five percent of children) as abnormal or of sufficient severity to warrant a “disorder” diagnosis.

So… is “my child is inattentive and hyperactive?” The answer is “yes”… and so are you. “Does my child’s inattention and hyperactivity deviate from the norm sufficiently to be an impairment relative to the demands of the normal environment (home or school)?” The answer is “I don’t know” and it is very unlikely that any other single observer will have the answer to that question (including physicians, psychologists, etc. are also biased observers). The solution… complete an evaluation that utilizes standardized measures.

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.