She had all the symptoms of classic ADD, but something else was provoking her demeanor.

 

Niki is a 9-year-old third grader that I have had the pleasure of taking care of since she was born. I have watched her grow and mature into a bright young girl who is active in Girl Scouts and quite an accomplished ballerina. Niki was ready for kindergarten well before she started school at 5 years of age, already reading at a first grade level. She did just fine and thrived in first and second grades.

 

Third grade, however, was a different story. She struggled to get her work done and the teacher said that she was off in space most of the time. It was hard to redirect her. Grades were so-so, and mom implied that “the wheels had come off”. Things had reached a crisis point when the parents met with the teacher, who happened to be a friend of theirs. They were told “I’ve been teaching for 20 years, and I have seen this many times in the past. A student who has ADD may do well in the earlier grades, but by 3rd grade it all falls apart because the work is more difficult. I shouldn’t be saying this to you, but you should think about having Niki tested for ADD.”

 

When they came in for a consult for possible ADD I was surprised because Niki had been doing so well. After taking a thorough history, things became a bit clearer. It turned out that in the summer between 2nd and 3rd grade, mom’s aunt, the matriarch of the family, was diagnosed with advanced cancer.

 

Mom was particularly close to this aunt. They invited her to live with them in order to have hospice at their house. The family was extremely close and loving but there was a lot of anxiety and sadness in the house. Niki was pleased that her great aunt had moved into her room. As a result Niki shared a room with her sister.The parents went out of their way to establish the normal family dynamics, but this was realistically impossible. Everyone tried to put on a positive front, but there was just a lot of stress in the house that the family did not perceive.

 

I asked mom if she thought this might be the case with Niki, and she quickly snapped, “Absolutely not!”

  
I had Niki take a continuous performance test, a computer test that takes 22 minutes and analyses for inattention, impulsivity and one’s response time. It does not diagnose ADD, but can be one of the modalities we use to see if there are tendencies of inattention or impulsivity. I wanted to see how she did on this test, but more importantly, I wanted Niki out of the room so I could talk candidly with mom. After Niki exited, the room became very quiet, and mom had tears in her eyes. I think it just hit her that this could all be related, and she felt terrible.

 
I told her that what the teacher had said was accurate. Some patients who have ADD with unmixed inattention, no hyperactivity or impulsivity, may sail through kindergarten, 1st and 2nd grades. But then they struggle in 3rd grade. This is because many of these children are naturally bright and get by the early grades on their sheer smarts. But by 3rd grade the work becomes more abstract; hence they struggle and get lost.

 

Since they do not have hyperactivity or impulsivity they don’t bother anyone. Often times the teachers say, “This is my favorite student. He/she tries so hard but just doesn’t get it.” These students are at risk because ADD may not be identified for some time.

 

I told mom that there are some patients that have what is referred to as secondary ADD. This means that they act like they have classic ADD, but only because of certain stressors in their lives that mimic it. Some of the more common stressors may be a divorce, loss of a close family member, bullying or any abuse. While these patients act like they have the problem they do not respond to the medications used to treat primary or actual ADD. In fact, the medications typically used, stimulants such as Methylphenidate or Dextroamphetamine, may actually make things worse.

 

The nurse did the test and brought in the results. As was expected, Niki did great and it was not suggestive of ADD. I suspected that the new home situation with hospice may be what was causing the change in Niki’s performance.

  
I advised mom that I wanted Niki to see a child psychologist to help her sort this out and to give her the tools to recognize and deal with the stress. It was suggested that the whole family could benefit from this. What they were doing for the aunt was admirable and with proper counseling could make it more meaningful for all parties concerned. Mom broke down and cried. She was relieved as if a weight had been removed. I call the psychologist while she was still there and set up an appointment for the next day. Mom shook her head and asked, “How could I have been so blind…”. I told her not to even go there.

 
The family had a wonderful experience with the psychologist and Niki did NOT have ADD. She responded nicely to the therapy and before long was excelling once again in school. The whole family benefited and, despite having their aunt undergoing hospice in their home, the tension, sadness and sorrow was greatly relieved. No one was walking on egg shells anymore. The mom told me a bit later that the teacher confided in her, “I’ve been a teacher for many years and I would have bet a million dollars that Niki had ADD!”