Dawn, a charming 14-year-old girl, just had her eighth grade graduation. Her parents had scheduled an hour appointment to discuss the possibility that she might have ADD. Sifting through her chart and my notes I was reminded that she was essentially a straight A student through grade school and middle school.
When I walked in the room Dawn flashed a big smile. She was all excited to tell me about the fun things she had lined up for summer, and how she was looking forward to high school. I asked the nurse to check Dawn's vision and blood pressure in the other room. This then would enable me to talk to the parents alone.
I asked Dawn's mom what exactly prompted this consult...was it generated by Dawn's teachers, or was it a concern of hers? After all, the child always had excellent grades and seemed to be a high achiever. She did well in sports and music. This hardly was the picture of a person you would suspect might have ADD.
When asking about her successes Dawn's dad spoke up. He clearly felt that this was an over-reaction on the part of his wife. The prospect of ADD did not sit well with him. He had all of her report cards, as well as certificates and honors from sports and school in a large folder. "How could a child with ADD accomplish all of this? " he asked rhetorically.
Superficially, I could see his point. ADD is a constellation of symptoms that include inattention, and/or impulsivity, and/or hyperactivity. In other words, to make a diagnosis of ADD, one may only have inattention and not impulsivity or hyperactivity. You need not have all three symptoms to make a diagnosis. With ADD the symptoms are present before the age of seven years. It is slightly more frequent in boys than in girls. The overall incidence in the United States is approximately two-to-five percent of all school age children.
"So, how could Dawn have done so well all through elementary school?" her dad appropriately questioned. The ADD patients with hyperactivity and impulsivity are usually identified at a relatively early age...often before kindergarten. The hyperactivity child is frequently described as a "ball of energy", and is easily diagnosed at an early age. The impulsive child may be a bit more subtle and difficult to diagnose. Since these children are unable to wait, often they blurt out answers when it's not their turn and seem to act before they think. They neglect to read instructions completely through which results in doing a whole section of a test wrong, even though they knew the material cold. Lastly, the child who has pure inattention is the one who is likely to be missed and will fall through the cracks. These are the daydreamers who bother no one, who get along well with classmates and teachers. Most of these children are very bright and pass through kindergarten, first, second, and third grades without any problems. They get by on sheer smarts. However, by fourth grade the work becomes too difficult. They often hit the wall at this point and begin to struggle.
That is the reason Dawn's dad raised these questions. If she had ADD, how could she have been so successful all through middle school? As we talked the picture became much clearer. Even though Dawn is very bright homework had been a family affair since first grade. A child should be able to do the homework independently by fourth or fifth grades. Certainly one might need help with math or certain topics, but for the most part a child should be able to do the bulk of it alone, turning it in the next day. In Dawn's case it became apparent that sending her to her room to do the homework alone would not work--it would never get done. Every night one or both parents would sit by her side to guide her through the assignments, and to keep her on task and focused. Mom always arranged with the teachers to have her sit in the front row. An arrangement was worked out whereby Dawn would have the teachers sign off in her daily planner that the homework was turned in for that day. Again, Dawn is a bright girl; all of this special help aided her in being successful, hence the straight A's.
Mom deserves a great deal of credit because she did a tremendous amount of research, questioning whether she was being a help or a hindrance to the child. The first semester of eighth grade was very much status quo...all A's But mom realized that high school would have to be different. She told Dawn that the last semester was basically on her own. Mom and dad would be there for any help that she might need, but for the most part, she was to do the work on her own, and be responsible for it. It was extremely difficult for mom to let go, but she realized that there was no choice. Very quickly it became evident that Dawn was struggling. She would spend hours in her bedroom doing her homework. In the end, none of the three subjects she was working on were done. There were nights when dad could not stand it. He would sit by her side and help her complete the homework. The only problem was it was rarely turned in. It was a trying semester for Dawn and her parents. When the report card came it was no surprise that she got one B and the rest C's. And that is what generated the consult.
After completing the testing it was determined that Dawn had mild inattention and was extremely impulsive. She had a beautiful response to medication and is now ready for high school. When I met with the parents for a follow-up to Dawn's being on medication for ADD, her dad commented how different things had become at home. Now it takes about five minutes to wash her face and brush the teeth in the morning. Before, it was a painfully long ordeal that usually ended in a shouting match after 20 minutes of pleading. "Now I can tell her to do three different things...and they'll be done. Before I could hand her a book and tell her to put it away in her room. I would see her walk to the kitchen and put it on a counter," he went on. "She wasn't being oppositional or difficult," he explained. "It just didn't seem to register with her." Mom, dad and Dawn are very pleased with her response to the medication. I have every confidence that she will excel and do well.
The take-home point of Dawn's story is that even though a student is getting A's and B's this doesn't preclude them from possibly having ADD. It would have been easy for Dawn to be coached through high school by her parents...to a certain point. Then the bottom would have fallen out. I commend mom for having the insight into the excessive help that she was giving Dawn, and the strength to let her fall down on her own.