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The Informed Parent

An Underachieving Sixth-Grader…More Than Attention Deficit Disorder

by Louis P. Theriot, M.D., F.A.A.P.
Published on Oct. 13, 2003

Joey is an affable, bright, 11-year-old sixth-grader who recently moved to this area from out-of-state. His father is an electrical engineer who was promoted and transferred to Southern California this summer. Mom, who has her masters degree in education, was able to get a position with the school district where Joey would be attending.

Since I was seeing the youngster for the first time as a patient, I questioned mom about his past medical history. We began with the pregnancy and moved forward chronologically to the present. Joey was in excellent health, having had nothing more than two ear infections as an infant, and an occasional flu-like syndrome. The big issue, however, was his performance in school.

Joey was diagnosed with Attention Deficit Disorder (ADD) in the third grade. He has been taking Concerta, a long-acting form of Ritalin, since he was diagnosed. Although he now seems more focused and on task, he continues to struggle terribly in school. He barely made it through the fifth grade with passing grades. Such disparity for a child who has been tested and found to have an IQ of 123; a child who truly works hard at his schoolwork, with his mother looking over his shoulder constantly. “What are we doing wrong?” his mother pleaded.

Joey’s history is an interesting one. There is no question that he does have ADD, as all of the testing and the positive response to the Concerta supports. As a pre-K and kindergartener he did just fine. First grade was a breeze, and second grade began that same way. Then, in the second half of second grade the teacher questioned Joey’s ability to stay on task.

If she was reading to the class, Joey would be staring out the window, or doodling on his paper. He never disrupted the class, or blurted out answers. He just seemed spacey. The teacher met with his parents in the spring and said, ”I don’t know what to say about him. He is very smart. He doesn’t give me any trouble in class. In fact, he is truly a helper and a joy to have around. I just can’t put my finger on it, but something is not right!”

After this discussion it was passed off as Joey being “all boy”, and probably a bit bored in class because he was so bright. They agreed to follow this situation very closely, as next year’s “no-nonsense” third grade teacher had a reputation for being strict.

By Christmas of the third grade year, the bottom fell out. Joey was in over his head. He was doing terribly in school; the teacher asked his parents to come in to discuss what should be done. Not only was he doing poorly on his tests, his work was not being turned in. She cited the example of giving the class a math quiz. Five minutes into the test the entire class would be feverishly working on the problems...except Joey. He would be staring out the window, looking at the gardener across the street blowing leaves. When lecturing the class, Joey would have a glazed look as if he was elsewhere.

I asked mom what homework was like during this time. She rolled her eyes, threw back her head and said, “All I can tell you is that by the end of the evening, ONE of us would be in tears”. If Joey had homework in three subjects, something that should take him no more than 30 to 40 minutes to complete, she would check on him two hours later and find that not one thing was completed. A few math problems would be done, and some spelling words written down. But there were candy wrappers all over the table, the pencil sharpener filled with all the pencils sharpened...but not one subject completed. This resulted in mom doing his homework WITH him. She would literally pull up a chair and walk him through the assignments.

This, too, proved to be futile, as he would forget to turn the work in. When this became a crisis the parents met with the teacher to go over his grades. It was discovered that he was missing the bulk of the homework. Mom was completely surprised since she had done some of the assignments herself. Confronting Joey about this, it was discovered that most of the missing homework had in fact been completed. It was simply crumpled and crammed into the bottom of his backpack. He had forgotten to turn it in.

Mom went on to describe the standard practice of having to call a friend to get the spelling words the night before a test. Joey had forgotten them at school. Often they had to drive over to a friend’s house to borrow a book. Joey had left his in his desk. After the meeting with the teacher, it was obvious that there was a major problem. This led to Joey’s being tested.

The tests revealed that he was very bright, with an IQ of 123. Given that, school should be a breeze for him. Further testing revealed, however, that Joey had ADD. Attention Deficit Disorder is a constellation of inattention, impulsivity and hyperactivity. A child with ADD does not necessarily have all three components; he may have just one, as was the case with Joey. He had pure inattention, and not the impulsivity or hyperactivity. That is why his problems did not surface until third grade. Being so bright he made it through kindergarten, first grade and most of second grade on sheer intelligence. Since he did not have hyperactivity or impulsivity, his behavior did not make him stand out or cause any problems in the classroom Then, by third grade with a demanding teacher, he fell flat on his face academically. This is often the case with this type of student.

The doctor correctly diagnosed his ADD, and properly treated Joey with Concerta, which worked beautifully. Literally, overnight, the teacher raved about the turn around in his performance in class. His parents noticed it immediately as well. Not only in homework, but also in soccer, karate, picking up his room and doing chores. It was like a miracle, and all were pleased.

Fourth grade was not too bad. Joey had a brand new teacher, and as mom explained, “It went all right, I guess. We thought Joey would do better, but we attributed it to the fact that the teacher was inexperienced. Also, the move to Los Angles was a big thing in our house.” Looking back on it she knew that something was not just right, but she did not want to admit it. Joey was still struggling, although he was working very hard. And focus and attention were not issues. The move consumed a lot of their time and attention, and he finished the fourth grade with “so-so” grades.

Now that they were settled here in California and fifth grade was underway, Joey was coming to me to anticipate where to go from here. After listening to mom, talking to Joey himself, and reviewing all the testing that had been done, it became clear where the problem was. Joey had an excellent evaluation for ADD. The Concerta was the correct medication for this problem at this particular time. There was no question that he was bright and that his IQ was 123. What I did NOT see was any testing to rule out specific learning disabilities (LD).

I explained to mom that as many as 50% of children who have ADD also have LD’s. When evaluating a child for school underachievement or ADD, these must be looked for. LD’s refer to auditory or visual perceptual problems. This has nothing to do with how well a child sees or hears, but how the sensory information is processed and assimilated by the brain. A child may have 20/20 vision, but not be able to read a simple story and understand it. Or a child may have excellent hearing, but not be able to “get it” when he is lectured to. LD’s can tremendously affect how a child does in school, or simply how well they function at home in terms of following orders. This greatly impacts other facets of their life such as music, sports, ballet, etc.

Joey was tested. It was found that he had severe auditory AND visual processing problems. As is often the case, everyone quickly picked up on his ADD and successfully treated it with such a stellar response. But the possibility of a LD was overlooked. Joey was focused and on task since he had been on the Concerta. He was truly making an effort and working hard. Because he was so bright, the LD’s did not cause much of a glaring problem until he got in the upper grades where the teachers do more lecturing and the work is a bit more abstract.

There are no specific treatments for learning disabilities. But there are tools that can be employed to compensate for them. They must be identified first. Once they are uncovered, a psychologist, who is experienced with these issues, can make specific recommendations for the student to help compensate and overcome these disabilities. Many of the recommendations will involve modifications in the structure of the class. Therefore the teacher will be an integral player in helping the child succeed.

That is what happened in Joey’s case. Our psychologist made recommendations for Joey which included having him tape record the lectures in class. He was assigned a “buddy” who took notes for him in certain classes. The teacher always checked the assignment daily planner to be sure his homework was properly listed. She encouraged him to learn to keyboard and use the computer. It was insured that he sits in the front row near the teacher. Since he had always been taller than most boys his age, he had sat in the back row ever since first grade.

These changes, along with his continued use of Concerta, made a tremendous difference in Joey’s life. He did great in school with an expected amount of effort on his part. Things went smoothly at home, and homework was now something that he did independently. In fact, HE would ask mom to look over his assignments. It was no longer a group effort in which she did the majority of the work. His self-confidence and self-esteem grew as a result.

Joey’s case is interesting, but not uncommon. When dealing with a student who is struggling in school, or is underachieving (not performing to their expected potential) and a diagnosis of ADD is being entertained, it is imperative that that child be screened for learning disabilities since they can be subtle and easily missed.

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