I was asked to see fifth grader Cody for a second opinion consult regarding his ADD. In obtaining the history Cody was diagnosed by his doctor in third grade as having Attention Deficit Disorder. He was placed on Concerta, a long acting form of Ritalin, and according to his mom the results were phenomenal.
It turned out that Cody was not hyperactive but had significant inattention and impulsivity. He was a bright boy with above average intelligence and did fine in kindergarten and first grade from an academic standpoint. But he had behavioral issues that would often get his card pulled, meaning he was disciplined. His teachers felt this was a maturity issue, and Cody was just being a boy.
By second grade things seemed to unravel. He had an older experienced teacher who was strict and ran a tight ship. Cody was getting good grades and met all his benchmarks, but in class he was disruptive and would blurt out answers when it wasn’t his turn. In the middle of a class session while the teacher was talking, he would walk over to the pencil sharpener to sharpen his pencil. It was a rough year but he managed to make it to third grade. However, his teacher had some real concerns.
The wheels came off shortly after third grade began. His new teacher had heard about Cody and watched him closely. The same behavioral issues surfaced. Mom was constantly getting calls from the teacher about his being disruptive in class and just spacing out. This was the first year he had actual homework. Mom was frustrated because Cody could/would not do his work independently. She would have him sit at his desk after clearing everything off, telling him to do the sheet before bringing it to her when he was done. She estimated this should take about 15 minutes at the most. An hour later, upon checking, only half of the math page was done…but he had built a fort out of his pencils and erasers. Homework had become a group effort, whereby she would sit next to him and walk him through each assignment. As if this wasn’t bad enough, he would forget to turn it in half the time.
Mom took Cody to his doctor who correctly diagnosed him as having classic ADD. He was started on Concerta--there was an immediate turn around. In fact, when mom picked him up from school the first day he had taken Concerta, the teacher came out to the car to report what a remarkable day Cody had had. The rest of third grade was a piece of cake, and life was good. He continued the Concerta for fourth grade and he again had a superb year.
Fifth grade was not so wonderful. Cody had a male teacher who was rigid and expected a lot from his students. He would lecture frequently and wanted the students to take notes. The day before a test, he would give a verbal review whereby he would tell them what major points they needed to know. Cody would get a D on the test even though his parents would review with him and felt he knew the material. The parents met with the teacher who said he all but told the class what was going to be on the test. Cody seemed dumfounded and swore he never heard him say that. Other parents were asked about this and they all corroborated the teacher’s story. This meeting followed up with the teacher’s concern about Cody’s attention in class. Whenever he lectured the teacher was losing Cody. It was as if he was zoning out. Cody’s desk was moved in front and he had to constantly cue him in by tapping on his desk or calling his name. It was becoming a problem. And that is why I was asked to see Cody.
The first thing mom asked was if the Concerta had stopped working, or did he need a higher dose. I did a thorough physical and found Cody to be a healthy boy. As he had taken his Concerta that morning, I had him do a continuous performance test in the office. This is a computer test that measures inattention, impulsivity and response time and is a good gauge of ADD. It doesn’t make a diagnosis of ADD, but will serve as a good baseline and can be used to establish response to medication. Clearly he was on a good dose of Concerta as he did great on the test and was focused and on-task throughout.
His mom was almost disappointed when we got the results because she wanted to be able to adjust the dose and have the problem fixed. She said, “Now what?” in a dejected voice. I told her that Cody HAD to be tested for learning disabilities. I explained to her that over 50% of all ADD patients have some form of learning disabilities. These can be auditory or visual processing problems. This doesn’t have anything to do with their hearing or vision, but rather how the brain perceives or decodes the sensory information. They can have 20/20 vision, or acute hearing, but when they read or hear, the information doesn’t reach the brain properly
As it turned out, Cody had a significant auditory processing problem and that is why he seemed to tune out when the teacher was lecturing, and why he missed all the test information when the teacher would review with the class. Cody was referred to a knowledgeable psychologist who worked with him and gave him the tools to work around this disability. Learning disabilities cannot be fixed or cured, but a good psychologist can help them establish techniques to compensate for these issues. They can also help the teacher make certain in-class modifications that will benefit the student.
In Cody’s case, the psychologist worked with him and his parents, met with the teacher and helped set up a list of modifications, and he remained on the Concerta. It took a short while but within a month, he was excelling in the class.
There are a number of important learning points from Cody’s story. Whenever one is being evaluated for ADD, it is imperative that learning disabilities are evaluated as well as over 50% of ADD patients also have learning disabilities. Learning disabilities can be diagnosed through a battery of tests that are done by an educational psychologist. Learning disabilities cannot be fixed or cured, but a student can be given tools to overcome and compensate for these disabilities. Managing an ADD patient with learning disabilities requires a team approach that involves the patent, the parents, the teacher and the psychologist. Everybody’s role is equally important, and it is the job of the pediatrician to coordinate everyone’s efforts and act as the quarterback of the team. Our goal, or the bottom .line, is that we want Cody and all the other students like him to be able to perform to their true potential and to allow them to be the best that they can be.