When I saw sixteen-year-old Jimmy for the first time he entered my office with trepidation. Once again he would have to launch into an evaluation for his poor performance in school.
He had been through this several times before. Some assessments yielded no other diagnosis than “he just is not motivated to do well”. Others, after several days of testing, gave no diagnosis at all. They yielded a large, wordy pre-programmed report that provided no help.
His very last evaluation, however, stated that Jimmy had ADD with dysgraphia, a disability in writing. He was launched upon a program of remedial writing exercises along with low doses of Ritalin. His writing did not improve, nor did his ability to stay focused. After many months of frustration, Jimmy’s mother decided to give it “one more shot”, and came to consult with me.
Once again they were put through a long, careful history session, including his life from conception to present day. We covered information about the pregnancy, birth, diet effect, prolonged illnesses, nervous system injuries or diseases, development milestones and a grade-by-grade assessment of his achievements and/or problems. A complete family history, involving relatives and current family situations, was investigated. It must be pointed out that I strongly advise this type of detailed history taking. It is necessary and critical in order to arrive at an accurate and complete diagnosis.
As we talked the reluctant adolescent relaxed and became a cooperative and interested patient. He later told me on a subsequent visit that I was the first physician to really listen to him.
The following was learned about him:
Finishing the history, we completed his neurological examination and evaluated his attentiveness with computer testing. The results showed that he did appear to have ADD without hyperactivity. He also had a written expression problem, either secondary to the ADD or primary unto itself. If it were primary the problem would not improve with medication. If it was secondary to his inattentiveness, it might show significant improvement on the same medication that controlled his ADD.
Jimmy left the office with hope and a higher dose of Ritalin that was better suited to his weight.
Repeated computer testing while he was on medication showed a dramatic correction of his scores. The final diagnoses were:
(Note:) Despite his actual writing problem Jimmy’s ability to “download” his thoughts by way of words was also normal. Motivation was not a primary problem with this patient.
Rarely do I see a primary unmotivated patient. The vast majority have other mental, emotional, physical or neurological disabilities that truly hamper the student’s performance. Not all poor writers will improve on anti ADD medication. But those who do have illegible writing, due to rushing distractedly through work because they can’t maintain concentration, can be greatly helped by giving them consistent focus.
As informed parents you can be a vital part of your physician’s evaluation and remediation.