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The Informed Parent

The Great Pretender

by John H. Samson, M.D., F.A.A.P.
Published on Sep. 01, 1998
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A young man sat bewildered as he came to the conclusion that college was more than he could handle. Reading had always been difficult. Extreme effort brought only mediocre results, but he could not continue the herculean effort needed to barely get through school. He had carried the diagnosis of dyslexia since the sixth grade. Although different remediations were tried, the condition did not improve.

Leaving the university life he entered the labor pool, a ploy to avoid reading. Hard work was gratifying as the years passed, but at the same time unfulfilling. Occasionally a novel was picked up but unless there was an intent interest no energy was extended to stick with it.

Approaching his 30's it became apparent that his occasional impulsive behavior was impacting both family and work life. A long-time friend, his pediatrician, noted this impulsive behavior and offered to evaluate this problem from the standpoint of impulse control in addition to dyslexia. Over the years this physician friend had become quite experienced in managing A.D.D. and learning disability patients.

The frustrated young man felt he had nothing to lose. Assessment of reading skills showed a performance at an eighth grade level. It had always seemed so hard to process the written word that quickly he would lose interest, and then put the book down.

His impulsivity keyed the physician to explore a new avenue of evaluation. Could this dyslexic also have an impulse control problem frequently seen with A.D.D.? He was not hyperactive, but he was distractable. Although this appeared primarily while reading, maybe it was primary and not secondary to dyslexia. Since 70% of A.D.D. patients have an associated learning disability, linked with but separate from their attentional problem, perhaps there was more than dyslexia, the pediatrician thought.

A careful history added more credibility to this theory. A meticulous neuro-physical examination yielded no new findings. As part of the workup he administered a continuous performance test, specifically an I.V.A. This test, as well as several other types such as T.O.V.A. and Connors, evaluates the consistency of one's reaction time scored hundreds of times in a period of 15 to 20 minutes. It is based on the premise that A.D.D. patients have very inconsistent reaction times, particularly as the examination length increases. It also bypasses dyslexia since it gives only two simple symbols that demand no reading skills.

Upon completion of his test the scores indicated extremely inconsistent reaction times, true to the diagnosis of A.D.D. He had never before taken a continuous performance test since hyperactivity and seeming intrinsic distractibility had not been considered as part of his dyslectic problem.

Now his impulsivity fit A.D.D., and his distractibility while reading fit both diagnoses. In order to assess the efficacy of stimulant therapy the doctor prescribed a dose of Ritalin to be taken one and one-half hours prior to the commencement of another I.V.A. test.

After taking the Ritalin on the morning of his second test he felt no stimulatory effect. He was neither energized, hyperactive nor over-talkative. In fact, he felt calmer than usual. Upon completion of the test the pediatrician sat stunned. The grossly abnormal prior test was now absolutely normal. In fact, it was above average. It became apparent that dyslexia was not his only problem. In order to avoid making a hasty diagnosis the patient agreed to take Ritalin three times per day for seven days to further judge the beneficial effects. Would he be less impulsive, less distractible?

Two days later the doctor was interrupted from seeing a patient by a potentially disturbing phone call. "Dr. Jones," the nurse advised."Mr. Roberts is on the phone. He says he must speak to you right away!" What happened? Did the Ritalin cause a reaction, the pediatrician thought. Why did I prescribe for an adult? I'm a kid's doc. Walking quickly to the phone he blurted, "Jim, what's wrong? What happened? Are you reacting to the medication?"

"I sure am, Doc," Jim replied. "I could cry. I just sat down and read 100 pages of a book at one sitting! Not only that, I understand it and could tell you what I read!" Jim's voice broke slightly, just on the verge of tears.
"Great, Jim! Let's have your reading skills re-tested while you're on the Ritalin," he suggested. "Fine, doc. You know, I've never been able to do this before!"

The educational psychologist did indeed re-test Jim and found his reading skills greatly improved. He could read without distraction; he did not have to re-scan lines over and over, and his comprehension was normal for age. To this day Jim's reading ability is exactly normal, and his impulsivity is under control as long as he takes his medication.

This young man did not have primary dyslexia; that is, deficient reading skills in and of itself. The apparent dyslexia was secondary to a primary condition of A.D.D. When the A.D.D. was controlled by medication the symptoms of dyslexia left, as well as the symptoms of impulsivity. It is important to emphasize that stimulant medication does not eradicate or control primary dyslexia, a visual processing problem. But it does obliterate the signs and symptoms directly caused by the A.D.D.

In this case, the inability to stay focused on reading presented itself as primary dyslexia. However, it was not a primary condition but only a symptom of something else.

It never hurts to reassess a patient. Twenty-eight years of practice have taught me never to stop re-evaluating my patients with a well known diagnosis. Medical knowledge, experience and testing modalities improve every day. These information tools allow for more complete and precise diagnosis and, in cases like this, treatment.

Jim, the well known dyslexic patient, turned out not to be one. Instead he is Jim, the A.D.D. patient, whose reading difficulties disappeared by treating his basic condition. Sometimes that which seems obvious is not.




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