Driven to Distraction (Revised) Page 6

  As we began to get more history—and the key to making a diagnosis in this complicated field is through the story of the child’s life, rather than through complicated tests—what emerged was a picture of an intelligent girl who had some language and attentional problems.

  Problems in the development of language can occur at a number of levels and in a number of ways. One can have difficulty with input or with output. Input problems, or what are called receptive language problems, can affect both what you take in and what you are able to put out, because what you put out is dependent on what you were able to take in. Output problems, or what are called expressive language problems, can affect what you are able to write or speak as well as what you are able to conceptualize within your brain.

  Although a full discussion of learning and language problems, including dyslexia, is well beyond the scope of this book, we cannot discuss ADD without some mention of language problems—and learning disabilities in general—since they so often coexist with ADD, each usually making the other worse. In addition, we will have to touch on other neurological problems that can mimic or exacerbate ADD, from the obvious, such as hearing impairment, nearsightedness, or a nerve problem that affects articulation, to the more subtle aphasias and memory problems and seizure disorders.

  I asked Polly if Penny were late in learning to talk. Although developmental milestones, as these moments of specific achievement are referred to, are not etched in stone, they do give a quick reference point as to whether it is a developmental delay worth investigating. You also have to be sure you and the parent have the same definition of “early” or “late.” Some parents consider their child late if he or she cannot recite Shakespeare by ten months, while others consider no language at all until age three just fine, if not a relief.

  “Yes, she was,” Polly said. “Her first words didn’t come until about twenty-two months, and little sentences didn’t come until she was three. Our pediatrician suggested that I read to her a lot and make up stories together. That’s where the Faraway Stories came from.”

  “She liked them?” I asked.

  “She loved them. That’s what was so touching. Even though I knew she wasn’t getting it all, she’d sit still and ask to hear more stories. And if I stopped in the middle, she’d pull on my arm and say, ‘I want more!’ ”

  “Could she play with words at all?” I asked.

  “What do you mean?” Polly responded.

  “You know, make rhymes, repeat rhymes, make up nonsense words—”

  Polly, who was leaning forward eagerly, interrupted to answer. “She couldn’t do rhymes exactly. But she made up words all the time. She couldn’t think of the right word, so she’d make one up. Instead of saying we’re going to the airport, she’d say we’re going to the plane place. Or instead of birthday present, she’d say box-day thing.”

  “You remember these well,” I said. “What would you do when she said them?”

  “I would correct her. Shouldn’t I have?”

  “No, it doesn’t matter at all. I’m just trying to get a sense of what this was like for her emotionally.”

  “She would say the new phrase I told her. I didn’t want her to think she was stupid.”

  “Did you think she was stupid?” I asked.

  “No, not at all,” Polly said emphatically. “If I’d thought she was stupid, I probably wouldn’t have corrected her so easily. But I knew she was smart and would want to get the right word. Plus, I thought her ability to improvise and make words up proved she was smart.”

  “You’re right,” I said. “It sounds like her problem was in finding the right word in her storage bin, so to speak. Or in finding the right storage bin. Or in remembering the word. Or in transporting the word from the storage bin to her mouth.”

  “This sounds pretty complicated,” Polly said.

  “Well, it is,” I said. “But that’s really good news that it’s complicated, and that we know that it’s complicated. Not so long ago we seemed to think all this was very simple. You were either smart or you were stupid. Oh, we had some ultra categories like genius and moron, but it was all based on a really simpleminded notion of intelligence. Smart versus stupid. And that was the basic ball game. But lately we’ve been finding out how complicated intelligence and learning really are. For example, Mel Levine, one of the great figures in the world of learning problems, talks about seven kinds of memory, and you can have a problem with any one of them that can interfere with learning. That’s what I was referring to when I was talking about getting words out of the storage bins. I just wanted to think of some analogy. You get what I mean?”

  “Yes, I do, and it’s exciting,” Polly said.

  “What about in school?” I asked. “What happened then?”

  “She fell behind in reading from the start,” Joe said a little glumly.

  “That’s not quite true, honey,” Polly said, gently containing her annoyance with his performance-appraisal approach. “She was more interested in books than any of the kids. She just couldn’t comprehend them all. But she always wanted me to read to her and she still likes to hear the Faraway Stories even to this day.”

  “What about the daydreaming?” I asked.

  Polly handed me a stack of papers. “These are teacher reports going back to first grade. You’ll see they all say about the same thing. ‘Tunes out.’ ‘Seems shy.’ ‘Can’t pay attention without frequent reminders.’ One of the teachers even wondered if she might be depressed, she seemed so quiet all the time. But it wasn’t until this year that Becky Truesdale—”

  “Who?” I interrupted.

  “Becky Truesdale, her fifth-grade teacher. She was the first to bring up the possibility of ADD or a learning disorder. I have to admit I’d never even heard of ADD. I only knew about hyperactivity in boys. But Becky says girls can get it and sometimes there’s no hyperactivity, just tuning out.”

  “Becky’s right,” I said. “Girls can have ADD as well as boys. Hyperactivity is the old name for the syndrome. More recently, the label ADD was invented to focus on the symptom of attention inconsistency these kids have. A lot of girls who have it never get diagnosed. Instead, they’re just thought of as shy or quiet or even depressed, like Penny.” In giving the McBrides an overview of the ADD syndrome, I stressed that ADD was often found in particularly creative, intuitive children. “Lots of kids who have ADD also have something else, something we don’t have a name for, something good. They can be highly imaginative and empathic, closely attuned to the moods and thoughts of the people around them, even as they are missing most of the words that are being said. The key is to make the diagnosis early before these kids start getting stuck in school with all kinds of pejorative labels. With some help, they can really blossom.”

  I took a few minutes to read through the teacher comments, which, as Polly had told me, were full of descriptions of absentmindedness or daydreaminess or unfinished work. The comments reminded me of a term Priscilla Vail uses in reference to children who don’t quite fit any mold exactly: conundrum kids.

  “Would you like to meet Penny?” Polly asked.

  “Of course,” I said. “But why don’t I go to her. Often kids with ADD can focus very well in the one-on-one situation of the doctor’s office. In here there is structure, and novelty, both of which drastically reduce ADD symptoms. Even the fear a child sometimes feels in a doctor’s office can increase concentration, and so mask the ADD symptoms. That’s why it can be so easy for a pediatrician to miss the diagnosis. The symptoms just aren’t there in the office. In a classroom you get a truer picture. So may I visit?”

  Polly and Joe McBride enthusiastically agreed and made arrangements with Becky Truesdale. Schools are usually quite receptive to this kind of visit. They are eager to share what they know. What they have to say is usually of great value.

  I slipped quietly into the classroom during what looked like math period and took an empty chair along the bookshelves in one corner of the room. Another teacher w
ho had guided me to the classroom pointed Penny out before she left. I watched her, trying not to stare. She was a cute little brown-haired girl with a ponytail, wearing a yellow dress and Nike sneakers. Her desk was where I’m sure she wanted it to be: at the back of the room, right next to a window.

  Now I should put in a word here about windows and schools and ADD. One can easily get the idea from a school that it thinks windows are the devil’s own work, placed in schoolrooms as a means of temptation, pure and simple. The good children look away from windows, while the bad cannot resist their transparent allure, free passage to the sky and trees and daydreams beyond.

  People with ADD do look out windows. They do not stay on track. They stray. But they also see new things or find new ways to see old things. They are not just the tuned-out of this world; they are also tuned in, often to the fresh and the new. They are often the inventors and the innovators, the movers and the doers. Good Do-Bees they may not always be, but we should be wise enough not to force them into a mold they’ll never fit.

  But what of these devilish windows? Is it so bad—a sure mark of educational decline—to look out them? I wonder instead if it isn’t the duller child who does not look out windows.

  Penny’s eye certainly found its way there. As she sat, her right cheek comfortably contained in the palm of her right hand, the fingers of her left hand tapped soundlessly on the wooden desk while she gazed out the window. I looked to see what she saw, but I could see only sky and an ascending branch of a nearby tree. That’s one thing about window-staring: you can never really tell what the other person is seeing out there.

  Every now and then, usually in response to a noise of some sort, Penny would look toward the blackboard and the numbers that were accumulating. Today’s board was sprouting fractions by the minute. Penny must have seen something in them because she’d wrinkle her brow now and again when she’d look at them. She didn’t seem troubled, just serenely uncomprehending. Then she’d brush back her hair, and, as if following the trail of a speck of dust, slowly turn her head back to the window. She made no noise. She caused no disturbance whatever. If anything, her serenity lent a calming influence to the classroom. It was easy to imagine how she could go unnoticed over the years.

  I introduced myself to her after class, as there was a break for recess. Her parents had told her I’d be coming. “Hello, Dr. Hallowell,” she said with a big smile. “My mom said you’re a nice man.”

  “Well, you have a nice mom,” I said. “Did she tell you anything else?”

  “I don’t think so,” Penny said, her face contorting into a there’s-something-I’m-supposed-to-remember-but-I-can’t look.

  “That’s OK,” I said. “Do you want to get outside for recess?”

  “Mom said you might want to talk to me,” Penny said.

  “Just for a second. Your mom and dad came to see me to ask if I could help out with how things go for you in school and stuff. Do you like school?”

  “Oh, yes,” Penny said enthusiastically.

  “What do you like about it?” I asked.

  “I like the teacher and I like the other kids, and I like the walk to get here from home and I like the time to sit and listen—”

  “What do you listen to?” I asked.

  “Oh, to anything,” Penny said. “Mostly my own thoughts. I like to make up stories in my head. Mom and I have a kind of game—”

  “She told me about it,” I said. “Sounds like fun. Is that what you were doing during math class this morning?”

  “Yes,” she said. “I was making one up about fat old men who looked like sixes and funny old women who looked like nines and they went dancing together and turned into eights.”

  “That’s great, Penny,” I said. “Do you think the eights will get back to sixes and nines?”

  “Maybe,” she said, pulling at the yellow-spangled stretch band around her ponytail. “I was actually going to have them lie down and become binoculars that could see very far away.”

  “All the way to Faraway Land,” I said.

  “Yes,” she said, blushing a little bit that I knew the name of the place in the stories.

  “Is there anything you don’t like about school?” I asked.

  Penny looked down at her sneakers. “I’m behind all the time. I don’t get the homework.”

  “Maybe we can find you some help with that,” I said. “Recess is almost over, I bet. Maybe we could meet sometime later when you’re not in school.”

  “Sure,” Penny said. “But you’ll have to speak to my mom. She makes all my appointments.”

  “Of course,” I said. “Great meeting you, Penny. See you later.”

  Becky Truesdale was a young teacher just out of a teaching internship at a private school near Boston. She knew a lot about ADD and learning disabilities. “I’m so glad you could come,” she said to me. “I didn’t want to call on Penny in class so you could see how she is when she’s left alone. She’s really smart, you know.”

  “Mmm,” I said, “and she seems happy, at least today.” I thought I heard a trace of a southern accent in Becky’s words. “Are you from the South?” I asked, the impulsivity of my own ADD overcoming the tact and sequentiality I should have given the exchange.

  “Why, yes,” Becky said, not annoyed by my change of subject. “I grew up in Charleston until my family moved to Maine.”

  “Quite a change.”

  “That’s for sure. And you?”

  “I actually lived for a few years in Charleston myself,” I said. “As a kid.” We paused. “How long have you known Penny?” I asked.

  “Just since the beginning of the school year. Six weeks. Not long enough to know her well, but long enough to like her. She reminds me of a young artist or something, sitting in the back daydreaming.”

  “Do you think she’s depressed?” I asked.

  “No,” Becky said with a laugh. “Far from it. She brightens right up whenever you talk to her. The other kids like her. Even when she stands off, they don’t pick on her. It’s as if they accept that that’s just her way.”

  “What is your main concern about her?” I asked.

  “That she really isn’t with us,” Becky said without hesitation. “And I’m afraid that the further she goes in school the more of a problem that will become. Even in this class she misses a lot, but somehow she compensates. Still, I know she could be learning more.”

  Becky and I talked until the end of recess. I thanked her for her help and said goodbye, promising to stay in touch.

  There was a list of conditions in my mind that could explain Penny’s situation. After I met with Penny in person again, met with her parents once more, and got some neuropsychological testing done, that list had narrowed to two: attention deficit disorder without hyperactivity and both expressive and receptive language disabilities.

  ADD exacerbates learning problems in the same way that nearsightedness does: you can’t focus as well as you should, so you are not able to use the talents you have to the fullest. The first step in treatment is to get glasses, or treat the ADD, and then reassess the extent of the residual learning disability.

  Just making the diagnosis, giving a medical name with a rational treatment to what Penny’s parents had thought was an immutable quirk of temperament, helped a lot. Once everybody understood what was going on, we started medication. While the medication by itself would not be sufficient treatment, the results in this instance were dramatic and quick.

  There are several medications used in the treatment of ADD. They all help the individual to focus better. In a sense, they act like internal eyeglasses, increasing the brain’s ability to focus on one task over time while filtering out competing stimuli or distractions.

  Of the various medications available at the time, we chose Norpramin for Penny. Norpramin is in the class of medications referred to as the tricyclic antidepressants. Although medications in this group are called antidepressants, they have many other uses than for the treatment of depres
sion, including the treatment of ADD, both in children and adults. The most common other group of medications used to treat ADD are the stimulants. Since the original publication of Driven to Distraction, great strides have been made in long-acting stimulants such as Concerta and Adderall. Today they would be our first choice, although used properly, both groups are extremely safe and effective.

  Within a few days of Penny’s starting medication, her parents as well as Becky were on the phone to me. They were all amazed. She was tuned in in class, focused on the work at hand, participating actively and creatively. Most of all, she was really enjoying school, and in ways she had not enjoyed it before. She was enjoying learning. The medication’s only side effect in Penny’s case was mild dry mouth, caused by the anticholinergic property of the tricyclics (that is, they block the neurotransmitter acetylcholine, which mediates various bodily functions, including salivation) as happens with many over-the-counter cold remedies. This is tolerable and may be counteracted with a Life Saver or other lozenge. The medication did not take anything away from Penny; she could still daydream when she wanted to.

  While this was only the beginning of the treatment, it was in many ways the most moving part for everyone, including me. As Penny’s mother put it to me in one of our follow-up visits, “It’s as if a veil has been lifted from Penny’s eyes. She can see us and we can see her. She’s still my dreamer, but now it’s on purpose that she dreams.”

  2

  “I Sang in My Chains

  Like the Sea”

  THE CHILD WITH ADD

  Our first knowledge of attention deficit disorder came from children, before we knew that the syndrome continued into adulthood. ADD is now one of the conditions within the field of childhood development about which we know a great deal. A conservative estimate would be that 5 percent of school-age children have ADD, and yet it remains poorly understood by the general public, often going unrecognized or misdiagnosed. The hallmark symptoms of ADD—distractibility, impulsivity, and high activity—are so commonly associated with children in general that the diagnosis is often not considered. A child with undiagnosed ADD is thought to be “just being a child,” only more so. It wouldn’t occur to anyone that the “more so” was a tip-off to a medical diagnosis unless they knew something about that diagnosis in advance.