What Is With This Gender Disparity?

Teaching in Family Medicine, Psychoanalytic Institutes, Child Psychiatry, and Social Work students has shown me a gender disparity that floors me every time. My students are overwhelmingly female. We discussed this today, before I launched into my talk on ADHD. “We are more nurturing,” one student said, implying that women are better at taking care of other. “Yes, but in the 60s, psychoanalysis was predominantly male.” I reply, saying that when there is more status, men are more likely to be attracted to the field. “Teachers are very important to our society, but their female dominance makes it a lower paying field,” I speculate out loud. I am a weary of delving deeper into this subject, as one, this is not my job, and two, I am speaking to students who have picked a career, in which I am suggesting will decrease in respect as more women go into it. Nevertheless, I continue. ”Is it women want to be home with their kids, or is there a glass ceiling which prevents women from obtaining more prestigious positions, or is it that women, as a group, are less genetically ambitious and so are more comfortable staying in lower paying positions?” We all agree that these are interesting questions, without clear answers. One thing, though, I feel certain about, is that a female-dominated profession will be thought of, by our society, as less important than male-dominated professions. Given that there are more women than men in the United States, I am inclined to think that many women share a typical man’s point of view about professional value. These are, of course, my musings. I do not claim to have expertise, only curiosity.

Low Self-Esteem or Disorganized: Hard To Tell

Elisa, thirty, misses appointments, forgets to pay her bills, does not return phone calls, and has trouble completing tasks. She suffers from ADHD, takes stimulants which she reports as “very helpful,” but she remains disorganized and thereby rude to her friends and family. As we explore her behavior, which occurs intermittently with our appointments as well, Elisa comes to the understanding that she runs her life in a “crisis mode.” By that she means that when they are just about to shut off her electricity, then she will pay her bill. Before that, “I just don’t see the need,” she says with a flat affect, seemingly uncaring that her two kids will have to suffer if the electricity gets shut off. “It seems like you need adrenaline to carry out a task?” I ask, noticing that the heat of a crisis bolts her into action. “Yes, absolutely, I have always been that way,” she responds rapidly. “Maybe that the adrenaline has to compensate for your general low sense of yourself and your general sense of unworthiness, such that you do not feel compelled to do the activities of daily living unless there is an immediate consequence which looms large.” I say, noticing that maybe layered over her ADHD is a sense that life is not much fun, that she is not much fun, if she has to be ordinary. “The sense that one has that it is OK to do ordinary things is often derived from a sense that one is OK. If you don’t have a sense that you are OK, maybe then you do not see the value in showing up and being a person of your word. Maybe you don’t think your word means much because you don’t feel that you mean much.” I say, again showcasing that perhaps if she had a larger view of her self-importance, maybe then she would comprehend why it is important to other people that she does what she says she will do. If she thinks low of herself, she may think that her word is not valued and therefore she is not obligated to follow through. I wonder. Elisa looks back at me mystified and unsure as to what I am talking about. “I don’t know what you are saying, but I will sure try to think about it,” she responds. “That is all I ask. Think about it.” I say, expressing hope that maybe through chewing on my idea,  Elisa can come up with her own ideas as to why she has trouble being responsible. She left confused, but also with a look of curiosity and reflection that made me think that we were involved in a deep journey.

Talkin’ To Teachers

Sometimes I have the pleasure of going to a high school to talk to teachers about ADHD. This fictionalized story illustrates a moment which made me pause. During the lunch session that I had with teachers, one teacher told me about a student who was hyperactive, although not severely, causing this teacher to pause in her discussion. When I inquired if she had told the parents about this student, she said I did not want to  ”worry them”. She made me realize that when a teacher reports a behavior to parents, they are faced with the uncertainty of how these parents will react. Some might get extremely anxious, and some might get angry. There is always the fear of the “kill the messenger” response. I never really thought before as to why teachers may not be communicating to parents about the concerns they have in their students. In the past, I had attributed poor communication to the fact that the teacher had too many students, or that the teacher was unaware of what was going on in the classroom. Now, I realize that teachers, like therapists, are faced with the sensitivity of parents who cringe at the idea that their child may not be ”normal”. No one wants to make a parent cringe. We all would rather have a narcissistic festival where the teacher and the student are thriving in this academic environment that we call school. A “problem” in that environment opens the discussion to a blame game, where the injured, in this case the parents, might throw the blame away from their child and on to the school. Sometimes, of course, the parents may appropriately assess that the school is failing their child. Other times, though, the parents are blaming the school, blaming the teacher, as a way of avoiding dealing with the problems in their child. It is obvious that everyone benefits from open communication and parents should be told when their child is a behavior problem in the classroom. It is now also obvious to me, another reason this open communication may be inhibited. As I said, it is a pleasure talking to teachers.

Undiagnosed ADHD: A Tragedy?

  Frank, thirty-seven, comes to see me because he broke up with his girlfriend of ten years. He is often late, forgetful of appointments, disorganized with his payments, and generally a “last-minute” guy. He is also a thrill-seeker. He jumps out of airplanes. He goes paragliding and bungee jumping. He does not like staying idle. “What were you like as a school-age kid?” I ask, realizing that I am not familiar with his childhood history. “I was smart but I hated school. The teachers hated me too. I was always in trouble.” “Do you think it is possible that you have ADHD?” I ask, beginning to think that his current behavior, combined with his self-report of his school history fits an ADHD diagnosis. “Well, yea, I have thought that for a long time,” he says, as if it is obvious.

    ”We have never discussed it before, and you have never been treated,” I say, knowing his psychopharmacological history. “Well, I thought I was too old, and besides, I had it so many years ago they weren’t treating it then,” he says with suspicious certainty. “Oh yes, they, meaning I, was treating it then,” I gently contradict him. “We could try a stimulant,” I say, “but I am also thinking about the years of your coming of age where you must have been misunderstood as a trouble-maker, and not someone who was struggling with organic issues which got in your way.” “Well yea,” Frank says, seemingly with minimal impact about the gravity of the lack of a diagnosis in childhood. “I wonder how your relationships would have been if you could explain to your significant other what your struggles are like.”  I say, emphasizing that part of having ADHD is understanding how it impacts relationships. “Maybe I would still have my girlfriend,” Frank says with acknowledgement that his ADHD interfered with his relationship, but also with a tone that lightens the discussion. Three days later Frank calls me. “Hey doc, that stuff you gave me is really helping me. Thanks.” He says, continuing in this light-hearted way, almost as if I gave him aspirin for his headache. “I am glad,” I say, with a heaviness which mismatches his tone. “That is really a big deal.” I say, marveling at the years in which he had no idea why he was so scattered and unreliable.

Is It Severe ADHD or Childhoood Bipolar? The Case For A Longitudinal Assessment

Alan, now eleven, has seen me since he was four years old. Zane, his dad, was diagnosed with ADHD when he was thirty. Zane does well on stimulants, such that he reports that “they changed my life.” Theresa, Alan’s mom is a speech therapist, specializing in children with special needs. Beth, their younger child, has no issues that concern them. By contrast,seven years ago,  Zane and Theresa reported that Alan’s behavior was “really not normal.” They continued to state “his moods shift rapidly. “We cannot handle him. We think there is something seriously wrong with him. He gets upset at the slightest thing. He is not like the other kids. He throws chairs when he does not get his way. He cannot focus on “anything he has no interest in.  We know he is smart, but that does not seem to help him. His tantrums are simply out of control. Maybe he is bipolar or something.” Theresa tells me her frustrations with Alan, with tears in her eyes and a look of deep concern. “I work with special needs kids, but I have never seen anything like this,” she tells me.

I do my usual investigative work: I talk with Alan’s teachers. I see Alan myself. I gather more information from concerned relatives. Based on my review of the history and my observations of Alan, I conclude that he has ADHD and he needs a stimulant. We do a stimulant trial and Alan gets worse. “You see,” Theresa tells me, there is something else going on.” “Not necessarily,” I explain. The fact that he did not respond to stimulants may mean that his brain is too young to reap the benefit, so that maybe as his brain matures, he will be able to handle a stimulant better.” I explain. Theresa and Zane are not convinced.

  Fast forward five years, and we repeat a stimulant trial only this time, it is a remarkable success. Alan is doing better handling frustration and focusing at school. Fast forward two more years, and Alan is back to where he was at four, only now he is approaching puberty. Once again, Theresa and Zane believe that his behavior cannot be explained by ADHD alone. They are deeply concerned about  whether Alan has a chronic mental illness such as bipolar disorder, even though there is no known family history of this diagnosis. “I think he needs a higher dose of his stimulants. I also think that puberty has exacerbated his mental state, such that with time, his brain will mature and his frustration tolerance will improve.” I explain, again, not convinced that his low frustration tolerance is related to childhood bipolar disorder.

  Alan only tantrums when he does not get his way; when he is not the center of attention. Theresa and Zane are admirable parents, but they need to understand that raising Alan is more demanding because of the severity of Alan’s ADHD. They need to work harder at  providing consistency and structure. We have talked about these parenting skills and they are on board, but still skeptical of Alan’s future mental functioning. “I think time is going to be on our side,” I say, explaining the wonders of maturation. “Medication will also help,” I say, agreeing with them, that parenting alone is insufficient to deal with the severity of Alan’s behavior.

Theresa and Zane, after much discussion, feel a bit relieved that we are still dealing with the same issues that we were dealing with seven years ago. Alan too, looks forward to increasing his medication, as he says “I don’t like that I behave this way. I really don’t,” with shocking insight into his difficulties. There is hope in the air. We will see how it goes.

ADHD:Who Should Treat It?

   Child psychiatrists, behavioral pediatricians, family physicians, child neurologists are all physicians who feel comfortable and confident in treating ADHD kids. Where should a family turn when their child begins to have behavioral problems at school? The path is not clear. Often, the family begins in primary care, either at a pediatrician’s office or a Family Medicine doctor. Then, depending on the comfort level of the provider, either they receive treatment in primary care, or they get referred. This referral can be to any of the above-named specialists, all of whom have a different idea about how to treat ADHD. The family is often unaware of the landscape, and hence they are blindly following the recommendations of their Primary Care Physician. Usually, the child ends up on stimulants, but the difference lies in the details. For example, child psychiatrists, as a group, are usually the only ones who insist on a two-parent consent process, whereas the other providers are satisfied with getting the history and the consent from one source. The other disparity is in how much attention is paid to the family dynamics. ADHD poses a severe risk to marriages, and neglect of other siblings. I contend that child psychiatrists are more attuned to those very important issues. ADHD kids often need an advocate at their school to make sure that their educational system is maximized given their disability. A child psychiatrist is more likely to emphasize the importance of altering a child’s education, given the diagnosis of ADHD.

  I am biased, I hear my readers saying. Of course. I speak from my point of view. Still, the medicalization of ADHD seems to narrow the scope of this large issue which occurs in a developing child, and hence impacts a family. Child psychiatrists are uniquely suited to understanding the need for medication, while at the same time, appreciate the need for multiple psychosocial interventions as well. Child neurologists tend to treat ADHD like seizures; they try to “get it under control” as if this is not a life-long struggle with many potential hazards downstream. Behavioral Pediatricians are well trained in the area of ADHD, but they hit their limits when the behavior becomes very aggressive and is unresponsive to psychotropic medication. I do not mean to disparage my medical colleagues. I would rather that we pool our expertise so that we can figure out how to refer to one another. I am not sure how to make that happen. My second wish is for the consumer (or the patient’s family, in these cases) to know the difference so that they can seek consultation in a place that makes sense to them. Medical care is in such high demand. It is too bad there is redundancy in our system, especially when healthcare workforce issues are coming to light. Clearing the road for consumers, such that there is greater clarity on who should treat ADHD,  might help patients streamline their efforts to help their child. I can hope.

 

See also…http://shirahvollmermd.wordpress.com/2010/04/25/is-it-severe-adhd-or-is-it-aspergers-the-case-for-a-good-assessment/

Moderate ADHD

   Larry, eleven, entering sixth grade, is about to enter into the pressured-filled world of applying to seventh grade, secondary school. Like the pressure of eleventh grade, where kids have to seriously consider how hard they work might impact their choices for college, so too, in the private school world, going to sixth grade forces kids to pay attention to their grades, not only for the sake of pride, but for the practical reason that their performance in school, to a large measure, will determine their secondary school. Larry is thrown into this pressure cooker, with the added burden of ADHD, and as such, although he is very bright, he does not perform up to his potential. He does not check his work. He hurries through his tests. He often forgets to turn in assignments. He has tutors, extended time, and he is on medication, but with that support, he is still underperforming, based on the discrepancy between his IQ and his grades. Should the parents try harder to have Larry perform in a way which matches his IQ? I wonder. Or, should they accept that ADHD limits his scholarly performance and that is just who Larry is? Maybe. Or, as Larry’s parents did, should they tell Larry to work harder because it is “really important.” 

  Understanding ADHD, like understanding anxiety, is a deep issue. Larry’s mom, Carol,  has ADHD, yet that does not seem to give her empathy for Larry’s struggles. Carol did fine in school, although now she has trouble organizing her life. I explain to Carol and Joe, Larry’s parents, that helping Larry with medication, educational tutoring, and extended time, is useful, it is also useful to understand that Larry may not perform to his potential, and maybe, just maybe, that is fine for now. Yes, he may go to what they call a “tier two” school, but maybe that is appropriate for him. Larry, like many ADHD kids, tend to be late bloomers. “Maybe he won’t hit his stride until college and maybe that is fine for him,” I say, knowing that Carol and Joe are thinking that he won’t go to a good college unless he goes to a “tier one” secondary school. Although I understand their concerns, the linear nature of their thinking concerns me. Like so many parents, there is a feeling that if things don’t go right when the child is eleven, (or even earlier in some circles), then the child will then be denied all of the privileges of the élite. There seems to be little allowance for deviating from the “path”. There also seems to be fear that such deviation will land that child in a “different” world, a world unfamiliar to the parents. It is not that Carol and Joe do not want the best for Larry. They do. Understanding what “the best for Larry” means is the tricky part. I offer an alternative point of view of the “best for Larry” based on my understanding of the disabilities associated with moderate ADHD. Layered over that, I feel for Larry and his struggles. Larry is a nice, sweet and charming kid. I wish he could just go seamlessly into the seventh grade. Unfortunately, that is not going to happen.

The Second Opinion

Sharlene, seventeen, has been diagnosed with ADHD since she was eight years old. She has substance abuse issues, truancy issues, and she does not do her chores around the house. Her biological history is that she was the product of a sperm donor father and a single parent mother. She was raised by her grandmother, Sherry, who is now age sixty. Although Sharlene is on medication for her ADHD, my advice to Sherry is that Sharlene needs a strict behavioral program to help her have more socially appropriate behaviors. “You would need to be responsible for instituting this behavioral program, I tell Sherry directly. “Sharlene’s problems are from her ADHD and you seem to not understand that,” Sherry tells me with tears in her eyes. “I do understand that, ” I respond, but ADHD often requires a two-pronged approach: medication and a behavioral program. “Well, you don’t seem to see that if Sharlene just understood her situation better, then she would behave more responsibly,” Sherry tries to persuade me. “Well, of course, you can always seek a second opinion, but it is my opinion that Sharlene, at this time in her life, is not open to looking inward, and hence an external program, one that gives her strict consequences for her behavior, is needed,” I say with conviction. “I think someone who understands ADHD better will see things differently,” Sherry says. “I am curious what the second opinion will say, and I think that another professional could be helpful, but at the same time, I am worried that you might be giving Sharlene implicit permission to act irresponsibly by implying that she has a condition that she cannot change herself,” I say, trying to explain that personal responsibility is key, despite the fact that ADHD is a biological disorder which is not Sharlene’s fault. In other words, I explain “Sharlene should not use ADHD as an excuse for antisocial behavior,” I say. “Well, let’s see what the next doctor says,” Sherry says to me, continuing with her tears. It was a tough session.

ADHD: Slowly Developing Brain

   “When is she ever going to grow up?” Arline, the mother of Jolie, age eighteen, asks me, with a tone of frustration, impatience and anger. “ADHD tends to cause a three-year lag in emotional development,” I try to explain to her in a flat tone to say that Jolie is going through a slower developmental trajectory than the average child her age. “Yea, but look at her,” Arline continues, “she is not motivated to do her homework. She is texting all the time. I mean all the time.” Arline continues with her frustrated tone. “I think you should use an incentive program for her to do her work, but at the same time, I think you need to understand that she is a late bloomer, so you need to have some patience with her development.” I try to explain in a way which is supportive to Arline and Jolie at the same time.

    Developmental change, the rate of development, is a variable in personality which is hard to contemplate because we cannot measure it. I imagine that the brain is developing, along with the other organs in the body, and as such, the DNA instructs this rate of development, as it does for height. Everyone grows at different rates, but most people stop growing around twenty. The rate at which people achieve their final height varies. Some people are done at twelve, whereas others are still growing in college. Girls tend to start their growth spurt before boys, and they tend to stop growing before boys as well. Brain development is probably similar. Girls mature before boys. In general, they reach their developmental milestones earlier. They develop speech sooner. Girls, in general,  are not smarter than boys, but a three-year old girl who has sophisticated speech seems smarter than a three-year old boy who is still speaking like a telegraph. Understanding that the brain is also developing at a rate which we cannot measure, but we can infer from the type of decisions the person makes, helps us understand that growth is in progress. With this understanding, intervention can be tailored to the person’s developmental, not chronological age.

    Arline looks at me and says “do you have children?” She seems to be trying to figure out if I have any idea about her parental frustrations, her worries, and her guilt. “I am happy to answer that question,” I say, “but tell me why you are curious. Do you think that if I have children, then I have a better idea of what it might be like to be concerned about how a child is eventually going to be independent, whereas if I don’t have children, then I would not be clued in to the feelings associated with having a child who is not responsible.” I ask, trying to guess why she is feeling so alone in our session. “Yea, I am not sure you understand how worried I am.” Arline says with deep feeling. “I am sorry if I have not conveyed my understanding, but I feel as if I do understand,” I say, trying to state that although she feels alone, I can feel, at least in part, her trembling anxiety over Jolie’s future. “I am going to think about this slowly developing brain idea, but right now, I don’t get it,” Arline says in a calmer voice. “Think about it,” I say, feeling like Arline is a bit more open, and perhaps more able to accept Jolie’s biology. “It is not easy being a mom,” Arline says with lightness. “Yep, I get that,” I say, mirroring her easy going tone. “There is a lot at play in helping a human being develop,” I say, stating the obvious, but feeling like I need to express the complexity of parenting. “More than I ever thought,” Arline says, allowing us to connect in a warm way.

‘I Need To Do It On My Own’

    Maryjane, fifteen, tenth grade, comes in after not seeing me for three months. “How did you keep up your supply of Concerta?” I ask, wondering if she stopped taking it, or if someone else prescribed it, or she was getting some illegally from friends. “Well, I need to do it on my own, so sometimes I don’t take my medicine,” Maryjane says, as if I would support her need for independence. “You mean that when you don’t take the Concerta and you can focus, you feel better about yourself, but then there are times when you absolutely cannot focus without it, so you take it?” I ask, trying to understand how a fifteen year old integrates stimulant medication into her new-found need for autonomy. “Yes,” Maryjane says, as if she meant to say ‘of course’.

     I understand Maryjane to be struggling with the diagnosis of ADHD which she has had since she was six, in conjunction with her need to see herself as a growing being who can be self-sufficient. She has come to a compromise with herself by taking medication occasionally. I appreciate the maturity in that decision. Whereas some adolescents will become black and white, either they will take their medication rigidly or they will decide that all of their doctors were incompetent and they do not need medication at all, Maryjane has found a middle ground. Stimulants can feel like a tool, similar to a laptop, which aids in the efficiency of getting work done. Alternatively, stimulants can be seen as a sign of defectiveness, a sign of weakness.

  In my experience, the attitude towards stimulants is highly variable, depending in part, on the attitude of the parents, and in part, on the genetic make-up of the child. Some parents take stimulant medication in stride, whereas others become very fearful that their child’s  need to take stimulants casts a negative shadow over their entire family. Similarly, some children take their medication without much thought, whereas others think long and hard about what it means for them to have to take a medication to help them think. Although I have known Maryjane for years, since before she went through puberty, I have never heard her express concern over taking stimulants. In the past, she had seemed appreciative that they help her stay in tune with classroom material. As she develops, as her brain develops, Maryjane’s thoughts about her Concerta are developing too. She, in an age-appropriate way, wants to feel enamored with her dawning adulthood. For her, this means being able to use stimulant medication, as needed, rather than daily. That way, she controls the medication and not the other way around. Maryjane likes that; she also needs that sense of control for her ego development. She is on a good path.