Jessica Kingsley Publishers

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Kids in the Syndrome Mix of ADHD, LD, Asperger's, Tourette's, Bipolar, and More!

The one stop guide for parents, teachers, and other professionals

Martin L. Kutscher MD
With a contribution from Tony Attwood
With a contribution from Robert R Wolff MD

Hardback: £27.99 / $44.95

2005, 234mm x 156mm / 9.25in x 6in, 224pp
ISBN: 978-1-84310-810-8, BIC 2: VFX JNC JNS

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Paperback: £12.99 / $19.95

2007, 234mm x 156mm / 9.25in x 6in, 224pp
ISBN: 978-1-84310-811-5, BIC 2: VFX JNC JNS

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Chapter 1

Read this Chapter! General Principles of Diagnosis

"Why am I reading a chapter on making a diagnosis?
I'm not a doctor."

The "syndrome mix"

Start with a real, live child-a kid with feelings, needs, and hopes. Mix in a double helping of attention defict hyperactivity disorder (ADHD), a touch of Tourette's, and a dash of dysgraphia. Stir gently. That is one possible "syndrome mix" that a child, parent, teacher, and other professionals may be dealt. That's what they have to deal with.

Who says that kids have just one problem? Multiple issues often cluster together in any combination. Common members of the syndrome mix include:

ADHD

learning disability

autistic spectrum disorder, such as Asperger's syndrome

sensory integration dysfunction

anxiety/obsessive-compulsive disorder (OCD)

Tourette's syndrome

depression

bipolar depression

oppositional defiant disorder

central auditory processing disorder.

If a child has any one of the problems out of the syndrome mix, then there is a very significant chance of one or more of the other problems occuring.

Not only does the same child tend to be born with multiple issues, but the issues also may exacerbate each other. For example, a child may innately have both ADHD and learning disabilities; but then the poor attention span makes it harder to learn, while the difficulty learning makes it harder to concentrate. The mix of syndromes keeps exacerbating itself.

Similarly, the problems can imitate each other. For example, a child constantly mulling over her anxieties can look distracted, and this behaviour can be confused with ADHD.

In addition, often the stressed child will find himself in a stressed home or school environment. True, that stressful environment may have been caused by the youngster, but the end result is that the child now finds himself having to deal with stressed-out adults-the last ingredient the child needs!

Also, many of the neuropsychiatric conditions run in families. Thus, the child may find him/herself coping with parents (and teachers/therapists?) with their own inborn problems.

For each area of difficulty, there is a gradient of severity. We need to separate whether it is a "problem" (i.e., significantly impacts the quality of a child's life and merits significant intervention) or a "quirk" (i.e., an unusual feature causing less impairment). Even if an issue does not rise to criteria for a "problem" status, it might still benefit from being addressed. Dr. John Ratey, a noted psychiatrist, refers to these low-grade issues as "shadow syndromes" (Ratey and Johnson 1998).

One reason, then, that parents and teachers may have trouble figuring out what the problem is that there is typically more than one, each occurring with its own degree of intensity.

First signs

When you think about it, psychologists, therapists, neurologists and psychiatrists do not stand on the street corner and randomly pick children to evaluate. Rather, the kids are all sent there because other people have noticed a problem. Those people are the ones on the frontline: the teachers and the parents. They may not know what the problem is, but these caregivers are the first to diagnose that there is a problem. Like it or not, the whole system depends on these first-responders. This chapter will help you feel more comfortable filling the role you have already been given.

No child's problem is diagnosed on the basis of one piece of information. Over time, multiple observers all become increasingly aware that there is some problem. The concerns typically brew over several years, until someone finally gets sufficiently frustrated to say, "Hey, there's a pattern here. Something is up!" What observations, then, typically lead to a diagnosis?

Parents' observations

No one knows his or her child like the parents. Mothers typically have nagging (or sometimes blatant) concerns long before anyone else will listen. They are the ones who keep seeing and hearing the same things. They are the ones with whom the child confides. They typically bear the brunt of the child's frustrations.

If a parent sees that something is wrong, they are typically right. After all, most parents are not interested in "making up" problems for their children. Would a parent schedule a school meeting or a doctor's appointment just for the experience of falsely declaring to the world that their child is not thriving? No, if a parent is concerned, then there is usually an issue. That is not to say, though, that the parents have necessarily correctly identified what the problem is, or who is responsible to fix it-just that there is a problem.

Teachers' observations

Teachers are incredibly valuable in the identification of a child's difficulties, for multiple reasons.

They spend a great deal of time with the child, second only to the parents.

They have had contact with many other children over time, helping them to establish a basis of "typical."

They have ongoing typical "control" children in the class. They can see which child is different from all of the other kids in the same classroom.

If a teacher is experiencing a problem with a child, then, by definition, there is a problem.

When report card comments are read in sequence, there is usually significant conformity over the years. This pattern attests that the difficulty is with a particular child, rather than a particular teacher/student match.

In order to find the teachers' concerns, though, we must be aware that the issues are frequently masked underneath otherwise positive comments. Especially if the child is perceived as kind, cute, smart, or hard working, then the instructor tries not to be too negative. For example, he might say, "Jill can do such amazing work when she puts her mind to it!" On the surface, it's a positive comment about Jill's intelligence. The subtext, though, is that Jill is not always on task.

In addition to written comments, checklists can also be helpful. Anyone can use the Behavior Checklist (see Appendix 1). For ADHD evaluations, guidance counselors or the doctor can provide a similar quick-rating scale.

So, here are the take-home messages for teachers:

Although the teacher's role may not be to make a specific diagnosis, their input is key to the process. Teacher feedback is the basis for diagnosing any school related problem.

Detailed written teacher comments allow for "hidden messages" to come through, and provide the doctor with objective information. Comments may be supplemented with check-off forms.

When a teacher identifies a problem, there usually is one. The teacher may be less accurate, though, at identifying the true underlying cause of the difficulty.

Teachers might seek the guidance of their school professionals (psychologists, guidance counselors, etc.) before broaching to the parents the idea of seeking a doctor's guidance.

Common pitfalls

If you find yourself saying any of the following, be very cautious. They are red flags of misinterpreting the child's behaviors.

"He's lazy." You'll notice that "Lazy" is not listed in this or any textbook as a possible diagnosis. I've yet to meet a child who woke up one morning and had the following silent conversation: "Hmm. I wonder if I should try my best today, get good grades, and be praised? Or, maybe I should deliberately blow off my work and get punished? Oh, the latter choice should be fun!" Yes, by the time an undiagnosed teen gets to high school, the child may indeed have been beaten down so often that he has given up. However, if we look back over the person's history, we usually find a young child bouncing with energy. Somewhere along the way, he's learned to give up.

"He's so unprepared. He obviously does not care." As we will see later, disorganization is a major part of ADHD and executive dysfunction.

"She only does it when she is interested." All of us do better when we are interested. The question is, "What is going on that she can't do it at all unless the task is totally intriguing?"

"She'd be better at it if she just showed more interest." No, it's probably the other way around, i.e., she'd be more interested in it if she were better at it. A child who is a poor reader will avoid the task. I doubt she ever said to herself, "Let's avoid reading until I get really bad at it."

"He is inconsistent. I've seen him do it, sometimes." Just because a child has occasionally done something right does not mean we should hold it against him or her forever.

"She is just a social butterfly." Boys tend to be labeled "hyper," whereas girls get called "social." True, it may be developmentally appropriate to be social; but is the girl really more interested in what her friend ate for breakfast than in learning her schoolwork, or is there some other problem? Inattentive ADHD (especially in girls) is harder to diagnose- but no less real-than ADHD with hyperactivity-impulsivity.

"I don't know if there is a problem. I'm just the teacher/parent." As we've seen, there is no one else like the teacher and parent to identify the child who is having some problem.

Formal evaluation

Psycho-educational testing

If the need for potential significant intervention arises, eventually the child might be given a "psycho-educational evaluation." This consists of a detailed series of tests:

Psychological tests (indicating a child's potential), such as the WISC-R (Wechsler Intelligence Scale for Children - Revised-commonly referred to as the "IQ" (intelligence quotient) test).

Educational tests (indicating a child's academic achievement), such as the Woodcock-Johnson or WIAT (Wechsler Individual Achievement Test).

The report prepared by the tester usually includes an explanation of these tests and their significance. A full child study team evaluation may also include reports from social work, speech and language, occupational therapy (for fine motor, handwriting, and sensory integration), physical therapy (for gross motor), neurology, or psychiatry. Anyone-parent or teacher-can request an evaluation by the school district's team, which should be done in a timely fashion.

The medical doctor's evaluation

So, what happens if the child gets sent to the medical doctor to be diagnosed? Nothing magical happens there that allows us to observe things not noted by parents and teachers over the years. In fact, the medical office is a poor place to observe a child's natural behavior. Let's take the case of a child presenting for an ADHD evaluation. One of the treatments for ADHD is a structured one-to-one situation with frequent, novel stimuli-just what occurs in the doctor's office. Thus, trying to make the diagnosis of ADHD is difficult while the child is in what should be a therapeutic setting. This is a point of confusion for many professionals, leading to the all too frequent, "I don't see anything wrong with your child." In addition, many problems such as poor foresight and organization need the laboratory of actual life over many months to be detected. Only caregivers outside of the doctor's office can make such long-term observations.

So what do experienced doctors do? In addition to their own observations, they rely on real-world observations by those people who care extensively for the child: the parents and the teachers. In other words, we talk to the kids; but mostly we talk to the parents, read the teacher reports, and read any testing that has been done. We try to fit all of the years of observed information into a pattern, and derive one or more diagnoses. If the medical/neurological history and physical exam suggest the need, we may sometimes perform blood tests, electroencephalograms, etc.

Choosing appropriate accommodations

Armed with all of the data, everyone gets together for the big day: teachers, guidance counselors, school evaluators, administration, and parents. This team hopefully reaches an accord as to the appropriate diagnosis and treatments.

Each country and state has its own set of laws regarding appropriate formal accommodations, and readers are advised to discuss these procedures with their local school program director. Readers in the U.S. can find accurate information about terms such as "504" and "IDEA" at the website of the National Dissemination Center for Children with Disabilities at www.nichcy.org/resources/laws2.htm. North American readers can find local resources at www.ldonline.org.

This book, though, focuses on common sense accommodations. These accommodations are not necessarily "mandated," but can be implemented by an appropriately helpful teacher/school. Many of them would be helpful to all students, not just those with special needs. Common sense accommodations might include educating teachers about the child's diagnosis, checking that the child really understands directions, preferential seating, etc.

Summary

The goal of helping each child to achieve his or her potential requires the cooperation and respect of the parents, teachers, and school administrators. Parents and teachers typically have quite good insight into detecting, over time, that there is some problem. In order to determine which problem(s) exist, the diagnostician depends upon the observations of those people who devote so much of their time to the children. Sorting out the syndrome mix can be difficult, since multiple problems can be born into the same child, can mimic each other, and can worsen each other.