Question (Q) from Karen Schiltz Ph.D.: "Tell me about your experience with Ella when you knew in your ‘gut' that something was ‘not quite right.'"
Lynn: "The signs were there. I knew that something was ‘not quite right.' One day I looked at my daughter and thought that things were just getting worse. She has always been forgetful. Her teachers also commented that she zoned out in class. Some of these things were not so obvious when she was young and in preschool. The teachers in kindergarten were very supportive and told me that Ella would probably grow out of it. My pediatrician told me the same thing. I was actually relieved when I heard these comments. As time went on, she had difficulty starting and completing her homework. I also wondered whether Ella was stressed. She was in a car accident a year ago when another car drove through a red light at an intersection. Ella was in the hospital for one day and was disoriented. She had headaches and was very tired for about four weeks after the accident. She got a ‘clean bill of health' after that. I'm wondering whether the accident affected her attention or if she always had the problems with attention before the accident. Ella is now 9 years old."
Q from Dr. S: "Studies have indicated that boys are diagnosed with an Attention-Deficit/Hyperactivity Disorder (ADHD) three to four times as often as girls by the time they reach school age. Some researchers have suggested that the diagnosis of ADHD is more complex in girls because of its late age of onset and more subtle clinical signs such as inattention as compared to boys. In addition, a recent study by Erica Coles and her colleagues indicated that teachers notice a child when their behaviors are greatly impairing them in the classroom compared to the number of symptoms that the child is actually exhibiting. They also noted that teachers are less likely to recognize children who exhibit inattentive behaviors compared to those who are markedly restless and impulsive. What is even more distressing is that girls with ADHD may go unrecognized and untreated. (1-4) I realize you did not stop your search and you were likely uncomfortable after seeing Ella's behaviors continue. What was your next step after you realized there might be a problem?"
Lynn: "I had a long talk with my partner. I decided to see our pediatrician again. I insisted on a physical, blood work, vision and hearing screenings. I also told the doctor there were continuing problems with Ella's attention and memory. She had trouble remembering math operations and concepts in science."
Q from Dr. S: "What did the pediatrician say?"
Lynn: "The doctor told me her physical, blood results, vision, and hearing tests were fine. There wasn't anything there that would have caused alarm. The doctor then told me I should have Ella tested by a neuropsychologist. She was wondering whether Ella had attention problems before the accident and to what extent her concussion was increasing her trouble with focusing on her work and chores at home. The teachers also expressed some additional concerns in November during the parent-teacher conference."
Q from Dr. S: "What were they specifically mentioning to you?"
Lynn: "The teachers thought she'd grow out of it again but they were still concerned. They told me Ella had trouble focusing in class, misplaced materials she needed for her work, but was not hyper. I also noticed these behaviors were occurring at home and during play dates. The teachers mentioned they enjoyed Ella in their classes but Ella seemed to require more prompting and redirection compared to other kids. They also told me she was not performing at her potential in the classroom. That really concerned me."
Q from Dr. S: "What prompted you to call for an assessment even though the teachers were not really concerned?"
Lynn: "I knew something was ‘not quite right.' Ella needed a lot of redirection and was not able to start and complete her homework unless I sat down with her. Also, she was not aware of time."
Comment from Dr. S: "You are bringing up an important point. You were gathering information from different people in your life such as your partner, friends, pediatrician, and teachers. You saw that your daughter's behaviors were not only present at school but also at home and when Ella interacted with her peers. An article by Amori Yee Mikami discusses the importance of early intervention in those youths with ADHD. (5) He also suggests that research provides initial support that children with ADHD are compromised in friendship skills. In addition, research has proposed that girls with ADHD experience as many problems in peer relationships and maybe more compared to boys with ADHD. The research helps us understand the importance of early intervention and the need to examine a child's specific challenges given their age and gender. (5-8) In your daughter's case, it is important to identify what is underlying her challenges so she can be helped. I'd like to ask you questions next month about your next move as you ‘chart' your course. Thank you."
Dr. S's additional comments:
• You are probably thinking the flags should be obvious. However, they may not be recognizable by you. In fact, the "flags " may be flying (see October 2011 blog) and parents (me included) might turn their head away (not intentionally). Problems involving attention and concentration, memory, and social difficulties may not be visible when our child is young or in certain classes. These difficulties may not even be apparent when a child has suffered from a head injury, carbon monoxide poisoning, or even reading and math disabilities in certain situations.
• The parents who have done their research have nothing to risk and so much to gain. Your first stop should be with your pediatrician if you suspect something is "not quite right." Check out if any problems are occurring with your child's overall physical health.
• Problems with vision and hearing may be affecting your child's attention, concentration, thinking, and emotions. Medical conditions can masquerade as learning and psychological disorders. (9) For example, children who have suffered from acute carbon monoxide poisoning may have problems with attention and concentration, memory, as well as flu-like symptoms. If the medical diagnosis is missed, these children could be undergoing interventions that are unnecessary and expensive.
• Subtle problems with attention such as inattention often go unrecognized. It is critical teachers identify and refer children who are inattentive for evaluation. It is also crucial these children be identified, as they will be under pressure as the demands in the classroom increase.
• Finding out the culprits underlying a child's challenges may involve assessments from different healthcare providers. Clarifying the issues and many times, a diagnosis, is typically a relief to parents. By doing this, specific interventions can then be targeted at the earliest opportunity in a timely and well thought out manner. (9)
I will be talking about the role of assessment next month. Have a wonderful holiday season and thank you for following this blog!
Karen L. Schiltz, Ph.D.
Psychologist (CA PSY 9508)
Private Neuropsychology Practice of Karen Schiltz Ph.D. and Associates
Associate Clinical Professor (Voluntary)
Medical Psychology Assessment Center
Semel Institute for Neuroscience and Human Behavior
Department of Psychiatry and Biobehavioral Sciences
David Geffen School of Medicine at UCLA
1. Pastor, P.N., & Reuben, C.A. (2008). Diagnosed attention hyperactivity disorder and learning disability: United States, 2004-2006. National Center for Health Statistics. Vital Health Statistics, 10 (237).
2. Keltner, N.L., & Taylor, E.W. (2002). Messy purse girls: Adult females and ADHD. Perspectives on Psychiatric Care, 38, 69-72.
3. Coles, E.K., Slavec, J., Bernstein, M., & Baroni, E. (2010). Exploring the gender gap in referrals for children with ADHD and other disruptive behavior disorders. Journal of Attention Disorders. Advance online publication. doi:10. 1177/1087054710381481.
5. Mikami, A.Y. (2010). The importance of friendship for youth with attention-deficit/hyperactivity disorder. Clinical Child and Family Psychology Review. 13, 181-198.
6. Ohan, J.L., & Johnston, C. (2007). What is the social impact of ADHD in girls? A multi-method assessment. Journal of Abnormal Child Psychology, 35, 239-250.
7. O'Brien, J.W., Dowell, L.R., Mostofsky, S.H., Denckla, M.B., & Mahone, E.M. (2010). Neuropsychological profile of executive function in girls with attention-deficit/hyperactivity disorder. Archives of Clinical Neuropsychology, 25, 656-670.
8. Rucklidge, J.J. (2010). Gender differences in attention-deficit/hyperactivity disorder. Psychiatric Clinics of North America, 33, 357-373.
9. Schiltz, K.L., Schonfeld, A.M., & Niendam, T.A. (2012). Beyond the label: A guide to unlocking a child's educational potential. New York: Oxford University Press.