I'm concerned about my 7 year old son, James, and wonder if you could help. His most recent report card stated that promotion to third grade was in doubt. Since he constantly brought home failed tests, I wasn't too surprised, but still shocked into action. I met with the teachers and principal and requested a complete learning evaluation by the school system. Part of me felt like this was over-reaction, but mostly I felt desperate to help him. The teachers' only comment has remained that he doesn't pay attention. I heard this in kindergarten, first grade, and now in second grade. This is the first year that he failed many of the tests. I thought it was a reading problem and enrolled him in a private phonics class at a learning center. It has helped him and he loves it there, but the ratio is 2/1 instead of 30/1 like his public school. James' first grade teacher thought he should see a psychologist. I finally did that for him this fall and I can't tell any difference in his behavior or performance. His psychologist didn't do any tests or surveys until I threatened to stop coming. The teacher's response to my son's classroom behavior again was lack of attention. She rated him moderate to high in the "hyperactivity" and "attention" areas on the survey. I thought that if James did have ADD the psychologist would diagnose him, but he hasn't, and doesn't make any suggestions, except how to talk to James. What I have read about ADD seems to suggest that a lot of children are misdiagnosed or that it is overly diagnosed. At first I was skeptical about the stimulants that are prescribed for ADHD, but now I'm wondering if it might help James to concentrate and so perform better in school and feel better about himself. When the psychologist didn't diagnose, I began to think maybe James had a learning problem that we had overlooked. He sometimes reads letters backwards, like "was" and "saw," and confuses "d" and "b." When I help him study for spelling and vocabulary tests, he seems to know them well, but frequently fails the tests anyway. I don't know what is going wrong. My questions are related to diagnosing for ADD. How and who should do it? The stigma of having learning problems and being taken out of the general classes worries me. How can I check to see if the people administering the tests on James are certified and not just classifying him to entitle the school to more government funds. I am concerned about James' nightmares and sleepwalking too. The odd thing is that James' personality is very social and fun loving. I believe he is smart too, but somehow it's not showing in his tests. My gut reaction is he is bored in class, but I don't know how to approach that one since he's failing. I almost feel like giving up and letting him repeat second grade, but I don't know that that is the answer either. I don't know what else to ask or do. I feel like I am at the mercy of the school and that's scary because I don't trust them. Thank you for listening. New York Mom Dear New York Mom: You've asked some pretty big questions: how to diagnose ADD, and, by implication, how to select a psychologist for your child. Neither of us has time for me to write a book in reply just now, so I'll try to be concise. I can't offer a second opinion in a case when I haven't made an examination, but I can tell you how I would approach a referral of a child with James' presenting problems and history, and maybe that will help. First, I would do a fairly comprehensive evaluation, including a battery of tests of "intelligence " (misnamed, but useful), memory, learning, perception, and academic functioning, including reading as decoding (sounding out words), reading as comprehension (including reading silently vs. orally), expressive and receptive language (ability to speak and comprehend speech), writing, math, etc. In the process, I would interview him, you (also looking at the family genetic history, as much as possible), one or more of his teachers, and anyone else who might be able to provide helpful information. I'd plan to observe him in school, possibly more than once. From that, I'd develop a report detailing the test results, my observations and impressions of James, and include diagnostic impressions and specific educational and other recommendations, as appropriate. Presumably, there would be one or more meetings at school in which I would review my findings with James' teachers and other appropriate personnel, which you would also attend. All that would take, on average, somewhere between 10 and 20 hours to do, depending on the complexity of the case. Assuming that there were diagnostic findings with educational recommendations, the school would then have to decide whether to try to implement some or all of the recommendations. If they tried, I might be on call to help out now and then, maybe to solve problems or fine-tune or modify the educational program. It might be helpful for James to have a private qualified learning disabilities tutor after school. I try to form a positive educational partnership among the parents, teachers, tutors, and child, whenever possible. But, if the school couldn't or wouldn't implement the recommendations, especially the most important ones, you'd have to decide whether to try to compel the school to implement them through a series of administrative hearings (for which you might need an attorney, and for which you might or might not be reimbursed, although I have known cases where parents who have won hearings have been reimbursed by the school systems for their legal expenses). Or, you might decide to transfer James to a private school that could provide him with a program closer to the kind of educational experiences he needs in order to learn. It would not make sense to me to see a child having academic problems for psychotherapy without having an evaluation; that would be like trying to fix a problem when you don't understand what it is. If the child's problems are due to a learning disability (and there can be many different kinds of learning disabilities, some looking very similar to ADD/ADHD), then remediation is called for, but it has to be specific to the problem. If he has an attention deficit disorder (and there are different kinds of attention disorders too), then appropriate interventions might include behavioral training for him, parenting training for you, developing a behavioral program for his teachers to apply with him, and medication. Even here, the type of medication could vary depending on the kind of attention problem and overall personality he seems to have; some children do better on stimulants, others on SSRI's or even the older tricyclic antidepressants. Finding a physician who would be willing to dose carefully, starting low and working up to the minimum effective dose, and monitor carefully thereafter--not just give you two months' dose and tell you to come back then--would be important. If James' problems were primarily due to anxiety or depression in reaction to the problems and events in his life, psychotherapy would be indicated, and medication might be considered, depending on how severely his emotional problems were affecting him and how well he responded to psychotherapy. Neuropsychological findings in his evaluation might indicate that further testing, such as EEG evaluation, would be appropriate. A word about selecting a psychologist: People are people, and psychologists, like physicians, auto mechanics, and every other category of worker, vary in quality and competence (see my earlier column on "Selecting a Therapist"). Another parent with a child with similar problems who has been helped by a psychologist might be a good referral source, and so might a teacher who seems to know, like and understand James. A word about school-based testing. Some of it is very good indeed, but much of it is not, because the staff are overstretched and have to concentrate on the more obviously disabled kids, so the more subtly disabled ones are often ignored. Some school systems, or smaller districts within larger systems, have decided to really concentrate on kids with learning problems, while others ignore all but the most severely impaired. It makes sense to have the school initiate testing, as they are legally required to do. But if the results don't explain the problem, you may just have to go outside to a private psychologist. Again, get a good referral before plunking down your money. Finally, a word about schools and kids. Obviously, some children thrive, or at least do o.k., in public schools, but others don't. Sometimes a smaller private school can provide an environment in which a child who can't succeed in a public school can find a niche that works better for him. So, it seems to me that the evaluation should come first, and the other possible steps--remediation, psychotherapy, decisions about trying medication or another school, or additional more specialized evaluation--should stem from that. I hope that helps. |