SelfhelpMagazine

by Thomas G. Shafer, MD & Susan V. Shafer, RN, B.S.N.

In part one we discussed the needs for an exact diagnosis of the underlying cause of hyperactive behavior and described true ADHD/ADD and medical problems which produce similar behavior problems. Now on to the Shafer's third Golden Rule of evaluating hyperactive behavior: "Children have brains, examine them."

There are several neurologic conditions which may mimic ADD and/or ADHD. One of the most common is Tourette's syndrome. In Tourette's, the child has multiple motor tics. This means they exhibit sudden movements such a jerks of the body and extremities. And they have vocal tics, where they will typically hum or make coughing noises or animal like sounds. Many of the parents of the children notice the child has a "call", frequently making a chirping, growling or whooping noise.

In extreme cases, you may see what is called coprolalia, which may be politely translated as "potty mouth." A child with coprolalia may blurt out insults, racial slurs or obscenities. This can obviously be hard on the teacher, but their utterances are completely uncontrollable, are often not related to anything that is going on at the moment, and definitely do not reflect the child's real opinion of the person or situation.

A"Clinical Pearl" here is when the teacher complains that the child is constantly talking and interrupting, suspect Tourette's. Also, if the child exhibits a lot of impulsive behavior and "taking dares" he/she may well have the syndrome. Finally, there is the famous Ritalin diagnostic test. A child with Tourette's syndrome who is misdiagnosed and placed an a stimulant such as Ritalin or Cylert will, in the words of the parents, "Go wild."

They will become impossibly overactive and often display totally uncontrollable tics. And, when the dose is raised, they just get worse. This is an especially important fact to remember because prolonged stimulant therapy in these cases may actually do permanent damage, leaving the tics much more severe than before.

Then there are seizure disorders. Now, there is controversy as to whether seizures may cause organized violent behavior but a child in the midst of a seizure may well strike out. More often though, the child has a petit mal seizure where their brain just shuts off for a brief period and they appear to "in another world" or "daydreaming."

And you may not see the classic jerking movements of limbs, tongue biting, and loss of urine or feces in such an epileptic child. Signs of the seizure may be as subtle as a little fluttering of the eyelids. These children do often have headaches after seizures so this may raise your index of suspicion.

The bottom line here is that a detailed neurologic history and examination is mandatory. This may be by a Pediatrician or Psychiatrist who is cross trained in Neurology or a Specialist in Pediatric Neurology. (We've also seen some amazing work done by Psychologists who are trained in Neuropsychological testing.)

And remember that Tourette's children are often embarrassed by their tics and will suppress them in front of the Doctor, so having the child observed in the waiting room surreptitiously by the doctor or office nurse may yield much useful information. And remember also, that an EEG (brain wave test) is perfectly safe and painless and should be done if there is any suspicion of epilepsy.

The Shafer's fourth Golden Rule, "Always ask, can little Johnny hear and see?"

Most schools do vision screening and most teachers notice when your child squints at the board and try the classic "Sit in the Front Row" test, so visual handicaps are not as much of a problem as they used to be. But, a professional eye exam never hurts in any case where a child has apparent learning problems.

Hearing deficits can be less apparent, especially since many children don't realize they have a problem or deliberately mask their problem. But a child who can't understand what is going on around them can get bored and agitated. Throw in a little teasing by classmates and you have aggression too.

And failure to think of hearing problems can sometimes lead to total disasters. I'll give an example from my medical school years. A young lady of 13 had exhibited almost total detachment from her environment and severe aggressive outbursts which had led to her being placed in a state hospital ward for the past four years. Obviously autistic or a case of mental retardation with ADHD, right?

Fortunately, a bright medical student (not me) noticed something peculiar. Every time the stereo was turned on loud, this child would go over and hug the speakers, placing an ear against them.

A quick test and two hearing aids later and she was found to be a child of near normal intelligence who quickly ceased her violent behavior as she learned how to communicate her needs. I heard later that she eventually did well, but it took years of outpatient therapy with her and her family to reverse the effect of four years of unneeded institutionalization.

This leads to the next Golden Question, "Can little Johnny learn?" Children with learning disabilities quickly get frustrated. A frustrated child gets inattentive and overactive. See the problem?

Now, neither of us claims to be an Educational Psychologist, so we can't discuss learning disabilities in detail. But be aware of the First Rule, "All that wiggles is not hyperactive" and insist on detailed testing by a pro. Can't afford it? No problem. By current Federal Law, schools are required to provide such testing at their expense. But be prepared to stick up for your kid's rights on this one.

This ends Part 2. In Part 3, the final section, we discuss other psychiatric conditions which produce hyperactive behavior and our recommendations for making sure your child or client gets a complete evaluation and accurate diagnosis.

Back to Part 1

About the Authors:

The Shafers are both graduates of the University of Virginia and have worked with childhood hyperactivity syndromes as both professionals and parents.