Pay Attention.

Lately, I find myself giving the same speech. It takes me a while to get the language right in explaining difficult concepts about child development, so when I do, I like to make it count and use my new speech whenever possible (apologies to people who attend meetings with me on a regular basis and get to hear me say the same thing). Anyhoo, I think my latest speech/analogy is a fairly decent one, so I will share it with you.

At my school sites, I have been getting a lot of requests for assessment for Attention Deficit Hyperactivity Disorder (ADHD) that sound a little like this: “So and so is inattentive and hyper. Does she have ADHD?” It’s a legitimate question, but it is not an easy answer. As in previous posts, like the one where I went to a Circus School to assess a student for ADHD (true story), ADHD is a complex assessment. Especially if you yourself are distracted by trapeze artists during your “school observation.” But I digress.

My new speech/analogy is:

“Attention is the ‘fatigue’ of the psychology field.”

Here is what I mean by that. I want you to imagine you have fatigue and you go to your doctor and say, “Doc, I have fatigue. Do I have Chronic Fatigue Syndrome?” The doctor (if they are any good, of course) would have to investigate all the potential causes for fatigue before concluding anything. Offhand, (and I’m not that kind of doctor), I can think of about a hojillion reasons for fatigue besides Chronic Fatigue Syndrome: the flu, cancer, pregnancy, working in a school district, depression, hyperthyroidism, hypothyroidism, anemia, seizure disorders, poor sleep…..and it goes on and on. “Fatigue” is a non-specific symptom.

The same is true for attention. Offhand, the “causes” of inattention can be: (um, all medical conditions above), ADHD, difficulties focusing because of a learning disability, anxiety, depression, low IQ, high IQ, autism, social-emotional distraction, situational factors, psychosis…..and it goes on and on. So, when people ask me if I will “test for ADHD”, they are really asking me to test for everything else as well. I enjoy ADHD evaluations. I feel like a detective looking for clues and hitting a bunch of dead ends until I get to the bottom of the inattention symptoms.

That is why it burns my soul just a little bit when I get reports from outside professionals who give one rating scale to the parent, and if it is elevated in attention problems, they get the diagnosis. They don’t interview the teachers, they don’t observe the kid at school, and they don’t rule out the other causes of ADHD-like symptoms. Really, it gives “my people” a bad name to do an incomplete evaluation like that.

Second pet peeve about ADHD evaluations is when a doctor then “prescribes” an IEP or Section 504 plan based on their results, without seeing if the inattention is really having an educational impact that requires special education or accommodations. I have had students with ADHD on the honor roll, earning all As and Bs, and the outside professional recommends an IEP. I always wonder what service they think the kid needs. Then I have a fantasy of calling them up and telling them what psychopharmacological medications to prescribe. Because you know, if they’re going to tell me what to do in my school without knowing what their talking about, surely I can pretend I’m a medical professional and tell them what to do. It’s only fair.

I realize that doctors and outside professionals are only trying to help. But I think that school psychologists are the ones best equipped to assess for ADHD (given they have had training and aren’t super old school psychs who should have retired during the Clinton administration or sooner). In some districts, school psychs are not allowed to assess for ADHD, and in some they are. In some, they do screenings and send the information to a doctor. In my private practice as a clinical psychologist, I do ADHD evaluations all the time. In my role as a school psychologist, it has gone back and forth about whether or not I am allowed to do them, even though I have the training. I feel bad for parents, whose doctor says to go to the school for an evaluation and the school says to go to the doctor. It’s confusing, and then the kids with legitimate issues get bounced between professionals.

I am curious how other school psychologists and districts handle referrals for ADHD. I find that it varies from district to district, school to school, and even by school psychologist comfort level in assessing for ADHD. I would be curious from other school psychologists what your district policy is on how ADHD evaluations are handled in your district. Discuss amongst yourselves...and feel free to try on the fatigue analogy at your next meeting!

Emotes.

Anyone who has been a therapist or counseling with kiddos for a while will appreciate this post. I don't know about y'all, but there are some things in my play therapy kit that I kind of want to throw away because every kid seems to want to play it and I'm so over it (Uno and Connect Four, I'm looking at YOU guys!). I often need play therapy toy "crop rotations" to mix it up. Of course, sand tray is always a classic that never leaves, but sometimes I throw a new dinosaur in there to see if it morphs into the principal or a bully at school. It's a good time.

There are some kids though who don't play with anything in the room or get bored easily with the materials you have. I had such a kiddo a while back. He was a kindergarten kiddo who was referred because of impulsivity and aggression in the classroom. He spent most sessions complaining about my toys and asking why he had to be there. At the same time, I had his middle school equivalent in my office a few hours later. Only instead of aggression in the classroom, he also showed aggression in the community. And would you believe I found a series of toys and activities they BOTH liked???

I think sometimes that boys present an extra challenge when it comes to helping them express the range of feelings they have. They tend to endorse "anger" pretty easily and the other stuff takes a long time to get to. That is, unless you have this fabulous tool called "Emotes".*



I was at a convention and was drawn to these little guys who each represented a different feeling, positive, negative and nuanced. For example, "Boom" is the angry one, "Joi" is the happy one, and "Can't" is the frustrated one. I bought the starter kit and the introduction book to try them out. My boys LOVED them. My kinder poppet wanted to read the story every time, and he loved finding the ones that matched his feelings (he gravitated toward Imp-the mischievous, Boom-the Angry, and Super-the confident). He started drawing them in class spontaneously and would do almost anything for a sticker of one of his guys. He even referenced them in reflecting on his own behavior (e.g. Dr. B, I was like "Hype" today in class and got in trouble) Como se dice AWESOME?

My middle schooler, who was notoriously "too cool for school" ignored their pointy little faces for about 2 weeks, and then finally gave in. He started playing with them and wanted to draw them and go on the website and find coloring pages or more stories about them. I did not see that coming! It gave us a way to talk about the feelings that underlie anger without him feeling like I'm a cliche "How does that make you feeeeeeeel?" counselor. Genius.

So after testing them out on my two toughest customers, I contacted the Emotes peeps and asked for them to send me more goodies so I could start integrating these little guys into the Kinder and 1st grade classes as class-wide feeling vocabulary lessons. Okay fine, I guess I am a "How does that make you feeeeeeeel?" kind of gal after all. I just think this is a more fun way to go about it. Plus, they have the books in Spanish. Holla.

Check out their stuff when you get a chance at www.emotes.com. Oh, and if you're looking at it at work, turn the sound down because it starts off with a jaunty little song and a loud exclamation, "How are you feeling today!" It made me feel like "Jumpi" the first time. But the kids love the website because they have comics and whatnot. Enjoy!


*Note: Not related to the term "Emo". When the term "Emo" first started percolating a few years back in the lexicon of my yoots, it took me a while to figure out what they were referring to. At first, I thought a group of students was calling a girl "Elmo" from Sesame Street, and I couldn't work out what it was about, until I asked. It's very different than Elmo, trust me. When I say Emotes, I also over-enunciate the "-tes" part of the word EmoTES to make sure I am clear. Emo has a bad connotation for kids.