Gifted Issues Discussion homepage Forums Twice Exceptional ADHD inattentive type?

This Spring we started IQ and achievement testing for DD9 and all those tests led us to today's appointment where the latest psychologist claimed that our DD has ADHD inattentive type. I would like to hear some thoughts and advice. I will put out what we know so far. Sorry for the length of post.

-DD: incredibly disorganized, cannot do multi-step tasks unless you write down the items, and she checks them off. She knows that she has “forgetfulness” which has caused her to believe that she is “stupid”. On the other hand she can focus for hours at a time on drawing and writing. When I read to her and DD10 at night, she has to do something else at the same time (Rainbow Looms or drawing). Teacher has noticed the same things (and has been sooooo patient). DD never gets in trouble at school, is a model student, just wiggly and forgets homework ALL the time. Her handwriting is atrocious unless she really focuses. Let me say again, DD thinks that she is not smart because she can’t remember anything. She will tell me that I am lying if I say that I told her four times to go brush her teeth. I can put my face right in front of hers, and she still will forget what I have said.

-Grades all 4s, 99% on all school achievement tests except the state one for some reason. She whizzes through tests and on the state test made careless errors. She will be AIG next year (4th grade) and receive Single Subject Acceleration in math. Her reading scores have her reading at a 9th grade level. Psychologist says that grade school is going well because DD’s cognitive skills are pulling her along. Psych. says it’s going to get really tough in middle school when she will be expected to be self organized and turn things in in a timely manner – executive functioning problems.

-Emotionally – this is really bringing her down. I had mentioned in an earlier post that she was having troubles, and this seems to be a big part of it. She can’t align the fact that she’s supposed to have such a “fast brain” according to the IQ tester when she can’t even remember to take her socks off when she steps into the shower!!! She is very angry as well.

-WISC scores – will be glad to post if you need them. Working Memory is lower than everything else. She did best on Perceptual Reasoning. WJ – way lower than WISC would indicate. Tester was concerned by this which is why we went to the psych. who gave the ADHD diagnosis.

504 – will be making a call for a 504 as soon as school starts back up again in the Fall.

Questions:
ADHD seem like a good call?
Need additional testing?
Meds – our child can’t get to sleep already and is very thin so we are very hesitant to use ADHD meds (we work in mental health and know a lot of the side effects of ADHD meds). BUT, we are open to hearing about those who have.
Behavioral interventions? Good websites? We are going with behavioral work first with the psych.
Is there a question that I am failing to ask?
Finally – just tell me that we are suddenly going to become filled with more patience now that we know she has ADHD because this child tests us!!!! I just pray for the time that I can ask her to feed the fish, and it will happen........

couple things came to mind reading your post.

--does she have issues with motor skills or look klutzy? If so, look at developmental coordination disorder on Wikipedia. Those with DCD often have working memory issues (the kind where you are disorganized and have problems with steps or sequences). The reason I ask is because you said her handwriting is a mess (which is common with ADHD, I think, but something like half of people with ADHD also have DCD).

--DD has ADHD and they are working on this stuff (executive functioning ability) in occupational therapy. If her writing is poor you could look at OT for that as well. Sounds like you are working with a psych and I'm not sure what the pros and cons are of going w/ a psych vs. an OT

--in terms of meds, DS's first grade teacher mentioned that she thinks he has ADHD--inattentive type. He looks very spacey at school (but he is the opposite and DOES NOT like writing, and half of what they do there involves writing. So it's hard for me to figure out if it's really ADHD, or executive functioning issues due to his DCD, or a learning disability like dysgraphia). I know how much meds help my other kid so we did a trial of ritalin (a low dose) with DS and the teacher said that it looked like a huge difference in the few days she was able to observe. It might be worth it to talk to the doctor about doing a trial, and see how much of a difference there is, and if there is a big difference, whether it's worth it to deal with the possible side effects. I didn't notice any side effects with DS, at least on that low dose.

How did she do with processing speed on the WISC? Coding was the lowest score with both of my kids on the WISC. DD actually has a good working memory on the WISC (at least when medicated)...it's in the 96th percentile. DS had a huge gap between perceptual reasoning in the 140's and everything else in the 110-120 range.

I'm glad you are getting answers. It seems you are well on your way to solving the puzzle. A child may feel frustrated/angry when they may be missing things which are going on around them if this causes them to feel they can't keep up or are somehow left out.

This may seem simplistic, but here are three ideas:

1) When asking her to brush her teeth or feed the fish, have you tried adding an element of body language? Also have you used her name at the beginning of speaking to her, and tried asking her to repeat back to you what she will be doing? Have you tried singing the to-do items? These strategies may help engage other parts of her brain which may help her compensate. This may help her create mental check-lists.

For example, using any melody such as walking up the scales, or twinkle twinkle little star: "(name), time to go and brush your pretty teeth!" Mime toothbrushing. Singing: "Tell me what you're going to do now."

Singing: "(name), time to go and feed our hungry fish!" Mime sprinkling food flakes. "Tell me what you're going to do now."

She may learn to sing or hum to herself to keep focused on a task and stay on track to completion. This may help her screen out other thoughts which may compete for her attention.

2) Another idea may be to gently ask her what she is thinking about, if you see she is drifting or has a far away look in her eyes. This may help her develop an awareness of her thoughts, possibly a step to controlling those thoughts and setting them aside to attend to matters of interacting with other people and completing to-do items such as turning in homework.

3) Because you mentioned she likes to write and draw, might she be interested to write and draw stories of her successes and foibles? This may help raise her awareness and also her ability to laugh at and accept the funny things like showering with socks on (my guess is that her feet felt cold to her and therefore already seemed to not have socks on). This may tie into asking her what she was thinking, not in a judgmental or disappointed way, but in a way that indicates there must've been a good reason, and encouraging her to take time and reflect on what she was doing (re-enactment can help with this, stepping through each action with her and seeing what she did and what her thoughts were at the time). Being able to successfully self-reflect and report may be helpful. Writing and illustrating her own book, possibly with thought bubbles, may be one way to do this.

Best wishes to you and this precious child.

ADHD is not "lack of attention," it is "inability to regulate attention." That intense focus can be as much of a problem as the lack of focus, depending on context.


Our ADHD-i family member always has something in his hand.


At home and school, she needs to be set up for success. Self-esteem is a major issue with kids like this, who are made to feel stupid when they are not.


Yep. I'd work on it now. And the self-esteem issue also cues working on it now.


Consider writing the letter to request it now, so that the process can start faster. Not a call, a letter.


Reasonable.


Not at this point.


For this you'd need a specialist, but there are real alternatives that do not (typically) affect weight or sleep. Strattera and Intuniv are two.


You can teach sequencing and organization as skills. We have found that our child has done best with meds plus behavioral interventions. The meds make it possible to learn and practice the skills successfully.


I wish you patience.

We have devised strategies. We have cues we repeat for personal hygiene or repeated tasks. ("Go do your teeth face hair. What are you supposed to do?" "My teeth face hair." [gets distracted] "What are you doing?" "Oh! my teeth face hair.")

Or you can give a "first next last" instruction, and have her repeat the steps back to you.

Our biggest win, honestly, was the meds, plus addressing issues at school (checklist on desk, checklist in locker, with teacher prompts to use those lists). Name labels in everything, so that lost items can usually be found. We talk a lot about time, since people with ADHD often have nearly no innate concept of time. We make sure to put our child into situations where he feels lovable and capable.

It's doable, and things will improve...

Even though your anecdata is probably more valuable than the drug manufacturers warnings, it doesn't hurt to have more than one source...

From Strattera site:
"What are the common possible side effects of Strattera?

Common side effects in children and teenagers include upset stomach, decreased appetite, nausea or vomiting, dizziness, tiredness, and mood swings."

From Intuniv site:
"The most common side effects of INTUNIV include sleepiness, tiredness, trouble sleeping, low blood pressure, nausea, stomach pain, and dizziness"

Everything that was said above is really excellent advice. I have very little to add.

I will just note that there have been some fMRI studies of ADHD young adults who had been medicated, comparing their brains to non-identified young adults and and non-medicated ADHD young adults, which find that those who have been consistently medicated through adolescence "normalize" compared to those who have not. (Or some have called it maturing, compared to those who were not medicated.) Personally, I think it likely that what is actually happening is that medication allows children to attend to the internal and external cues and feedback that naturally-reinforce the development of executive functions, which then operates on brain development during this plastic stage. If one can provide this without medication, I would suspect that the same brain maturation/development would take place.

I always think of psychotropic medication as scaffolding. A person who is deeply depressed or anxious cannot access the best cognitive-behavioral therapy. A severely attentionally dysregulated child might need the same kind of psychopharmacological scaffolding to access social skills and organizational training. The objective should be to gradually wean the scaffolding as skills and coping strategies improve.

I'm not an MD, so this is of course just based on my anecdotal experiences and personal opinions.

I don't remember, so can you remind us again - was the focus on testing initially due to obvious signs of needing more advanced work, or due to concerns about behaviors or other issues and learning she was gifted was an unexpected surprise?


I wouldn't put too much weight into this one behavior - all three of my kids do this, all three have wildly divergent personalities, none are genetically related, and none of them have ADHD diagnoses, and all of them remember every detail of what is read to them.


I don't have direct experience with ADHD, but my ds who has Developmental Coordination Disorder was *incredibly* disorganized when he was your dd's age (and beyond). His completed homework was constantly disappearing into the ether at school in spite of me verifying it was in his backpack when he hopped out of the car at school and in spite of his teachers having very easy-to-follow systems for returning homework and having reminders in place. What helped our ds with organizational skills was providing him with a lot of structure, daily oversight, and repeating repeating repeating until he was ready to do it on his own. It took about two years, but it really did work. You can provide the structure and oversight in different ways (school can help, you can help as a parent, you can hire help)... but the key is to just keep in mind that being organized is a skill and not all children develop the ability easily and at the same time that it is expected in school. School supports that helped our ds were teachers who were very repetitive in the types of assignments that they asked for - for example, a math teacher who assigned homework every night, and expected it to be returned in exactly the same place at the start of class each day. Social studies was more difficult because the assignments were more randomly assigned with varying due dates - but starting with little successes such as the math work helped ds realize that he was capable of being organized, which helped him stick with it until the rest came more "naturally". Our ds' school didn't give him enough intense support to help with this type of EF, but I'd read about another parent who hired a college student to pick her child up at school at the end of each day and go through his daily homework assignments for each class to make sure he had them written down, make sure he had the books he needed to complete them etc. I didn't hire a tutor but did this same thing for my ds essentially - I met him after school, reviewed what happened that day in each class and what his homework assignments were, made sure he had his books, did a locker check with him etc. He didn't like it, but I told him that it wasn't a choice - we were going to do this until he was successfully turning in all his homework, and then we could negotiate the daily checks. After a few weeks of that type of oversight, ds saw that it was actually really helpful. We kept at it for all of 6th grade and the beginning of 7th, when ds felt like he was ready to take on the responsibility himself and I pulled back to once-a-week checks and after a few more months was able to stop the checks completely (although we still review what happened in class each day and what his homework assignments are each day - but now it's more the type of "what's up" discussion and "how do I need to plan to be sure I don't infringe on the time you need for homework tonight" rather than me helping him figure out how to stay organized.

This may all sound a bit simple, but I think it's important to just realize - my other kids didn't need this type of support. The organizational skills they needed developed naturally as they were expected of them in school each year. For ds, it was a huge gap and it required a *lot* of repeating and structure - but it also was the type of skill that can be learned with repetition and structure.


I am not questioning her ADHD diagnosis, but also wouldn't necessarily use this as a data point *for* diagnosing ADHD. I paid a lot of attention to handwriting when my ds was younger because he was dysgraphic, and I also spent a lot of time in class as a volunteer during writing workshop. I saw a *lot* of kids in elementary school who would rush through writing assignments and their handwriting looked horrid when they rushed, but looked great when they took the time to focus on it - which they usually did during the type of class assignment where they were supposed to be producing neat handwriting, but not during group projects or during writing workshops where they were focused on creating stories etc. That was one of the most difficult things we had to advocate through as the parent of a dysgraphic child - teachers would point out constantly that the "messy" handwriting my ds had was not all that different looking from most of the other kids' in class when they didn't focus on neatness.


This makes me wonder if it's all about ADHD. Was the psych that you saw recently a neuropsych or educational psychologist, or a psych who specifically diagnoses ADHD? The reason I ask is there are different types of memory, and if the primary diagnostic tool that you've had to assess memory is the WISC, it's jmo but the WISC seems (to me, just a parent, not a professional) - to have limited diagnostic value re some types of memory challenges. One of my dds has a relatively severe challenge with associative memory and it doesn't show up at all on her WISC profile, but instead shows clearly on the WJ-III Test of Cognitive Abilities and on other types of testing. Please note - I'm *not* recommending you seek other types of testing, just curious if the eval your dd had was a comprehensive neuropsych type eval, or a psych looking at "does she or doesn't she" have ADHD. The reason for the curiosity is that symptoms overlap between ADHD and various other challenges. My dd who has the associative memory challenge doesn't do exactly what you've mentioned above, but has similar types of odd can't remember things that seem obvious behaviors.


I wouldn't put too much weight on one anomalous test score - unless she repeatedly scored lower on the state testing year after year. Anything might have happened on any one day that would make one test invalid. Instead I'd look at all the repeated scores she has through the years and take those as meaningful.


I wouldn't panic over this - for two reasons. You have forewarning that there may be a challenge for your dd re this, so you can start putting supports in place now and start helping her develop the skills now. The second reason - this may not be the same in your schools, but we found in our schools that most 5th/6th grade classes had a lot of built-in organizational supports simply because the teachers were teaching *all* the students how to be organized as they prepped for middle and high school organizational demands. It wasn't enough for a child with an organizational challenge in and of itself, but it was also much more structured re organization than you might expect and it was helpful.


One thing that has helped my 2e children is to talk about how we all have *different* strengths and different challenges. Also give her details about the nitty-gritty of specific types of skills - I'm guessing the "fast brain" the tester referred to is Processing Speed? If that's it, explain what Processing Speed really measures, and what brain skills are needed for remembering to take socks of when you step into the shower - they are basically two entirely different things. Humor also helps - leaving socks on when getting into the shower is the type of thing my ds with DCD does a lot of, and for him it's related to his DCD. It can be frustrating, but these are also the types of things we can choose to laugh at. The world isn't going to fall apart if a pair of socks gets wet. The world might *feel* likes it's falling apart when our kids feel different among peers due to their challenges - and that's something that isn't funny - but having a bit of a sense of humor about these things where it doesn't mock or cause harm does seem to help develop a sense of resiliency and "it's not all about (whatever)" in our kids which in turn helps with self-confidence and helps with taking their focus off what they can't do as well as others.



Do you have a sense of what specifically she is angry about or angry at? Is it the actual challenges she has or is it the attention being paid to them at the moment? Is it school, is it home, is it academic challenges, is it just being different - is it being different than peers, than siblings, etc?


I think that sounds fairly typical for an ADHD WISC profile - but my question would be how much lower? Greater than 1.5 SD or less? Our ds has a gap in WM on his first WISC also (given at 8 years old), and his neuropsych had no concerns about it - she explained WM as something that is more "on/off" than the other types of abilities measured on the WISC, and also that it is the one area of the WISC that she sees scores increase on as some children mature. When ds was re-tested on the WISC three years later, his WM score had gone up considerably without any specific interventions.


While it might be ADHD, this type of gap between WISC and WJ-III can also indicate LDs or other types of challenges. Was there any type of testing given by the second psych other than ADHD-specific tests/surveys? Was there any pattern to the type of differences in scores on the WJ-III - were some high and some low, or were all the subtest scores lower than expected? How much lower than her ability scores?


ITA with DeeDee on this - don't wait for fall, make a written request now.


I found with my kids that the more I learned about their specific learning challenges, the more it helped me have patience. I'm not a patient person! But understanding them better absolutely helped with it Re feeding the fish, make it as simple and as one-step as possible. Or make that chore someone else's responsibility and give her a different responsibility that is simple, one-step and that she can handle with reminders. Don't expect her to do things without some type of reminder - just add that "reminder" or support in as part of the task (from your perspective). When she's got the one-step task down and is taking care of it independently, add in a second step etc. Stepping stones essentially

Hang in there,

polarbear

polarbear has already given you a lot of great information. I'll just throw out an excellent reference work on ADHD and executive functions:

Peg Dawson's "Smart but Scattered". She has a few other works on executive function which are equally informative, if somewhat more technical.

http://www.smartbutscatteredkids.com/

From Black Cat: does she have issues with motor skills?

- No, she is doing well there. Her fine motor skills are fantastic when she is drawing (strong skill). I asked about this since her writing is so bad, and the psych. said this isn't unusual. I just got back all her homework for the whole year, and I found that actually a lot of her handwriting wasn't so bad. It's just her journaling and such that is terrible. It seems situational.

.
From Indigo:
When asking her to brush her teeth or feed the fish, have you tried adding an element of body language? Also have you used her name at the beginning of speaking to her, and tried asking her to repeat back to you what she will be doing? Have you tried singing the to-do items? These strategies may help engage other parts of her brain which may help her compensate. This may help her create mental check-lists.

-All good ideas. I have to frame them so they don’t come across as “baby ideas” to her. She seems defensive about some of my ideas. I told her about how in art school we all had ridiculous ways we remembered facts about artists, and she thought that was not helpful at all. We have tried singing spelling words (which really helps me and the other DD!!), and this one doesn’t always like it. I bet if I get a book about it, it will come across more “professional” vs. a mommy idea!!!

Indigo: Writing and illustrating her own book, possibly with thought bubbles.
- Great idea! She’s a huge writer!!!

DeeDee/Zen Scanner/aeh
You can teach sequencing and organization as skills. Our biggest win, honestly, was the meds, plus addressing issues at school.

- I can’t wait for the psych. to start giving us some tools to use with DD. And I will be sending a letter to the school ASAP for the 504. The school is good about jumping on those 504’s and putting them in place. As I said above, we will see about meds. I have seen them do fantastic things for some kids!!
________________________________________
Polar Bear: was the focus on testing initially due to obvious signs of needing more advanced work, or due to concerns about behaviors or other issues and learning she was gifted was an unexpected surprise?

- Obvious signs for needing advanced work (and grandmum is an AIG teacher so she had been pushing for it too)

Polar Bear: What helped our ds with organizational skills was providing him with a lot of structure, daily oversight, and repeating repeating repeating until he was ready to do it on his own. It took about two years.

- Reading your method is very helpful. My other DD’s middle name is “organization” so I have been very hands off about homework plus other things are going on that have made it rather crazy around her. It sounds like DH and I will need to become more organized ourselves to help DD.

Polar Bear: This makes me wonder if it's all about ADHD. Was the psych that you saw recently a neuropsych or educational psychologist, or a psych who specifically diagnoses ADHD?

- Well, my husband wonders as well. As stated above he’s leery of this label. And I did look at more of her handwriting, and it’s not all horrible as what I had seen at home.
- The psych. gave the teacher, my husband, and I some survey that screens for ADHD issues, and that is how she made her determination. She was not concerned by the lower scores on the WJ Achievement as the previous tester was. My husband is adamant that DD not get any more testing at the moment. DD is adamant that she not do any more testing at the moment!!
- She was just a general psychologist. As I stated above, she saw my daughter once, me once, then gave me, my husband, and the teacher a survey (I wish I remember which one), and then met with my husband and I to discuss her findings.

Polar Bear:develop a sense of resiliency

- I think this will be the major work of the therapist!!!!!!!!!!!!!!!!!!!

Polar Bear: Do you have a sense of what specifically she is angry about or angry at? Is it the actual challenges she has or is it the attention being paid to them at the moment? Is it school, is it home, is it academic challenges, is it just being different - is it being different than peers, than siblings, etc.?

.

AEH – will be checking out the book!

If she is speeding through things, that may be more along the lines of combined-type ADHD or hyperactive-impulsive, than inattentive. With both of my kids (one combined type and one is maybe inattentive type--I'm not sure yet if he really has ADHD), the main issue seems to be focus, which includes schoolwork. So they come across as doing things slowly and have work piling up. If a child is getting the work done and is fast, then I would guess ADHD is not an issue unless it's the hyperactive-impulsive type. But I'm not an expert, this is just based on my own observations. I'm not clear from your posts whether she is able to focus on schoolwork, and if she can is it just for a limited amount of time and then she starts to zone out or get distracted, at least with things that don't interest her much? If she really loves writing, she may be able to focus on it well, just like my DD is able to focus on reading for long periods of time (but when I read to her, she does tend to wiggle or actually get up and pace around--she'll look like she's not paying attention even if she is).

Hi Blackcat.
Big concerns - she does speed through work at school. She cannot follow multistep directions to save her life (never).Trying to get her ready for school, church, etc. is a nightmare as she always forgets what you asked her to do. She is the kid who loses everything and anything.
Not a concern - If she is interested she can hyper focus for hours. She usually can do well at school if she has a patient teacher (last 2 years she has).
You had asked about her scores. What were your thoughts about them?
I will need to check out "combined type ADHD". I don't know anything about that.

combined type is basically where a kid has characteristics of both hyperactivity/impulsivity PLUS a lack of focus or attention and they are both major issues. Whereas some kids are mostly hyper or impulsive but don't have major issues with focus, and some kids are mainly inattentive and don't have any problems with hyperactivity or impulsivity. When DD is not medicated her voice is 5 times louder than normal, and her body seems to be in constant motion (unless she's doing something that really interests her, like reading a book or playing computer games). I was late giving her her medication today and I took her to the store, and she started running down the aisles a few times like a toddler and was constantly touching and poking her brother. If your DD is not hyper and is able to focus fairly well even on things she doesn't really enjoy (like a boring math worksheet at school, for example), then she probably doesn't have ADHD. My DS seems fine at home but when I watched him at school he looked like a space cadet and the teacher said the work is piling up. So I'm not sure what it means if he seems overall Ok at home (but of course, it's not like I'm having him do a ton of work here either).

My DD is the opposite of yours in that she has slow processing speed and is slow at school but her working memory is very good. She has combined type. DS is also slow but I'm not sure about working memory. He can memorize math facts fine but DD has a major problem with them (despite her good working memory on the WISC).

It sounds like your DD has executive functioning issues, but that is not always ADHD. I am really disorganized as well, and forget what I'm doing. Just a few hours ago I headed for the car because I knew I had to get something out of the trunk, but on the way there something distracted me and I forgot about the car. This happens all day long. But I don't think I have ADHD and I doubt medication would help me at all.