Nico: labelled with Attention Deficit Disorder (ADD)

Nico is a 10 year old boy. He is quiet but has a wide smile that lights up his freckled face. He enjoys reading and computer games but also plays cricket and he swims. Other favourite pastimes include wrestling and playing imaginary games with his younger brother. Nico was born with a clubfoot but no intellectual impairments. An IQ test given during Grade 1 showed a superior intelligence.

In spite of this, he has not thrived in formal schooling. His Grade 1 teacher reported that he was not completing tasks and showed concentration problems and a lack of interest in schoolwork. She suggested that he may be suffering from attention deficit disorder as he tends to fidget quite a bit. After he learned to read, there was some improvement and it seemed that he was making a special attempt to finish his work in order to be allowed to go to the book corner. However, in following years, the slow pace of work became noticeable again.

During his Grade 4 year, his teacher reported extreme aggression at school towards other children and herself. School also caused Nico to suffer from headaches. These were located at the back of his head and occurred frequently, especially when he felt tired, upset or hungry. He reported that at times the headaches were so severe that he was unable to work. He had been wearing glasses since Grade 2 to help his eyes to focus but they did not seem to help the headaches. The headaches were far less frequent during vacation times.

Nico’s parents believed that his slowness was related to boredom with the level of work and the headaches to frustration. His handwriting, which is almost illegible, was blamed on his lack of interest in trying harder.

However, his teachers didn’t want to give him work that could perhaps have been more stimulating because they argued that he was completing so little of the prescribed work that they felt it would be a waste of their time to offer him additional material.

Background information

Nico’s mother reported a normal, problem-free, full-term pregnancy during which she was active and content. The birth, with an epidural procedure, progressed quickly at first but Nico became lodged in the birth canal and was extracted with instruments. His birth weight was 3.64 kg and his APGAR scores were normal. He was given oxygen after the birth because of the long delivery time.

Breastfeeding was not successful due to a problem with inverted breast nipples so after 6 weeks Nico went onto a bottle. He sucked well, seemed to flourish and slept through the night from 8 weeks. He still sleeps well, although he sometimes falls out of bed when he has bad dreams.

His club foot was corrected by two operations, the first being done at 3 months with a cast up to his knee. After the second, his leg was plastered to the hip joint and removed just after his first birthday. This meant that he was unable to crawl for a long while as he walked at 14 months. Other milestones were all within normal limits. He teethed early and also achieved bladder and bowel control at an early age.

Nico was a healthy boy but did suffer from frequent ear infections requiring many antibiotics and tubes on several occasions, the last being removed at 8.5 years. He has been through 15 surgical procedures in total, including the two for his foot, on for the removal of tonsils and adenoids and the rest for insertion of tubes.

Medication was prescribed for his allergies (dairy products, cat dander, dust mites and pollen), which have resulted in an asthma attack. He uses an asthma pump to aid his breathing when necessary.

In the area of sensory stimulation, Nico shows some issues with tactility. He is very ticklish and cannot bear to have people touch him lightly; he dislikes certain foods due to their texture and refuses to wear certain items of clothing if they feel “uncomfortable.” He particularly resists wearing sweaters. He was a very active toddler but his mother reports that he is less so now – perhaps because he likes to read.

Observations

Nico was very cooperative throughout the assessment and enjoyed the humour that we introduced for fun. He showed a preference for quick closure which meant that he sometimes missed details that required more careful observation.

He was able to complete all the tasks but it soon became obvious that his eyes were not working efficiently. Nico could not nurse satisfactorily as a baby and it is possible that this contributed to his visual difficulties as the act of nursing demands intense pulling with the mouth which developmentally helps the eyes to begin working as a team. On a task which involved tracing around some figures, he turned the paper so that he could draw on the vertical rather than on the horizontal or diagonal, indicating a problem with visual tracking.

When faced with a design completion task involving linear line diagrams, during which he was not allowed to move the paper, he struggled to succeed and his lines were inaccurately placed and uncertainly drawn.

Furthermore, he showed jerky eye movements when having to follow a moving object with his eyes. He tended to use his head to track and eventually his eyes failed to track at all. He reported that this task made his eyes very tired. In addition, he found it difficult to focus on an object at near distance, showing problems with convergence.

When he was asked to wear a pair of spectacles with one blue and one red lens he said that he saw blue and red interchangeably. This was another indication that his eyes were not working together as this alternating suppression means that the eyes are fighting for dominance. He also reported a sensitivity to bright lights, glare and difficulty adjusting to transition from dark to light (as when the light is switched on in his room when he wakes up in the morning).

Hard sucking during infancy strengthens the ring, or sphincter muscles and this light sensitivity could be due to his pupillary sphincter’s inability to filter light well enough due to the problems with nursing. Other tasks he found easier with his eyes closed, showing that his visual system was demanding a great deal of energy and attention.

Nico showed a tendency to support his upper body by leaning on the desk during the evaluation and this was validated by his mother who reported that he tends to prefer slouching in a chair or on a couch. Nico says he likes to sit in “big, comfy chairs at school when I can.” When drawing circles on a blackboard, his low muscle tone caused uneven pressure on the chalk, resulting in faint and wavy lines. On a midline crossing task, he became confused about which hand was doing what when engaged in conversation and he was also slightly challenged with tasks requiring integration of the brain hemispheres. Nico also showed certain strengths during the evaluation: his sense of kinesthesia is well developed as is his knowledge of where his body is in space. He shows good auditory sequencing by being able to repeat strings of up to seven nonsense syllables and was also able to repeat a thirteen word sentence correctly and answer three questions about it.

Conclusions

Nico’s reported history of a prolonged and difficult birth, ear infections and numerous operations together with his performance during the assessment made it possible to understand what difficulties his system is having to deal with.

Areas of weakness are vestibular functions, tactility, muscle tone, ocular motility and binocularity, all of which are closely interrelated. A clue to mild proprioceptive issues may be that he still falls out of bed on occasion, as being able to stay in bed once asleep depends on a knowledge of where the body is in space.

The preference for having his body supported and the wavy lines indicate low muscle tone which would contribute to Nico’s slow pace of work at school and his very poor handwriting.

The compensatory technique of moving paper in order to draw or trace efficiently may help him to cope with his challenged visual system but would certainly be difficult in some school situations. The fact that his eyes become very tired when having to work hard is a possible cause for the headaches as well as the concentration required to complete tasks needing interhemispheric integration.

The inefficient communication between the hemispheres is another clue to why Nico cannot work at a satisfactory speed in school – he needs more time to allow incoming messages to transfer from one hemisphere to the other. It was also noted through his hesitation when having to find words to express himself and by the quality of circles he drew on the chalkboard that his right hemisphere is processing information more quickly than the left.

The weaknesses in these systems are clues to weakness in the vestibular system which is directly or indirectly responsible for efficient functioning in all systems above the level of touch, taste and smell. Chronic ear infections and the inability to perform visual tracking are clear signposts to damaged, underdeveloped or immature vestibular functioning and Nico’s earlier need to move in order to stimulate this system demonstrates how it demands attention away from external stimuli – such as the teacher’s instruction.

Thus Nico is unable to give his full attention to classroom events. Although he tries his very best, his system cannot support him adequately and his exhaustion and frustration may well lead to the explosive aggression towards others, as described by the teacher.

Recommendations

Nico and his mother were shown certain exercises and activities designed to strengthen his weak systems, notably his vestibular system since it is needed to support the visual system and muscle tone. As his vestibular system gained in efficiency, more activities were added to develop the visual system, improve interhemispheric integration and to strengthen the left hemisphere.

In addition to the specific exercises, it was recommended that Nico use cold packs on his eyes when they felt tired after school or after homework and he was given Essential Fatty Acids to ensure that he had sufficient omega-3 in his system.

Follow-up

Nico returned eight days after the initial evaluation for an exercise check to ensure that he was following the programme correctly and that all the activities were at a comfortable level for him. His initial greeting was enthusiastic and when asked how things were going he replied: “Very well, this really, really works. I haven’t had a headache at all last week!” So this motivated boy continued to do his exercises and activities faithfully each day and at the next meeting, scheduled to review the programme six weeks later, he had still further progress to report.

His headaches are still very much reduced in frequency; his teacher has commented on his neater work because his handwriting is smaller and more legible and, most significant of all, he is able to write much quicker and is finishing his work.

Three months following the initial evaluation, Nico wrote the end of year exams and scored 100% for Mathematics, 100% for History and Geography; 89% for English and Science and 75% for Afrikaans (a second language). His superior intelligence is now showing itself!

There are still some remaining problems with convergence so Nico has now been referred to visual therapy, in the secure knowledge that his vestibular system is strong enough to support more intensive work on the eyes. He will continue with his programme for another few months to ensure that progress in interhemispheric integration continues.

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