Thursday, July 4, 2013

ADHD, Laziness, or Neither?

Child and adolescent psychiatry, like much of life in general, has its seasonal variations. Around September, I tend to get a cluster of new patients (usually kindergartners and first graders) whose parents or teachers are concerned that they cannot seem to sit still or keep on task during school. The winter months bring in more people with depression and anxiety as the stress of work/school, decreased hours of sunlight, and more time spent indoors take their toll.

In the past month, as the school year ended, I've seen multiple new patient evaluations for another reason: high schoolers or college students who have made it through the academic year, but just barely. Most of them have gotten good grades in the past, but have had gradually declining academic performance over the past few years. Now their parents—and it's almost always the parents who make them come in—want to know if they have ADHD, or if it's "just laziness."

I'm fairly confident whether I can diagnose ADHD, but I'm not even sure how to answer the second part of that question. How does one determine whether someone is lazy? Is being lazy equivalent to "procrastinating" or "avoiding hard work?" It definitely feels more pejorative, like a character flaw that will never go away. Fortunately, I've been able to avoid the issue somewhat, since it seems there is always something else going on besides laziness.

In general, I do not readily diagnose older adolescents with ADHD if they had been able to focus on schoolwork previously. ADHD generally manifests long before high school, though it's still possible that an older teen may have previously undiagnosed ADHD. Often, these teens have a fairly high IQ and never had to study much prior to high school, but they eventually get overwhelmed by academic demands. However, multiple other causes of poor school performance are much more likely. Below are some of the ones that I've come across lately.

Depression: An obvious contributor to lower grades, but it surprises me how often parents (and even the patients themselves) miss this. Perhaps it's because they have difficulty telling depression apart from the normal moodiness of adolescence, or perhaps depression often manifests in adolescence as anger, irritability, and mood swings. However, a teen doesn't have to be clinically depressed to be unhappy, and I believe that unhappiness can also lead to academic decline. One example I saw recently is a patient who moved across the country right before 11th grade, and her grades went from A's to C's. Not having any friends at her new school and being somewhat shy, she spent most of her evening time trying to stay connected with old friends via texts and social media. Studying made her feel less happy, so she did much less of it.

Anxiety: I often see teens who are perfectionists, afraid of making a mistake, and stay up late at night unable to sleep because they can't stop worrying about an upcoming test or assignment. The anxiety can also contribute to procrastination, because thinking about the work brings up unpleasant feelings that dissipate when the teen does something else, like checking Facebook. Of course, actually starting the assignment can decrease the anxiety as focus shifts and a sense of self-efficacy builds, but Facebook is often easier and more fun.

Sleep: Teens often go to bed late and have to wake up early. However, in recent years this has been greatly exacerbated with the proliferation of bright back-lit devices that teens have access to their bedrooms, combined with a dearth of parental monitoring/control. It's amazing to me how much coffee or energy drinks teens are consuming these days to avoid falling asleep at school.

Substance use: Yes, drinking and smoking weed (and/or hanging out with those who often do) can make it harder to focus on doing schoolwork.

Family conflict: Family dynamics are complex, but needless to say, many different types of stress within the family can contribute to a teen not doing well in school. For example, I saw one teenager whose drop in grades seemed to have no rational explanation, until I found out that his parents were alcoholics who had recently both taken up drinking again, leading to a big decrease in the time the family spent together doing other things. Even though this patient insisted that his parents' drinking did not bother him, it seems that when he started to fail in school, his parents ended up engaging with him more, even though they continued to drink. In another case, I had a patient whose parents divorced and her mother almost immediately found a boyfriend, who moved in a few months later. The patient denied feeling upset by this, but her grades tanked when she "just couldn't motivate myself to do homework" after school. This caused considerable distress for her mother, who valued academic success.

Habitual avoidance: This is certainly not a DSM diagnosis, but I do believe avoiding work in favor of fun can become a habit that is difficult to change. I'm not calling it laziness, which implies a flawed character. Rather, I think this has a lot to do with the interaction of culture, parenting style, and a child's temperament. Most of us would rather not do hard or tedious work if we didn't have to. Society tells adolescents that they should have fun and enjoy themselves while they're still young, while parents often tell their children to work hard for some benefit that will accrue years down the road. Unfortunately, some parents want to avoid conflict themselves, so they may not impose the necessary consequences or structure to back their words. Furthermore, adolescents can avoid the tedium of work by multitasking like mad: simultaneously listening to music, texting friends, checking social media, all while trying to study with the TV on in the background. Thus, many teens never develop good study skills (to say nothing of the capacity for deep, focused thought); it's amazing to me that more aren't failing school.

More often than not, the reason for an adolescent's falling grades is a combination of the above factors. I used to be a big believer in laziness, in the sense that I was quite sure it existed as a trait. However, after being asked to evaluate for laziness many times and finding more plausible explanations, now I'm not so sure.