Now let’s listen to an interaction where Dr. Denke takes a more understanding approach and listens more.
DR. DENKE: So, I’m going to be asking you some questions that I ask all the teenagers I see with symptoms like the ones you’re describing.
ELLA: Uh, okay.
DR. DENKE: And I want you to know, anything you tell me today stays between you and me unless you say otherwise. Or unless you or someone else is in danger, okay? (Ella nods) But I know there are some things that are easier to talk about when mom is out of the room, right? (smiles)
ELLA: (nervous, talks quickly) I guess. I mean, it was her idea to come here.
DR. DENKE: (neutral tone, reflecting) It was your mother’s idea to come here. You weren’t concerned about your heart racing during track.
ELLA: I don’t know. I mean, I guess I was just glad to go home.
DR. DENKE: (sympathetic) You didn’t want to be at track.
ELLA: I don’t know. I know I have to do it because… applications. And I used to really like it, but this year it’s just, like, too much.
DR. DENKE: It sounds like you’re feeling a little overwhelmed.
ELLA: It’s been a lot, you know, since we moved here? I mean, maybe it’s just high school, ‘cause sophomore year is when everything starts to count, right? Which is weird, because it’s not like anyone was saying, “Oh, this doesn’t matter” in middle school… (collects her thoughts) But, I mean there’s so much to do, and I just can’t, like, focus on anything. And then my heart starts skipping.
DR. WORNIK: Reflecting Ella’s statements without judgment helped her open up. Often, reflecting a patient’s own thoughts or feelings back to them, sometimes with a little guess as to why they’re thinking or feeling that way, can be more effective than asking questions. Dr. Denke could continue reflecting to find out more about the pressure she’s under and her trouble focusing; but let’s see what happens when he changes gears.
DR. DENKE: You indicated on your form that you occasionally drink alcohol with your friends. (Ella looks down and gives a small nod) Can you tell me a little more about that?
ELLA: It’s nothing big. Just sometimes at parties or something. Just beer. Not much.
DR. DENKE: In the past year, on how many days did you have more than a few sips of beer, wine or any drink containing alcohol?
ELLA: More than a few sips? Almost never. I-I don’t want to get drunk, you know? Like, I’m awkward enough already... what if I lose control and do something really embarrassing?
DR. DENKE: You’re absolutely right. Drinking can impair your judgement and make you do things you could regret.
DR. WORNIK: Often teens who misuse prescription stimulants are also heavy users of alcohol or other drugs. But since Ella’s screening shows limited alcohol use, SBIRT guidelines recommend responding with brief positive feedback about what she’s doing right, plus information and advice about why to avoid drinking. Had she fit a higher risk category, more intensive interventions would be called for. Let’s listen as Dr. Denke continues with this line of questioning.
DR. DENKE: Have you tried any other drugs?
ELLA: No. (laughs nervously) I’ve heard a few kids talk about smoking weed, but I wouldn’t even know where to get it.
DR. DENKE: What about prescription drugs?
ELLA: What do you mean?
DR. DENKE: Sometimes we hear about kids who try other people’s prescription drugs. Their parents’ or their friends’. Have you had any experiences with that?
ELLA: Um… (long pause) Well, not like a drug drug, but my friend Dana, she has ADHD, you know? And she saw how I’ve been having such a hard time, with not being able to focus and stuff. So, she let me try her Adderall. And it made a big difference. I think she’s right, I have ADHD, too. Right?
DR. WORNIK: Often teens don’t think of prescription medicines as “real drugs,” so they may be more willing to admit use. There are many ways Dr. Denke could respond to this admission, but the one he chooses is to engage Ella with the Ask-Tell-Ask technique: asking a question to engage the patient, telling information tailored to what they already know, and then asking a follow-up question to re-engage the patient.
DR. DENKE: Why don’t you tell me what you know about the medication your friend takes.
ELLA: Um, it helps her focus, not get distracted. And, uh, she doesn’t have to sleep as much.
DR. DENKE: That’s right. ADHD medications are actually very powerful stimulants. And for people with ADHD, those stimulants can calm down their nervous systems. But for people with anxiety, those same stimulants can make symptoms worse. Or sometimes they feel better for a short while, and then worse when the drugs wear off. Can you tell me what your experience has been?
ELLA: Uh, I guess, yeah. A little like that. Like, the first time I took a pill, I was able to stay up all night finishing a paper and still come in and kick butt on my test the next day. But the day after, I felt awful. Just shaky and exhausted and having all these weird thoughts. And then the next time I took one, that’s when my heart started the whole racy thing. But it helped so much, I just kept doing it.
DR. WORNIK: Notice how Ask-Tell-Ask resulted in a helpful, two-way flow of information, and Ella is highly engaged in this conversation. Let’s listen as Dr. Denke uses Ask-Tell-Ask again.
DR. DENKE: People say a lot of different things about ADHD. I’m wondering what exactly you’ve heard.
ELLA: I mean, it’s just like, you can’t focus on anything and it’s really hard to get anything done. But if you take the right stuff, you can just be normal.
DR. DENKE: (nods) It’s a pretty complicated condition, actually. Not something I could diagnose here in this visit. I’d need to hear from your parents, your teachers, and probably a mental health specialist.
ELLA: (off-balance) Oh.
DR. DENKE: There are some questions I can ask you right now to see if it makes sense to get you evaluated for ADHD. What do you think of that?
ELLA: Uh, sure.
DR. WORNIK: Rather than starting a tug-of-war with Ella over whether or not she has ADHD or should be taking Adderall, Dr. Denke is directly addressing her concerns by screening her for ADHD. Let’s see how this plays out.
DR. DENKE: You said you have trouble focusing, so I want you tell me a little more about that.
ELLA: Uh, just I have all these thoughts always flying around, like, “Did I practice my band solo enough?” and “How many pages does that report have to be?” and “Did I forget my lunch?” and sometimes it feels like they’re all jumping up and down trying to get my attention and it’s just too hard to know which one is supposed to be the most important.
DR. DENKE: And what about the things around you -- the other kids talking or a bird flying outside? Do you find yourself paying more attention to them than to your work?
ELLA: Uh, not really. Unless I see someone and they, like, remind me of something I need to do. Mostly, it’s nothing outside; more what’s happening, like, in my head.
DR. DENKE: Okay. A lot of kids with ADHD have trouble sitting still, especially in the early grades. They’ll say that they can’t stop fidgeting, or that they need to get up and run around. Do you find that your teachers often have to remind you to stay in your seat?
ELLA: Um, not really. But recently, it’s… like, gotten harder. Sometimes, when I’m sitting at my desk, I just start to feel trapped. Like I can’t even take a breath and, and... (at a loss for words, knowing how crazy this sounds) you know, like the walls are closing in on me and I want to just run away. (pause, then uncomfortable) Man, that sounds crazy.
DR. DENKE: Would you say you’re feeling panicked?
ELLA: Yeah! Like, like something terrible is gonna happen.
DR. DENKE: Have you ever noticed yourself doing things impulsively, just… doing something and not even thinking about it?
ELLA: Ha! I wish. I get paralyzed trying to just do anything, because I have all these thoughts racing around in my head about it and every time I start to decide one way, I worry if that’s the wrong choice and so I don’t end up doing anything.
DR. WORNIK: Now Dr. Denke will use a reflective summary to draw Ella’s attention to what her own words are telling her.
DR. DENKE: Let’s look at everything you’re telling me: You don’t get very distracted by things around you, but you have a lot of worries that sometime make it hard for you to focus. You’ve don’t have a high need for activity, but you do feel panicked in class sometimes. And you often feel paralyzed because you’re worried about making the right decisions. Does that sound right?
ELLA: Yeah. I guess… (shyly) Does that sound like ADHD?
DR. DENKE: Not really… Medically, we call excessive worrying “anxiety,” and it’s a really common issue for both kids and adults. And anxiety can share a lot of the same symptoms as ADHD -- having trouble focusing and struggling with schoolwork -- but it doesn’t really respond to the same treatments.
ELLA: Then that’s not what I have, because Dana’s meds, like, really help me.
DR. WORNIK: Any time a teen is misusing stimulants, it’s a good idea to get them evaluated for an anxiety disorder, as there is a very high correlation. Rather than arguing with Ella over whether or not she has an anxiety disorder, he instead respectfully asks her to stop using Adderall, refers her to a specialist, and suggests some changes to her schedule. He could also refer her to a cardiologist if he wants to rule out heart problems.
DR. DENKE: Okay, based on what you’ve told me today, there’s a lot we can do to help you. ELLA: (with relief) Good.
DR. DENKE: But if you keep using Dana’s medication your symptoms are only going to get worse, and I am going to ask you not to use any more, okay? (Ella nods) If there’s a medicine that will help you, we’ll find it.
ELLA: Oh. (crestfallen, worried) But if they--like, whatever you prescribe--doesn’t work, then what can I do?
DR. DENKE: Everything you’ve talked about is very treatable, so let’s discuss some of those treatment options, okay? (Ella nods) I think it would be a good idea for you to talk to someone who is a specialist in this area. They’ll be able to work with you to determine whether what you’re dealing with is anxiety, or whether it’s ADHD, or both. How do you feel about that?
ELLA: I don’t know. (fidgets) My parents don’t really think anxiety and stuff are, like, real. They think I should just be able to deal with stuff, you know, like they did--just grit your teeth and get through it.
DR. DENKE: (nods) I can talk to them. (Ella hesitates) If you like, we can explain it as a kind of tutoring, just like you would do to get ready for the SATs. But instead, you’ll be learning skills to help yourself feel better when you start to get worried.
ELLA: That… that sounds like a really good thing to know.
DR. DENKE: One thing that you can do right now that I think would really help is to make some changes to your schedule so you’re under a little less pressure.
ELLA: But... applications…
DR. DENKE: Do you feel like you can keep on at the pace you’re going for another two years?
ELLA: (shakes her head) Maybe I can drop band…? Or Latin. (second thoughts) Well, my dad really wanted me to take that… Maybe you could… talk to my mom about this? She doesn’t listen to me, but maybe if you tell her...?
DR. DENKE: Of course. We can bring her in right now and talk about the follow-up plan I’m recommending. And maybe we can take a quick look at your schedule and make sure there’s room in it to get some sleep. Your mom may not understand how important that is for your health…