I Wish I had a Truck Brain

The decision to homeschool didn’t take long once the idea was in our heads. We needed a modern solution to an outdated social standard and homeschool was it (private school was the runner up, but it shared many of the same problems as public schools. This topic is discussed elsewhere, and if you’re not convinced public school is outdated and potentially harmful, I’ll convince you).

As a bit of background, we refer to Kallan’s active brain as a shiny race car — beautiful, powerful, and able to take turns that would cause any other brain to sail off the edge of the cliff.  My brain is a large, somewhat rusty truck which putters along but can store an amazing amount of material. It may not be fancy, but I’ll take my family’s race cars and trucks over all the sedans jamming up the streets.

Anyway, a mere four months into the curriculum we knew there was a problem.  Our son’s self-confidence started to plummet, and we heard comments he had never uttered before:

“Mommy, I’m just not as smart as the other kids.”

I realize I may be biased, but frankly, our son is a fucking genius who sees the world in a unique way I envy. Want evidence? Here is a Ghost Robot he invented when he was two years old.

ghost robot

Kallan was no longer the forever-smiles kid, and we could no longer endure his self-defamation. But when to start homeschooling? Should we wait until the end of the year? This seemed reasonable at first, until my son dropped a ton of bricks on me.

“Mommy, I don’t like my race car brain. I wish I had a truck brain.”

That was the moment the decision to homeschool was made. We would not allow my son to feel inferior simply because schools pattern lives around imaginary constructs called grades. Naturally, Kallan’s internalized shame hit my husband hard, as he can relate to Kallan more than anyone else in the family. Rob knows what it’s like to be told you can’t keep up with the others, when inside you’re bursting at the seams with brilliant ideas. He’s still thinking about it, as evidenced by the following:

“I Wish I had a Truck Brain”

They say my brain is special.

I think faster than the rest.

Daddy thinks like me,

But Mommy’s is the best.


She can study really hard;

She can memorize.

When I sit down to study,

I’m completely paralyzed.


They say if I “can just slow down,”

Enough to learn this thing…

But that’s just it!

I can’t slow down.

I want to play and swing.


I want to learn like all the rest,

I hate my race car brain.

Why can’t I be normal?

Why suffer through this pain?


They say my brain is special,

Not some sadistic jest.

But I wish I had a normal brain,

‘Cause Mommy’s is the best.

–Written by Robert Ren.

You’re Just not Motivated

[This is a work in progress and mostly unedited. It will be completed soon, but feel free to start reading.]

It’s terrible, but true: some patients are the jagged little rocks scattered about your otherwise peaceful Zen garden. They never leave (either your practice or the actual appointment), have bizarre needs, and always manage to turn your feng shui into feng fray. When I was an intern, the martyr resident who normally treated Julie’s family called in sick, necessitating a rescheduling of the day’s appointments. Three of us had an available opening, but the other residents had a slightly panicked look on their faces.

“Hey, uh, Ren! You need numbers for graduation. You could get both kids in one visit!” grinned Dr. G. with a snap. “Two in one.” His smile was suspicious … everyone knows interns are incapable of smiling until the next wave of indentured servants start in July. Besides, he kinda looked like this:

totoro creepy smile

“Uh huh. You’re an intern too, why don’t you want the numbers?”

Pfft. Are you kidding? I’ve got tons of numbers. I was just being nice.” He turned to walk away muttering something along the lines of “harbinger of doom,” which naturally led a group of mature, budding physicians to burst into an infantile battle of “you-owe-mes.” Our nurses were not amused.

Unhappy Laverne

Our Attending intervened with the perfect solution of Rock-Paper-Scissors, and thereafter I remained the physician for Julie and her two sons.

They didn’t come in much, but when they did, I had thirty minutes to address problems with both boys. Rather than thirty, however, these clinic appointments often stretched to an hour, putting the rest of my day off an already tight schedule. The boys, Andy and Mark, both possessed frames made for quarterbacking, whereas Julie was extremely thin and looked like she either lacked enough money to buy groceries, was anorexic, or was doing drugs (cocaine can produce a similar wasted-away effect, and I often thought this was one of her demons). Her children were polite but silent as I listened to a high-strung, poorly educated, suspected drug-abusing mother tell me about how they were defiant, violent, destructive, and often ditched school. They were early teens, maybe 14 and 16 years old. There were entire days Julie had no idea where her boys were until they made their way home after dark.

“Andy? Mark?” I’d ask gently, knowing very well there were two sides to this story. “What do you think about what your mother has to say?”  Frankly, I always trusted the boys more than their mother, who was either high when she came in, or manic from untreated bipolar disorder. I was never sure what she wanted me to do. She thought there was some kind of magic pill I could provide to “bring the boys in line.”

In response, the boys would shrug and tell me stories about how school “just didn’t work for them.” How they “couldn’t learn anyway,” and had “worthless teachers.” While they sat there, they would fidget. Constantly. Tapping shoes. Grinding teeth. Getting up to pick things up in the room or play with the otoscope. Shake their knee. They just couldn’t stop, and their mother was no better. She was practically vibrating in place, opening and closing her purse, rubbing her arms (another drug hint, usually associated with meth), and shifting in her seat. I could never get more than three sentences in before she was interrupting me again. By the time they left my office with encouragement to visit their social worker to be set up for further psych testing, I was exhausted.

Several months after one family visit, the mother came to see me alone. I winced when I saw her name on my schedule, but I entered with a smile and asked how the boys were doing.

“Oh, same as always.”

I nodded, as I noticed she looked less gaunt than normal.

“Did you ever get them into the case worker?” I prompted, already knowing the answer.

“Ah, well, I meant to, but I just keep forgetting. You know how it is. But, listen, doctor, I won’t take up your time. I just needed to know how far along I am.”

I paused. “Along?”

“I’m pregnant. I need to see if I’m early enough to get an abortion. I just can’t have another kid, yet alone one like those boys.”

I’ll save the description of my inner turmoil during this patient case, lest I launch into a ten-page diatribe about responsible reproduction.  But to summarize, I followed through with my medical obligations the best I could, and provided all the information to my patient for her to make a safe choice. Julie was relieved she was under twenty weeks and was scheduled for an abortion the next day. It was her eighth abortion, and twelfth pregnancy.

This case may be an odd one to use for an ADHD topic, but it has some excellent points that fit into the larger cultural debate about ADHD and the validity of the diagnosis. Certainly, Julie and her family could be the case study of countless social issues including poverty, lack of education, drug abuse, teenage violence, and reproductive rights. But what I wonder is, how much of what I saw was the result of nature, and how much was nurture?

So, let me first summarize the debate surrounding ADHD: Is it a real diagnosis, or is it a made-up shenanigan by pharmaceutical companies which doctors and teachers have bought into? This is a question of vital concern to those who are confronting ADHD in their lives, either because a teacher has suggested it to a parent, or because a child is having learning difficulties, or because an adult is struggling to manage his or her life. There is a perception among social and professional circles that ADHD is a misleading title for what the medical profession calls PPP: Piss Poor Parenting. But is it really?

Naturally, I’m writing a blog about ADHD, so my readers can assume I believe in the medical validity of the diagnosis. I am also a physician trained to recognize it (although its treatment I deferred to specialists). I’m a clear advocate for the diagnosis, but I will also tell you why and list the points used against it. The reader can decide for himself. Julie’s family will provide a case study for us to consider throughout this discussion.

ADHD is Still Debated Among Medical Professionals

This is a common assertion made by anti-ADHD advocates. But is it true? From personal experience, there was never a time in my medical career, either pre-med, medical school, or residency, when the diagnosis was up for debate. It was presented as fact, with copious amounts of evidence regarding the diagnostic method, the associated factors (e.g. an increased incidence in males), and clearly positive results after patients started stimulants.

The Pianist

Mrs. G was one of the tiniest women I had ever seen. She was in her nineties. When I met her, she was enveloped in the blankets of her hospital bed, like a newborn wrapped in an over-sized baby blanket. She couldn’t have weighed more than seventy pounds. Her skeleton was easily traced for there was no muscle left. Purple veins cross-crossed under her skin, like a child had drawn on her with purple marker. Her skin was fragile and soft…ever so soft, like paper made from tissue wrap. Like rose petals. I loved touching her arm. Even over the hardness of her sunken frame, her skin was like silk.

You see, Mrs. G was dying. Quickly. Her tiny frame, her emaciated and fatigued body, was courtesy of stage four squamous cell carcinoma of the lung. That is usually a cancer caused by smoking, but Ms. G never touched a cigarette in her life. Her husband, on the other hand, smoked around her daily. He died three years prior of his own lung cancer.

Ms. G was a pianist. She loved music. Even dying, she recounted the works of all the great composers. She played the piano in the air, her deft and thin fingers commanding a tune only she could hear. She was sick but her mind was sharp. She had much to speak about. Her grandchildren. Her garden. Her parents. She tended to regress when she got her Morphine. That’s when she talked about learning to play the piano and that’s when her eyes were the brightest.

When in a peaceful delirium after pain medication, she told me about the keys of her father’s piano. The softness of the ivory. Her dad’s finger marks on the keys, telling her where to place her hands. Her father died when she was a teenager, but she continued to use his piano until she was older and married. She said following his fingerprints was like being taught to play by an angel.

As the days passed, she had more trouble breathing. Eventually, she was placed on a BiPAP. I’ll never forget how shocking it was to walk in the room and see this small woman strapped to an enormous face mask. She was alone at the time. The machine forced air into her. As it did so, it took away her ability to speak, dried her out, and imprisoned her. Never have I seen such a perfect example of a treatment being worse than the disease. Her delicate fingers were clutching the bed covers as the machine battered her with breaths. It was violence. The BiPAP was her aggressor. I couldn’t stand it and neither could she.

When I walked closer, I realized she was saying something under the mask. I lifted it. “Take it off. Off,” she whispered.

“Ms. G, if we take it off, we will have to give you lots of Morphine.”

She nodded.

I hesitated. “It will be…it will be the end. You won’t wake up.”

A single tear fell down her cheek. “I know.”

So we did it. We gave her a loading dose of Morphine and pulled off the monstrosity wrapped around her face.

She went quickly. Faster than expected. Her family did not get there in time.

But her hands were in mine when she passed.

Rose petals.

Playing music.


The Diabetic

It was Saturday afternoon. It was one of those rare days when the weather was perfect for laying in the cool, newly sprouted Spring grass while chubby white clouds drifted over. Glancing out the window with unadulterated yearning on my face, I ached for the rare potential to relive a careless day from my youth. Instead, I was making rounds in the hospital. Since it was the weekend, I had double the patient load. My hope to escape to the outdoors was piteous. There would be no escape from the sick today.

Standing inside a dark room while my pneumonia patient coughed violently into the bedside commode, I felt as if I was going through clinical withdraw from…from life. My dark reverie was cut short as the pager went off for the hundredth time that morning, its aggressive soul-puncturing beep calling me from the room on yet another unpleasant errand.

The nurse who paged me informed me her 53 year old patient, Ms. D, had a blood pressure of 220/120 and was refusing any medications. I sighed and reviewed the medical information on my patient list. “Morbidly obese, urinary tract infection, high cholesterol, chronic kidney disease; admitted for hypertensive emergency.” In other words, our average patient. I made a quick check of her morning lab work before visiting her and was unsurprised to discover her diabetes test had come back positive. Very positive.

When I entered the room, it was with a smile. Maybe the patient was scared and no one had explained the urgency of treating her high blood pressure. Maybe she just needed someone to spend time with her. I went in with a goal—to bring her blood pressure down to a safe level and to have a much needed discussion about her new diagnosis.

The nurse met my eyes when I entered. I could tell from her exasperated look the patient was being difficult. There’s a certain visual malevolence nurses get when they are fed up with a patient. It’s as unmistakable as a stray dog watching you from a bowed head…reach for that food bowel and you’re going to get bitten.

Ms. D met the profile I expected with her list of diagnoses. She was fantastically obese, her stomach overhanging down her thighs. Her small knees sat above large calves which were marred by the leathery skin changes caused by lack of circulation. Her gigantic upper arms strained the cuffs of her gown’s arm holes. She had an IV in place which was secured with half the hospital’s available tape…if that thing came out, it wouldn’t be replaced easily. Her legs jutted out in a splayed and aggravated fashion, her bed sheets kicked carelessly off the side of the bed. She was hot. The room was freezing. She looked old, much older than early fifties. She breathed heavily, a consequence of the pressure from her immense abdomen, as well as the pull from two massive breasts which rolled off to the side since she was also braless.

She was Caucasian. Her hair was flaxen and thin, pasted to her forehead and uncombed. It had the yellow tinge of nicotine, indicating she was a heavy smoker. She had a dour look on her face, accompanied by silver-framed glasses squished against the bridge of her nose. The lenses were covered with greasy finger prints. She had pig-like eyes hidden behind the flesh of her face. She had few teeth.

As soon as she saw my white coat, she ‘harumphed,” and turned her face to the wall.

I paused. The patient was easy to dislike from first glance, but I thought maybe I would be the doctor who could get through to her. “Ms. D, I am Dr. Ren. I’m one of the resident physicians here. I am helping to cover for the weekend.”

“You’re too damn young ta be a doctor. Get out and send a real one.”

I laughed, gently. “What does a real doctor look like?”

She turned then, looking as if I surprised her. “A real doctor is old…like me.”

“Unfortunately, I’m the only one here. My attending will be by later. He has grey hair, if that will suit you.”

She sat up with some effort. “Never mind. If you’re it, you’re it. I suppose you want me to take some of that crap for my blood pressure?”

“I do. Your blood pressure is high enough it could hurt your brain or your kidneys.”

She crossed her arms like a petulant child. “I don’t want it. I came here because I was pissing fire and now you all have me here like a prisoner! Day after day after day of medicine and bullshit! And the food here sucks! Just sucks! No salt, no taste!”

I smiled to myself as she ranted. Glancing at my patient list, I saw she was only admitted yesterday morning and had been placed on a low sodium diet because of her blood pressure.

“You’re always free to leave, Ms. D. Though it would be nice to take care of some of your other medical problems while you’re here.”

“I ain’t got no problems! Just this UTI or whatever you call it.”

“Actually, your high blood pressure is a big problem. If you would let me treat it, we could talk about it more.”

“No. No medicine.”

I thought maybe she didn’t understand what hypertension was. “Do you know what high blood pressure is?”

“Yeah, I know. Means my heart is working too hard.”

I was surprised. “Do you know what can happen with pressures as high as yours?”

“Yeah. I can have a stroke.”

I paused, not knowing where to go from there. “Can I ask why you won’t let us treat it?”

“CAUSE I DON’T NEED IT!” She burst into a shriek which was heard down the entirety of hallway. I sighed and sat in the chair in the room, hoping it might make her less confrontational. I kept a cool temper, though she was starting to irritate me. The outside looked lovely from her room and I couldn’t believe I was sacrificing a beautiful day to deal with her nonsense.

I thought a change in subject might help. “Can we talk about another issue? Besides your blood pressure, I saw some concerning things in your blood work. Would you like to discuss it?”

“Go right ahead, little miss doctor.”

I took a moment to cool down. The nurse was watching me with a conspirator’s grimace as I began to recognize the enormity of the problem this patient must have caused for the nursing staff.

“Do you know what diabetes is?”

The patient looked at me warily from the corner of her eye. “Yeah…a sugar problem.”

“In a sense, yes. It looks like your other doctor tested you for diabetes and it came back positive. I would like to tell you what tha—”

“YOU GAVE ME THE DIABETES?!” Her voice rose to an impressive level. I wouldn’t have thought her smoker’s lungs would have allowed such projected volumes.

“Diabetes happens over time—” I started to explain.

“I DIDN’T COME IN HERE WITH DIABETES, AN’ I’M LEAVIN’ WITH DIABETES, SO I GUESS THAT MEANS YOU GAVE ME DIABETES!” She said this with complete condescension in her voice, as if I were wearing a dunce hat instead of a white coat. I suppose that’s when I got…irritated. I stood.

“Ms. D,” I said tersely. “You have diabetes because you’re fat and you eat junk food. You did this to yourself. There is only one person to blame here.”


A glance at the BP monitor continued to read her blood pressures at dangerous levels. Mine was probably not too impressive at the time either. I left the room and grabbed her chart so I could document. I had to ensure my story was written down, to protect myself legally whenever Ms. D inevitably stroked out.

I paused in the middle of the hallway, feeling defeated and angry. I’m embarrassed to admit it, but a part of me wanted something awful to happen so I could say, ‘I told you so.’ I wanted to scream back. Write a passive-aggressive note in her chart. I was full of rage that this fat, mouthy woman accused me of something ridiculous, tested me, and tossed my kindness back into my face. I wanted to cry, because the world outside was beautiful and I was tied to these awful people. These sick people who couldn’t take care of themselves or understand why they were sick. I felt enraged at a social system that encouraged chronic illness and failed to treat it. And I felt hopeless, because she would leave the hospital and be right back in, waiting for the next white-coated victim to try and help her.

Sometimes, there’s no way to help, no way to explain. And yet, I’m the one who felt like the failure, for losing my temper, for failing to reach her. All the training I had about trying to understand the core of a patient. Was she afraid? What was her emotional reaction really caused by? Did she want to die? Did she need attention so bad? What could I have done different? Did I do the wrong thing by giving up and walking out? And…is it really my job to proffer psychological analysis on each difficult patient? I just don’t have the time.

The nurse followed me out, asking what she should do.

“Just put her on a sugar free diet.”

I went to write my note.

Child in Motion

Those who do not deal with ADHD children cannot possibly appreciate their need for movement. Allowing a hyperactive child the ability to move is absolutely vital and often underestimated. This is not only underestimated at school, but at home as well. Frankly, an ADHD child cannot possibly succeed in any task unless the surrounding adults recognize the issue and accommodate it.  Often, teachers and parents worry about their child conforming to an educational ideal–a child who can sit at a desk and absorb information. Forcing a hyperactive child to remain at a desk virtually eliminates all his potential to learn that day. It would be the same as putting ear plugs in a non-ADHD child, then demanding to know why she can’t answer any questions. This happens all the time, and I am guilty of it too. After all, I was the average student in school and I had certain assumptions about education. It’s an understatement to say my son’s interaction with the world took me by surprise. But, I’m learning.

In this article, I hope to convince readers hyperactivity should be recognized and accepted as part of the ADHD child, and is not something which can be altered any more than you could alter his or her eye color. In a separate post to come, I will discuss some of the ways to handle hyperactivity in a positive way. But for now, let’s see what living with the overly excitable child is like.

From six months on, my son was a “flapper.” At first I didn’t recognize it for what it was–I remember him laying on his back as a chubby, happy baby, flapping his arms as hard as possible. With his little fat arms pressed against his side, his hands flapped at the wrists so fast they blurred. He looked like a turkey desperately trying to reach the sky. Or this…

 I laughed, commenting about his energy and assuming, like most children, he was simply exploring what his body could do. In addition to flapping on his blanket, he loved, loved, loved the jumper.  He would spend almost two hours at a time in it, bouncing nonstop until someone finally took him out of the seat. Again, I thought this was benign activity that would slowly fade away.


The flapping continued. As he hit nine months, I worried because I knew autistic children flapped as a way of managing excitement and emotional intensity. I reminded myself many children are flappers in their infant and toddler years. Several times in clinic, I told parents not to worry about this trait, as long as the child met his developmental milestones. Physicians are quite confident until it’s our own child!

Kallan was extremely sociable, however, so I gave up my autism fears, but I could still tell something wasn’t quite “normal.”  When Kallan flaps, he doesn’t just move his arms a little, he literally flaps like a baby bird trying to launch himself out of the nest. It’s impressively fast, and somehow, he is unconscious of the activity. And it happens all the time.  And it’s catchy–our two year old daughter has started doing it too, simply because big brother does it. The flapping happens continuously: when he’s imaging something exciting, watching a movie, hearing a story, playing a game, talking about anything, receiving praise, etc. I can certainly imagine how this would not only be distracting in a school setting, but a target of ridicule as well.

And flapping is not Kallan’s only chronic activity. While it’s the most observable, he is constantly moving.  He paces the room round after round, often lost in imaginative play. He sits on the edge of chairs because he can’t stay in one place long enough to bother. He chews his nails. He chews his shirt sleeves. He sometimes rubs his palms rapidly on his inner legs (which I know is his way to have hand stimulation, but of course its terribly embarrassing in public). He is constantly talking. He grabs things without permission and without thinking, which is often worrisome in stores. I know we are not the only parents dealing with this behavior, and it’s no wonder parents finally resort to medication. The problem, however, is that Kallan needs this kind of activity in order to learn. As soon as he is restricted physically, any attempt at teaching is lost.

So what does a parent or teacher do? Hyperactivity is not socially acceptable, and before one knows it, you’re in a meeting and they’re recommending your child undergoes a physician’s assessment to start medication. In the case of our public school, we haven’t had this conversation, but I know they simply don’t have the resources to properly filter Kallan’s activity load. We live in a middle-to-upper class district, and our schools are still underfunded and have too many children per class. Kallan’s kindergarten class has 25 students! How can a single teacher possibly deal with all those children while also fostering an ADHD child?

As a parent, the first step is recognizing the hyperactive behaviors. The second step is to realize the hyperactivity is not intentional. Once parents realize their son/daughter cannot help the activity, it helps to unburden us from anger and frustration. This is extremely important, because ADHD children can sense they are failing. They know when mommy and daddy are frustrated, and when parental anger is over something the child cannot control, children begin to feel shame. The longer ADHD goes unrecognized, the more shame children start to carry. Trust me, you can ask my husband about this one–his ADHD wasn’t diagnosed until adulthood and his path to emotional recovery has been long (and the focus of another posting).

Really, that is the first step: believe the hyperactivity is unintentional. It’s unintentional when your child doesn’t listen, says “what?” for the thousandth time, leaves the dinner table again, and runs around the store uncontrolled (making you look like a crappy parent while the other shoppers watch). They can’t help it,  and being criticized over and over again for hyperactivity they cannot control starts to undermine children’s confidence.

For many people, especially those who have not dealt with ADHD before, this is a hard thing to accept. It’s hard to believe a child cannot remember to sit at the dinner table after you’ve told him to sit four times. It’s natural for parents to eventually blow up, but if parents cannot recognize the involuntary nature of ADHD, they will not be able to deal with the hyperactivity without anger. Parents must be advocates for their children, because there are many people out there who believe ADHD is a made up diagnosis. Once you see your child’s over stimulation for what it is, how do you manage it without resorting to raised voices? How can you redirect hyperactivity at home and at school into a positive experience? That is the subject of my next post.

When Doctors are Bored

…we write hikus. At least, I do. These were written during one of the orientation lectures my Intern year.

The zombie shambles
Toward my peaceful abode
Shuffling to his end;

The season is right
For quaint winter with red snow,
Weather of shotgun

The zombie pieces
Decorate spruce and pine;
Christmas in July.


Squeeky chair my bane,
Sweaty butt makes farting noise,
I swear it’s not me.


Two hour lecture,
My mind begins to wander
To thoughts of darkness;

A man that is bat,
A hero vigilante
I would violate.

Alas, life is real,
I married a mortal man
Who is wolverine


I should be list’ning
But I was denied Starbucks
Please kill me quickly.

I am certain that
God does not sleep deprive you
In eternal rest.


Hoping a code blue
Will not greet me first day on;
I will micturate.