The little girl sitting on the consulting room table, Sara Miller, was solemn and plump, with brown hair cut in bangs. She and her mom, who looked a lot like her, were from a rural community about two hours away, referred by their local G.P.to the neurology clinic where I was doing my training. Because she was one of my first patients, I remember her particularly well, although I saw her decades ago.
“Her teacher says she’s ADD, and isn’t paying attention,” Mrs. Miller said. “And she is kind of dreamy. I thought since she’s so young—Sara is in first grade—she might just grow out of it. But our physician Dr. Rice said no, and put Sara on Ritalin. He’s puzzled, though, because it hasn’t done a bit of good.”
As her mother talked, Sara frowned with concentration, knowing that the conversation was about her, and trying to understand what was said. As I smiled to reassure her, I saw her eyelids flutter. For perhaps ten seconds, the little girl simply looked into space. “Sara?” I said. It was clear she didn’t hear me. As I repeated her name the spell seemed to lift.
“Right there, that’s what we’re talking about,” Mrs. Miller said. She seemed distressed by having witnessed her daughter’s momentary vacancy. I on the other hand felt relieved. Now I had a pretty good idea what we were dealing with.
“I’m sure you’re right about the Ritalin not helping,” I told Mrs. Miller. Explaining to Sara’s mom what her child’s staring spells were, I said, “I’d like to do an EEG to confirm what I think is going on, but I think we can come up with a more useful diagnosis.”
After the technologist set up the EEG, Sara twice experienced periods of vacancy, each time seemingly unaware that she had been “away.” The EEG showed exactly what I suspected. Sara had a mild form of epilepsy called “absence” that consisted of many small, momentary staring spells over the course of a day. Sometimes a child might be “absent” fifty or a hundred times in twenty -four hours, severely hindering her ability to concentrate and learn. Usually occurring for the first time between the ages of four through eight (although these spells can start as early as age three or as late as twelve) absence is a relatively common condition. But because its signs are so subtle, it can be overlooked or misdiagnosed.
Ritalin was not a useful drug for this disorder. But when I prescribed an anti-seizure medication, the spells went away.
“It’s a real difference,” Mrs. Miller told me after about two months. “I hadn’t realized it, but I was getting aggravated because she often seemed not to hear me when I asked her to do something. It was affecting the way I felt about Sara and how I treated her. And Sara hadn’t been keeping up with her class. I believe her teacher thought she was slow. Now that she’s taking everything in, she’s right where she ought to be. The medication hasn’t changed Sara, it’s letting her be herself.”