Q. I am a special education teacher and I work with a student who self injures, pulls out individual hairs, scratches off skin flakes, and recently he has been eating the skin flakes. His only diagnosis is ADHD and he is on Ritalin. He stares a lot, shows very narrow interest in topics (guns and army equipment), and has great difficulty completing any written assignments. Math concepts are especially difficult. His mother says "That's just the way he is." She has taken him to a psychiatrist and reports the doctor states it's just a school anxiety problem. How can I help this boy? What does the eating signify?

A. While I can't offer a diagnosis in this case, I would be very surprised if the symptoms you describe could be explained simply by the presence of attention-deficit hyperactivity disorder (ADHD). The sort of self-injurious behavior he exhibits would be more likely in someone with a pervasive developmental (autistic) disorder; mental retardation; or schizophrenia, than in someone with uncomplicated ADHD.

Pulling out hairs might point to trichotillomania, which some believe is related to obsessive-compulsive disorder. Regarding the eating of skin flakes, this type of behavior (termed "pica") is sometimes seen in those with autistic disorders, schizophrenia, or mental retardation. It is hard to say what it signifies--it may sometimes be a form of self-soothing, or else a compulsive activity related to brain damage.

Given the staring spells in this case, another consideration would be some form of epilepsy, such as petit mal seizures. I would strongly recommend that this student undergo a thorough neuropsychiatric evaluation with an expert in neurodevelopmental disorders. You might begin by speaking with your school psychologist, and finding an appropriate referral source in your area; e.g., a department of child psychiatry at an academic medical center.

This is almost certainly not just a case of school anxiety"! A number of medications, as well as behavioral therapy, may be helpful.

Other Resources

• More Questions on ADHD

March 2003

Disclaimer Back to Ask the Expert