The ABC's of Attention Deficit Disorder

Today I will discuss a commonly misunderstood condition, Attention Deficit Disorder.  There is much confusion, fear and misinformation floating on the web that either stereotypes, catastrophizes or minimizes this condition.  This post will outline the disorder; explain some of its more unusual symptoms and explain how it is diagnosed.

Description and Symptoms:

Attention Deficit Disorder (ADD) is a medical diagnosis associated with significant difficulty in sustained focus, listening and concentration. Additional symptoms often include forgetfulness, a propensity for losing or misplacing personal possessions and an inability to accurately estimate the time it takes to complete a given task. A consistent pattern of difficulties with planning, organizing and executing activities is also evident.  Challenges with visual-spatial processing are frequently exhibited as confusion with geographical directions as well as academic challenges in the areas of math and reading comprehension.

Are these deficits caused by the way an individual thinks? Could permissive parenting styles generate Attention Deficit behaviors?  Is it possible that these symptoms are a response to where we live and work?  Let’s examine these possibilities. 

The Thinking Brain:

The frontal lobe of the brain is also known as the hub for executive functioning.  Executive functioning is the process of how we (1) generate an idea; (2) then formulate a plan; (3) organize that plan into functional steps; and (4) finally execute that plan.  In essence, it is our ability to transform a creative thought into a substantive product.  Normal frontal lobe development occurs from approximately age four through age 20.  Research suggests that symptoms associated with Attention Deficit Disorder may reflect a lagging development of the frontal lobe.  That would explain why some children with ADD seem to “catch up” with their peers in the areas of executive functioning during college.  Attention Deficit Disorder is not related to intelligence.  It is related to how we process information!

Visual-spatial ability is the way our brains can “see” dimensions (think geometry) as well as how we read maps and even comprehend what we read.  Our ability to differentiate left from right and east from north, west and south are also a function of “picturing” spatial relationships within our brain.  Reading skills are very dependent upon visual-spatial acuity. In order to comprehend what we read, we transform words into mental pictures that have meaning.  When the ability to translate words into meaningful pictures is compromised, deficits in understanding what we read are very possible.

While there are not structural differences in the brains of individuals who are diagnosed with Attention Deficit Disorder, clearly how the brain processes incoming information is involved in this diagnosis.

Behavioral Origins:

Is it possible that an individual’s behavior causes Attention Deficit Disorder?  No! The connection with what may seem like unruly behavior and Attention Deficit Disorder is more likely the impact of how mental distraction and disorganization affects behavior. This is often observed when an individual seemingly jumps from one activity to another or forgets important materials needed to complete a given task when compared to their peers.   For example, your child may forget to bring their workbook home (the one they needed) although they do remember to bring home the textbook! 

An adult with Attention Deficit Disorder may return to the market several times while preparing a meal because they “forgot” key ingredients despite being there hours earlier!  These examples more accurately reflect an inability to plan and organize their activities rather than deliberate oppositional or defiant behavior. 

  

Unfortunately, to the frustrated parent these behaviors may appear to be intentional; a behavior that could be remedied with more discipline. An individual with Attention Deficit Disorder often feels frustrated and embarrassed by their behavior. In this situation, firmer discipline is rarely effective. I believe it is important to understand that these seemingly scattered behaviors are the outward expression of what the brain is internally struggling to keep straight. 

Environmental Origins:

What about our environment?  Could it cause Attention Deficit Disorder? Highly unlikely!  Is there a definite correlation between the environment and the exacerbation of ADD? Absolutely!  Recall that individuals with Attention Deficit Disorder struggle with organizing and processing information within their brains.  Living in a cluttered home or attempting to function in a chaotic academic or work environment further stresses their ability to organize yet another system in their lives.  The options are: (1) to spend precious time and emotional energy attempting to organize the chaos prior to tackling their assignments; (2) attempt to ignore the chaos and focus on the task at hand; or (3) become caught up in the chaos and accomplish nothing. 

An individual with Attention Deficit Disorder may valiantly attempt to organize their clutter by purchasing organizational tools such as bins and specifically designed organizers only to get side-tracked when determining which color to buy.  A student may dive into a project and then become

overwhelmed by the thought of how to organize their outline. They may choose to escape this internal chaos by focusing on a video game. In both of these examples, little re-organizing will occur without assistance from family and/or friends.

An alternative approach to manage a chaotic environment may be to extract themselves from the chaos and hyper-focus on the task at hand. The mental exhaustion required to complete the original task amid the chaos depletes the energy required to then reorganize their environment.  This may be incorrectly identified as laziness, when it may be emotional and mental exhaustion! 

The least healthy approach is to get lost in the chaos.  This may look like halfhearted attempts to organize the environment followed by halfhearted attempts to focus on their work with little impact on either situation.  Generally this approach is followed by surrender on both fronts. Therefore, we may conclude that Attention Deficit Disorder is definitely affected but certainly not caused by the environment.

Interactions Between the Brain, Behavior and Environment:

Attention Deficit Disorder is a neurological disorder that originates in the brain that challenges the processing of information as well as affecting sustained attention and concentration. Often loved ones first observe behaviors that may prompt concern.  Environmental factors, especially chaos and clutter certainly may exaggerate symptoms and further compromise functioning.  But neither behavior nor the environment causes ADD.  Who then is qualified to diagnose Attention Deficit Disorder?

The Diagnostic Process:

In most states, a medical professional is qualified to diagnose Attention Deficit Disorder.  However, many physicians refer their patients to a psychologist who will administer tests and evaluate relevant family history prior to making a recommendation of this diagnosis.  Research suggests that there may be a genetic transmission of Attention Deficit Disorder.  Most recent research also suggests that maternal smoking and alcohol consumption during the second trimester of pregnancy may also be correlated with Attention Deficit Disorder in children. These are several reasons that a comprehensive familial history is important when evaluating this diagnosis. It is also important to rule out the possibility of depression and anxiety. These emotional conditions may also impact an individual's ability to focus and process information and thus may mimic symptoms of Attention Deficit Disorder.  A psychologist is also qualified to assess as well as rule out emotional issues that may confuse the diagnostic picture.

CONCLUSION:

An adolescent or an adult cannot suddenly develop Attention Deficit Disorder!  While this diagnosis may not be determined until adolescence or even adulthood, symptoms must have been present prior to age seven to meet diagnostic criteria. Frontal lobe development, family history, behavioral observations, academic and home environments, and possible emotional issues must be considered prior to confirming this diagnosis. If you or your loved one seems to be struggling despite conscientious efforts to succeed, consider an evaluation for Attention Deficit Disorder.  A variety of treatment options are now available that may make the road to success more clear and more readily attainable!

Are Children Who Underachieve Lazy? - Part Three

This post will discuss what may happen once you decide to contact a private practice clinical psychologist to conduct your child’s assessment.  I will also share with you some final thoughts on this topic.

Contacting a Psychologist:

As stated above, a licensed clinical psychologist can offer your child comprehensive educational and psychological testing in one setting.  When researching psychologists, I would advise you to conduct a brief phone interview prior to scheduling an appointment.  Relevant information to assist in your decision making would include areas of expertise, availability, who conducts the actual testing, interpretation, and report writing, approximate number of face-to-face hours required, and turn around time.  Ultimately, note your level of comfort during the call.  Does this person seem like they could be a “good fit” for your child?

The next step is generally a consultation, also known as an intake.  There is no hard and fast rule regarding this step. The purpose is to gather all relevant history.  In my practice I prefer to have the parents alone during this session so that they feel free to openly discuss any sensitive issues that may be relevant to the testing but not appropriate for their child to hear.  I ask parents to bring with them report cards, any previous testing, and samples of their child’s artwork and completed spelling and math assignments.  This session serves as a framework for test selection, duration of sessions and approximate costs.  Some psychologists would prefer that the child is present at this point.  You should decide which option feels most comfortable to you.

The pace of the testing sessions is based upon the child’s ability, stamina, and focus.The goal of testing is to explore your child’s strengths as well as weaknesses; therefore sensitivity to their threshold of fatigue is essential. Often testing is conducted over several sessions.  In my practice, I personally administer all the tests, interpret the results and write the report.  If a psychologist employs graduate level interns, they may conduct the assessment under the psychologist’s supervision.

A basic comprehensive assessment will include tests of cognitive functioning, academic as well as neurological and psychological screening. Based upon initial screenings, more extensive neurological and psychological assessment may be included.  Once testing is completed, a comprehensive written report is provided to the parent that includes all test results, interpretations of those results, any relevant diagnoses, and relevant treatment recommendations.  At the parent’s discretion, these results may be shared with their child’s pediatrician, the school, and/or their child’s therapist.

Cost:

An assessment is an investment for your child’s future academic and personal success. Each assessment is designed to uncover probable explanations for your specific concerns.  They may be cognitive in nature such as how information is learned and retained, or possibly achievement – at what grade level is your child performing?  Perhaps psychological issues like the impact of family stressors are impacting focus and attention.  Frequently it is a combination of factors that require evaluation.  Therefore, the cost may range from $500 to $4000 depending on the complexity of the assessment.  Costs are generally determined by the amount of time the assessor spends reviewing relevant documents, administrating, scoring and interpreting the tests, as well as treatment recommendations and report writing. 

Conclusion:

Ultimately the decision to label your child as lazy is yours to make.  Whether underachievement is due to psychological issues and exhibited as oppositional behaviors, or masking an underlying learning deficit or even giftedness on which side would you prefer to error?  I continue to assert that laziness is a manifestation of resignation.  As a parent I would want to know from where it originates.

As you know I am a licensed clinical and consulting psychologist. One of my areas of specialty is assessment.  I am passionate about every step in the process.  If you would like to schedule a consultation on behalf of yourself or your child, feel free to contact me through my blog.  It is completely confidential. 

Are Children Who Underachieve Lazy? - Part Two

Part One of this post raised the question of whether underachievement was an indicator of laziness in children.  As previously discussed, this is not necessarily a causal relationship and many different factors, like potential physical health problems, should be examined.  Assuming those possibilities have been ruled out, what are the next steps in determining the source of what appears to be laziness?

One course of action obviously is to discuss your concerns with your child’s teacher(s).  While often a useful addition to your investigation, teachers’ perspectives may be limited in two ways: 1) they have precious amounts of time to spread among an entire group of students and cannot specifically monitor your child throughout the day; and 2) your child’s behavior may differ dramatically between school and home. Let’s dive in to why that may occur.

Most children understand their role as a student and apply their energy to learning while at school.  However, for children who are struggling to keep up in class, their fears of exposure and possible ridicule are significant emotional stressors that may shift their attention from learning.  When they finally arrive home it is often difficult to contain those emotions so parents often witness behaviors that are not displayed at school.  If there is a significant disparity in your child’s behavior between what teachers observe at school and what you observe at home, you may want to consider additional diagnostic evaluation.

Assume you’ve decided to have your child evaluated, how do you begin?  At this point, there are several questions to ask yourself: (1) Will you involve the school? (2) Who is qualified to assess my child? and (3) What do I look for in selecting an assessor?

School-Based Assessment or Private Assessment:

There are potentially two paths from which to choose when you are ready to have an assessment: 1) School-based assessment, or 2) Private assessment. If time is an important consideration for you, a private assessment would be more streamlined compared to the school-based assessment process.  Generally, school-based assessments are subjected to district guidelines for the filing and approval processes.  The only constraint in a private assessment is assessor and client availability.  If your child meets the requirements for a school-based assessment, an assessor will be assigned to your child.  In a private assessment, you have the autonomy to select an assessor who meets you own standards for education, professional standing and personal compatibility. Regardless of which path you choose, know that assessment results are valid for three years. So, the effort and costs incurred in this process will not become an annual event!

School-Based Assessment:

One possibility for an assessment could be through the school system.  If the school agrees with your concerns, there are specific district procedures that you will be required to follow.  Understand that a comprehensive psychological assessment differs from an assessment that a school conducts as part of an educational evaluation.  The focus of an educational assessment is your child’s potential for learning.  Generally, the parents must seek out a psychological assessment independent of the school environment. Exceptions may arise if the school has a licensed clinical psychologist on staff. Based upon the testing results your child may be entitled to special accommodations within the school’s academic environment. The results of educational assessments are shared during a parent-assessor-teacher conference or an Individual Education Plan (IEP) meeting set by the school district.

Refer to your State’s Education Code for more details about school-based assessments.

Private Assessment:

If this is your preference, the process is fairly simple: you contact the professional and he or she will advise you of their approach and fee structure.

How do you find a professional assessor?  A common route is to ask for recommendations from your child’s pediatrician, your family practice physician or nurse practitioner, and possibly administrators at your child’s school.  Other parents are also a great source of information.

Choosing A Professional:

Even if a professional is highly recommended, be certain to ask about their qualifications. Begin by looking at the initials after the assessor’s name.  Does the assessor hold either a Master’s Degree (M.A.) or a Doctorate Degree (PhD, PsyD)? Master level assessors are certified to administer certain tests depending on where they conduct them (school or college) and for what purpose (career guidance and some learning difficulties).   Psychologists who hold either a Doctor of Philosophy (PhD) degree or a Doctor of Psychology (PsyD) are qualified to administer all types of testing.  An independent licensed assessor in California would be a clinical psychologist.  Individuals who have a Doctorate in Education although they are not licensed by the State specifically for testing may also offer testing.

The following excerpt from the chapter “Get Smart About Tests” by Rocklin Publications offers a nice summary of which professionals can administer what tests:

“The professionals who administer standardized educational and psychological tests often are psychologists, but other professionals, such as counselors or vocational and educational specialists, as well as classroom teachers, are permitted to administer some tests. The classroom teacher, for example, typically will be the one who administers the proficiency tests your child will take in school. (Most tests administered by teachers, such as quizzes and classroom tests, are developed by the teachers themselves and are a different breed than the standardized educational and psychological tests that take years to develop.) A career or vocational counselor may give career interest inventories and certain aptitude tests in order to help a student choose the right career path. And an educational specialist may administer certain educational tests to determine whether a learning problem exists or to determine which remedial approach works best for a particular student.
   Because standardized educational and psychological tests are such sophisticated instruments, anyone who administers them must be properly trained and have experience administering and interpreting tests. This is important because the person using tests needs to be familiar with the technical and statistical properties of the tests to make sure they are right for the child being evaluated. Just as it would be unwise to have an untrained and inexperienced person perform and interpret medical tests, it would be equally unwise, and unethical, to have an untrained and inexperienced person administer and interpret educational or psychological tests.
    The psychologists, educational specialists, and counseling professionals who administer tests are highly trained. Many will have a doctoral degree—a Ph.D. (Doctor of Philosophy), a Psy.D. (Doctor of Psychology), or an Ed.D. (Doctor of Education)—but a good many also will have a specialist degree, such as an Ed.S. (Educational Specialist), or a master’s degree, such as an M.A. (Master of Arts), an M.S. (Master of Science), or an M.Ed. (Master of Education). You may be wondering whether medical doctors, such as M.D.s (Doctor of Medicine) and D.O.s (Doctor of Osteopathy) administer tests psychological or educational tests. Typically they do not.
    Having one of these degrees does not necessarily mean a person is qualified to administer and interpret psychological and educational tests. They also must be licensed or certified through state licensing boards. And in order to become licensed or certified, most professionals must have appropriate training and experience as well as pass a rigorous written exam and oftentimes an oral exam.”  http://www.rocklinpub.com/whocanadministereducational&psychologicaltests.

A key point to remember is just as all children are not alike,

neither are all mental health professionals. This excerpt suggests that professional licensing may also be important to consider before choosing an assessor.  If a professional is licensed by the State, they are issued a license number and that information is accessible to the public.

Once you have determined that your choice will be to contract a licensed clinical psychologist in private practice, what happens next? We’ll explore that step in Part Three of this post.

Are Children Who Underachieve Lazy?

Do your child’s academic reports contain comments such as “not working up to potential?” What does that mean?  I receive many “emergency” calls from parents once they receive progress reports and report cards.  They are confused and scared.  A common question is whether their child is lazy. Parents often tell me how their children did well for a period only to then demand more and more of their parents’ time to supervise, assist and even complete their homework and projects.  Is this a common occurrence in your household?

I do not believe that children decide to become lazy.  I do believe that children mask feelings of fear, embarrassment, anger and sadness as apathy. They can develop a fairly sophisticated set of behaviors to defend against those feelings. They may come across as lacking interest, may begin “forgetting” books, turning in poorly done or sloppy assignments, barely passing exams, blaming teachers and their parents as being too demanding, and sometimes, completely refusing to engage at school.  These behaviors tend to surface in transition years: third/fourth grade, middle school/junior high, high school and college. 

In the next several posts, I will focus on alternative explanations for “laziness” drawing on medical, cognitive, neuropsychological, academic/achievement and psychological perspectives. 
 

Medical Considerations:

Generally the child’s pediatrician is the first point of call for many parents seeking explanations for their child’s changed behavior, and rightfully so:  general health significantly impacts our ability to learn and retain information.  Vision and hearing deficits are a possible explanation for a perceived lack of interest.  Diet, exercise and sleep also may impact learning.  Before considering any other probable cause, a medical clearance is highly recommended.

Overall Intelligence:
 
Assessing a child’s overall level of cognitive functioning is an excellent next step.  Cognitive assessments provide a foundation for performance expectations and reveal relative intellectual strengths and weaknesses. 
 

Neuropsychological Considerations:
 

Neuropsychology refers to the relationship between the nervous system, especially the brain, and cerebral or mental functions such as language, memory, and perception. Determining your child’s learning style is an essential tool in determining the fit between a teacher’s instructional style and the ability of the child to assimilate what is being presented.  Is your child a visual, auditory or combined modality learner? Individual differences in working memory and long-term memory storage, as well as issues related to attention, focus and hyperactivity also are included in the neuropsychology category.  Some or all of these processes may impact your child’s motivation as well as their academic success.

Academic/Achievement Considerations:
 

What has been your child’s academic history?  Were there remarkable differences during their transitional years?  To what types of educators did your child most enthusiastically respond?  What was the student to teacher ratio when your child seemed to flourish?  Grades are not the only benchmark of academic proficiency, nor are the annual standardized STAR or IOWA basic skills testing administered by the schools. There are specialized testing protocols that can help assess everything from reading comprehension to math fluency and writing mechanics. 

Psychological Considerations:
 

The final category for consideration is psychological.  Low self-esteem, fear of failure and social embarrassment are all-too-common causes of performance issues.  Significant life events like births, deaths, divorce and relocation also greatly affect children.  Occasionally your child may even be suffering from depression or anxiety, both of which may appear very different in children than what we would expect to see in adults. 

Psychological factors are complicated and can be difficult to isolate. The good news is that most of these issues can be successfully addressed through a period of professional counseling.  

The categories are now outlined.  Does your child fit one and only one category? Not likely.  Frequently the causes are multi-dimensional.  Uncovering what may be impacting your child’s lack of motivation does not necessarily result in a diagnosis!  The main concern is that parents label their children “lazy” or “unmotivated” and then levy stricter punishments or restrictions prior to determining whether they are warranted.  The quality of your relationship with your child, a more chaotic home environment and a source of contention between you and your spouse may be at stake!  This is a situation that requires qualified professional intervention.   Assuming you see value in exploring alternatives to the label of “laziness,” stay tuned…. my next post will explain how to proceed. 

Is Dating a Game?

Relationship success has become a high stakes industry. This industry represents a diversity of professionals yet it lacks specific criteria for education, professional conduct and personal experience. All forms of media, coaches and experts alike believe they found the solutions to your loneliness. There are numerous television shows whose entire focus is matchmaking: for millionaires, bachelors and bachelorettes. Love happens while surviving on an island in the South Pacific, as well as racing across the globe and even while competing in a fierce battle to lose weight and become healthy. Viewers are left wondering why their quest for a mate is so difficult when it seems so easy on television.

That raises an important question and the basis of this post: Is dating a game? If so, are there specific rules and winners and losers? Are relationships games as well? If not, how do they differ?

If the goal is meeting your soul mate, then dating presents a platform to discover potential partners. Assuming that both individuals share this common goal, often the approach is more deliberate than casual dating. So what are the parameters of a deliberate approach? Are there secrets that once revealed will minimize the heartache that results from incompatibility? Are there really systematic processes that, if followed, will guarantee a proposal within a year of dating? 

Let’s begin with a brief synopsis of the self-help section on dating/relationships. Here is where many singles begin their search for answers. A quick survey reveals two themes among male authors: instructing women how to catch a man (is that similar to catching a fish?) or a more serious topic of what qualities identify a woman as a keeper (sorry, another fishing metaphor). There are so many conflicting suggestions! “Why Men Marry B*#&*$@” and apparently, why they also fall in love with them. Then there are books/podcasts/videos written by self-proclaimed bad boys serving as both a warning and an enticement. After following the steps (aka traps) and attending a very pricey seminar, you too will catch your own bad boy and ride off into the sunset on his chopper. Finally, there are the male relationship coaches turned authors, who claim that there are essentially three qualities that you must possess for a man to commit to you (i.e., “you become a keeper”). Really? It only takes a year subscription and a few seminars to suddenly possess these qualities? If only it was that simple!

Next is a category for women by women. I will make a very simplified distinction of subsets within this category: (1) Love yourself the way you are and love magically follows; (2) Change yourself (diet, exercise, plastic surgery) then love magically follows; and (3) Commit based purely upon his assets and/or potential access to those assets and who cares if love follows. The operative word in the first two subsets is magically. While love may feel magical, it is not magically bestowed upon you; dating is relationship building and that involves compromise and a personal commitment to growth. If it were a simple process this industry would not enjoy such success!

Are all of these how to strategies without merit? Absolutely not! Many of them make solid points but lose their validity by overpromising success. As a consumer, I would be very wary of taking relationship advice from a professional who has not yet experienced a successful relationship. That being said, I have not found one source that provides a comprehensive strategy that I would endorse in my practice. Why? Quite simply, one size does not fit all. 

Again, dating and relationships are not without challenges! They were not simple as teenagers and they certainly become more complicated as we re-emerge as adults. Unresolved pain we carry into a new dating experience and/or potential relationship increases the likelihood of disappointment and eventual heartache. No book, video or podcast can guide you through the process of self-awareness and eventual healing. That is a process that requires commitment and consistent effort. 

Equally relevant is the faulty belief that we are “perfect” and the right mate will recognize that. I agree that the essence of our personalities needs to be appreciated! But make no mistake: acknowledging that we have much to offer a potential mate does not constitute a free pass to forego ongoing improvement and maintenance of our intellect, our emotional stability, our appearance, our social skills and our overall health. The laws of attraction assert that interesting individuals attract interesting individuals! 

My original question was whether dating is a game. It very well may be if that is your choice. Base your decision on an honest evaluation of your motives. If you then choose to view dating as a game, seeking advice from experts who attempt to positively impact your relationship potential would be an unproductive endeavor.

However, if you are seriously seeking a relationship and have not been able to connect, here are a few suggestions: (1) Consider stepping away from the dating scene for a while; (2) Get into a professional relationship with a psychologist and explore your emotional barriers. Heal from your past relationships. Bolster your self-confidence by getting to know yourself better; (3) Give the self-help materials a well-deserved break. At some point they become overwhelming! (4) Get healthy: try a new sport or hobby because it interests you; and (5) Learn to feel comfortable being alone: Once you like that person, others will be drawn to you as well. 

From my perspective, dating can be fun without making it a game. While love is never a game, the journey needs to be fun! Listen to your heart, do the work to make yourself the best possible you, consider it an adventure rather than your life's mission, and never give up hope!