Richard Drake, the father of my nine-year-old patient James, shifted irritably in his seat, as if the diagnosis I had just mentioned in relation to his son, Attention Deficit Disorder, was something the parent just couldn’t sit still for. “That makes no sense to me,” Mr. Drake burst out. “I know James has a problem. His teacher says if nothing changes he’s really going to have a hard time with fifth grade. But it’s more of a discipline thing. I ask James to take out the trash. Half an hour later, he’s emptied one wastebasket, and he’s standing next to the sink playing with a Gameboy.
"His mom tells him to get ready for bed, and she finds him sitting on the floor, half dressed, building something with Legos. His teacher says she gave the class an assignment, and he lifted the lid of his desk to get out some paper, and found his library book, and just sat there reading, with the desk lid up, while everybody else got to work. My question is: if he has an attention deficit disorder, why is he able to pay so much attention to the stuff he likes?”
This is a question I often hear from parents whose children seem to have an endless ability to concentrate on the things they care about, but no steadiness of purpose when it comes to what is required of them.
“The role of motivation is huge when it comes to attention,” I told Mr. Drake. “And to help James we’re definitely going to have to use that. One way is to say no screen time until after homework, for example. But you’re right. It seems paradoxical that a child who has trouble paying attention can literally spend hours playing a video game. It’s one of the reasons that some neurobehavioral experts think that instead of talking about Attention Deficit Disorder; it would be more accurate to say that some children have attention regulation issues, and both over-focus and under-focus. They have trouble fine-tuning it to the appropriate level.”
An assessment showed that James did indeed have attentional issues of two kinds: he had trouble sustaining interest and had difficulty switching from one activity to the next. I suggested that he receive a combination of behavioral therapy and medication. His parents were hesitant about the meds and so we worked on ways, in addition to his therapy, that James could learn to maintain focus. Instead of giving James chores to do, his parents did household tasks with him. They created a homework routine that James gradually learned. He did improve, although he still tended to zone out at school, particularly in math. His father had gained a lot of insight over the course of the year and now said sympathetically, “James finds math particularly difficult. I know it’s hard to focus on what you don’t understand and feel bad about.” Thinking about what might motivate James, his father rephrased all his son’s story problems in terms of Harry Potter. It actually helped a lot.
His parents and teachers had made good efforts to motivate James and his issues with attention had improved noticeably. But going into fifth grade meant moving to a system where children changed classrooms for different subject areas. James completely fell apart. He lost things, forgot things, started to slip behind academically, and called himself “stupid” when he made mistakes. At this point, his parents decided to try medication.
But this in no way meant that behavioral therapies and changes at home and in the classroom hadn’t been useful. His parents had learned to make the effort required to help James become more focused, and James appreciated it. They felt much closer. And because he had worked for the better part of a year on improving his performance, he valued the effectiveness of his medication. “I concentrate better, so I learn more, so it’s more interesting, so it’s easier to concentrate,” he told his mom. “It’s a vicious cycle – but for the good.”