Until he hit fifth grade Matt was the kind of child I rarely see professionally. Outgoing, athletic, good-natured, and active, he was also extremely bright. He was the child his teacher chose to read stories to the first graders or to peer-tutor a classmate in math. He tackled difficult spelling words with ease and did his homework in a matter of minutes. He felt great about himself. This is what I gathered from him and his parents during their first visit. His father had called to make an emergency appointment, so I waited to hear about the sudden onset of a really alarming symptom.
But it turned out that Mr. Matthews was a high-expectations, excitable kind of guy. The trouble with Matt wasn’t an emergency, it was a gradual slide into confusion. Now that this skinny, brown-haired boy was in middle school the number and complexity of his assignments caused him to be massively disorganized. His grades were slipping; his work was half done. He’d left his library books on the playground and it rained overnight and they were ruined. He’d lost the check he was supposed to take his teacher to pay for an upcoming field trip. He was always in trouble for failing to complete assignments. He was no longer regarded as the smartest kid in the class. Often he hadn’t read the material and didn’t know the answers. “I feel terrible about myself,” Matt said candidly, “but I don’t know what I’m doing wrong all of a sudden and I don’t know how to fix it. I feel—“ he made a swirling motion with his hands—“like there’s just too much going on.”
We did a careful evaluation and also observed Matt during the school day. The evaluation confirmed that Matt was extremely bright. Compared to how bright he was, he had a relatively slow processing speed, although it was still above normal. His writing skills were also less well developed than one might expect from his I.Q. He had a slight Attention Deficit Hyperactivity Disorder and some impulsivity. But his greatest challenge was in Executive Function.
Executive Function is the ability to organize and to plan and to allot one’s time appropriately to different tasks. It is a set of activities based in the frontal lobes. This is the last part of the brain to myelinate, which means to develop a fatty sheath over the neurons that speeds up the transmission of signals. In some individuals this process is not complete until the mid-twenties, and while it is incomplete the individual is far less capable of planning and organizing. That is why when Matt was writing, despite excellent language skills, he had difficulty framing an argument or summarizing a plot. It was why he lost things, forgot things, and failed to complete assignments. The mild ADHD of course didn’t help.
When I met with the Matthews family to convey these results, I indicated a twofold approach to treatment. First we would try a behavioral approach consisting of extensive tutoring in Executive Function skills. Depending on how Matt was doing, we would then consider adding medication to address the ADHD. The always impulsive Mr. Matthews actually leapt to his feet to protest the uselessness of tutoring. He wanted a more intensive dose of medication “to fix this immediately. “Let’s do the meds and then see if he even needs coaching,” he demanded.
I said no. “It would be better to start with organizational support, because that’s where the real deficit is.”
Mr. Matthews wouldn’t agree.
“There are plenty of people who will do what you want,” I told him, “but I’m not one of them.”
That was the last I saw of Matt and his family for a while. But after a few months I got a call. Matt’s pediatrician had prescribed drugs for ADHD and his attention had improved “somewhat.” But his school performance was as inconsistent as ever—a sad litany of lost assignments, homework undone, the wrong page of math problems turned in, notebooks left at home, textbooks missing. He loved soccer, but kept showing up without the right shoes or his shin guards. He wanted to do well. But he needed more help than he was getting to keep it together. Or as Matt put it, with rueful humor, “Now I can really pay attention to how I’m screwing up.”
This time, Matt’s dad allowed me to prescribe sessions with an organizational tutor, who started patiently to build the kind of support – good habits, mental associations, lists and color-coding– that would allow Matt to get things done. Matt’s school was really helpful, and allowed the tutor to suggest ways that the process of getting organized could be enhanced. Within a few months, there was substantial improvement, largely because Matt was whole-hearted about trying to use the techniques he was taught. “I embrace the list,” he joked, “I embrace the chart.” After a moment, and in a changed voice he added, “And it’s working. I feel like myself because I’m doing okay again.”
A few months later I got a note from Mr. Matthews thanking me for the clarity of my approach and telling me that he now had an Executive Function coach too, who was really helping him to get things together at work.