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Attention Deficit DisorderThe Unfocused Mind in Children and Adults
By Thomas E. Brown
Yale University PressCopyright © 2005 Thomas E. Brown
All right reserved.
Chapter OneMisconceptions about Focus and Willpower
MYTH: ADD is just a lack of willpower. Persons with ADD focus well on things that interest them; they could focus on any other tasks if they really wanted to.
FACT: ADD looks very much like a willpower problem, but it isn't. It's essentially a chemical problem in the management systems of the brain.
Most individuals who suffer chronically from an impaired ability to pay attention are able to focus their attention very well on activities that interest them. So why can't they pay attention during other activities that they recognize as important? To answer this riddle, we have to look more carefully at the many aspects of attention, recognizing that processes of attention in the human brain are more complex and subtle than we might have imagined. One way to understand the complexity of attention is to listen carefully to patients with ADHD as they describe their struggles with inattention. Meet a patient of mine, a teenaged hockey player whom I'll call Larry:
Larry, a sturdy, sandy-haired high school junior, was sitting in my office with his parents as we began ourfirst session together. While introducing the family, the parents mentioned that Larry's hockey team had just won the state championship. Proudly they told of how well he had played. As goalie he had successfully blocked thirty-four shots in the championship game and led his team to victory. Larry smiled modestly, but with obvious and well-deserved pleasure.
Then Larry's father stated their dilemma. "When he is playing hockey, Larry is amazing in how he pays attention to all the action. He knows where that puck is every second. He protects the goal and at the same time he watches what the other guys are doing and helps keep his team organized and motivated. He is always totally involved and on top of his game."
"But at school," his father continued, "it's an entirely different story. We know that Larry is very bright. His IQ test scores show he's in the superior range, in the top 3 percent. Usually he scores high on semester exams and he did very well on the PSAT, but his day-to-day work and his report card grades are always up and down, from A+ to almost failing."
"We know Larry wants to get good grades. He's always talking about how he wants to become a doctor and how he needs to get his grades up so he'll get into a good college and then medical school. But for years he has been totally inconsistent in his schoolwork. Once in a while we see him burning the midnight oil to do some reading or write a paper, but most of the time he procrastinates and avoids his schoolwork. We're constantly getting complaints from his teachers, the same frustrations every year."
"They say that once in a while Larry will make some comment in class that shows how smart he is, how well he understands whatever they are working on. Once in a while he'll write an excellent paper or do an amazing job on an assignment. But most of the time, the teachers are complaining that Larry is uninvolved and out to lunch. He's not a behavior problem, but he is gazing out the window or staring at the ceiling. They say that in class discussions he often doesn't even know what page they are on. And we're always getting reports that his homework is late or just not done."
"How can Larry be so amazingly good at paying attention to his hockey, and yet be so amazingly poor at paying attention to his schoolwork?"
Larry had been staring at the carpet as his father spoke, but then he raised his head. His eyes were moist as he quietly said to his parents, "I don't know why it keeps happening. I'm just as frustrated and even more worried about this than you are. When I saw my last report card, I went to my room and cried." "I know what I have to do and I really want to do it because I know how important it is for all the rest of my life. I try to get into it like I'm into hockey. Sometimes I can get into it for a while, for this assignment or that class. But mostly I just can't make it happen."
"I really want to, and I know I should be able to do it; I just can't. I just can't make myself pay steady attention to my work for school anywhere near the way I pay attention when I'm playing hockey."
A very similar dilemma was experienced by Monica, a shy girl in fifth grade who hung her head as her mother angrily described to me her problems in school.
Her teachers say she can't pay attention for more than three minutes at a time. I know that's not true! I've watched her play Nintendo. She can play those video games for three hours at a time without moving. And the teacher says she's "easily distracted." That's nonsense! When she's playing those video games she's locked onto that screen like a laser. When she's into those games the only way you can get her attention is to jump in her face or just turn off the TV.
I've done everything I can think of to get her to shape up in school. I've gotten daily reports from school and praised her when she did well. I've tried to bribe her with rewards for good work. I've tried punishing her, taking away her Nintendo or making her do long time-outs in her room. None of it works. I know she can pay attention when she really wants to. I don't know what else I can do. She's not a dumb kid and she's not a bad kid, but if she doesn't start paying attention to her schoolwork pretty soon, she's never going to do any better in school than I did. I never finished high school and I really regret it. I want something better for her. If only I could get her to pay attention to her schoolwork the way she pays attention to those video games.
Everyone I've ever evaluated for chronic problems with inattention has some domains of activity where they can pay attention without any difficulty. Some are artistic; they intently sketch and draw. Others are childhood engineers constructing marvels with Lego blocks and, in later years, repairing car engines or designing computer networks. Some others are musicians who push themselves for hours to learn chords for a new song or to compose a new piece of music.
Attention and "Willpower"
The examples of Larry and Monica bring us back to the central riddle of chronic inattention: How can someone who is very good at paying attention for some activities be unable to pay enough attention to other tasks that they know are important and really want to accomplish? When I have asked this question of patients with ADHD, most answer with something like: "It's easy! If it's something I'm really interested in, I can pay attention. If it's not interesting to me, I can't pay attention, regardless of how much I might want to."
Most people respond to this answer with skepticism. "That's true for anyone," they say. "Anybody's going to pay attention better for something they're interested in than for something they're not."
But for some individuals there is an important difference. When faced with something boring that they know they have to do, that's important to them, most people can make themselves focus on the task at hand. Yet some lack this ability unless the consequences of not paying attention are very immediate and severe. One middle-aged businessman, Henry, whom I had diagnosed with attention deficit disorder, once reported:
I've got a sexual example for what it is like to have ADD. It's like having impotence of the mind. If the task you are trying to do is something that turns you on, you're "up" for it and you can perform. But if the task you are trying to do is not intrinsically interesting, if it doesn't turn you on, then you can't "get it up." You can't make it happen. It's just not a willpower kind of thing.
Facets of Attention
What do we mean by "paying attention"? Over one hundred years ago, William James wrote:
Everyone knows what attention is. It is the taking of possession by the mind, in clear and vivid form, of one out of what seem several possible objects or trains of thought. Focalization, concentration of consciousness [is] its essence. It implies withdrawal from some things in order to deal effectively with others, and it is a condition which has a real opposite in the confused, dazed, scatter-brained state which ... is called distraction. (1890, vol. 1, pp. 403-404)
James held what I call "the spotlight theory" of attention: the notion that attention is a solitary, powerful beam focused by the mind on some "objects or trains of thought" (in James's words) selected from the many other perceptions and ideas that might otherwise be attended to in that same moment.
This "spotlight theory" is too simple. It describes only certain types of attention-visual attention, for example, in which one looks steadily at one point rather than flitting around aimlessly to see many different points, or simple auditory attention, in which one listens to one sound, or a series of sounds, while ignoring others. But when we look carefully at the descriptions of Larry and Monica, for example, we notice that they do many things at once. They are not only watching and listening to what is happening on the screen or on the ice, but also engaging in complex actions that may occur simultaneously or in rapid-fire sequence. As Monica plays her video games, she is not simply staring at the TV, but also actively monitoring rapid movements of many objects on the screen, deciding which ones might enrich or destroy her icon. She responds quickly by pressing control buttons and guiding her icon with adept movements of the controls. Monica keeps track of her score and her levels in the game, all while recalling and engaging strategies useful in earlier games. She also contains her alternating feelings of frustration and triumph so that she can attend to the game without overreacting to its ever-changing ups and downs.
Likewise, Larry's success on the hockey rink depends on multifaceted and simultaneously implemented aspects of attention. He not only tracks the puck in its quick movements around the ice, but also monitors his teammates and opposing players, trying to anticipate moves and to alert his defensemen to dangers and opportunities. Simultaneously, he keeps track of the passage of time-how many minutes or seconds are left in the period, or how soon a player will be released from the penalty box.
Larry also notices subtle cues of flagging effort in his teammates and calls out to encourage and challenge them. He stops himself from thinking too much about a goal he just blocked or one that just got by him into the net. He keeps in mind and tries to follow tips given by his coach in practice last week or during the momentary time out. And he tries to ignore provocative actions and comments from opposing players or spectators. All this and much more is included in Larry's paying attention while he is playing hockey.
Larry's father suggested even broader meanings of attention when he spoke of how Larry exercised year round in the gym to stay in shape for hockey and how he pushed himself hard to build strength, endurance, and skills during team practices. He elaborated on how Larry planned his daily schedule to be on time to every practice. And he told of how carefully Larry managed his equipment, keeping his skates sharp and his pads and uniform in good repair. He related how this boy attended special training clinics and studied plays of college and professional goalies so he could use their strategies to improve his moves on the ice. From this description it was clear that Larry gave intense and continuing attention to hockey in a wide variety of complex ways.
The Many Components of Inattention
If "attention" is more than just a simple "beam of focus," we can reason that "inattention" is multifaceted as well. When teachers and parents complained about Larry and Monica's poor attention to their schoolwork, they were not using a simple "focus the spotlight" concept of attention-that is, they were not complaining simply about these students not listening to the class discussion or not watching what was being written on the blackboard. They were talking about a much broader, more complex range of attentional functions.
Larry's problems with lack of attention to schoolwork included a chronic failure to engage himself with the various tasks of school. He reported not only excessive distractibility, but also chronic difficulty in getting started on assigned work; he would intend to do it, but procrastinate until it was too late. He told of poor planning, losing track of what readings were assigned or what math problems were to be done. This boy who was so careful with his skates and hockey equipment often lost his textbooks and couldn't find the notes he needed to do his homework. He told of how he often would start an assignment and then lose interest in it, setting aside the task to do something else and frequently not returning to it.
Larry also complained about his memory for schoolwork. Although he had become a virtual encyclopedia of statistics and other detailed information about many hockey players, he reported chronic forgetfulness about directions given by the teacher or the content of readings he had done for class. Often he was unable to recall for an exam information he had studied carefully and seemed to have mastered just the day before.
Larry said he often felt drowsy in class and while he was trying to read texts assigned for homework. He described how he had to struggle to stay awake in those situations, even when he had slept well the night before and was not overtired. This sluggishness was in sharp contrast to the heightened alertness he felt anytime he was thinking about or engaged in tasks related to hockey.
Inattention as a Disorder
When we look carefully at the details of Larry's chronic academic difficulties, it is clear that this boy's inattention is broad-based and complex. It includes problems of excessive distractibility, procrastination, difficulties in organizing his work, avoidance of tasks requiring sustained mental effort, insufficient attention to details, losing track of belongings, failure to finish assigned tasks, and excessive forgetfulness in daily activities.
What do all of these problems have in common? They are all impairments in facets of "attention"-impairments that are elements of what I describe in Chapter 2 as "ADD syndrome." And all of these chronic difficulties are listed among the inattention symptoms of the disorder ADHD in DSM-IV, the fourth edition of the diagnostic manual published by the American Psychiatric Association (2001). "Inattention" as it is described in DSM-IV is a broad term. Under its umbrella are a wide variety of cognitive impairments recognized as chronic, but not necessarily constant. The diagnostic manual notes: "Signs of the disorder may be minimal or absent when the person is under very strict control, is in a novel setting, is engaged in especially interesting activities, is in a one-to-one situation ... or while the person experiences frequent rewards for appropriate behavior" (p. 79).
Everyone experiences difficulty in exercising these various aspects of attention from time to time. But those who legitimately are diagnosed as having ADHD by DSM-IV criteria are persons who manifest ADHD symptoms "to a degree that is maladaptive and inconsistent with developmental level" (p. 83). In other words, they must have these symptoms to a degree that makes consistent trouble for them in ways that most persons of the same age and developmental level do not often experience. Moreover, the ADHD symptoms must produce "clear evidence of clinically significant impairment in social, academic or occupational functioning" (p. 84). That is, the ADHD must disrupt significantly the individual's schoolwork, employment, and/or relationships with other people.
Excerpted from Attention Deficit Disorder by Thomas E. Brown Copyright © 2005 by Thomas E. Brown. Excerpted by permission.
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