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CA S E 4
Attention Problems or Distracted by Life?
Colby, a 14-year-old teenager in the ninth grade, came to the clinic accompanied by his
mother, Tina. The appointment had finally been booked after Tina found Colby’s midterm
report card crumpled in the garbage can.
Not only was he failing one course, he was performing miserably across all subjects. When
confronted, Colby lashed out at her, saying it was her fault, and ran out of the house. Tina
admitted to running down the street after him, yelling like a “maniac.” It was at this point that
she realized that things had gotten out of control and that she needed help with Colby. His
academic performance and temper outbursts were getting worse and worse. Tina explained
that she also felt less able to cope with circumstances lately, due to her recent separation from
her husband, Josh. Colby and his 7-year-old sister, Susy, continued to visit with their father
every Wednesday and every second weekend.
Colby’s parents both have university degrees. Tina works as an advertising ac:;:count execu~
tive and Josh is an entrepreneur.
DEVELOPMENTAL HISTORY/FAMILY BACKGROUND
Despite a normal and full-term pregnancy, Tina stated that the labor was lengthy (12 hours)
and ended with a forceps delivery. Tina reported that she was under a lot of sttess during her
pregnancy due to marital conflicts and admitted to smoking and having an occasional drink
during the pregnancy. Colby weighed 6 pounds, 2 ounces, and although somewhat underweight, he seemed to be in good health at birth. The first three months were very difficult for
Tina and Colby due to Colby’s sensitive digestive system. After eating, Colby would often have
bouts of projectile vomiting, diarrhea, and colicky behavior. Although Tina tried to nurse
Colby, he was constantly hungry (feeding every two hours), and after six weeks, the doctor
felt that Colby and mom would both be better off if he went on formula. Eventually, Colby
settled into a better routine, although digestive problems and poor sleep patterns continue to
72 PART A: PROBLEMS OF ATTENTION AND SPECIFIC LEARNING DISORDERS
be areas of difficulty for him, especially when under stress. On occasion, Colby will complain
of stomachaches and ask to stay home from school. He also has difficulty both falling asleep
and staying asleep. On many nights, Colby is still awake when Tina goes to bed, which is
Developmental milestones were achieved within normative expectations, with the excep~
tion that Colby started to read spontaneously at 2 years of age. His first sight word was
“Sears”; he pointed to the catalog after seeing a commercial on TV. After that, he started
recognizing labels and logos on billboards and on the television. He was able to read printed
words on paper by about 2 _I_ years of age. Language skills also developed rapidly, and Colby’s 2
conversational skills were very advanced by the time he entered nursery school.
Although Colby’s health has been generally good, he had a severe outbreak of hives at 5
years of age (source never detected) and was placed on an elimination diet for one month,
during which time his food was restricted to rice and lamb broth. Colby has never been hos~
pitalized, although he does have a tendency to be accident prone and has experienced cuts,
scrapes, and bruises from falls and bike accidents. Colby’s hearing and vision have both been
assessed. Hearing is within normal limits, and glasses have been prescribed for distance vision.
When asked about family history, Tina noted that Colby’s maternal grandmother has
always been an anxious woman who has many fears and who has been on medication for
depression. Colby’s maternal grandfather was a heavy drinker and often became aggressive
and physically abusive to his wife and eldest son. Colby’s maternal grandfather also had
Parkinson’s disease and eventually died after a lengthy battle with Alzheimer’s. Tina feels that
her mother also likely suffers from post-traumatic stress disorder (PTSD), due to the violence
in the home. Although Tina’s parents lived some distance away, Colby has maintained contact
with his grandmother through her biyearly visits. Tina is herself an anxious woman who was
a witness to domestic violence. Colby’s paternal grandmother and grandfather are deceased
and, according to Tina, there was no known pathology. There is a paternal uncle who has
problems with alcohol and is also believed to have some psychotic features (hallucinations
and delusions). He is unable to support himself, is currently on assistance, and is basically
estranged from Tina’s husband.
Tina described her marriage of 15 years as very turbulent. There was a previous marital
separation due to Josh’s infidelities, about eight years earlier; however, Tina discovered that
she was pregnant with Susy and they reconciled the marriage. Tina was never able to rees•
tablish a sense of trust in Josh, and their relationship continued to slide. During the past year,
the children had been exposed to many arguments and verbal accusations that centered on
Josh’s denial of any infidelities. Although Tina and Josh had been living in the same house for
the past year, they slept in separate rooms. Six months ago, the house finally sold, and they
moved into separate quarters. Tina has been Seeing a counselor for the past year.
REASON FOR REFERRAL
Colby presented himself as an articulate and well-mannered adolescent. According to Colby, ‘
his mother got very upset and angry when she found his report card. He wasn’t eager to share
it with her, because she got very angry at him after the parent-teacher conference in January,
He described the parent-teacher conference as embarrassing and frustrating. First of all, bo
Colby Tyler 7 3
his mom and dad were present and were throwing cold stares at each other across the room.
All his teachers were in the room at the same time, and he felt like he was on trial. Only one
teacher-his English teacher, Mr. Brighton-had anything good to say about him. The other
teachers made him angry by saying that he wasn’t trying, wasn’t motivated, and didn’t care
about his schoolwork. Mrs. Fischer said that most times Colby wasn’t prepared for class and
didn’t even bring his text with him. All accused him of wasting his potential. After all, Colby had
been identified as a “gifted” student as part of the Grade 4 screening for the Gifted Program.
Colby’s IQ was 147. However, in spite of all this intelligence, Colby had never really been a
shining academic. In elementary school, Colby managed to get by with the little amount of effort
he put in. However, Colby began to really slide academically when he entered Grade 9. Currently,
Colby’s grades are well below what would be expected, and he may not pass chemistry at all.
Colby is up most nights until very late, and he can’t get up in the morning. He has been
late many times, and the school counselor has called Tina often to complain about Colby’s
Historically, Colby has always had problems sleeping. As a consequence, getting ready for
school in the mornings had been problematic, with one exception. One day a week, when
Colby attended the Gifted Program, he would have no difficulty getting up or being on time.
The Gifted Program was Colby’s favorite day of the week, and Colby was noticeably distressed
upon learning that the Gifted Program would not extend into the secondary school level.
The level of Colby’s intelligence was evident in his articulate conversational style and the
depth of his knowledge in areas of interest, such as computers. He was an engaging youth who
was very captivating. However, as the conversation turned toward academics, Colby’s entire
d~meanor changed, and he became very quiet. Tina addressed the issue of homework, which
. was a constant source of frustration for both of them. Colby seemed to have tremendous dif~
ficulty staying on task; everything was a potential distraction. Little things, such as the telephone ringing or a noise outside, would be enough to break Colby’s concentration, and once
off-task, it was very difficult to get him back on track. However, when Colby was playing
computer games, he was riveted to the screen, and it would become very difficult to disengage
Colby from the task. Tina could not understand how Colby could be so intensely focused when
interested in something and so distractible when interest level was low. Like Colby’s teachers,
Tina thought it was a question of motivation. Tina described how Colby would begin each
academic year motivated and excited about school: new binders, pencils, and so on. Within a
matter of weeks, however, old patterns would return and Colby would begin sleeping in,
assignments would remain incomplete, and pencils would be lost or misplaced. According to
Tina, Colby was the master of good intentions. Although Colby would often start projects with
great enthusiasm, he had considerable difficulty sustaining this effort over the long haul. The
Gifted Program was the only place where Colby really seemed to do well.
When asked what was so special about the Gifted Program, Colby said the teacher was
fantastic, most of the kids were great, and they did a lot of computer work and mind-bender
logic games. Tina interjected that she had talked at length with the teacher of the Gifted
Program, who described Colby as a great kid and a wonderfully creative and divergent
thinker. The teacher of the Gifted Program thought that one of Colby’s difficulties might be
that he had so many ideas that it was very hard for him to put things down on paper. He had,
as she described it, “an explosive mind for brainstorming.” Colby said that outside of the
Gifted Program, it was difficult to concentrate and focus. When asked what helped to clear
7 4 PART A: PROBLEMS OF ATTENTION AND SPECIFIC LEARNING DISORDERS
his head and give him a better ability to stick with something, he immediately said, “Walking
or riding my bike in the park.” Colby explained that sometimes he had the clearest thoughts
just walking by himself on the golf course. He wished he could bring that kind of focus into
When asked about temper outbursts, Tina said that at times, Colby seems incredibly
patient, and she saw this behavior at its best when he was tutoring younger children in a
reading program and giving golflessons. However, at other times, Colby could be highly reactive and respond with a short fuse. At these times, Colby would be more prone to take things
personally, be less responsive to logical reasoning, and be in a highly aroused state. When in
this aroused state, it would not be possible to reason logically with Colby until he settled
down, which could take a while.
According to Colby’s mother, behavioral outbursts had increased since the marital breakup.
Tina stated that Colby has never adapted well to change and that the emotional split and
physical move have likely added to the intensity of Colby’s reactions. Having to shift between
two households was not easy for Colby, especially in light of his problems with losing things
and misplacing his notes. Colby now seemed even more disorganized than before. Tina also
wondered whether Colby, at some level, somehow blames himself for the split.
When asked about the separation, Colby said very little. He said that his little sister was
upset because he got to choose where he wanted to live and she didn’t. He said she doesn’t
understand: “It’s awful to have to choose.” Colby said his dad asked him why he chose to be
with his mom, and he said, “Because she is closer to school.” Colby said that his dad called
him “shallow.” According to Tina, Colby has a tense relationship with his father because Josh
tries to compete with Colby instead of supporting him. Tina said she is afraid that unless
there are some answers as to what is going on with Colby at this stage, Colby may end up
having real problems. As it is, he can get very angry and flare up in a second, and this is really
beginning to worry her. In response to that comment, Colby just looked at his mother and
said, “I have been living in a house that is like the movie The War of the Roses … and you
wonder why I get angry.”
Guidelines for the interpretation of standard scores and T scores are available in Appendix C,
as are descriptions of the assessment instruments used in the current assessment as well as
other resources. Colby’s case serves as the prototypical case for this book, and with this goal
in mind, actual test scores for each assessment measure and anecdotal examiner comments
are available in Appendix A, along with scores for the assessments of three other children
(Scott Michaels, Shirley Yong, and Arthur Watson). In addition, there is an in-depth discussion
in Appendix A. concerning how the clinician arrived at the case formulation for Colby based
on differential diagnosis: evidence in support of a diagnosis of attention~deficit/hyperactivity
disorder (ADHD; primarily inattentive type) and the rationale for ruling out other comorbid
or competing diagnoses. There is also a written report wherein the clinical psychologist
reports and shares her clinical and diagnostic impressions of Colby based on the assessment
results. Since there is significant supplemental information for this particular case in
Appendix A, the summary of assessment results in this chapter will be relatively brief.
Colby 1yler 7 5
Responses to the Wechsler Intelligence Scale for Children confirmed overall intellectual
functioning within the very superior range (full-scale IQ of 147; range 141-151), with minimal difference noted between standard scores for the Verbal Comprehension Index (VCI =
155; range 145-158) and Perceptual Reasoning Index (PR!= 149; range 137-153). Colby’s
overall IQ score places him within the top .1 % of the population (99. 9th percentile). However,
his scores were not evenly distributed among the different aspects of the IQ profile. As might
be anticipated, although within the superior range, Colby’s score of 129 on the Working
Memory Index (range 119-134) was significantly below his VCI and PR! scores, while his
score of 103 on the Processing Speed Index (range 94-112) was severely impaired relative to
all his intellectual scores. Slow speed of psychomotor responses noted on paper-and-pencil
tasks was accompanied by fatigue, awkward writing style, and ease of distraction. Despite
adequate core academic skills (reading, spelling, math calculations), Colby had significant
problems organizing his ideas when asked to write a short paragraph. Colby had difficulty
getting started on the task, changed his topic many times, and, after approximately IO minutes, ultimately produced a very short but well-written passage of two lines.
Colby’s mother completed the Conners Parent Rating Scale and the Child Behavior
Checklist. Significant elevations were noted on scales of Somatic Complaints, Anxious~
Depressed Mood. and Attention Problems. Teacher responses on the Thacher Report Form
also noted significant Somatic Complaints, and significant problems with Inattention and low
frusttation tolerance (Emotional Liability) were noted on the Conners Thacher Rating Scale.
Colby’s self-ratings on the Youth Self-Report, Conners-Wells Adolescent Self-Report Scale,
and Beck Youth Inventories revealed significant elevations for Internalizing, Inattentive
Behaviors, and Low Self~Concept and significant elevation of Depressed and Anxious Moods.
Further assessment with the Children’s Depression Index ruled out significant depression or
ISSUES, TRENDS, AND ALTERNATIVE TREATMENT METHODS
ADHD is a commonly diagnosed neurodevelopmental disorder, with between 3 % and 5 % of
school-age children meeting criteria for the disorder (American Psychiattic Association [APA],
2013; Barkley, 1998). Although once thought of as a childhood disorder, it is now estimated
that between one-third and two-thirds of children with ADHD will continue to exhibit symptoms of the disorder throughout their lifetime (Wender, Wolf, & Wasserstein, 2001), with
prevalence rates in adulthood around 2.5% (APA, 2013). Although hyperactivity and impulsivity decline with age, inattention and distractibility are likely to persist (Larsson, Lichtenstein,
& Larsson, 2006) at a time when the educational setting is becoming more demanding
(increased workload and expectations) and complex (multiple teachers) and requires more
self-discipline and organization (Barkley, 1998).
Adolescents with ADHD are at increased risk for academic problems. difficult interpersonal
relationships, Jow self-esteem, and car accidents and have a higher incidence of psychiatric
disorders, substance use disorders, and antisocial behavior (Grenwald-Mayes, 2002; Thompson,
Molina, Pelham, & Gnagy, 2007). Mannuzza and Klein (2000) found that children who demonstrate deficits in social skills and self-esteem continue to experience difficulties in these areas
throughout adolescence and adulthood. Although there has been significant research and
7 6 PART A: PROBLEMS OF ATTENTION AND SPECIFIC LEARNING DISORDERS
theoretical emphasis devoted to the primarily hyperactive-impulsive type of ADHD (Barkley,
1997), less is known about the predominantly inattentive type of ADHD, which has only been
recognized as a separate type of disorder since the DSM-III(APA, 1980). The DSM-5 (APA, 2013)
has included increased descriptions of how symptoms may manifest in adulthood (e.g., work
is inaccurate; has poor time management; fails to meet deadlines; problems reviewing lengthy
papers; misplaceslloses important items, such as keys, mobile telephones, etc.). The number of
symptoms required for a diagnosis in late adolescence (17 years or older) and adulthood has
been reduced to five symptoms (six are required for children) from a list of nine possible symp,
toms in the inattentive or hyperactive/impulsive symptom categories (APA, 2013, pp. 59-60).
Medication as a Treatment
From a neurobiological perspective, ADHD has been associated with low levels of the cat,
echolamines (dopamine, norepinephrine, epinephrine). neurotransmitters that impact atten~
tion and motor activity. Dopamine is especially important, since pathways usually rich in
dopamine (such as the prefrontal cortex) are underactive in brains of individuals with ADHD
(Barkley, 1998). The most widely researched treatment for ADHD is the use of stimulant
medication. The most commonly prescribed medications for ADHD are methylphenidate
(Ritalin), dextroarnphetamine (Dexedrine), and pemoline (Cylert), which act to increase the
number of catecholamines in the brain. Each of these medications has been demonstrated to
be effective in reducing the symptoms of ADHD in numerous clinically controlled trials
(Greenhill, 1998; Spencer et al., 1995). Recently, a nonstimulant medication, atomoxetine
(Strattera), a selective norepinephrine reuptake inhibitor, has met with FDA approval for ADHD.
Although some parents are concerned that giving their child medication for ADHD can result
in a gateway phenomenon, leading to abuse of other types of substances later on, most research
supports the opposite conclusion. Adults with ADHD who were not treated are more likely to
abuse substances later in life compared to those whose ADHD was managed medically in their
youth (Biederman, Wilens, Mick, Spence~ & Faraone, 1999). Wilens (2001) found youth with
ADHD who took medication had lower rates of substance use (marijuana, cocaine, alcohol)
compared with controls. Howeve~ Molina and Pelham (2003) conducted an eight-year follow-up
of chlldren and youth with ADHD and found higher levels of substance use across all substances
(alcohol, tobacco, illicit drugs) compared to peers without ADHD. Surprisingly, the greatest sub,
stance use was related to the severity of attention problems, not impulsivity-hyperactivity. as had
been noted previously (Barkley, DuPaul, & McMurray, 1990). However, in their longitudinal study
of drug use outcomes for youth, August and colleagues (2006) found that youth with ADHD who
also demonstrated externalizing problems had significantly worse drug outcomes (frequency of
use and substance disorders) than those with ADHD-only or community controls, suggesting that
ADHD without externalizing problems is not an increased risk for drug problems.
Although medication has been proven effective in reducing symptoms of inattention,
impulsivity, and hyperactivity, effects have not consistently been demonstrated to carry over
to other areas such as social relationships or academic achievement (Pelham, Wheeler, ~
Chronis, 1998). There has been significant controversy regarding the overuse of stimula11f
medication for children with ADHD (Diller, 1996). Although research has supported the us~
of methylphenidate (Ritalin) as a performance enhancer for children and adults with ADHIJ;\-
it has been estimated that the use of stimulant medication has increased as much as 3001’1′ . since 1990 (Hancock, 1996; Robison, Sclar, Skaer, & Galin, 1999). Although a recent study: O · ,
Colby ‘fyler 77
prevalence rates for primarily inattentive, primarily hyperactive, and combined subtypes of
ADHD conducted in Tunnessee (Wolraich, Hannah, Pinnock, Baumgaerrel, & Brown, 1996)
revealed 4.7%, 3.4%, and 4.4%, respectively, as many as 10% to 12 % of all boys in the United
States are currently taking Ritalin for ADHD (Leutwyler, 1996).
In part, the tendencies to overprescribe medication may result from the fact that the core
symptoms of inattenti.on, restlessness, and impulsivity found in ADHD also occur in other disorders, such as anxiety, learning disorders, childhood depression, bipolar disorder, and PSTD.
There is also evidence that only one-third to one-half of children diagnosed with ADHD by their
pediatrician have had any type of psychological or educational assessment to support the diagnosis (Leutwyler, 1996). More recently, Reich, Huang, and Todd (2006) studied treatment patterns for a large sample (1,555) of twins diagnosed with ADHD and found that 60 % of boys and
45 % of girls who met full diagnosis for ADHD were on stimulant medication, while 35 % of the
sample was receiving stimulant medication but did not meet DSM criteria for ADHD.
Multimodal and Alternative Treatment Methods
Some children may be unable to tolerate the side effects of medications for ADHD, or some
parents may opt for alternative methods to treat the disorder. For these reasons, and the wide
range of possible negative outcomes for children and youth with ADHD, the management of
ADHD will often require a multimodal approach, combining psychosocial approaches in lieu
of or conjoint with medical interventions. Other forms of treatment that have been used to
treat children and youth with ADHD include behavior modification and contingency management in the classroom, cognitive behavior modification (CBM), parent training, and a variety
of coaching techniques (Goldstein, 2005; Hallowell, 1995; Pelham et al., 1998).
There are many examples in the research literature of attempts to justify the use of CBM
for children with ADHD in programs designed to increase verbal self-instruction, problemsolving strategies, cognitive modeling, and self-monitoring. The underlying premise in these
approaches is that training in problem solving will assist children with ADHD to manage
behavioral self-control better (Hinshaw & Erhardt, 1991 ). However, while initial results of
CBM were encouraging, more recent evidence suggests that CBM in isolation does not
enhance outcomes for children with ADHD (Pelham et al., 1998).
In collaboration with the National Institute of Mental Health, the MTA (multimodal treatment study of ADHD) investigated treatment alternatives for ADHD in six independent
research centers. The investigators compared medical management alone (MEDMGT), behavioral modification (BEH), combined treatment (COMB), and a community comparison (CC).
The BEH and CC groups did not receive medication. At the completion of the study, only the
MEDMGT and COMB groups demonstrated symptom reductions (Swanson et al., 2001).
However, follow-up at 14 months revealed that the effect size was reduced by 50 % , while
follow-up at 24 months revealed further deterioration. Within-group analysis revealed the
greatest deterioration was for those who took medication as part of the study but discontinued after the study was completed, while the greatest long-term reduction in symptoms was
for those children who were not medicated during the study, but who began taking medication once the study was completed (MTA Cooperative Group, 2004). One important side effect
for the group who took medication the longest (throughout the study and remained on
medication throughout the follow-up periods) occurred after the first two years; they demonstrated a 20 % reduction in stimulant-related height gain (approximately 2 cm.) compared
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