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By Jenny C. Yip, Psy.D. and Sarah A. Paxson, Psy.D.
Julie's parents and teachers are worried. She is in the 4th grade and falling behind in her studies. Although she has a complex vocabulary and demonstrates a high level of general knowledge, she is not performing to her ability in the classroom. She has difficulty copying off the board, consistently falls behind in her class work, is unable to complete tests within time limit, and spends an inordinate amount of time on homework.
Julie's teacher is concerned, because although Julie seems to have much potential, she appears disengaged in the lessons, and often stares out the window. She shows an interest in school projects; however, she often forgets to bring the necessary supplies to complete projects that she had been excited about. Julie herself reports that she gets bored easily.
Julie's parents and teachers have noticed that she also has difficulties in social interactions. She tends to keep to herself, and her parents note that she rarely brings friends home. Her teacher reports that she appears uncomfortable when given tasks that require her to lead the class in activities. Although she maintains a high interest in world events and will often talk about such events with adults and peers, she does not initiate social interactions and often waits to be approached.
A doctor has diagnosed Julie with Attention Deficit Hyperactivity Disorder (ADHD). However, even after following proper treatment protocols and taking medication appropriate for ADHD, Julie shows no sign of progress, and in fact, appears even more distracted. Julie's parents desperately want to help her before these issues further impact her learning and self-esteem. How do we get Julie on the right track?
To get Julie on the right track, we must determine the root cause of her behavioral manifestations. In other words, we know that Julie is experiencing academic and social difficulties and appears inattentive. However, why is she experiencing these difficulties? The fact is that many of Julie's symptoms can be attributed to any number of diagnoses, including ADHD, an anxiety disorder, or even giftedness. Thus, in order to put Julie on the right track, we must first accurately determine what it is that we are treating. In order to establish the correct diagnosis, we must uncover the reasons behind Julie's inattentiveness. Is Julie's inability to sustain attention due to her persistent distractions from worrisome thoughts? Does Julie have a hard time paying attention, because she often gets bored easily? Or is Julie's inattention due to her pure inability to attend to tasks? Each of these three possibilities gravitates toward a different diagnosis. Therefore, a proper diagnosis that allows for proper treatment is the first step to put Julie back on track to her full potential. On the other hand, a misdiagnosis or even a partial diagnosis- such as only diagnosing ADHD when both ADHD and anxiety are present- can actually lead to treatment that may exacerbate Julie's initial symptoms.
Let's take a closer look at Julie's symptoms, and break down the specific problems. First, we will go through Julie's difficulties with completing tasks on time. One of several reasons may contribute to her problems copying off of the board. For instance, an anxious child may be spending an abundant amount of time perfecting their handwriting, checking repeatedly that nothing is misspelled, or writing everything on paper so that it looks exactly as the board. In particular, children with Obsessive-Compulsive Disorder (OCD)- a specific type of anxiety disorder- may spend an inordinate amount of time on rituals associated with writing to ensure that all "rules" are followed exactly, such as making sure their handwriting slants a certain way, or erasing and rewriting a certain number of times. On the other hand, a child with ADHD may have difficulty copying off of the board, because he or she loses focus during the lesson and may not know what to copy. Still, a gifted child may lose focus and not know what to copy due to boredom and being disengaged from the classroom. The gifted child may also assume that he/she does not need to copy material from the board, only to realize later that he or she needs to reference those materials from the board. In each scenario, copying off the board becomes a time-consuming process. Consequently, the child's focus on the particulars of copying interferes with the processing of information taught during the lesson.
In terms of falling behind in class work, the anxious children tend to spend an inordinate amount of time reviewing and perfecting their work. The anxious child may also doubt and become worried that he/she fully understands the lesson taught, which results in time spent ruminating about a perceived ineptitude. Children with ADHD are often behind in class work, because they do not work steadily on assignments to completion. The ADHD child may become distracted and start a different project, or become restless and abandon the assignment altogether. Gifted children often procrastinate, in part because they know that they generally require less time to complete projects. However, this becomes problematic if the gifted child underestimates the time needed to complete the assignment. For the gifted child, procrastination may also signify anger for having to do the assignment, and may be a way of acting out.
Secondly, let's explore possible reasons behind Julie's inattentiveness in the classroom. Anxious children often disengage from lessons, because they are distracted from worries that may be unrelated to the lesson (e.g., ruminating over a poor test score just received, repeatedly checking for mistakes, mentally reviewing a previous interaction with a peer, etc.). A child with OCD may be fixated on a compulsion and not be able to refocus on the material being taught. In ADHD, inattention is a classic symptom that occurs because the child is not able to pay attention to the particular subject for a prolonged period of time. Children with ADHD are also less able to pay attention when the lesson is not interactive or when the lesson is taught to a large classroom. For gifted children, the material being taught is often not challenging enough, and thus, leads to boredom and disengagement. Nevertheless, paying little attention to the lesson plan can start a vicious cycle:
The child
- Is not engaged
- Does not learn the material
- Becomes discouraged because he/she now can not follow the lesson
- Pays less attention/ becomes less engaged
- Learns less
Therefore, it is important that we discover the reasons behind Julie's inattentiveness, so that we can implement measures to help her stay on task and learn the material.
We also noted that Julie often forgets her materials for projects. Anxious children may be so focused on a school project at the micro level that he/she becomes oblivious to the gestalt or "big picture." For instance, an anxious child may be completely concentrating on creating an exact replica of an Egyptian pyramid and forget other supplies necessary to present the project, such as note cards. Children with ADHD are typically disorganized and often forget the necessary supplies. If not written down, the child may even forget the homework assignment altogether. Gifted children will generally bring the proper materials to class for a project unless he/she is distracted by something more interesting.
Thirdly, this case example highlights Julie's difficulties with social interactions, specifically with making friends, leading activities, and discussing world events. Anxious children, children with ADHD, and gifted children may all have difficulties relating to their peers. Anxious children are often self-conscious and shy. They may appear introverted, because they are unsure of themselves in social settings and fear looking foolish. Some children with ADHD have under- developed social skills, which hinder their ability to interact in a way that fosters peer friendships. Children with ADHD are often oblivious to the social cues of others. They may blurt out inappropriate comments, and have problems waiting or taking turns. Gifted children may have difficulty relating to peers, because they tend to be socially, emotionally, and/or intellectually more mature and advanced than their same-aged peers. In fact, gifted children may downplay their intelligence in their struggle to make friends. Because of their emotional maturity, gifted children are also prone to mood swings. Thus, the anxious child may be self- conscious leading an activity, because he/she fears making a mistake. Whereas, the gifted child may be uncomfortable leading an activity due to his/her inability to relate to peers. Furthermore, a child with ADHD may not hesitate or appear uncomfortable leading an activity. However, this child is unlikely to be effective in leadership skills due to a lack of organization and social skills.
To determine whether Julie's discussion of world events is appropriate, we need to further explore the content of these conversations. Is Julie discussing worrisome events that concern her, such as wars, fires, or death? If so, she may be anxious. If she is discussing random world events that do not carry a theme, and she discusses them out of turn or at inappropriate times, she may have ADHD. If she discusses highly intellectual world news, and seeks to integrate her own thoughts with others' opinions of the event, she may be gifted.
In summary, by considering only the behavioral manifestation of her symptoms alone, Julie fits into several diagnostic patterns. In order to make a correct diagnosis, we must delve into the reasons behind Julie's problems and understand why the behaviors occur. We can achieve this by carefully observing patterns in her behaviors noting when they occur, communicating with her parents to document consistency of her behaviors, and coordinating with members of the school team who interact regularly with Julie. When talking directly with Julie, it is also important to frame questions in a way that allow her to answer honestly without feeling ashamed. By taking these steps, we can uncover the root cause of Julie's problems and determine the most effective treatment that will allow her to perform at her fullest potential inside and outside the classroom.
To find out more about pediatric anxiety, visit the RFC website: http://www.RenewedFreedomCenter.com
© 2011 Renewed Freedom Center for Rapid Anxiety Relief - Division of Strategic Cognitive Behavioral Institute, Inc.
