Archive for January, 2012

31
Jan
12

Attention Disorder? Felicitous Flaw

Steve was not a kid. He was a middle-aged Professor in some arcane scientific field, a member of the National Academy of Sciences, an international scholar. He was getting depressed because he couldn’t master some coursework in mathematical computations he had been trying to learn.

Steve’s IQ turned up at the 150 mark, higher than 99.9% of the adult population, far into the exceptional range. But measures of attention were peculiarly lower, not dismal, just too low for such an otherwise gifted person.  No history of psychiatric disorder or  recent trauma could account for these low scores.

But in discussion with him, he recounted how hard he had to work in school, how he spent so much time on homework, especially with foreign language work (“I hated French!  Math was hard too, until I got to calculus and statistics.  They were easy.  I don’t why,” ).  He told me how he had to double- even triple-check his work and still find mistakes, how he had to re-read everything. He said he got good grades because he worked much harder than his classmates. He figured he was just average but did well because he just spent all his time with schoolwork.

I reported to him the results of my testing, his exceptional scores, his singular intelligence. He stared at me as I reported these facts to him. Then he began to cry, just for a short period, quite against his will. He was embarrassed: “I’m sorry. But this is a real shock!  All my life, I just thought I was, you know, sort of slow and certainly not smart.”

Steve had been laboring, all those years, under the adverse effects of a rather severe Attention Deficit. He had been young when he could handle all the re-reading and double-checking that his deficit demanded of him. But now, in this current coursework which required strict attention, he was unable to generate the extra energy and effort  necessary to learn the material.  And it was demoralizing and depressing him.

We discussed the benefits and liabilities of medication, among other treatment options. In a subsequent conversation, he reported that he had tried the medication – on an as-needed basis – and had found it “incredibly helpful”. “I could concentrate!”, he exclaimed.

But then something really odd happened.

For when I said, “It’s a shame this medication wasn’t available to you when you were younger”.  He replied: “I’m glad it wasn’t.” A bit stunned, I asked why. “Well,” he said, “over the years, I learned to learn in different ways, ways that made the job easier though it  never became really easy.  But these “different” ways led me to think about things from original or unconventional points of view.  And that’s what won me all the accolades and honors I’ve enjoyed over my professional career, my ‘unusual’ ways of looking at things and all the discoveries and insights those ‘ways’ generated.  IF I’D TAKEN MEDICATION I WOULD NOT HAVE LEARNED THESE WAYS AND I DEFINITELY WOULD NOT BE WHERE I AM TODAY!” 

Steve made me think, hard and long.  And I realize now, as I’ll report in future posts, that there are real advantages to having an Attention Deficit, that strengths of enormous amplitudes can spring from that “deficit”.  He taught me a deep respect for the legitimacy and dignity of all learning types and styles . . . . if I would only take the time to look for them. Needless to say, I have.  Thanks to Steve.

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28
Jan
12

He’ll catch on; he’s such a nice boy

Kyle’s 8 years old now. But he’s just beginning second grade; he was “held back” in kindergarten because his teachers thought he was immature. Kyle’s Verbal abilities reached into the Superior range at 124, better than 94 % of the kids his age. Put another way, he had the “mental age” of a child two or more years older than he. That is, he answered test items that the typical 10 or 11-year-old would answer. Of course, that age group is in the 4th/5th grade NOT the first month of 2nd grade.

Kyle was told to write about his dream house. He dutifully positioned his lined paper on his desk and began to scrawl, gripping he pencil tightly as if at any moment it would squirt from his fingers and clatter on the classroom floor and invite a warning from his teacher, Miss Warmsly.

He thought of a lot of things, actually pictured his dream house in his mind’s eye, colorful and detailed in ways only children can imagine. His house would be near the ocean; it would be a house boat so he could watch the fish go by and swim any time he wanted.

Below you can see what he wrote.  He spent ten minutes on it. When his teacher strolled by his desk, she cooed, “Good job, Kyle. Why not add some more?”

But Kyle knew that the tangle of lines and curves he’d just engraved on his paper were garbage. They made no sense to him. As a matter of fact, he wasn’t sure whether they were wrong or right because when he went to write, he couldn’t think of how the letters should look, “How do you make a ‘y’?” he’d asked himself when he started to write the word “you”. Just a vague knot of lines floated momentarily in his head. He prayed (he was a good Christian boy) he wouldn’t have to read his description to the class because he  had no idea of what his markings “said” or even when  one word ended and the next began. How did the other kids do it, he wondered and make it look so easy and even add illustartions.

Kyle was very bright. And so knew he was an abject failure; kids had laughed at his work before. Anger and tears competed just below the surface as Kyle stared at his paper.  Miss Warmsly was sooooo nice and he wanted so much to please her. But he knew her coos and smiles and kind gaze were basically those of sympathy and pity and well-disguised disappointment. He knew these things because  her coos and all were replaced by genuine sounds of praise and pleasure when she looked at the other kids’ papers… and because he was sharp, insightful.

Kyle dreaded the possibility that anyone would see his “writing”. He dreaded it so much that nausea began to get  jumbled in with his anger and tears. So, he put his head down on his desk and wouldn’t look up, put his arms and head over his paper so his shame would be hidden.

Later, a “learning specialist” tested Kyle’s writing skills and concluded that they were in the “average” range and that he should try harder because she and all his teachers “knew he could do it”. The specialist did note that “Kyle’s spelling errors and sentence structure made it difficult to gain meaning from his writing” but that “overall, Kyles’ writing skills were in the avegrage range.”

Two months later, Kyle became obstinate,”oppositional”, even “defiant”. He was sent to the principal’s office several times. His parents were called in. They were told he had an emotional problem, that he needed help and, of course, that he was “coming along” in his writing.

Three months later, Kyle was in my office so I could see how he was doing. He was sullen, defensive. He did not smile at all…only once when he talked about a science fair he went to with his Dad. He was severely limited in both reading and writing. Indeed, he was a long way from literacy, a very long way.

Kyle’s dream house remained invisible to everyone, friends, family, teachers. It stayed in his head, this elegant floating boat house on a sapphire sea, beautiful fish leaping at the bow, the sun so warm on his face. He swore to himself he’d never, ever, ever again put his heart on paper where it would be ridiculed and trampled in the laughter of his classmates.

At a meeting I attended, one where his teachers and specialists and parents gathered to discuss Kyle’s  “issues”, I asked if any one  of them would be so kind as to read Kyle’s “dream house” paper  aloud (I’d made copies for all). They politely declined. “He’s such a nice little boy!” his teacher cooed.

Kyle will be in therapy soon, superior intelligence and all.

The humiliation of a dyslexic

25
Jan
12

I heard what you said; I just forgot

An Attention Disorder is manifested in numerous ways because, quite simply, attention is involved in nearly every activity, even the generation of thoughts.

One common feature of an Attention Deficit is rapid forgetting of what one has just read or heard.  Consider Liz, whom I described in my 1/22/2012 posting.  Essentially, she couldn’t reliably register and maintain incoming information for a period of time sufficient to interpret or manipulate it in some way.  This process of data-maintenance is a function of Working Memory.  But Working Memory must be extremely reliable if one is to respond correctly to whatever the incoming information requires. And its processing powers are formidable.

If someone says the word “grand”, for instance, you will not be able to understand it until you register all the sounds of that word in Working Memory.  “Grand” consists of five sounds, /g/, /r/, /short a/, /n/, and /d/.  So each of these five sounds must be identified precisely.  If any one is inaccurately identified, you will not be able to identify the word.  Or you will misidentify the word (e.g. as “grand” or “grunt” or even “”can’t”).  In fact, you may not be able to tell whether what you heard is a word or not. When you listen to a young child speak, a person with a foreign accent, a drunken slur  or one with an unfamiliar dialect, you find yourself concentrating very hard. You narrow your eyes, watch their lips and facial expressions, focus intently on the sounds they’re producing and often enough ask them to repeat.  All you are trying to do is identify  sounds  so that you can assemble those sounds into a word you recognize.

Meanwhile, you are “holding” the sounds you do hear in Working Memory, sustaining them there until you finish your analysis or give up. I’ve been amazed with young mothers whose toddlers seem to be saying “Ahwanceal” and the mother instantly responds,“No it’s lunch time; cereal is only for breakfast.”  You might notice here that even determining how many words were said can be daunting because you can’t tell where one word ends and the next one begins (locally, the spoken unit “Jeweet?” is easily segmented into “Did you eat?” by a listener familiar with the local dialect patterns.).  Indeed, our ability to recognize slang, “accent” and dialect variations depends on precise identification of aberrant sounds as acceptable variants of standard sounds (the unit “Yall” is nonsense since there is no such word, yet few have difficulty assigning it the meaning of “You all”.)

Recognize that the time it takes to say “grand” amounts to a small fraction of a second. Recognize further that you effortlessly identify all its sounds in that sliver of time. The sentence, “I’ll be reading Dickens this afternoon” contains 25 sounds, yet all of them are easily identified in about 1.5 – 2.0 seconds. That’s over ten sounds a second.  And all this “Auditory Processing” takes place in Working Memory.

So, Working Memory  has to be extremely efficient and reliable.  But suppose it is NOT.  Suppose information (sounds) entering this system are very rapidly corrupted (deleted, mis-sequenced, garbled).  Or suppose that something heard exceeds the limits of Working Memory because it’s too long. Then, the information is lost or misinterpreted.  So, what was happening to Liz was that her Working Memory could not reliably and correctly “hold onto” language data (sounds, mainly).  So, before she could interpret what she heard, the data themselves were being corrupted…or erased.  And then, she suffered the consequences: misunderstanding in some cases, in others, instant and wholly INvoluntary forgetting.  In circumstances where she couldn’t request a repetition, she was defeated.  For her, forgetting what people said to her, forgetting what she’d just read were all too common experiences.  And when her job depended on efficient auditory processing, where the consequences of mis-hearing or mis-reading a direction, dosage amount, drug or patient name could be lethal, she despaired.  Because she couldn’t stop forgetting.

25
Jan
12

Right Church, Wrong Pew

Liz wanted to be a nurse. And so she went to college, got her degree, then earned a Masters degree in Nursing at a prestigious university.  She graduated with a 3.95 GPA, with honors and everyone’s applause.

Finding immediate employment at a world-renowned hospital, she soon started to become depressed and anxious, disenchanted with the job though she loved working with other professionals and the patients. But the demoralization continued  and she sought therapy. The therapist referred her to me for evaluation. “Something doesn’t make sense,” the therapist said. “Liz is very bright, she’s  had a stable upbringing, has lots of friends, no trauma, no evidence of familial disposition to mood disorders. But she keeps complaining about the work, how nervous she gets. Maybe you can help clear up this matter.  She’s on medication, an antidepressant, but that’s not making much of a difference.  I’m at a loss.”

And so, a few days later, Liz entered my office.  Congenial, cheery, sophisticated and very mature in her ways, despite her youthfulness (she was 24), Liz seemed the epitome of all that makes up a competent and sensitive human being.  And she was hard-working, intent on doing her best on each task I presented her.  Her IQ reached into the 90th%ile+,  superior.  It would have been higher had she not obtained two remarkably lower scores. One was on a subtest called Digit Span, another on a subtest called “Arithmetic” .

Both are very sensitive to attention span. The possibility that an Attention Disorder was related to her depression soon occurred to me.  But more evidence was needed. So I asked some questions like the following;

1. Do you ever have to re-read something you’ve just read.

“All the time, even in high school and always in college.  I’d spend hours on homework!  I mean, I could read just one paragraph and then realize at the end of it that I was thinking of something else.  And then I’d have to re-read.  But that was OK. I never minded working hard.  I’m not really very smart if you want to know the truth.  I just work hard.”

2.  Do you make little mistakes, like forgetting to write some words in a sentence or miscalculate in math?

“Well, yeah. But they were never really a problem because  I’d double-check my work.  But I always hated math because no matter how many times I checked, an error would show up anyway, always a careless error, dumb, stupid. “

3.  How about lecture note-takng in college?

“I was OK if the professor didn’t talk real fast.  And I became a really FAST writer. I never participated in class because I was so focused on getting the notes that I couldn’t concentrate on WHAT the teacher was talking about.  Same thing with foreign language; I had to try really hard to remember what was said in French so I could translate it.  But I’d keep forgetting, and so my translations sucked.  I HATED French!”

I asked her about her nursing job.  I LOVE nursing, but… I…it’s getting to me, getting me down.”

And then the tears began, pained sorts, robbing her of the dignity and  self-possession she’d worked so hard to project.

” I have to give out all these medications, different dosages, sometimes three or more for some patients.  And I’d keep forgetting who got what.  And I’d study and study the dosage charts and names and still catch myself making dumb mistakes,  forgetting this or that. I’d spend hours reading and re-reading the charts.  But I was taking too much time, and the supervisors were getting on me because I was not giving enough attention to my patients.”

I was afraid I was going to hurt  somebody! “

Liz did have an Attention Disorder, quite severe.  It corrupted her ability to remember “little”  things, data, details, numbers and the like.  It compromised her efforts to monitor her work for “dumb” mistakes because those errors came so quickly, she didn’t know she’d made them; they were INvoluntary and so she could not know where her mistakes were.

Liz, at my encouragement, sought another position in Nursing, one that required far less charting and record-keeping, one where she had time to do her job well and with pride and satisfaction. Her depression lifted; it has not returned. She has become the very competent, sensitive and compassionate nurse she always wanted to be, that in truth she always had been.  In a Psychiatric position, she excels in her understanding of the human condition, of struggle and suffering, and her great empathy for her patients.  She found her calling.

21
Jan
12

Gifted and Learning Disabled?

Asymmetric Intelligence (note the scores above are derived from an older version of the Wechsler scales, It is displayed here to simplify the issues discussed in this posting. Later versions of the Wechsler scales, which I will address in subsequent posts, include "Index" scores that needlessly complicate the explication of the central issue in this posting: The differences between Verbal and Non-verbal Intelligence measures.

This set of IQ scores, including subtest scores, was obtained by a young man in his teens. He was angry, depressed , very sophisticated and confused. And he was brilliant and mediocre at the same time.

You should look at the difference between his  Verbal Score and his Performance Score. The former, Verbal, was of a magnitude shared by LESS  than FIVE in every THOUSAND kids his age; he was clearly gifted verbally.  His score far exceeded the mean even in his fast-paced private school setting, where the “average” was the 90th percentile. Even in this competitive milieu, he distinguished himself. His ideas were abstract, insightful, far beyond his years. He effortlessly generated fluent, grammatically complex and stunningly insightful comments and test responses, embedding in them vocabulary items both precise and scholarly. He read voraciously, debated issues with his teachers and refused to agree with things just because some authority said so. He loved TRUTH. He was respected, even awed by some of his teachers; he intimidated some with his astute reasoning and flawless logic.

But he was getting poor grades. He hated Science and Math. His writing was a scribbled tangle of lines and curves. He said he hated to write. His parents complained that he was disorganized, lazy, argumentative . But they loved him. “He’s a sweet boy,” his mother said. His father often discussed…and argued about…politics, the economy and especially morality, right and wrong. “He just seems frustrated all the time,” his father observed, just a hint of sadness in his voice. “He seems confused.”

Eric had good reason to be confused ! Look at his Performance score. About 50 of every 100 kids his age would score lower. BUT 50 would score higher. And so, in his high-powered, academically rigorous independent-school classrooms, he was well BELOW the average for that population. So, mathematical concepts like “square root” or “acute angle” didn’t make much sense to him. He could memorize formulas and procedures. But he couldn’t apply what he was learning. He couldn’t reason well at all when such concepts were involved.

When I asked him how far it was from New York to Los Angeles, he said “About 30,000 miles.” When I asked him to show me how big a “foot” was by holding his hands apart, the space he produced between hands was a good three feet. On an outline map of the U.S., he drew the Mississippi River horizontally from Texas to California. He “lost” things, he said. “I can never remember where I put something.” And though he was close to getting his driver’s license, his parents worried because he got lost so easily and couldn’t read maps at all.

Because what the Performance subtests measure, the ones called  Block Design, Object Assembly , Coding, etc .(see above), is NON-VERBAL abilities.  Notions of abstract space, proportion, orientation, direction, even time participate in these Performance functions. And so, when weaknesses and deficits occur in them, concepts like “The day after tomorrow” or “bilateral symmetry” or “atomic shells’ , even  left-right , the order of months in the year, ratios and congruency become nearly impenetrable mysteries because they cannot be “pictured”, because the word and terms connect with NOTHING or only the most nebulous of mental representations. Handwriting is sloppy, planning efforts are perfunctory and athletic competition is minimized.

Eric could, I guess, be called gifted-learning disabled. He was rare, rarer than many a gifted child, but common enough for me to have seen quite a few over the years. In later posts I’ll discuss what becomes of such individuals, what can be done to support them, what they can do themselves.

I explained a lot of this to Eric in a conference after testing. His parents asked me to. He had a thousand questions. He smiled a lot.

18
Jan
12

Dysgraphia: An Unforgiving Learning Disability

NOTE: The reader is asked to examine the writing sample following the text below. “Zooming” in will help in examining the errors cited below.

Dysgraphia is a Learning Disability characterized by deficits in handwriting and spelling. In the sample below, Nick executes a variety of errors  he incurred while trying to copy text. What you see is the amount of text he copied in 120 seconds, statistically, a second grade level equivalent…though Nick was 11 years old in the 5th grade. The numbered arrows identify malformations caused by poor grapho-motor coordination. For instance, Error # 1  illustrates a spontaneous reversal of direction, a leftward move as he began the letter “o” that Nick simply terminated AFTER he noticed it was wrong. Dysgraphics cannot depend upon the sense of touch or direction of motion that a functioning writer takes for granted. That is, even young writers know when they’ve made a mistake even BEFORE they see it because they unconsciously  compare what they INTEND to write against what they sense their hand is doing. This sort of “motor feedback” is what typists depend on as they type; they only occasionally check their work visually.

Estimating spatial constraints is clearly difficult for Nick. Err0r #14 reflects his mistake in estimating how much space he would need to use to write the word “brought” . Note how he “handles” this by splitting “brought” into broug and ht. Nick’s  spatial mis-estimates can also be observed in the inconsistent spacing of written lines. His erasure of the “n” in “an”, Error # 12, typifies an “anticipation” mistake. He knew he was going to follow the article “a” with the word “new”, but he executed the “n” of “new” ahead of time, ahead of the space that should have been there. Here, he simply erases the “n”, again AFTER he sees it.

While I could explicate several other sorts of Nick’s grapho-motor mistakes (e.g. his poor grasp of letter “bridging” :cf. Errors 4, 13, and 9), the major issue for Nick is the overwhelming frustration he must experience as he tries to write. Recall that his verbal intelligence EXCEEDS that of 90% of his age-peers and that such ability permits Nick to enjoy sophisticated abstract thought, rapid vocabulary growth and the oral language capacities of a 13 or 14-year-old. Recall also that here Nick is simply copying something. Imagine his frustration and demoralization when he attempts to communicate his own ideas in written form, in “neat”, “accurate” handwriting, correct spelling and punctuation, all legibly and automatically performed. To do the latter, he must work VERY slowly, very slowly, ever tracking, checking the “formal” features of his work, constantly miscuing, ever unsure of the spellings of words he so effortlessly uses in oral communication. That he says he “hates” writing is understandable; indeed, it is quite reasonable. For Nick, for all dysgraphics, this learning disability silences them even as it exposes them to relentless admonition, criticism and demeaning comments from teachers and insensitive, uninformed or mean-spirited parents.

After Nick could exploit computer technology and writing applications, he began to enjoy communicating his thoughts on paper. And as he finally displayed his intelligence in written form, others noticed, invited him into their academic communities and awarded him a Masters Degree in Comparative Literature some 12 years after he laboriously copied the above.

 

16
Jan
12

Mothers DO Know Best

Parents know their children very, very well. And while fathers are good at acquiring this knowledge, mothers know the most, to the greatest depth, in the greatest detail.

I am not able to explain this phenomenon. But when mothers sense something is “wrong”, their “sense” is remarkably accurate, much moreso than the impressions of “professionals” who teach or test them.

How mothers acquire this knowledge is remarkable because they have NOT had the opportunity to compare their children to other children except by brief, informal observations of those others. Yet, their descriptions and inferences about their own children are almost invariably true. Somehow a mother “knows” when her child is depressed, angry, confused, happy, demoralized, fearful, or excited. Moreover, a mother knows what circumstances and activities elicit these different states in her child.

Of course, a facile explanation is that a mother spends a lot of time with her child and gradually learns patterns. But that explanation is extremely simplistic. To identify demoralization in a child, for instance, entails repeated, close  observations of that child in widely varying circumstances and then somehow aligning the properties of certain circumstances with the many ways that emotions can be physically expressed (e.g. by a change in facial expression or voice tone or body position, or all of these combined) . She must discriminate between “shows” of demoralization and genuine indicators of demoralization. This particular discrimination is one even the most experienced, sensitive “professional” can miss altogether…understandably, since it takes so much time to learn these distinctions. That is why I invariably advise mothers to believe what they feel, to trust their own judgments and intuitions and to question closely those specialists and teachers and psychologists when these latter make pronouncements about their children.

One of the most common experiences a mother has is when a teacher tells her that her child is “doing fine” in school when the mother senses he/she is not. Worse,  a child can be labeled “inattentive” (or even ADD by a psychologist) when the mother believes he/she is bored. So often the mother’s opinion is trivialized, treated with a dismissive and patronizing “I understand; he/she is your son/daughter so you don’t want to acknowledge his/her problem” and patted on the hand.

But mothers KNOW.  Sometimes, they can be convinced that they CAN’T know, that the professionals know better because, well they’re “trained” and “experienced”.  And so, I constantly exhort mothers to believe in themselves. For in the end, THEY ARE the EXPERTS.