Colby Tyler 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 account executive 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 stress 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 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 around midnight. Developmental milestones were achieved within normative expectations, with the exception 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 years of age. Language skills also developed rapidly, and Colby's 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 hospitalized, 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 reestablish 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, both 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 teacherhis English teacher, Mr. Brightonhad 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 tardiness. 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 demeanor 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 difficulty 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 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 the classroom. 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 golf lessons. 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." ASSESSMENT RESULTS 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 (PRI = 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 PRI 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 short paragraph. Colby had difficulty getting started on the task, changed his topic many times, and, after approximately 10 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 Teacher Report Form also noted significant Somatic Complaints, and significant problems with Inattention and low frustration tolerance (Emotional Liability) were noted on the Conners Teacher 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 suicidal ideation.

According to Barkley (1997), sustained attention comes in two different forms: contingency-shaped attention and goal-directed persistence. Factors that can be instrumental in increasing or decreasing contingent attention include task novelty, intrinsic interest, reinforcing properties inherent in the task, fatigue state of the participant, and presence or absence of adult supervision. According to Barkley, this form of sustained attention is often not problematic forADHD children. However, goal-directed persistence requires sustained persistence of attention and effort in the absence of highly reinforcing task properties, which is extremely problematic for children with ADHD.

1. Based on Barkley's descriptions of the two forms of sustained attention, prepare response for Colby's mother that would address her questions regarding why Colby can stay focused for long periods of time playing video games but is extremely distracted while attempting his homework assignments. How might Colby's "gifted" intelligence serve to further exacerbate his problems?
2. Based on the information presented in the case study, would Colby's symptoms match the criteria in the DSM for ADHD? If so, which type of ADHD does Colby exhibit?
3. Colby was identified as "gifted" when he was in the fourth grade. Do you believe that Colby's gifted label was ultimately a positive factor or a negative factor in his development? Explain.
4. Identify Colby's strengths, presenting problems, and support networks. What interventions do you believe would be best for Colby based on these factors? How do you believe these factors will affect treatment outcomes?