“His mom tells him to get ready for bed, and she finds him sitting on the floor, half dressed, building something with Legos. His teacher says she gave the class an assignment, and he lifted the lid of his desk to get out some paper, and found his library book, and just sat there reading, with the desk lid up, while everybody else got to work. My question is: if he has an attention deficit disorder, why is he able to pay so much attention to the stuff he likes?”

This is a question I often hear from parents whose children seem to have an endless ability to concentrate on the things they care about, but no steadiness of purpose when it comes to what is required of them.

“The role of motivation is huge when it comes to attention,” I told Mr. Drake. “And to help James we’re definitely going to have to use that. One way is to say no screen time until after homework, for example. But you’re right. It seems paradoxical that a child who has trouble paying attention can literally spend hours playing a video game. It’s one of the reasons that some neurobehavioral experts think that instead of talking about Attention Deficit Disorder; it would be more accurate to say that some children have attention regulation issues, and both over-focus and under-focus. They have trouble fine-tuning it to the appropriate level.”

An assessment showed that James did indeed have attentional issues of two kinds: he had trouble sustaining interest and had difficulty switching from one activity to the next.  I suggested that he receive a combination of behavioral therapy and medication. His parents were hesitant about the meds and so we worked on ways, in addition to his therapy, that James could learn to maintain focus. Instead of giving James chores to do, his parents did household tasks with him. They created a homework routine that James gradually learned.  He did improve, although he still tended to zone out at school, particularly in math. His father had gained a lot of insight over the course of the year and now said sympathetically, “James finds math particularly difficult. I know it’s hard to focus on what you don’t understand and feel bad about.” Thinking about what might motivate James, his father rephrased all his son’s story problems in terms of Harry Potter. It actually helped a lot.

His parents and teachers had made good efforts to motivate James and his issues with attention had improved noticeably. But going into fifth grade meant moving to a system where children changed classrooms for different subject areas. James completely fell apart. He lost things, forgot things, started to slip behind academically, and called himself “stupid” when he made mistakes. At this point, his parents decided to try medication. 

But this in no way meant that behavioral therapies and changes at home and in the classroom hadn’t been useful. His parents had learned to make the effort required to help James become more focused, and James appreciated it. They felt much closer. And because he had worked for the better part of a year on improving his performance, he valued the effectiveness of his medication. “I concentrate better, so I learn more, so it’s more interesting, so it’s easier to concentrate,” he told his mom. “It’s a vicious cycle – but for the good.”

Sandra dutifully Nate prepared for the new experience. They bought a backpack and talked about reading books from the school library and bringing a book home in his backpack. She told him about all the new kids he would meet and how they could play after school at each other’s houses. When they heard that Nate’s teacher would be Mrs. Anderson, Sandra learned about her from other parents and told Nate that his teacher had a Scottie dog and two grown up sons, and drove a cool old car that she repaired herself. Nate and his mom even got to meet Mrs. Anderson the day before school started.

All the preparation paid off. Sandra walked Nate to the door of his classroom, where Mrs. Anderson was waiting to greet them. Mrs. Anderson showed Nate a cubby with his name on it, where he could put his backpack. Then Nate glanced around the room, decided what he wanted to play with, saw a friend from summer art camp, and said, “Bye!” to his mom over his shoulder as he headed over to say hello. 

In a way, Nate’s mom was startled, even hurt, that he’d separated from her so easily. Then she decided she was relieved.  Was this really going to be so simple? 

Apparently so. Nate came home and said the teacher read the class a book called Dinosaurs Beware that was really funny. Nate had drawn a picture of one of the dinosaurs going down a slide headfirst. They had eaten tiny graham crackers. They had had partners and walked around the school. They met the gym teacher Mr. Conway. “School was good,” Nate said. “I liked it.”

So his mom felt upbeat when she woke him the next morning with a cheery “Time to jump out of bed and go to school!”

Nate sat up and gaped at her, absolutely astonished. “Again?” he said.

I loved Sandra’s story because Nate’s “Again?” puts the emphasis right where it belongs—on establishing a rhythm, and making a challenge easier through familiarity and repetition. In planning, adults focus on unique events, like the first day of school, but success actually depends on a matter-of-fact, day-in-day-out establishment of habits that carry a child through, on good days and bad days. This may sound strange coming from me, because I often talk about creating a learning environment uniquely tailored to a child’s needs, but that doesn’t mean that everything is up to the child. Children also need to learn that some things in life don’t depend on how you feel about them or what you want, they just have to get done.

For that reason, it’s vital to create good routines, because making decisions afresh each day is hard. Doing what you’ve always done is much easier. That’s why Sandra’s creating a framework of familiarity and good habits for Nate will make all the difference.

For ten years, all through grade school and high school, we worked on Greg’s organizational skills. He had executive function support for his homework. He learned to make lists and to create a schedule for when each part of a long-term project was due. Much of his life was organized by his mom who woke him up, reminded him when he had to be some place, and helped him keep track of his stuff. His friends on the lacrosse team made sure he got to practice. His girlfriend planned their time together and organized events like starlight bowling with friends and team barbecues.

By the age of 18, Greg had grown into a slender, crew cut kid with decent grades and a very manageable life. A strong social network helped Greg function at a high level.

He got into the college he’d hoped to attend and we talked about the organizational challenges he might confront freshman year. Nevertheless, when we met during winter break after his first semester, he let me know there was trouble. “I don’t have my grades yet,” he said. “But they’re not going to be good.”

“How do you know?” I asked.

He shrugged. “I forgot a lot of work I should have done,” he said. “I never woke up for my first period biology class, and when you miss the lab, you can’t do the assignment. I had a lot of stuff to do like laundry, but I never got around to it. I brought it all home at Thanksgiving and the back of my car is full of it again. I feel like I’m slipping. I’ve missed team practice. I don’t remember to do assignments. I find myself studying for tests at the last minute and staying up all night. I don’t understand it. I was doing a lot better in high school.”

“In high school you learned to structure your schoolwork, but at college you have to structure your whole life— waking up, working out, homework, classes, social life, self maintenance like haircuts and laundry and meals,” I said. “A lot of kids have a hard time managing at first.”

Because I didn’t want Greg to feel overwhelmed, I suggested he choose two things to work on. Wisely, he chose homework and getting up on time. When Greg and his family had been selecting a college we had made sure that each possibility offered a resource center with special tutoring for students with learning difficulties. Greg knew his school’s Study Center existed but had resisted going there, hoping to do everything on his own.

Now I reminded him that there was a place on campus that would help him get organized. “There’s nothing shameful about using it,” I said. “They didn’t build the center just for you. There are a lot of people who do better because of it.”

Greg agreed. “Half gone, half good,” he said cheerfully, meaning that the first half of the year might have been wasted, but the second half would be better.

His optimism was justified. He got a friend to wake him every morning, and stopped missing classes. He went to the campus learning center—and bumped into a girl who lived two doors down in the same dorm. He’d been wanting to get to know her. Suddenly going to tutoring became a social thing.

Gradually Greg created the same social network that had enabled him to flourish in high school. At the end of his first year he sent me a card with a photograph of two men and a bear, pushing on the back of truck stuck in the mud. Underneath it was a quote from Ashleigh Brilliant: “The best thing about needing help is that it’s a good way to meet people.” Once again, this great kid had overcome his difficulties by building on strengths.

Many of the kids I treat really do count the days. The effort to produce academically when there’s a difficulty with learning or regulating behavior can push children to the limit. The relief of being free of school, of no longer being judged on the basis of activities that often make these children feel they are at a disadvantage, creates a sense of buoyancy and lightness. Everything in daily life gets easier over the summer for the children, but also for their parents. Or it can, if you keep a few simple guidelines in mind.

1. Don’t recreate the pressures of school at home. Some parents are so focused on the challenges of the school year that they forget to create an atmosphere in which a child can relax and feel good about himself or herself. Even kids who benefit from tutoring over the summer should have at least one week of every four when there’s no work to do. This is the time to travel, play, pursue a hobby or sport, sleep late, and see friends.
2. Monitor screen and phone time. A couple hours a day of computer time, video games, or talking on the phone can be a pleasure for a child and is often a social experience. But too much time in front of a screen interferes with the chance to focus on a personal passion – an activity that the child really loves or a skill that a child could develop.
3. Monitor your own screen and phone time, too! If you have a chance to be with your child—pushing a stroller, driving a car pool, or spending an evening at home—stay off the computer and/or phone and talk to your kid about what you’re both seeing, feeling and thinking. Discuss movies, books, a game you’ve seen. Make a meal together and eat it at leisure.
4. Relax! Not every moment should be purposeful and productive. Don’t pack your child’s schedule or your own. Leave time to think and take walks. Give in to (positive!) impulses. If your child comes down to breakfast talking about dinosaurs, draw dinosaurs together, jump in the car and go to the Field Museum,  head for the library to get dinosaur books, or together do a computer search on dinosaurs.
5. Model the behaviors you want your children to learn. Sign up to clean a beach or deliver meals on wheels. Build something for Habitat for Humanity with your teenager.
6. Foster relationships with your extended family. A visit to grandparents, a week playing with cousins, going to museums with a favorite aunt, or learning to fish with a favorite uncle, can make a child’s summer memorable.
7. Let children help to plan and organize trips and activities. All too often children who lack organizational skills are asked to develop them around activities they don’t enjoy such as homework or tutoring. They’ll have a lot more incentive to strengthen their skills planning a trip to Great America or scheduling things to do during a cousin’s visit.
8. Let summer be a time to experience new possibilities. Children—particularly those who struggle during the school year – need to know they’re not boxed in by the status quo. One of the activities they try for the first time this summer—horseback riding, painting, SCUBA diving—could become a long-term passion, a source of self-worth, and a connection to the world.           

I remember the first time I was overwhelmed by the wonderful personality of a child I was treating. It was decades ago when I was doing my residency at the University of Minnesota Hospitals. John B. was a little brown-haired boy of seven from a tiny Minnesota town. He came all dressed up in a little shirt and tie because the hospital was in the big city. John was bright and thoughtful, but seizures and learning issues made things hard for him and he had become shy and withdrawn. He didn’t speak at first, but he had a wonderful way of connecting non-verbally. A great smile. An expressive, intelligent gaze.

Luckily it was relatively easy to be very helpful and John improved rapidly. The first thing we needed to treat was the seizures and the first medicine we tried worked. He was thrilled. It was such a relief to him and to his family.

Beyond that, he had learning issues, so I talked to his teacher. She hadn’t realized that he had a hard time copying spelling lists and math problems from the board. After we talked, she gave him a written sheet of the information. It helped enormously. So he wrote me a note. “When you talked to my teacher it was like a Christmas present, and it’s only November. The teacher has started giving everyone a copy of what she gives me. Now it’s easier for the whole class and I feel even better.” It melted my heart.

You might think that I fell in love with this child because he was cheerful and grateful and because it mattered to him that not only he, but his classmates, were helped by the intervention. It might seem as if doctors don’t feel that way about children who are difficult or act out. But I love them, too. I know that no child wants to be upset and angry. No child wants to earn the annoyance and disapproval of parents and schoolmates. There are reasons why a child is difficult, and my job is to discover what they are and to create a healing space where that child doesn’t need to be a problem anymore.

When I can do that, when I’ve worked hard to find a solution and a child and his or her family has worked with me wholeheartedly, it’s like a gift. My young patients and their families often tell me they are grateful. I thought I would take time on Valentine’s Day to let them know I’m grateful, too.

Recently I was invited back to the same school building in Marin County. It now houses a private school that is particularly accommodating to children with learning differences. The head of school and the director of another private school in Marin County had united to discuss children who required learning support. They also invited a third school in San Francisco to participate. Because parents at these schools felt they needed education and support, I was asked to lead a parent group.

I began by giving parents a framework to think about neurobehavioral issues. We discussed four kinds: those involving sensory-motor skills; social-emotional learning; reading and other forms of academic learning; and disorders of regulation. Determining the nature of such neurobehavioral issues as precisely as possible, and as early as possible, is what enables effective treatment. I went on to discuss the part played by genetics, and the considerable role played by a child’s environment. Very often, I said, whether something is defined as a problem is the result of existing expectations.

Thus one part of my talk that parents seemed to find most helpful was a discussion of when a difficulty becomes a disorder. For example, a child may have a sensory-motor issue that causes a lack of coordination. It may be a comparatively mild issue that causes a certain amount of clumsiness. If there are no consequences – if the child accepts the problem and recognizes his own value nonetheless, if the family is similarly accepting, and if other kids don’t make a big deal out of it— the child’s difficulty remains just that—a difficulty with a given skill set.

The difficulty becomes something more serious when it is regarded by the child or others as part of who that person is. If the child is teased by classmates, or berated by a more athletic parent, or starts thinking of himself as a klutz, the difficulty becomes a dysfunction. If the dysfunction persists and has an impact on other activities—if the child develops an internal sense of himself as a person who is a failure or is incompetent, or feels socially inferior, for example—then the difficulty has become a disorder.

In this way, surrounding expectations, values, and social norms may create a disorder. Dyslexia, a difficulty with reading, is a good example. In the Middle Ages, when few people were expected to read and write and a successful life was not dependent on those skills, dyslexia rarely became a dysfunction or a disorder. Today, when the expectation of literacy is much greater, dyslexia is a difficulty that generally has a substantial impact. But the effect of the environment also means that creating the right surroundings for a child to learn and thrive can help enormously. Even when there is a disorder, a normal life and wonderful childhood are still possible.

After I spoke to the parents at the three schools, they had a turn to talk, and what they talked about was their kids. Who they were. What was great about them. How they struggled in school or at home or in social situations. What helped them.

Many of the parents were enormously proud of their children’s progress. Some of them cried at the obstacles their children faced. I respected the depth of their passion to offer their children the best they could provide. I have been talking to parents for decades, and yet it still took me days to deal with the emotions raised by those sessions.

I saw that for parents just beginning to grapple with the problems of a child with learning differences, the child’s issue had become huge, rippling outward and seemingly impacting every aspect of a family’s life. It is part of my work—and part of what parents’ groups can do—to get the problem back under control so it is a merely a part of life. Acquiring the right sets of skills allows a parent to build on a child’s strengths. And yes, every single child I’ve seen does have strengths.

Normally I use this space to pass information to parents. But as the New Year begins I wanted to thank parents for everything they have taught me and taught each other. Together we can be a powerful force for change in the lives of the children we love.

“When there is a whole crowd of people and a lot going on,” her mother Sarah says, “Alicia just tenses up. Everything bothers her: this isn’t right, she needs that, she can’t eat those, she hates wearing a dress, she doesn’t want to play with her cousins because they’re too loud. And she worries. When will they pass out presents? When is dinner? What if it’s something she doesn’t like? Will she have to eat with the older kids? When they do pass out presents, what if nobody likes what she got them?’ Pretty soon she says she feels sick to her stomach. Or she just bursts into tears.”

Like many children with anxiety disorder, Alicia responds to small worries with all the emotional and physical reactions most of us experience when we are greatly at risk. She can only relax when she can anticipate what will happen and has some measure of control over events. Her mother understands that, and does a great job of preparing Alicia for new experiences. She knows when something is likely to be a problem.

“We have to go to my husband’s mom for Christmas every year and I’m really dreading it,” Sarah says. “My husband and I can’t enjoy ourselves, Alicia sure won’t enjoy herself, and the rest of the family are beginning to think of our child as a real pain.” This is not Sarah’s only worry. “Alicia has almost as much trouble at school that week before break. What if she doesn’t get picked to perform in the school pageant? What if she does? What if the present she buys for Secret Santa isn’t something people think is cool?” Alicia’s mom sighed. “One problem is her distress. The other is how people are coming to think of her.”

Fortunately there are many things a parent can do to help a child like Alicia enjoy the holidays, spend time with friends and family, and experience a meaningful celebration. Children who experience anxiety disorder need to know in advance exactly what’s happening. What looks like pickiness or standoffishness is often a desperate attempt to control circumstances that seem overwhelming to the child. Just as many adults enjoy planning surprises for their children, and create a hectic bustle of parties and gatherings  that their children will find exhilarating, parents like Sarah can prepare for a good winter break by making sure there are no surprises, and that there are ways for her child to manage the sensory overload of crowds and festivities.

The first thing to do is to call the school and find out exactly what the holiday schedule will include. Winter Pageant. Rehearsals. Holiday Party. Ask what exactly will happen during each event, then put the details on a calendar and talk to your child about them. Ask the teacher if your child can have non-stressful roles, such as decorating for the party or making costumes for the pageant. If children exchange presents in the classroom, have the teacher suggest some gifts that have been regarded as a good present in past years.

The next step is to think about vacation. The unstructured time of a school break is bliss for most children, but children who need structure are just going to rattle around the house wondering what they are supposed to be doing. So on the same calendar plan some things that will help your child prepare for the holidays and that have real meaning. These should be events the child can enjoy without being in the spotlight: going to a carol service; making a holiday ornament or gift, going with you to prepare meals in a shelter. 

If there are gifts to buy, talk to your child about what each person on the list would really enjoy. Discussing what other people like will help your child think less about worries. Thinking of gifts to make or bake is a good idea. But if crafts and cooking aren’t your child’s—or your—strong point, make a list together of everyone’s interests and plan a trip to a bookstore. Who in the family would like the book on gardening? The graphic novel about zombies? The collection of puzzles?

Skipping Christmas at a family member’s house is probably not an option, but there are ways of making the experience easier. Some children are not comfortable in holiday clothes (I still remember the parent who told me her 6-year-old son, unwillingly put on a sailor suit, looked at himself in the mirror and said, “I look like a perfect fool.”) Make a stressful experience easier by choosing an outfit together well in advance.

To prepare for a party at another family member’s house (for example, a grandmother’s) call the week before and ask if your child can come and help grandmother prepare by decorating the house or helping with some of the cooking, or setting the table and making place cards. That way the child will spend some meaningful time with her relative, will know what will be happening, and will have more of a stake in the event going well. The child will know the menu in advance, and you can discuss the polite way of dealing with foods the child does not enjoy, which is to take a small portion, and say nothing.

Another part of good preparation is to explain to family members that the child has an anxiety disorder. Ask the relative who will be your host to suggest a good place to sit quietly away from the festivities. For example, is there a room where your child could put a holiday puzzle together? The structure of the activity would be calming, and if an uncle or cousin joined the child for a few moments hunting for a piece of the sky or the missing bird’s beak, it could be a companionable activity.

We all have a vision of a perfect holiday. The trouble comes in trying to make everything fit into the same vision. Not everyone enjoys the same things. If your child is happiest on the periphery of the action, give the gift of understanding by accepting your child’s needs.

Click here for information on RNBC’s Stress and Anxiety Clinic

So when Alan came in for a routine visit and reported that everything, going into middle school, was just great, it was a surprise to his mom when he added, “We need to talk about something, Dr. Lipton. I want to try going off my meds.”

Before I could ask him about it, his mom demanded, “Do you feel like they’re not working?”

“No.”

“Are you having side effects you haven’t told me about?” she persisted.

“No,” he said again, and turned to me, hoping I would understand why he wanted to give up a drug that was apparently making his life so much easier.

And I did understand. “Sometimes when kids get to middle school they feel really independent,” I said. “They want to rely on themselves. Alan wants to know if he really needs to take medications. And that’s an excellent question. I think you should stop taking your meds and see how it goes.”

I explained that off meds, Alan might feel it was harder to work steadily at a task. He might be more easily distracted. He might find he had more of an appetite. “It’s important for you to notice any changes,” I told him. “Your feedback is really important in deciding what to do next.”

I could tell Alan’s mom didn’t feel great about this decision and the next day she called to tell me so. “Children do change,” I said to her. “It’s just possible that Alan, with the excellent study habits you’ve helped him develop, will do okay with this. But you’re right, it’s far more likely that he won’t do as well without his meds. It’s important, however, to give children the freedom to be partners in their own treatment, so they know they have arrived at the right decision on their own. I know there are clinicians who would force the issue, just as I know that there are children who battle their parents over this, and spit out their medication.”

About five weeks later, the Barrets were back in my office. “What did you find out?” I asked Alan.

Alan smiled and shook his head. “I finally told my mom, ‘Look, I can’t pay attention to anything any more. I really noticed the difference. When the guy next to me was taking notes, I could hear the noise of his pencil on the paper. I notice the cars outside stopping at the light. The lavatory next to our classroom has a door that bangs twice, ba-boom, and now I hear it every time, even with the classroom door closed.”

“Alan started taking his meds again at the beginning of this week,” his mom said.

“It really makes a difference,” said Alan. “It makes me a real learner. Without meds, everything’s a mess. With them, it’s perfection.”

“All of us have things that need a little correcting,” I said. “I need glasses. I see kids who need insulin for diabetes. If you got an ear infection, you’d take antibiotics.”

Alan nodded. “I know. It’s lucky there’s something that helps.”

“Isn’t it great,” I asked his mom, “to have raised a child who makes the right choices and is so self-aware? The choice to stop taking meds and the choice to begin again, were both Alan’s. And they were both right.”

When Rachel is not available, she runs in circles, she screams, she repeats the same phrase over and over. Her parents don’t react with distress or disapproval. They call Rachel’s name, calm her down, and gradually pull her back to a more attentive state. They are better at it than anyone I’ve seen. The more time Rachel is “available” the more time she has to learn, so that’s what they work for. They’ve also gotten Rachel the help she needs—occupational therapy, speech and language therapy, developmental therapy.

They don’t respond with distress or annoyance, but they’re not matyrs—they take care of themselves and enjoy their lives. They’re a model of how parents can do a phenomenal job in a difficult situation. They realize Rachel’s problem is not about them—they don’t blame themselves. They react to Rachel’s “unavailable” moments as most of us do to rain at a baseball game—it’s not something to be mad or upset about. You wait until it’s over and go on.

You can never foretell what a child’s progress will be. And you can’t ever be sure, when a child does beautifully, if it’s the result of therapy or natural development. But in this instance, my guess is that Rachel is making progress because of the calm, caring environment her parents have created for her.

One of the smartest things about Rachel’s family is that they distinguish clearly between being “available” to learn and listen to reason and “unavailable.”  All children, when they are distraught or exhausted, can slip into that “unavailable” mode.  Parents can save themselves a lot of frustration by recognizing the difference and not taking the episode personally—as a challenge to their authority or a failure on their part or the child’s. As the Warners say, “No matter what you say when she’s like this, she won’t hear it.” Accepting this, actually makes the “unavailable” time less, and helps parents and children enjoy their time together far more productively.

Then do the preparation, in five easy steps, that makes the transition back to the school an easy one.

1.      Find the school reading list and make sure there’s reading built in to your schedule so the child doesn’t feel overwhelmed when school begins. Also, preparing for the new hours of the school day can help a child feel less overwhelmed. At least ten days before the start of school, begin to change your child’s sleep schedule.

2.      If your child hasn’t been seeing school friends, reconnect before the first day of classes. Children’s interests, friendships, and levels of maturity can change a lot in three months. It’s better to experience social changes away from the stress of a new school room.

3.      If your child is transitioning to a new school, walk around with your child and find the gym, the lunchroom, the library, and any classrooms the child will be in. Talk to someone who’s been in the new teacher’s class so the child has some idea of what to expect.

4.      Involve the child in decision making about after-school schedules: homework, snacks, having friends over, and activities such as sports or art lessons. You can set rules and offer suggestions, but make sure your suggestions are in accord with your child’s strengths and interests.

5.      If your child has issues with executive function (getting organized, keeping track of belongings) discuss ways to improve results. This is a great time to make a fresh start on correcting problems and enhancing skills.

And once you and your child have done back-to-school planning, get back to the business of enjoying summer. The last few weeks of summer should be different from the rest of the year; clambakes, flashlight tag, playing sardines, canasta games that involve six decks and take all afternoon, camping out, rafting, or just taking a picnic to the lakefront.  Maybe you’ll fly kites. Maybe your child will show you what it’s like to chew six pieces of bubble gum and blow a giant bubble. Maybe everyone will put on bathing suits and give the dog a bath. Before the school year gets started, give your child time to be a kid. Summer’s lesson is this: enjoy what you have while you’ve got it, especially when what you’ve got is good weather and free time. One of the most important things a busy parent can teach a child is how to relax.