PROBLEMS OF ATTENTION
AND CONCENTRATION
LEADING TO STOP STUDYING
BY HIGH SCHOOL AND
UNIVERSITY STUDENTS:
A REPORT ON 4 TYPICAL
CASES.
Renato COCCHI,
neurologist and medical psychologist
Summary
Difficulties in attention and in concentration often lead to drop out
by senior high school or college students with normal or above average
intelligence.
Although there are intermediate forms, difficulties in attention and
memory affect mainly subjects with somatic depression and asthenia. These often
arise in springtime and can increase in intensity as years go by until studying
becomes impossible.
Difficulty in concentrating affects students with a previously
brilliant school career, and is inclined to become severe in autumn. The main
characteristic of this trouble is the continual presence of intrusive thought,
which inhibits concentration and the progress of information from the short-term
memory store.
Students with such concentration difficulties due to intrusive
thinking are more likely at risk of psychotic evolution.
Four cases, (1 senior high school and 3 college students) are
presented. An individualized drug therapy resulted in a brilliant diploma being
obtained by the high school subject and the recovery of studying in the
remaining 3 cases who had considered themselves as being definitive drop outs.
Key words: Attention; concentration;
difficulties; high school students; college students; drop out; hemispheric
impairment; recovery; drug therapy.
It has been found that, in Italy, 70% of all
university entrants do not manage to graduate. The explanation given for this,
which is no doubt true in the vast majority of cases, is that of insufficient
teaching ability on the part of university lecturers to motivate studying.
Even though the defects of the Italian
university system are well known, this is still not always a valid explanation
and analysis of the phenomenon is certainly complex.
The cause of so many failures can be broken
down to at least 4 factors of varying incidence:
- enrolling at university only while waiting
for something else to do (find a job, get married, etc.);
- dropping out of university for
personal difficulties arising (a change in family circumstances, usually of a
financial nature;
- pregnancy and getting married etc.); .
- dropping out for problems concerning
attention and memory;
- dropping out due to it becoming impossible
to concentrate on one's studies.
The last two causes for interruption concern
learning difficulties arising in subjects who had previously shown good or
excellent intellective capability.
The causes concerning problems of attention and
memory are partially understood and sometimes worked upon.
The loss of capacity to concentrate however
seems unknown and misunderstood. When one or the other of these factors lead to
the cessation of studies the event is accepted as a "misfortune" about
which nothing can be done. Not certainly a problem for which the help of a
medical specialist could be sought.
Learning difficulties in subjects of normal intelligence
Learning difficulties in compulsory
schooling have been receiving attention for some time now, especially
concerning the diagnostic aspect. However, the same problems in the last years
of senior high school and at university are as yet unchartered territory.
Two factors seem weigh heavily in this lack
of consideration of the problem: the appearance of these difficulties in
subjects of normal or above average intelligence; not having found a coherent
psychological frame of reference to tackle successfully and, conversely, not
wanting to accept, or not having considered that biological mechanisms may be
involved.
An understanding of these learning problems
requires a reminder of how we define attention and concentration.
Attention is the individual's capacity to
select particular stimuli within the perceptive field, and may be voluntary or
involuntary. Concentration refers to the capacity to maintain voluntary
attention, for a certain period of time, while the individual is occupied in
specific tasks.
Both attention and concentration are
indispensable pre-requisites in the phase of committing information to memory.
It follows that both of these constitute fundamental factors for every learning
process, above all in scholastic learning.
Difficulties in attention also arise in the
years which follow compulsory education. Concentration difficulties, on the
other hand, are more typically found in the younger student, in the final years
of senior high school or during the university years.
These are however two quite separate
phenomena which seem to affect two distinct groups of young students, but where
incidence, course and outcome partially overlap.
Both attention and concentration can
decrease in particular stress situations of varying origin and not necessarily
only psychological. Study in itself, and the emotional tension brought on by impending
exams are both stressful agents; the first more physical, the second more
psychological.
Problems of attention and memory
Problems of attention are more frequently
found in students who are well disposed towards the humanities (but not always because
of the philosophical speculation) rather than those scientifically orientated
and in particular mathematicians.
The problems are linked to a reduced
response capacity in a double stress situation: the seasonal change and the
effort of studying.
Usually these are problems which are not new
to the individual, having already experienced them in his scholastic career. In
the student's past history there will have been recurrent difficulty, more
evident in springtime - the final months of the school year.
Springtime psychophysical asthenia, with the
relative loss of capacity to involve oneself in studying (loss of "the
will to study ") was a kind of appointment, faced with some anxiety but
always overcome, sometimes through the use of drugs such as glutamine,
pyritinol, fipexide, perhaps integrated with group B vitamins and vitamin C.
The final objective, to finish the school year, in some way had favoured some
strong gritting of the teeth.
In the Italian university system, this
individual experiences the same seasonal performance loss but with three
aggravating circumstances. There is no longer a precise annual objective
followed by a period of relaxation (the end of the school year and the summer
holidays). There is no longer the daily application of study, verified or
verifiable (tests and exams), and this lack of control leads to deferment. In
the third decade of life those depressive symptoms, which had earlier been
successfully masked and overcome without any specialist help, can start to show
themselves more intensely.
This depression, originally of a somatic
nature, can no longer be spontaneously resolved by the organism.
The substances taken previously as
auto-medication are not efficacious any more. This condition therefore tends to
persist making it impossible, in the end, to continue studying. In this
situation there are two risks. One is to evaluate only the possible external
cause. Convinced that the studying is the cause of the depression, it follows
that the ultimate remedy is to stop studying altogether ("health is more
important!").
Undoubtedly studying does involve stress,
which a young organism resilient to stress does not usually feel more than it
should. In those a little more fragile, the realization of not being able to
recover from the effort of studying can produce a depressive effect. The
latter, as a negative psychological cause, can bring about a secondary reactive
depression which makes the situation even worse.
The second risk is to believe that if the
problem is of clearly psychological origin, there is no way of curing it.
If the "reconstituent" cure fails,
various other remedies are tried as a second line of defence. Transfer to a
less "exacting" university or passing over to an easier course are
expedients which sometimes work.
Often however, a collateral activity is
embarked upon which initially can be seen as a "distraction" but then
takes up more and more time rendering not inconsiderable remuneration. The
thought of continuing studying passes into second place until it is eventually
abandoned.
In other cases, above all through parental
insistence, university attendance may continue but it is only a parking place,
when not interrupted, in a certain number of male students, by the requirement
to leave for compulsory military service.
From a neurophysiological point of view
there could be a deficit in energy due to exces-sive consumption, in subjects
with a hemispherical dominance which was already biased to the left, as is
prevalent in right-handed subjects (which constitute 90% of the normal
population).
The neurotransmitters implicated in the
brain would seem to be gamma-aminobityric acid, glutamate, acetylcholine,
serotonin and, peripherally, substances such as glutamine and adenosine-triphosphate
( Squire 1986; Matheis 1989; Brunelli & Traina 1992). Often, in the history
of these subjects problems are found pertaining to the pre-natal or birth
periods or the first month of life.
Two cases
F., male, a sportsman (footballer), attends
the final year of senior high school (classical grammar school).
Since his upper middle school times has
found learning difficulties particularly acute during the spring term, usually
in scientific subjects where he does not do so well. Until now he has been
regularly promoted in june but admits that he was always given a helping hand,
because of his excellent results in the literary subjects, during the autumn
term.
He comes to the end of the school year
exhausted, with difficulty in attention and memorization, unfounded physical
tiredness, with a gradual decrease in ability to study after lunch as well as
diminishing performance in sports. In spring he always has a slight cold.
He suffers the cold, both hands and feet.
Sleeps well, does not talk in his sleep, does not lose saliva and moves very
little while asleep, does not suffer from nightmares. No nocturnal cramps, only
daytime ones in the past linked to his sports activities. In the morning he is
immediately hungry and likes sweet things, in particular chocolate, a normal
appetite for broth, his alimentation is correct and varied. He is not
intolerant of the light, noise or confusion.
No emotional sweating of the hands. In the
afternoon he is always a little more tired and finds difficulty in studying.
Thinks a lot but does not have the impression that his brain goes off
restlessly on its own trail of thought. Rare episodes of cephalalgia at the top
of the head. No known problems in the foetal period reported and the birth was
regular.
There are no symptoms during the first month
of life to indicate any possible pre-, peri-, or neo- natal suffering.
He refers to a certain number of relatives,
both paternal and maternal, with depressive histories.
Treated since february with a low dosage,
balanced combination of glutamine, pyridoxine, ascorbic acid, hematoporphyrine,
carnitine and bromazepan, he has not experienced the usual seasonal low, not
even in his sports activities, and has maintained efficient attention and
memory, finishing school with a 56/60 result. He has not suffered the usual
spring cold.
M, female, 23 years old, enrolled on a
pedagogics course, cannot manage to sit for any more exams. Her last was in the
february session 16 months ago. She needs to take another 6 to graduate.
She is thinking of leaving university, much
to the dismay of her parents, in order to help out in the family-run tourist
business. She can no longer study, loses heart because she cannot achieve
anything because she is easily distracted and has great difficulty in
memorizing.
She finds it hard to fall asleep and always
feels tired. At home she lies on the couch watching T.V. a lot. She has cut
down her contact with ex-senior high school (linguistic grammar school)
companions, with whom she had a previously healthy rapport. Her parents insist
on her going out with friends but she does so unwillingly and only rarely to
please the parents.
There have been no triggering events in what
is overtly a depressive episode of an inhibitive kind. Since the start of the
tourist season she has been more active however, helping out in the family
business.
The mother's pregnancy was quite regular but
the subject was born with cyanosis after a prolonged labour, as well as having
a neo-natal pathological jaundice treated by ultra-violet light.
During the first year of life she had
sleeping and alimentation problems, constipation and a tendency to contract
infectious respiratory conditions (seen as indications of previous cerebral
suffering).
She never experienced any scholastic
problems, even if she found mathematics a little challenging. She was in any
case placid, apparently of good disposition, but with just a few well chosen
friends. She admits to always having felt a little insecure even if she did not
give that impression.
She suffers from the cold, enjoys sweet
things, and likes meat or stock broth; on getting up in the morning she
breakfasts normally.
Her diet is correct, but she complains of
having slow digestion and being constipated (atonic). Her menstrual cycle is
rather short. She goes to sleep around midnight -1 a.m. but at this time of the
year feels none the worse for it as she is busy until late. In the previous
months she was taking drops to help her sleep.
Once reached, her sleep is undisturbed but
she wakes up tired "as if I have no strength". She does not slaver in
her sleep, experiences no nocturnal cramps and does not talk in her sleep. She
is slightly intolerant to the light but not to noise or confusion.
Sometimes she weeps for no particular
reason, but not that often. She feels empty headed, with some episodes of
frontal cephalalgia. She sometimes feels short of breath and sometimes her
heart speeds up, for no apparent reason.
A low dosage balanced therapy was prescribed
using glutamine, fipexide, pyridoxine, ascorbic acid, chlorimipramine,
nimodipine and medazepam, to be checked four times per year.
Starting from the initial improvements after
two months when asthenia soon disappeared, she started sitting exams again
after five months' treatment obtaining excellent results. After 13 months she
had finished all her exams. She is now completing her thesis for october. She
took up a more suitable social life for her age almost immediately and found a
steady boyfriend from her university environment.
She has been advised that she can stop the
treatment after her thesis but may suffer further depressive episodes in the
future.
Comment
The two cases are quite similar, even if the
actual origins of the troubles seem different. The first case is probably a
hereditary depression, while in the second there is clearly a birth trauma.
Both are more fragile subjects therefore, but only in the case of the girl is a
depressive collapse of the biopsychic balance in the third decade of life
evident.
The learning difficulty is very similar in
both cases too. Attention and memorization are affected but in the girl, the
left hemisphere, home of the linguistic faculties, seems to have become more
impaired, with quite an obvious study blockage and reactive depression.
Substitutive drug therapy produced favorable resultsin both cases in a short
time.
Problems of concentration
Unlike problems of attention, concentration
difficulties often arise "out of the blue". It is often the case with
students that up to a year previously they had been extremely bright, with
particular ability in mathematics or philosophical speculation, or both.
These aptitudes had already coloured their
choice of senior high school, usually the liceo scientifico (Liceo Scientifico,
i.e., Italian scientific senior high school), or a technical/industrial
institute (more rarely commerce) and they continued their studies entering a
scientific faculty (excluding history and philosophy).
There is no specific seasonal tendency
characterizing concentration loss as in the case of difficulties in attention,
even though the end of the summer and the beginning of autumn seem to be more
unfavorable to university students.
The basic symptom is the progressive
inability to concentrate on one's studies, and so memorization becomes more and
more difficult and tiring, until it becomes completely impossible. Aspects of
asthenia are not present but, if anything, irritability and impulsiveness are.
If the right questions are posed the student admits that his brain thinks a
lot, even while sleeping, and his thought train goes ahead of its own will
"like a treadmill which is constantly turning". The content of what
is being studied is not memorized due to a series of spontaneous and
uncontrollable thoughts continuously interfering, which impair concentration.
If these resulting "intrusive" thoughts are of a specific emotional
content, e.g. existential or religious worries, or sexual insecurity, then
these cause further concern which adds to the painful awareness of no longer
being able to obtain any profit from one's studies.
From a neurophysiological point of view
there seems to be a strong hyperfunction of particular areas in the
non-dominant hemisphere (the right hemisphere , more concerned with non verbal
processing and emotivity in right-handed individuals). This would already have
been more active than the dominant side, as the mathematical competence would
also seem to indicate ( not to be confused with computational competence,
governed more by the left hemisphere, as confirmed by Grafman eta al., 1982).
This situation therefore leads to an
increased number of vagal neurovegetative responses. The intrusive thought
seems to be a symptom of the necessity to use up an energy excess
("consummatory" symptom). Often it exists alongside the compulsion to
count objects ( steps, tiles, car registration numbers, etc.) for no reason at
all almost without realizing it. There is the risk, remote but recognized, that
this anomalous function may worsen into a psychotic decompensation, and so the
interruption of one's studies can precede the onset of a syndrome of a
schizophrenic nature.
Within the brain, at least initially,
gamma-aminobityric acid, glutamate, acetylcholine and noradrenaline, and
perhaps glycine and taurine are all implicated Squire, 1986, Matheis, 1989,
Brunelli & Traina, 1992). Peripherally: acetylcholine and
cortico-suprarenal incretion.
Two cases
G. male 20 years old, reading for a degree
in history and philosophy. Seen at the end of the summer. Has not sat any more
exams as he is no longer able to concentrate. While studying at the liceo
scientifico (Italian scientific orientated grammar school) he was an
exceptional student with particular leaning for mathematics and philosophical
speculation. He chose a history and philosophy degree course because in the
nearby university town there was no mathematics degree course available.
He has always been a very
"sensitive" individual, a characteristic which seems to be
hereditary. Now he has become even more emotional and irritable leading to
conflict with the father over futile things or for reasons which would be
easier to comprehend if he were still an adolescent. No problems arising in the
foetal period, at birth or in the first months of life can be traced. Up to the
age of 6 months he had some trouble in maintaining sleep. His impact with
nursery school was quite dramatic for some weeks with scenes of desperation
when his mother left him. He was a very lively child.
Now he suffers more from the heat, is not
hungry in the morning and can get through to lunch time on just a coffee. He is
not keen on sweet things, apart from ice-cream and chocolate; has no liking for
meat or stock broth. His overall alimentation is correct. Has no difficulty in
falling asleep, but his sleep is agitated and lately he has noticed that the
pillow is wet with saliva on waking. He has had some episodes of nocturnal
cramp. He wakes up tired, "as if I had used up all my energy during the
night" and it takes him some hours to recover.
Recently he has noticed some dizzy spells
and two or three times he has had the impression, for a fraction of a second,
of being about to faint. He has become intolerant to confusion and noise but
not to the light. He feels more disorientated in the morning with a heavy
headedness, dazed but with no headaches. Over the past few months he has
noticed sudden stomach pains followed by an attack of diarrhea which then
disappear.
Now his hands sweat easily and he is often
pale with shadows round his eyes for no apparent reason.
He says he thinks a lot but cannot always
control the thought direction. He feels he thinks even when he is sleeping. He
finds a need to employ his brain by reading irrelevant things such as the daily
sports pages which have never interested him much in the past.
A therapy using pyritinol ,
argine-glycine-citrulline-thiamine-cyanocobalamin, pyridoxine, amitriptyline,
carbamazepine and bromazepam, at low dosages has in a short time cleared his
head more and allowed him to resume studying, achieving excellent results.
After the exam period he has always suspended the treatment, which he then
takes up again two months before the new session. He does not like the idea of
"having to rely on extraneous substances" but, however, he has recoursed
to the cure many times over a 15 month period. He is now negotiating with his
father because he wants to leave his present degree course in order to take up
a mathematics course in a larger university but which is further away from
home.
C., male, 28 years old, enrolled on an
Economics and Commerce course, after obtaining an excellent (scientific) high
school diploma, has been in a blocked situation for at last five years now
being unable to concentrate on his studies.
He needs to sit 11 more exams to graduate
and in the first years of university had achieved excellent results. He is now
extremely concerned about his situation and can see no way out. The family are
aware of his dilemma and do not pressure him about it any more.
The idea of seeking specialist help was
insistently advised by his sister, a middle school teacher, and in the end he
decided to comply. He has unresolved problems of a sexual nature with
homosexual ideas feared but never put into practice. He has never gone further
than a superficial relationship with the many girls he has had around him for
this reason.
He noticed that he was no longer able to
concentrate on his studies owing to the continual intrusion of these thoughts
of a basically sexual kind.
There are no pre-natal, birth or neo-natal
problems in his history. He was a lively , spirited, active child who always
got on well with the others. He practiced athletics, which he has since given
up, and according to his coach was "quicker off the mark" than others.
There is a family predisposition for troubles of a "neurotic" or
neurovegetative kind.
He says that his brain "labours"
continually. If not thinking, he repeats obsessively a musical motif. He feels
as if he thinks in his sleep too, and so wakes up tired. While sleeping he
loses saliva, grinds his teeth and sometimes talks.
Sometimes he wakes up looking pale with
rings under his eyes. In spring, before taking up swimming in the sea again, he
experienced a certain number of episodes of nocturnal cramp. In the morning he
does not eat because of a feeling of nausea, sometimes verging on being sick.
He makes do with a little tea without sugar,
because he does not like sweet things. Meat or stock broth gives him diarrhea
straight away as does milk. He tolerates cheese normally. His alimentation on
the whole is well-balanced.
Despite this, he has episodes of intestinal
pain, followed by an attack of diarrhea which happens at least once a week.
Lately he finds it necessary to urinate more often. He suffers the heat and sweats
easily without reason. Some mornings he feels he off-balances when walking. He
has had very brief sensations of feeling faint, from which he has immediately
recovered. He feels the need to stay amongst friends and so tends to go to bed
late and indulge himself with beer.
He is intolerant to confusion but not to
noise or to the light. Does not suffer from headaches but only
heavy-headedness, and a sense of confusion which is more acute in the morning.
He is attracted to telephone numbers which he memorizes obsessively. He has the
impression that others are looking at him and asking themselves why he has no
steady girlfriend. In certain moments he has also thought about suicide but
says he would not have the courage to carry it out.
A therapy of pyritinol, taurine (later
substituted by arginine pydolate), pyridoxine, carbamazepine, amitriptyline,
aloperidol and chlordemetyldiazepam (later substituted by oxazepam) all at low
dosage, allowed him to resume studying after 40 days. In 20 months he completed
his exams and gave his thesis, achieving top marks.
In the meantime, feeling better, he started
up a relationship, for the first time sexual, with a girlfriend and this has
given him more confidence. Shortly after graduating he found a good job.
He says that his sexual doubts have
disappeared and he now criticizes them as having been mere unfounded fears.
Comment
These two cases of difficulty in
concentrating also have many common symptoms. Capability in mathematics; no
previous scholastic difficulties; "intrusive" thought; absence of
troubles during pre-natal, birth or the first months of life; a certain family
"predisposition" towards neurovegetative responses which are
excessive or otherwise; all these seem to indicate precise characteristics.
Both cases exhibit symptoms of depression which they react to differently.
In one, the recourse to irritability may be
a peripheral compensation governed by the cortical-suprarenal hormones (one
thinks of those people who find any kind of pretext to anger themselves because
afterwards they "feel much better").
In the other, more inhibited, case there
appear to be basic errors of judgement about reality. Memorization is impaired
by a blockage of cerebral progress of the information which cannot seem to get
beyond the short-term memory store.
Discussion
The four examples reported here were chosen
purposely as cases to show a possible different involvement of the two cerebral
hemispheres.
The characteristics of subjects who are no
longer able to study are not always so well defined. Forms of attention and
memorization difficulties progressing to problems of concentration are found. The therapies must also then be adapted on the basis
of symptoms which provide information about the neurotransmitters affected,
both within and outside of the Central Nervous System, the substances involved
with them and their precursors. Thus the importance of the questions on the
subject's alimentary habits: sweets for glucose and broth for glutamate and
glutamine, both precursors of glutamic acid and gamma-aminobityric acid, to
name but one example.
As for the question of choice of medicines,
I promise to return to this area in the future, when I will concentrate more on
the therapeutic aspect rather than the psychopathological one, as I have in
this initial report.
The return of the ability to study has
always come about in the students I have treated, apart from cases which had
already set into an overtly psychotic syndrome.
I continue to believe that development into
psychosis is quite rare even if through my work, I have by now seen at least 10
such cases. My experience of treating subjects arriving only after having
reached a breakpoint in their studies is obviously biased. It is probable that
I have not yet come into contact with all the forms in which this disorder can
present itself.
How widespread is the problem of abandoning
studies due to difficulty in attention and memorization or concentration? I am
unable to provide any reliable figures but, at a conservative estimate, even if
the problem affects only 10% of the 70% of Italian students who do not complete
their studies, the number will be considerable , in the region of more than
17,000 students per year.
How much does all this cost from an
emotional point of view to the subjects themselves and to their families? What
is the cost in economical terms to the families and to the state? I do not
consider the posing of such questions to be out of place here.
The phenomenon is too large and has too many
implications under various aspects not to merit the attention which, abroad
too, it has never received.
(Four other texts on this topic)
References
Brunelli M., Traina G.: Meccanismi cellulari
e molecolare della memoria. In: Brunelli M., Macchi G., Gainotti G., eds):
Plasticita' neuronole. Pytagora, Bologna, 1992.
Grafman J., Passafiume D., Faglioni P.,
Boller F.: Calculation disturbances in adults with focal hemispheric damage.
Cortex 1982, 18: 37-50.
Mathies H.: Neurobiological aspects of
learning and memory. Annu. Rev. Psychol. 1989, 40: 381-398.
Squire L.R.: Mechanisms of memory. Science
1986, 232: 1612.
Printed on It. J. Intellect. Impair. 1994,
7: 29-38.
Authors's address: dr Renato COCCHI, via
Rabbeno, 3
42100 Reggio Emilia (Italy).
renatococchi@libero.it
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