Stories from the Documentary:
Nathan V.LaurenSarah LeeAdamNathan S.
||ATTENTION: Basics | Difficulties | Responses|
Difficulties with AttentionAccording to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a standard reference source published by the American Psychiatric Association, there are three patterns of behavior that indicate ADHD: inattention, hyperactivity, and impulsivity (difficulty controlling one's actions). Signs of inattention as outlined in the DSM-IV include
Because everyone shows some of these behaviors at times, the DSM-IV contains very specific guidelines for determining when they indicate ADHD. The behaviors must appear early in life, before age 7, and continue for at least six months. In children, they must be more frequent or severe than in others the same age. Above all, the behaviors must create a real handicap in at least two areas of a person's life, such as school, home, work, or social settings. A child with some attention problems but whose school work or friendships are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active at school but functions well elsewhere.
Proper diagnosis offers some insight into what a child may be experiencing and helps direct parents and teachers to appropriate responses. Dr. Mel Levine and other researchers are developing an understanding of how brain function contributes to attention, and what interventions may work for some students. Dr. Levine views attention as consisting of three control systems: mental energy, processing, and production. Some children experience problems with all of these attention systems, while others may show strengths and weaknesses in different systems.
Attention Control Systems
Mental EnergyThe first attention control system, mental energy, regulates and distributes the energy supply needed for the brain to take in and interpret information and regulate behavior. Children whose mental energy is not working effectively may become mentally fatigued when they try to concentrate, or have other problems related to maintaining the brain energy needed for optimal learning and behavior.
There are four mental energy controls. The first is alertness, a state of mind in which a child can effectively listen to and watch information being presented. Children who experience difficulty with alertness can appear to be daydreaming.
The second mental energy control is sleep and arousal balance. This control affects the ability to sleep well enough at night to be sufficiently alert during the day. Children who are experiencing trouble with sleep and arousal may find it difficult to get to sleep at night, or they may sleep poorly. They then have trouble getting up in the morning and may appear tired in class.
The third mental energy control is mental effort. This control initiates and maintains the flow of energy required for a child to start, work on, and complete a task. Mental effort is particularly important when children are faced with tasks that may not be especially interesting or personally motivating. Children who have difficulty with mental effort can benefit from having tasks broken down into smaller, more manageable parts.
The fourth mental energy control is performance consistency. It works to ensure a reliable, predictable flow of energy from moment to moment and day to day. Children who have trouble with performance consistency don't have problems all of the time. Sometimes they can concentrate and perform well, while other times they cannot. Their work output and behavior may be impossible to predict.
ProcessingThe second attention control system is called processing. This system helps a child select, prepare, and begin to interpret incoming information. Children who have difficulty with processing may have a range of problems related to regulating the use of incoming information.
There are five processing controls. The first is saliency determination. It involves selecting which incoming information is the most important. Children who have difficulty with this control may be distracted by things that aren't relevant and miss important information being presented.
The second processing control is depth and detail of processing. It controls how intensely children can concentrate on highly specific data. It enables them to focus deeply enough to recognize and remember necessary details.
The third processing control is cognitive activation. This active processing connects new information to what has already been learned through prior knowledge and experience. Children who are inactive processors are unable to connect to prior knowledge to assist their understanding of new information. In contrast, overactive processors are reminded of too much prior knowledge, making it difficult for them to maintain focus.
The fourth processing control is focal maintenance. This allows a child to focus on important information for the appropriate period of time. As Dr. Levine explains, "It isn't so much how long your attention span is, as it is how well-matched the duration of your attention is to the target at hand." Some children who don't concentrate long enough on certain things may concentrate too long on others.
The fifth and final processing control is satisfaction control. This control involves a child's ability to allocate enough attention to activities or topics of moderate or low levels of interest. "Insatiable" is a term used for children with poor satisfaction control who may be unable to concentrate on activities that are not exciting enough.
ProductionThe third attention control system is production. This area governs output -- including what children generate academically, behaviorally, and socially. Children with production control problems have a range of difficulties related to regulating academic and behavioral output. They may do things too quickly without thinking, planning, or previewing outcomes.
There are five production controls. The first is previewing. It involves considering more than one action or response and anticipating the likely outcome of a particular choice. Children who have difficulty with previewing may plunge into activities instantly and react too quickly.
The second production control is facilitation and inhibition. This is the ability to exercise restraint and not act immediately, to consider multiple options, and to choose the best one before acting or starting on a task. Children who have trouble with facilitation and inhibition frequently act impulsively and may appear to be doing only the first thing that comes to mind. These children may blurt out answers before being called upon in class.
The third production control is pacing, which means doing tasks or activities at the most appropriate speed. Pacing difficulties often show up in children's reading. Their reading pace may be so fast that they skip over words, have difficulty with multisyllable words, and show little reading comprehension.
The fourth production control is self-monitoring. It allows children to evaluate how they are doing while performing and after completing a task. This control allows children to regulate their attention and take corrective action.
The fifth production control is reinforceability. It allows children to use previous experience to guide current behavior and approaches to current tasks. Often called hindsight, this ability enables children to make use of precedent, experience, and prior knowledge to guide their decision making and actions.
CauseAlthough scientists still know very little about the cause of ADHD, research suggests the disorder is biologically based. This means that there are likely chemical and/or structural problems in the brains of people with ADHD that inhibit their ability to focus, plan ahead, finish tasks, and so on.
Studies have shown significant structural and functional differences in the brains of children with ADHD relative to the brains of children who are progressing normally. One such study found several brain regions (prefrontal cortex, striatum, basal ganglia, and cerebellum) of children with ADHD to be significantly smaller than the same regions in children without ADHD.
Similarly, a study found that children with ADHD had much lower activity levels in areas of the brain that control attention, social judgment, and movement relative to non-ADHD kids. These decreased activity levels may be the result of structural problems in the brain -- connections that just don't exist -- or they may originate in chemical differences between ADHD children and non-ADHD children.
The neurotransmitter dopamine is an important brain chemical that has been linked to ADHD. A kind of chemical messenger, dopamine is thought to facilitate critical brain functions, including the ability to pay attention. In people with ADHD, researchers have found that receptors in the brain that normally respond to dopamine fail to work properly -- either because the brain is not producing enough dopamine or because it is reabsorbing the chemical too readily. Many researchers believe stimulant drugs like Ritalin work by making more dopamine available. Read about the medication debate.
Unfortunately, there is still much that remains a mystery. While researchers have identified chemical and structural differences between children with ADHD and non-ADHD kids, they are no closer to understanding what may cause these differences. Current research is focusing on environmental toxins, drugs, and genetic factors as possible causes of ADHD.
Given this uncertainty, the debate about how best to manage attention problems is not surprising. Although there is clear evidence that some children have benefited from drugs like Ritalin, for others, this may not be an appropriate response.
Signs of Attention ProblemsA common misconception about children with attention problems is that they aren't paying attention at all. But children who struggle with attention may actually pay attention to everything; their difficulty is deciding what to focus on and maintaining that focus. And since attention is a complex neurocognitive process, there are several areas where signs of struggle appear.
Mental EnergyA student:
If any of these signs occur inconsistently or in a particular subject area, they may be pointing to a different learning problem. When children struggle with reading, for example, because of a neurological breakdown that hinders their decoding ability, it is very difficult for them to concentrate and stay focused.
A controversial diagnosis
This question has nearly as many answers as there are people willing to voice an opinion on the subject. There has never been a consensus about the validity of the ADHD diagnosis in large part because researchers had, until recently at least, found no evidence of a biological cause. The question is further confounded by the fact that the criteria doctors use to diagnose the disorder are common behaviors that nearly all of us have demonstrated at some point: failing to pay attention to details, having difficulty waiting in line, and so on. See the essay to the left for more detail on diagnosis.
One view embraced by some neurologists, psychiatrists, and teachers asserts that there is no fundamental difference between people who regularly struggle with attention and those who can focus easily whenever they need to -- that any variation is only a matter of degree. These critics argue that scientific research has not uncovered a legitimate biological cause of the behaviors the American Psychiatric Association uses to define ADHD. They say the differences researchers have uncovered recently between people diagnosed with ADHD and people without are simply differences among people and not the causes of a disorder. ADHD-like behavioral problems, they argue, result instead from social factors, possibly including deficiencies in the parenting and education a child receives.
In contrast to this view, the majority of medical and psychiatric professionals accept that ADHD is a neurobiological disorder, meaning that the condition is caused by an abnormality in the brain -- either structural, or chemical, or both. They say the differences in diagnostic test results between someone with ADHD and someone without are measurable -- and significant. And, according to many ADHD researchers, their assertion of a likely biological cause is increasingly supported by brain research. Neuroscientists have found that, in general, certain areas of the brain are smaller in people with ADHD than in people without it, and their brains also produce smaller amounts of an important neurotransmitter.