Pediatric Annals

Attention Deficits: The Diverse Effects of Weak Control Systems in Childhood

Melvin D Levine, MD

Abstract

Disordered attentional processes comprise a common and perplexing source of academic underachievement. Attention deficits are variably associated with information processing weaknesses, behavioral maladaptation, academic skill deficiencies or inefficiencies, poor social adjustment, and behavior problems.1 Children harboring signs of attentional difficulty constitute a widely diverse group, likely to differ from each other in precise clinical manifestations, cognitive profiles, etiologies, responses to therapy, and prognoses.2 Yet, there are shared attributes that justify a unified conceptual model to account for symptoms among these challenging children.

Children with attention deficits can be thought of as manifesting dysfunctions of neurobehavioral control systems that regulate learning and adaptation. Nine such control systems may be affected to varying degrees and on varying bases in children with attention deficits.

THE CONTROL SYSTEMS

1. Focal Control

Many children with attention deficits have problems confronting an array of potentially informative stimuli and selecting the most salient features for processing, retention, and utilization. A child with attentional difficulties may perseverate or concentrate upon unimportant data or may focus with too little intensity to foster sufficient depth of processing to hold relevant information in memory. In addition there may be problems controlling focal time allocation. A child may be said to have a "short attention span. " However, this is likely to be an oversimplification since the same children who fail to concentrate long enough on salient data may perseverate or overattend to other (less relevant) stimuli. The basic problem is one of allocating the right amount of time and focal intensity to informative data.

Some children who lack focal control exhibit a considerable degree of cognitive impulsivity. They have trouble mobilizing the necessary reflective behavior to plan and organize their work or their problem-solving activities. Therefore, they tend to leap before they look, plunging into academic tasks in a disorganized helter-skelter manner.

2. Sensory Control

It is common for children with attention deficits to exhibit varying forms of sensory distrac tibility (typically visual, auditory, and/or tactile distractibility). While attempting to listen, for example, they may fail to inhibit visual attention, so that a student may stare out the window or focus intently on an inconspicuous crack in the wall or loose screw in a door hinge. Even within a sensory modality control can be poor; a child seemingly listening to the teacher may be tuning in to background noises thereby missing critical facts or instructions. Children with auditory distractibility may have great difficulty in school because of their listening problems. Those with strong language skills may succeed during the early grades only to underachieve in secondary school because of chronically deficient listening. In elementary school they could generalize from context and take advantage of linguistic redundancies. In secondary school, their lack of sustained auditory attention causes underachievement in critical content areas. Problems with the control of visual distraction may impair reading skill and the appreciation of detail in mathematics.

3. Associative Control

Many children with attention deficits have difficulty controlling free associative thinking. They are easily diverted into the "free flight of ideas" (sometimes known as "daydreaming"). Words, sights, or feelings too easily elicit a protracted chain of associations distracting them from more relevant pursuits in a classroom.

4. Appetite Control

It is not unusual for children with attention deficits to have difficulty delaying gratification. They seem insatiable; what they want tKey want desperately. When ultimately they fulfill their desires, they lose all interest and almost immediately erect new targets for their intense appetites. This leads to chronic restlessness, a seeming inability to delay gratification, egocentricity, difficulty sharing, and a tendency to be intolerant of equanimity. Insatiable children frequently crave intense…

Disordered attentional processes comprise a common and perplexing source of academic underachievement. Attention deficits are variably associated with information processing weaknesses, behavioral maladaptation, academic skill deficiencies or inefficiencies, poor social adjustment, and behavior problems.1 Children harboring signs of attentional difficulty constitute a widely diverse group, likely to differ from each other in precise clinical manifestations, cognitive profiles, etiologies, responses to therapy, and prognoses.2 Yet, there are shared attributes that justify a unified conceptual model to account for symptoms among these challenging children.

Children with attention deficits can be thought of as manifesting dysfunctions of neurobehavioral control systems that regulate learning and adaptation. Nine such control systems may be affected to varying degrees and on varying bases in children with attention deficits.

THE CONTROL SYSTEMS

1. Focal Control

Many children with attention deficits have problems confronting an array of potentially informative stimuli and selecting the most salient features for processing, retention, and utilization. A child with attentional difficulties may perseverate or concentrate upon unimportant data or may focus with too little intensity to foster sufficient depth of processing to hold relevant information in memory. In addition there may be problems controlling focal time allocation. A child may be said to have a "short attention span. " However, this is likely to be an oversimplification since the same children who fail to concentrate long enough on salient data may perseverate or overattend to other (less relevant) stimuli. The basic problem is one of allocating the right amount of time and focal intensity to informative data.

Some children who lack focal control exhibit a considerable degree of cognitive impulsivity. They have trouble mobilizing the necessary reflective behavior to plan and organize their work or their problem-solving activities. Therefore, they tend to leap before they look, plunging into academic tasks in a disorganized helter-skelter manner.

2. Sensory Control

It is common for children with attention deficits to exhibit varying forms of sensory distrac tibility (typically visual, auditory, and/or tactile distractibility). While attempting to listen, for example, they may fail to inhibit visual attention, so that a student may stare out the window or focus intently on an inconspicuous crack in the wall or loose screw in a door hinge. Even within a sensory modality control can be poor; a child seemingly listening to the teacher may be tuning in to background noises thereby missing critical facts or instructions. Children with auditory distractibility may have great difficulty in school because of their listening problems. Those with strong language skills may succeed during the early grades only to underachieve in secondary school because of chronically deficient listening. In elementary school they could generalize from context and take advantage of linguistic redundancies. In secondary school, their lack of sustained auditory attention causes underachievement in critical content areas. Problems with the control of visual distraction may impair reading skill and the appreciation of detail in mathematics.

3. Associative Control

Many children with attention deficits have difficulty controlling free associative thinking. They are easily diverted into the "free flight of ideas" (sometimes known as "daydreaming"). Words, sights, or feelings too easily elicit a protracted chain of associations distracting them from more relevant pursuits in a classroom.

4. Appetite Control

It is not unusual for children with attention deficits to have difficulty delaying gratification. They seem insatiable; what they want tKey want desperately. When ultimately they fulfill their desires, they lose all interest and almost immediately erect new targets for their intense appetites. This leads to chronic restlessness, a seeming inability to delay gratification, egocentricity, difficulty sharing, and a tendency to be intolerant of equanimity. Insatiable children frequently crave intense experience and are distracted by their overwhelming desires. They tend to be oriented very strongly toward the future, always seeming to be looking ahead as if there is a sense that conditions this afternoon will be far more satisfying than they are this morning.

5. Social Control

Frequently children with attention deficits have difficulty "filtering out" their peers. In a classroom, they perpetually tune in to others and thus cannot focus on a teacher or text when other children are present. They exhibit an inordinate need to inspect, manipulate, or provoke their peers. Their social temptations and drives are frequently out of control.

6. Motor Control

It has been known for decades that children with attention deficits may be physically overactive exhibiting either fidgetiness or overt total body hyperkinesis. It should be stressed, however, that not all children with attention deficits display overactivity. Some in fact are normally active and others are underactive or lethargic. Often, however, motor activity is inefficient or not goal-directed.

7. Behavioral Control

The capacity to regulate conscious behavior is reduced in some children with attention deficits who fail to facilitate acceptable actions while inhibiting those that are inappropriate. In particular, they may not foresee the social consequences of their actions. Often affected children are impulsive; they act precipitously and allow little or no time for the prediction of outcomes. The result is a pattern of recurrent unpremeditated behavioral offenses. Often the child disclaims any role in the illegal act because it transpired so quickly and was unplanned.

8. Communicative Control

Some children with attention deficits are verbally disinhibited. They are loquacious and say the wrong things at the wrong times. They seem unable to predict the consequences of their statements; in some instances, they have trouble taking the perspective of the listener so as to determine what communication will please, what will oifend, and what will engender conflict.

9. Affective Control

Children with attention deficits are often described as emotionally labile. They vary considerably in their affect, exhibiting wide mood swings that are often difficult to predict or account for. At times, the mood seems not to match the occasion or circumstance in which a child finds him or herself.

ASSOCIATED MANIFESTATIONS

In addition to their weaknesses in several or all of the nine control systems described above, other propensities are common among children with attention deficits. Like the deficiencies of control systems, these associated manifestations can be major determinants of academic competency and social/behavioral adjustment.

Performance Inconsistency

One of the puzzling and agonizing features of weak control systems is their predictable inconsistency. It is critical to recognize and acknowledge that children with attention deficits do not have attention deficits all of the time! In virtually all cases, the often ineffective control systems operate well from time to time, thereby creating diagnostic and moral confusion. A child who seldom is able to focus on mathematics one day does so and completes all 12 word problems exhibiting superb concentration, admirable sustained reflection, and keen self- monitoring. This leads to the nearly inevitable accusation: "We know he can do it. We've seen him do it. The other day in math class he sat there and did all of his work magnificently. We know that when he puts in the effort, he can concentrate and live up to his potential." Such admonitions augment the suffering of children with attention deficits, as their performance inconsistency is as enigmatic to them as it is to adults. The inconsistency can lead to inexplicable error patterns on tests. A child may miss easy items while succeeding on more difficult ones. Quiz scores in secondary school may vary dramatically, ranging from a 98 one day to a 31 two days later, depending largely upon the extent to which any focal control was operative during the test or study session. Similarly, there can be inconsistency of behavior, of communication, of appetite control, and of motor regulation.

Fatigue

It is not unusual for children with attention deficits to experience substantial mental fatigue, especially when they concentrate or engage in sustained cognitive effort. Many of them yawn and stretch when required to listen for detail. Some appear to have a sleep/arousal imbalance. They sleep lightly or erratically at night and experience problems remaining fully aroused in the classroom. In many cases they must become physically active or fidgety to remain mentally alert. As the amount of detail and the demand for prolonged passive listening grows in secondary school, many students with attention deficits become increasingly inefficient and disorganized. Their fatigue weakens focal control as well as their other control systems.

Reduced Feedback Sensitivity

It is common for children with attention deficits to exhibit difficulties with se If- mon i tor ing. They exercise little quality control over their work and may be insensitive to social feedback cues as weil. Any task that entails se If- monitoring is performed carelessly. Additionally, such children may be relatively insensitive to both positive and negative reinforcement. They may tail to appreciate the significance of feedback, including either praise or criticism.

Memory Dysfunction

It is common for children with attentional difficulties to encounter certain typical problems with memory. Frequently they underachieve in secondary school when the mnemonic demands become particularly convergent and stringent. Because they are accustomed to registering nonsalient information in memory, they have a tendency to recall mainly trivia or incidental information while experiencing failure in courses that stress precise and rapid retrieval of factual details and/or previously learned skills. High school subjects that demand cumulative memory may be especially frustrating for these students.

Cognitive Dys-synchrony

Often children with attention deficits exhibit extraordinary ideational fluency enabling them to synthesize interesting thoughts at a rapid rate. They indulge liberally in divergent exploratory and creative thinking processes which often transpire at a rapid tempo. Commonly there is originality and scintillation in their ideas. However, other developmental functions are unable to keep pace with the fast flow. In particular, verbal fluency, precise memory retrieval and graphomotor speed may not be well synchronized with ideation. This is a very common cause of the writing difficulties so often seen in children with attention deficits. Their poor writing is frequently blamed on a fine motor problem but, in reality, they cannot synchronize motor movements with emanations from their thinking, remembering, and verbalizing processes. Consequently, their writing is labored, and poorly representative of the quality of their thoughts or extent of their knowledge.

Social Imperception

Some children with attention deficits endure social problems. Their impulsivity, their insatiability (and associated egocentric i ty), their tendency toward the free flight of ideas (and associated "spaciness"), and their unresponsiveness to social feedback cues place them in jeopardy, especially with regard to peer acceptance. Often they have no idea why they are unpopular, which can generate anxiety and elicit a series of maladaptive race-saving strategies, such as clowning, excessive controlling, aggression toward siblings, and the acquisition of a "macho" veneer.

COMPLICATIONS

The most common complication of attention deficits is chronic success deprivation. Children who have experienced long-standing attentional difficulties may be lacking in mastery and overdosed with criticism from the adult world (and sometimes from peers and siblings), which engenders low self-esteem, anxiety, and reactive depression. Academic underachievement is common. Further, it is not unusual for children with attention deficits to appropriate certain maladaptive face-saving strategies. At times the efforts at racesaving are believed to be the primary problems; the attention deficits may go unrecognized because the methods the child deploys to deal with them are more conspicuous than the direct effects of the weak control systems.

The complications of attention deficits extend into early adulthood. Underemployment, marital instability, criminal behavior, college dropout, and automobile accidents may be sequelae.3

THE QUESTION OF PRIMACY

There is growing evidence that certain highly specific central nervous system biochemical or perhaps anatomical lesions can predispose to attention deficits. An aberration in neurotransmitter metabolism has been suggested as one such factor. 4 It is likely, however, that the symptom complex comprising attention deficits ultimately will turn out to be nonspecific. That is, weak control systems in childhood may represent the developmental equivalent of inflammation as a concomitant of many infectious and autoimmune diseases. There are a limited number of ways in which the central nervous system can communicate that all is not well in its "wiring" and/or in its interactions with the outside world. The various forms of loss of control we have cited may constitute the nonspecific phenomenology of broad neurodevelopmental/behavioral dysfunction. Ultimately, it will be important to develop a more precise taxonomy, to be able to elucidate the subtypes of attention deficit. It is likely that various forms of attention deficits will differ with regard to etiology, pathophysiological mechanism, optimal treatment and natural history.

A general approach to subgroups of children with attention deficits can be suggested at this time. The following classification can be helpful in designing a management program:

Primary Attention Deficits - Children might be said to have primary difficulties with attention if they have had long-standing signs of multiple weak control systems that have affected their function in many situational contexts. These children often show minor neurological signs (such as synkinesias or associated movements). They commonly reveal high levels of impulsivity, insufficient attention to detail, inconsistency, and easy cognitive fatigability.

Processing-Specific Attention Deficits - These are attention deficits that are secondary to information processing deficiencies, such that a child may develop attentional difficulties because concentration repeatedly goes unrewarded. For example, a student with a significant language disability may fail to receive reliable information through verbal processing. Consequently, he or she chronically "tunes out" and becomes distracted in a classroom. Ultimately, this behavior spreads to other contexts. The child becomes overactive, impulsive, easily fatigued, and susceptible to sensory and associative distractibility. A child who endures recurrent episodes of otitis media during the toddler years may fail to have auditory attention rewarded with good information. This can promote a tendency to escape into visual distraction with a subsequent loss of focal control. Once again, there is a possibility that such secondary attentional difficulties can manifest themselves in multiple areas.

Anxiety-Induced Attention Deficits - Some children are preoccupied and chronically anxious. Attention is dislodged by their preoccupations. Compelling problems at home, conflicts with peers, or even more elusive forms of dysphoria may compete with and displace academically salient attentional foci. Multiple control systems can be adversely affected by anxiety. It is of interest that many of the symptoms of childhood depression overlap with those of attention deficit. 5

Neurotoxic and Medically-Induced Attention Deficits - A growing number of medical conditions are known to interfere with focal control as well as other control systems. Children who endured low level lead intoxication during their toddler years have been found to have attentional difficulties subsequently.6 There are some indications that low iron levels can promote attentional problems.7 Various medications have been implicated as possible sources of weak attention. These include aminophylline-containing compounds, antihistamines, and certain anticonvulsants (such as primidone). Moreover, a number of neurological disorders can mimic a primary attention deficit. Included are Tourette's syndrome, some seizure disorders, and space occupying lesions.

Situational Inattention - Some children reveal weak control systems only in specific situations wherein a child is mismatched with environmental circumstances or expectations. For example, a student from a culturally deprived home may become inattentive and lose control in school because of the formidable disparity between language and values at school and at home. A child whose learning style differs markedly from the teaching style of a particular teacher may tend to "tune out" frequently. What characterizes such attentional difficulties is that they are highly specific to particular circumstances and settings.

Mixed Forms - The above categories of attentional difficulty are not mutually exclusive. In fact, we have found that approximately 60% of children with attentional difficulties will also have associated information processing weaknesses.8 Sometimes it is difficult to tell whether their attentiona! problems have resulted from rheir processing problems or whether their processing problems stem from their attentional weaknesses. For example, in a youngster who has both language disabilities and multiple signs of attention deficit, it can be hard to determine whether that child developed attentional problems because of the futility of listening or whether the language problems evolved because he or she so seldom listened! Furthermore, as we have noted, children with attention deficits experience inordinate criticism and failure in life which can foster anxiety and even depression which, in turn, can aggravate pre-existing attentional problems. Additionally, such a child may be placed in a classroom with a teacher who is overly critical and lacks understanding of the child's plight. Thus, a primary attention deficit may be complicated by an information processing deficiency, by anxiety, and by situational inattention.

Attention deficits may sometimes occur in isolation. A child may have a primary attention deficit with no signs of anxiety or additional information processing weaknesses. Some youngsters, however, have been said to have attention deficit plus. That is, in addition to their primary attention deficit, they have other developmental dysfunctions. In many cases, these are not substantial or pervasive enough to create secondary attentional problems. Instead, they comprise associated weaknesses, most commonly involving deficiencies of memory. Sometimes, however, there are problems with sequential organization, visual processing, and/or language.

EVALUATION

The assessment of a child with attention deficits is complex but ultimately rewarding and vital. It is critical that the affected child undergo a thorough assessment that takes into consideration the multiplicity of sources and ramifications of attention deficits. The following components must be included in any complete evaluation:

Symptom Inventories

It is necessary to document individual symptom complexes. Certain youngsters with attention deficits concentrate most or all of their problems in a very few of the control systems, while others have more pervasive manifestations. Data usually can best be obtained by utilizing parent and teacher questionnaires, such as the one illustrated in the Figure. Ultimately, it is more important to derive a picture of the distribution and relative severity of different symptoms than it is to dwell upon a total score on a questionnaire. For this reason, the ANSER System questionnaires elicit highly specific clusters of symptoms as indicative of the nature of a child's attention deficits; such questionnaires are filled out by parents, school personnel, and the child.9 Of interest is the fact that these sources of data do not always agree with each other.8 Contradictions or differing perceptions can have important implications for management.

Direct Observations of Attention

It is most revealing to observe the child in the act of performing. This can be done with the use of neurodevelopmental examinations, by direct assessments of attention (such as vigilance tests), during intelligence or achievement testing, or through actual classroom observations. Typically children with attentional difficulties display their impulsivity, their tendency to yawn and stretch, their distractibility, their lack of selfmonitoring, and their performance inconsistency. It should be stressed, however, that it is not unusual for a child with attention deficits to reveal no symptoms whatsoever when being tested on a one-to-one basis. If he or she finds the experience highly motivating and challenging, it is likely that attention will strengthen beyond its usual intensity so that an unreliable or misleading behavioral sample is obtained. For this reason, it is essential that a diagnostician be willing to overrule his or her own direct observations when the history is compelling. We have often employed a rule of consensus when evaluating such youngsters. In comparing the perceptions of the parents, the school, and the diagnostic team, we have felt that if any two of the three sources agree that a child shows manifestations of multiple weak control systems, it is concluded that some form of attention deficit is present.8

Evaluation of Neurodevelopmental Status

It is essential that children with attention deficits undergo thorough evaluation of a broad range of cognitive/developmental functions. These should include the following:

Table

Figure. The inventory of symptoms shown above is completed by parents of children with possible attention deficits. It is part of the ANSER System Questionnaires. The capital letters to the left side of each item represent the particular component of attention that is being assessed. FSQ = focal strength and quality; SAB = sleep arousal balance; RIM = reflectivity-impulsivity; AMP = associated memory problems; PCN = performance consistency; FBR = feedback reception; SEC = sensory control; ASC = associative control; APC = appetite control; SOC = social control; MOC = motor control; BEC = behavioral control. There is a companion teacher questionnaire which has most of the same items and all of these categories represented. A clinician can scan a completed inventory to survey the relative manifestations of specific symptoms.

Figure. The inventory of symptoms shown above is completed by parents of children with possible attention deficits. It is part of the ANSER System Questionnaires. The capital letters to the left side of each item represent the particular component of attention that is being assessed. FSQ = focal strength and quality; SAB = sleep arousal balance; RIM = reflectivity-impulsivity; AMP = associated memory problems; PCN = performance consistency; FBR = feedback reception; SEC = sensory control; ASC = associative control; APC = appetite control; SOC = social control; MOC = motor control; BEC = behavioral control. There is a companion teacher questionnaire which has most of the same items and all of these categories represented. A clinician can scan a completed inventory to survey the relative manifestations of specific symptoms.

Table

Figure. The inventory of symptoms shown above is completed by parents of children with possible attention deficits. It is part of the ANSER System Questionnaires. The capital letters to the left side of each item represent the particular component of attention that is being assessed. FSQ = focal strength and quality; SAB = sleep arousal balance; RIM = reflectivity-impulsivity; AMP = associated memory problems; PCN = performance consistency; FBR = feedback reception; SEC = sensory control; ASC = associative control; APC = appetite control; SOC = social control; MOC = motor control; BEC = behavioral control. There is a companion teacher questionnaire which has most of the same items and all of these categories represented. A clinician can scan a completed inventory to survey the relative manifestations of specific symptoms.

Figure. The inventory of symptoms shown above is completed by parents of children with possible attention deficits. It is part of the ANSER System Questionnaires. The capital letters to the left side of each item represent the particular component of attention that is being assessed. FSQ = focal strength and quality; SAB = sleep arousal balance; RIM = reflectivity-impulsivity; AMP = associated memory problems; PCN = performance consistency; FBR = feedback reception; SEC = sensory control; ASC = associative control; APC = appetite control; SOC = social control; MOC = motor control; BEC = behavioral control. There is a companion teacher questionnaire which has most of the same items and all of these categories represented. A clinician can scan a completed inventory to survey the relative manifestations of specific symptoms.

1. Memory

2. Language

3. Visual Processing

4. Temporal Sequential Organization

5. Fine and Gross Motor Function

6. Problem-Solving and Higher Order Cognition (including the use of cognitive strategies)

Specific neuropsyc ho logical test batteries or neurodevelopmental examinations can be employed for this purpose. Simply giving an intelligence test may not be sufficient to detect possible information processing deficits.

Assessment of Emotional Status

The child's overall emotional status requires evaluation. Signs of depression, autistic tendencies, or other major forms of psychopathology need to be ruled out. At the same time, sources of environmental turmoil must be identified and assayed with respect to their impact upon the child.

Physical and Neurological Examination

It is necessary to rule out any primary medical conditions that may be eroding attention. Some laboratory tests can be helpful (such as a serum Ferritin to rule out underlying iron deficiency). In some cases, an electroencephalogram is helpful in detecting an underlying seizure disorder. In general, however, this procedure does not have a high yield. A thorough neurological examination should always be performed and should include an assessment of minor neurological indicators (so called "soft signs"). The latter can be part of an overall neurodevelopmental examination.

Educational Assessment

Educational skills should be evaluated by a psychoeducational specialist who can uncover the child's specific error patterns as well as his or her stylistic approach to learning and task completion. Such observations can lead to specific recommendations for the classroom teacher as well as for special educational intervention (if needed).

Most children with attention deficits can benefit from an evaluation by a multidisciplinary team. If this is not done, there is a danger that only one facet of a child's difficulties will be identified. In complex cases, it is possible that individuals trained in a particular discipline will be biased toward seeing within the child the particular clinical conditions that they were trained to find. Thus, a youngster with attentional difficulties who only sees a language specialist may be diagnosed as having a "central auditory processing problem." Such a language therapist can be valuable in elucidating the linguistic implications of the attention deficit. However, that specialist should not be the only individual who assesses the child. Similarly, a particular professional may focus only upon the psychodynamic issues, the neurological dysfunctions, or the educational problems. It is only with effective interdisciplinary collaboration that the child's broad needs can be determined and addressed.

MANAGEMENT

Children with attention deficits can be managed successfully; their informed care can prevent the devastating complications of chronic success deprivation, depression, and maladaptive strategy deployment. It has been shown convincingly that various forms of multimodal therapy can be highly effective in caring for children with attention deficits.10 The following components (in varying combinations) are likely to be beneficial:

Demystification - Children with attention deficits and their parents are in desperate need of information regarding attention deficits. Such education can alleviate anxiety, guilt, and accusatory crossfire. The demystification has to be non-accusatory and nontechnical. Concrete examples and good analogies should be used. Children must come to recognize that they are not pervasively defective but that they have trouble "tuning in," that they are like television sets whose channel selectors or antennae are malfunctioning. Phenomenology such as performance inconsistency, impulsivity, and the lack of attention to detail must be dealt with directly in a supportive matter of fact tone. At the same time, the child must come to understand that he or she is accountable for steady (if slow) improvement. Attainable short-term goals must be set to facilitate this accountability. Optimism should be fostered. The process of demystification needs to be ongoing.

Educational Accommodation - Changes often need to be made in the school program so that attentional difficulties do not totally abort a student's education. "Bypass strategies" are needed in the classroom. A child may require preferential seating close to the teacher. There may need to be frequent feedback regarding whether or not there have been any "mind drifts." The child may need more frequent breaks. Sometimes there may need to be more repetition of instructions, less dense detail, and smaller chunks of required work. In older youngsters whose attention difficulties are complicated by memory problems, there may need to be some alteration in course selection. For example, a foreign language may need to be postponed until eleventh grade so as to mininme the heavy memory drain that is typical of ninth grade. Many children with attentional difficulties need special provision to lessen the writing burden which they encounter in late elementary and junior high school.

Cognitive/Behavioral Management - Children with attentional deficits appear to benefit from some form of cognitive/behavioral therapy.11 This may be done by a specially trained psychologist or educational specialist. Such counselling entails continuing démystification regarding a child's attentional difficulties combined with specific exercises to work on the most bothersome or severe traits. Thus, a child may be helped to understand his or her impulsivity. Then certain tasks may be designed to enable that child to practice being less impulsive. The child may be given a mathematics problem that would ordinarily be rushed through in 20 seconds and told to do it in a few minutes instead. This can both strengthen reflective behavior at the same time that it enhances the child's personal insight into his difficulties. In some cases, programs of reinforcement can be developed to encourage the more reflective approach. In a less formal manner, most children with attention deficits and their parents can benefit from ongoing advice. They desperately seek suggestions on how to handle specific situations. A structured behavioral and cognitive management counselling program can be rewarding. Those children who also have social interactional problems can gain from social skills training. Generally speaking, a psychotherapeutic approach that offers little if any concrete management advice tends to be unsuccessful with this particular group of patients.

Medication - The use of stimulant therapy for attention deficits has been well established as an important element of treatment. There are good reviews of this subject.12 In general, stimulant drugs (such as dextroamphetamine, methylphenidate, and pemoline) have been used effectively. It is important to stress, however, that these stimulant drugs, which appear to help arousal and establish more effective focal and behavioral control, are never panaceas. They appear to be much more effective when they constitute one component of a multimodal approach to treatment. Children should not be begun on such medication without having a complete evaluation and without attending to their counselling and educational needs. Although isolated pharmacological treatment may result in a temporary improvement, it is likely that associated problems will fester and ultimately cause difficulty. Some anxious children with attention deficits benefit from antidepressant medication (such as imipramine). In cases where Tourette's syndrome is confirmed, haloperidol may suppress the impulsivity as well as the tics. Other drugs, such as thiodorazine are sometimes effective in resistant cases. In general the stimulants should be tried first unless there is evidence that a child has Tourette's syndrome or a major psychiatric disorder.

Other Therapeutic Modalities - The treatment of children with attention deficits must be individualized. Certain youngsters will also require language therapy, occupational therapy (for motor weaknesses only), or mental health intervention (especially where there are difficulties in the family or when the child is significantly depressed). Most children with attention deficits desperately need success induction as part of their treatment. A clinician should identify underutilized or unrecognized areas of developmental strength and guide the child into activities in which he or she can experience mastery.

Advocacy and Monitoring - Children with attention deficits desperately need advocates. Often the pediatrician can serve effectively in this capacity. Parents need support in dealing with schools, especially those institutions that fail to recognize attentional difficulties or that subject these children to too much humiliation and criticism. Students deemed ineligible for services because of arbitrary state criteria may be in particular need of strong advocacy from their physicians. As with any other chronic conditions in childhood, follow-up is of critical importance. A child's pediatrician or another interested clinician can fulfill this function by scheduling regular follow-up visits during which progress is monitored and ongoing advice dispensed. Generally, children with attention deficits evolve over time in their needs. This means that anticipatory guidance is called for. Advocacy also entails helping parents to resist irresponsible interventions. As they become increasingly desperate, parents may be tempted to try therapeutic interventions that are unscientific, expensive, and sometimes even fraudulent. A responsible clinician needs to warn parents and hopefully divert them from such tempting quick cures.

OUTLOOK

In dealing with children who have attention deficits, there is every reason to foster optimism. Many of the traits of affected children have the potential to evolve into strengths during adult life. Insatiability during youth can become ambition in adulthood. Distractibility can mature into creativity. Overactivity can emerge as high productivity. Impulsivity can engender a strong closure orientation on the job. Moreover, as we have seen, attention deficits can be effectively managed. The pediatrician's challenge is to increase public awareness of this problem and to mobilize resources within communities to offer the multimodal therapy that can redeem these children. If the challenge is met, we can avert the heavy toll that these children and society ultimately pay when their needs are neglected.

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11. Douglas BI, Parry P. Marton P. et al: Assessment of a cognitive training program for hyperactive children. J Abnorm Child Psychol 1976; 4:389.

12. Bartley R: A review of stimulant drug research with hyperactive children. Book Suppl/ Child Psychiatry 1977; 18:137.

Figure. The inventory of symptoms shown above is completed by parents of children with possible attention deficits. It is part of the ANSER System Questionnaires. The capital letters to the left side of each item represent the particular component of attention that is being assessed. FSQ = focal strength and quality; SAB = sleep arousal balance; RIM = reflectivity-impulsivity; AMP = associated memory problems; PCN = performance consistency; FBR = feedback reception; SEC = sensory control; ASC = associative control; APC = appetite control; SOC = social control; MOC = motor control; BEC = behavioral control. There is a companion teacher questionnaire which has most of the same items and all of these categories represented. A clinician can scan a completed inventory to survey the relative manifestations of specific symptoms.

Figure. The inventory of symptoms shown above is completed by parents of children with possible attention deficits. It is part of the ANSER System Questionnaires. The capital letters to the left side of each item represent the particular component of attention that is being assessed. FSQ = focal strength and quality; SAB = sleep arousal balance; RIM = reflectivity-impulsivity; AMP = associated memory problems; PCN = performance consistency; FBR = feedback reception; SEC = sensory control; ASC = associative control; APC = appetite control; SOC = social control; MOC = motor control; BEC = behavioral control. There is a companion teacher questionnaire which has most of the same items and all of these categories represented. A clinician can scan a completed inventory to survey the relative manifestations of specific symptoms.

10.3928/0090-4481-19870201-06

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