CHAPTER 2

ATTENTION

  1. INTRODUCTION
    1. Levine argues against the idea that ADD is a separate disorder. Viewing it as a separate disorder that is defined by a list of traits creates the following problems:
      1. It neglects the heterogeneity of people with attention problems
      2. It separates attention from other cognitive functions such as memory and language and prevents people from considering the effects of attention on other processes
      3. It prevents people from examining how the subfunctions of attention operate
    2. Attention can be conceptualized as a network of interactive controls that play a managerial role in the mind. Attention controls fulfill three functions. They
      1. activate
      2. regulate
      3. monitor
    3. Attention controls can be grouped into three systems
      1. mental energy controls
      2. processing controls
      3. production controls


  2. CONTROL SYSTEMS AND BREAKDOWN POINTS
    1. Functions of the three control systems
      1. Mental Energy controls regulate the flow, allocation and maintenance of a mental energy supply
      2. Processing controls regulate the intake and interpretation of information
      3. Production controls regulate the mind's output
    2. Each control system can impact one or more of the following areas of learning:
      1. Cognition and academic performance
      2. Behavior
      3. Social skills
    3. Mental Energy Controls distribute resources needed to concentrate
      1. Arousal and Alertness Control
        1. Alertness - maintaining enough mental energy for concentration
        2. Sleep/arousal balance - feeling alert during the day, sleeping soundly at night
        3. Arousal regulation - being able to increase level of arousal when needed
      2. Dysfunctions of Arousal/Alertness Control
        1. Excessive mental fatigue in the classroom
        2. Intermittent difficulty with concentration
        3. Fidgeting, squirming, yawning, stretching = ways of combating fatigue
        4. Feeling "bored"
        5. Tired during the day, trouble falling asleep at night, trouble waking up in the morning
        6. tendency to tune in and out
        7. Can't match intensity of mental energy to specific context - over-aroused or under-aroused
      3. Mental Effort Control
        1. Mental effort is the energy a person needs to summon up when the task is hard or unappealing and the current state of energy is not enough to perform a task.
        2. Involves the ability to engage in activities requiring effort, ability to exert more effort when needed, and to maintain a steady level of effort
      4. Dysfunctions of Mental Effort Control
        1. Difficulty exerting mental effort when tasks are not motivating
        2. Appears to be lazy, oppositional, or negligent
        3. Has trouble getting started with a task and/or finishing what was started
        4. May have difficulty controlling behavior, results in loss of behavior control
        5. Mental effort control is inconsistent, so performance is eratic
    4. Processing Controls regulate the intake and use of information
      1. Saliency Determination (Selective attention)
        1. Determining which sources of information are purposeful or meaningful and focusing on them
        2. Focusing on specific data that is relevant to the current situation
        3. Prioritizing the importance of incoming information
        4. Identifying the main points of a message
        5. Being alert to important but infrequent information (vigilance)
        6. Dividing attention between equally important sources information
        7. Analyzing and learning from experience (knowing what was important)
      2. Dysfunctions of Saliency Determination
        1. Distractibility - may involve one or more of the following
          1. visual - distracted by irrelevant or trivial visual details
          2. auditory - distracted by background sounds
          3. tactile - distracted by touching or handling objects
          4. temporal - distracted by thoughts of future or past activities
          5. somatic - distracted by trivial body feelings, scabs, scars
          6. social - distracted by peers
        2. Difficulty identifying the significance of information, such as
          1. main ideas
          2. information in math word problems
          3. what to study
          4. taking notes, underlining
        3. Difficulty proofreading (vigilance for infrequent information)
      3. Depth and Detail of Processing
        1. Concentrating hard enough to gather information needed
        2. Balancing concentration between the big picture and the details
        3. Concentrating hard enough to retain information
        4. Concentrating hard enough to appreciate fine detail
      4. Dysfunctions of Processing Depth and Detail
        1. Information goes "in one ear and out the other" - need for frequent repetition
        2. Too little concentration on fine details - results in "careless" errors
        3. Too much concentration on fine details - results in getting bogged down in details
        4. Difficulty registering information results in memory problems
        5. Unintentional failure to attend to and process rules, warnings, etc. appear to be intentional misbehavior.
      5. Cognitive Activation
        1. Cognitive activation is the process of connecting new information to prior knowledge and experience - an active processor keeps on connecting and associating.
        2. Attention controls and calibrates the intensity of cognitive activation
      6. Dysfunctions of Cognitive Activation
        1. Passive processors - child makes few associations, relies on rote memory, feels understimulated at school
        2. Overactive processors - child has overactive mind - new information elicits many irrelevant and distracting connections (free-flight distractibility) (These kids may be very imaginative)
        3. Child may have inconsistent ability to regulate level of activation - sometimes extremely passive, sometimes extremely active.
      7. Focal Maintenance Control
        1. Focusing long enough to process fully
        2. Changing focus when task if finished (not perseverating)
        3. Continuing to focus on what works, discontinuing focus on what is not relevant to task.
      8. Dysfunctions of Focal Maintenance Control
        1. Short concentration (short attention span)
        2. Concentrating too long; difficulty shifting focus (perseveration)
      9. Satisfaction Control
        1. Being able to postpone rewards
        2. Reducing intensity of wants and desires
        3. Being able to curtail a gratifying activity and start another activity
        4. Feeling motivated to concentrate
        5. Being able to feel satisfied without high levels of excitement
      10. Dysfunctions of Satisfaction Control
        1. Insatiability -some children don't feel satisfied without intensity, entertainment, and immediate gratification. They have trouble concentrating when they don't feel satisfied and are distracted by their needs and desires
        2. Types of insatiability
          1. Material insatiability - child desires material possessions; may be collectors or accumulators
          2. Experiential insatiability - child desires intensity of experience; may "stir things up" or be bored/unmotivated
    5. Production Controls allow the mind to operate slowly and deliberatively when planning and executing any sort of product or action
      1. Previewing Controls (prediction) = the mind's facility with forethought and foresight
        1. Academic - estimating a calculation, predicting the outcome of a story
        2. Social - foreseeing effects of one's actions on others
        3. Behavior - foreseeing consequences of one's actions
        4. Planning any product or action, e.g.:
          1. foreseeing what the final outcome will be
          2. predicting the steps in an activity and what might come next
          3. preparing for a new activity
      2. Dysfunctions of Previewing Controls
        1. Poor foresight leads to disorganized products: homework, reports
        2. Children get into trouble because they don't predict the consequences of their actions
        3. May be taken by surprise, unready to respond
        4. Unprepared for changing activities, don't have needed materials; may create high anxiety
      3. Facilitation and Inhibition Controls (Selective Intention)
        1. Reviewing options for behavior, verbal communication, problem-solving, or undertaking any task
        2. Facilitating the option most likely to succeed while
        3. Ignoring and inhibiting other options
      4. Dysfunctions of Facilitation and Inhibition Control
        1. Impulsivity - acting and reacting in ways that reflect the first possibility that comes to mind
        2. Low frustration tolerance, "flying off the handle." This may be due to not having other options to deal with frustration.
        3. Possible excessive or purposeless motor activity (hyperactivity) (Note: not all people with attention problems are hyperactive)
        4. Motor inefficiency, overflow movements
      5. Tempo Control
        1. Selecting and applying the appropriate rate or pacing for a specific activity
        2. Synchronizing simultaneous activities
        3. Appreciating the time needed for an activity, time management
        4. Breaking down complex activities into sequential steps
      6. Dysfunctions of Tempo Control
        1. Doing things too quickly - appears to be hurried and careless
        2. Doing things too slowly
        3. Poor time management
        4. Overwhelmed and discouraged by complex tasks with multiple subparts
      7. Hyperactivity and Impusivity are probably the result of a combination of several attention control problems.
        1. Hyperactivity could be the result of
          1. needing to "wake up" and become more alert
          2. motor disinhibition
          3. poor tempo control
        2. Impulsivity could be the result of
          1. poor previewing
          2. weak facilitation and inhibition
          3. poor tempo control
      8. Self-Monitoring Controls
        1. Monitoring cues indicating social success/failure
        2. Monitoring academic errors
        3. Monitoring effects of one's behavior on others
        4. Monitoring the location and activity of one's muscles
        5. Evaluating degree of success/failure of activity
      9. Dysfunctions of Self-Monitoring Controls
        1. Frequent "careless" errors
        2. Difficulty proofreading
        3. Lack of awareness of what one is doing
        4. Difficulty evaluating one's own performance
        5. Lack of awareness of social and behavioral cues
        6. Handwriting difficulty
      10. Reinforcement Control
        1. Ability to learn from previous experience
        2. Sensitivity to reward and punishment
        3. Ability to reuse methods and strategies that have worked successfully in the past
      11. Dysfunctions of Reinforcement Control
        1. Relatively unresponsive to rewards and punishments
        2. Little hindsight
        3. Does things the hard way
        4. Doesn't learn from past mistakes
      12. General Considerations about Attention Controls
        1. Attention controls are highly interdependent- they enhance or restrict each other
        2. If only one attention control is weak and others are adequate, there may not be a general attention deficit. Instead the single weak attention control may be a secondary effect of some other processing problem.
        3. Often attention controls are not continually weak but rather inconsistent and unreliable. They may deteriorate in unfavorable conditions
        4. Attention controls are very closely related to all other processing areas
        5. Anxiety and other emotions can interfere significantly with attention controls
        6. Assessment of attention controls must consider these five points


  3. ATTENTION CONTROLS AND THEIR BRAIN LOCATIONS
    1. There is still much to be learned about the neuroanatomy of attention
    2. The following locations can be identified
      1. Mental energy controls - reticular activating system in the brain stem
      2. Processing controls - various locations in the midbrain and cortex
      3. Production controls - prefrontal cortex


  4. ONSETS AND LIFE HISTORIES OF INDIVIDUALS WITH ATTENTION DEFICITS
    1. Onset
      1. The time of onset varies considerably. Attention problems may surface prenatally, during preschool, at school entry, during elementary or high school.
      2. The number of symptoms and persistence of those symptoms vary considerably. Some symptoms get better; others get worse.
    2. Life Histories
      1. Typical symptoms in infancy
        1. Insatiable, unpredictable, irritable
        2. Overactive, twisting, squirming, arching the back
        3. Abundant exploratory behavior, but not necessarily purposeful
        4. Excessive crying
        5. Unusual sleep patterns
        6. Unpredictable feeding patterns
      2. Typical symptoms in preschoolers
        1. Children with hyperactivity may be noncompliant, fearless, unresponsive to discipline, driven, out of control, accident prone
        2. May or may not have language and cognitive delays
      3. Typical symptoms at school entry
        1. Difficulty remaining seated, staying attentive, restless
        2. Difficulty interacting socially
        3. Overly egocentric, unable to share
      4. Typical symptoms in elementary school
        1. Difficulty sustaining attention, especially as demands for using more precise language increase in middle grades
      5. Typical symptoms in secondary school
        1. Students who have difficulty focusing on details have increasing problems in high school as demands increase
        2. Tendency toward passive processing
        3. Higher levels of impulsivity, problems with planning, difficulty with self-monitoring, and trouble learning from experience
        4. These students are seen as poorly motivated, lazy, careless, negligent
        5. Since they are not living up to expectations, they become depressed, anxious, and suffer from poor self-esteem
        6. The normal problems of adolescence make things even more difficult
        7. If the student has other processing problems, the demands of high school increase the strain even further
        8. Insatiability becomes more pronounced - perpetually unsatisfied
        9. Greater discrepancy between demonstrated potential and day-to-day achievement
        10. Adolescence is a transition time - some find an interest that coincides with their strengths, a special niche, and make a remarkable "recovery," others deteriorate.
      6. Typical symptoms in early adult life
        1. High risk and negative outcomes
          1. Wide range of impulsive behaviors persist
          2. Very poor driving record
          3. Tendency toward delinquency, divorce, instability of relationships
          4. Tendency toward depression and other emotional problems
        2. Resiliency and positive outcomes
          1. Insatiability may be transformed into drive and ambition
          2. Distractibility and free-flight of ideas may develop into creativity and inventiveness
          3. Impulsivity may be transformed into decisveness and productivity
          4. May become big thinkers, entrepreneurs, conceptualizers who need administrative assistants


  5. ASSESSMENT OF ATTENTION
    6.
    1. Types of Assessment Instruments
      1. Questionnaires - usually these are behavioral checklists completed retrospectively by parents and teachers
      2. Direct measures of attention - usually computerized, can detect weakness in
        1. vigilance
        2. impulsivity vs. reflectivity
        3. attention span
        4. focus on detail
        5. cognitive flexibility
        6. strategy use
      3. Guided observations of attention - observer can evaluate attention over time and on specific tasks
    2. Precautions Regarding Assessment of Attention
      1. Some questionnaires focus more on behavior and less on the impact of attention on academics. These tend to over-identify ADD.
      2. Questionnaire scoring systems that rely simply on counting the number of symptoms may not be valid because they don't consider the severity of the symptoms.
      3. There is no standard against which to validate a good questionnaire
      4. Interscorer agreement (reliability) on questionnaires is often low
      5. Direct tests of attention may be affected by the child's current state. They are one-time measures, but ADD is a chronic problem in which inconsistency is frequent, so a one time test may miss the problem.
      6. Direct tests only measure a few attention controls.
      7. Children with ADD often do well on direct tests because the situation is novel, challenging, and one-to-one. All these factors increase level of attention.
      8. Direct observation can be highly subjective and depend on the observer's tolerance, astuteness, and level of experience.
      9. Accuracy of direct observation may also depend on the current context in which the child is operating.
    3. General Guidelines for Assessment of attention
      1. Use several methods, and look for consistency of results across methods and instruments
      2. Try to evaluate specific attention controls as they affect academics, behavior, and social interaction.
      3. The end product of an assessment of attention should be a descriptive profile of the child's strengths and weaknesses across the attention controls


  6. MANAGEMENT OF ATTENTION DEFICITS
    7.
    1. Demystification
      1. Children need to learn about the various attention controls and related vocabulary so they can talk about their strengths and weaknesses
      2. Teachers need to talk to children with ADD about the various attention controls and help them identify and understand their strengths and weaknesses. This needs to be done periodically.
    2. Management Strategies - For a list of suggestions see Chapter 2 pp. 60-64
    3. Other forms of Management
      1. Counseling
      2. LD Remediation
        1. Strengthen areas of weak processing
        2. Remediate areas of academic skill deficiencies
      3. Social Skills Training
      4. Parent Groups
      5. Medication (see Chapter 15)
      6. Possible Indications for the Use of Stimulant Medication
        1. Persistent mental fatigue
        2. Hyperactivity
        3. Extreme, frequent impulisvity
        4. Trouble focusing (not accounted for by other processing problems or anxiety)
        5. Inexplicable serious inconsistencies in school work
      7. Long-term Follow-up and Advocacy