CHAPTER 8: Why Can't They Pay Attention?
The reason our children don't follow directions is that they're tuned out. These children don't listen. They have so much stimulation --they're used to the TV blaring, the stereo, the household commotion. I'm not sure so many are ADHD; they're just restless because they don't have anything inside. They're so used to being-entertained. -- EIGHTH-GRADE TEACHER, SUBURBAN SCHOOL, GEORGIA
They have a much better store of general information than children twenty years ago. If they listen, they can follow directions, but it is difficult to keep their attention long enough to explain what to do. -- TEACHER, UNGRADED RURAL SCHOOL, MINNESOTA
The kids are sharp and intuitive, but -- listening skills? Not as good as students in the past. Some seem to have forgotten how to learn without visual stimulation and affirmation of what they hear. Concentration and memory are just not as important to them. They seem to have their own agendas in life, and school gets in the way sometimes. -- FIFTH-GRADE TEACHER, URBAN SCHOOL, OREGON

FIGURE 3 [Teacher] Students, turn to page 94. You will need a pencil, paper and your ruler. [Girl] What else do I need besides a pencil and paper? [Boy] What page did you say that was? [Boy] Do we need our books? [Boy] What page? Courtesy of Dodie Corpening and Gifted, Created and Talented Magazine.
THE PROBLEM OF ATTENTION
Although "attention deficits" are involved in the vast majority of learning-disability referrals, teachers of all students complain more about diminished attention spans than about any other characteristic of their students. As soon as I began to talk with educators, I discovered that merely mentioning the word "attention" opened a floodgate of response. To my surprise, I also heard the same concerns expressed from abroad, although in other countries the diagnosis of "learning disability" and ADHD are much less prevalent.
In Tours, a large city southwest of Paris, the director of a primary school and an instructor in the highly esteemed Ecole Normale (Teachers' College), told me, "The teachers here complain a lot; they say the children don't listen anymore, they are restless. This is only my personal opinion, but I think one learns not to listen when one watches television. I think the children get in the habit and then when the teacher talks, they don't hear her either." She went on to describe other concerns remarkably similar to those I was hearing at home about hurried lifestyles, overprogrammed children, and the decline of thoughtful conversations around the family dinner table. "Personally, I don't think the parents encourage calmness or listening," she mused. [1]
It is clear from the preceding comments that declining listening abilities are the main symptom, but most teachers sense that they also reflect students' problems with focusing and maintaining internal control of attention in any situation. Overall mental restlessness and inability to persist in solving problems, reading "hard" books, or doing work perceived as "boring" are even more serious symptoms. In the United States a national crisis in "problem-solving ability" -- the ability to stay focused long enough to reason out and solve a mental challenge -- has become the primary agenda item of the National Council of Teachers of Mathematics and the Association for Supervision and Curriculum Development.
Could these trends simply represent inevitable signs of progress? Will children be better off if they learn early to respond to the pace of the contemporary world? Certainly, to be adapted to today's surroundings, young brains need to deal with a lot of rapid-fire stimuli. To reason effectively and solve problems, however, growing minds also need to be able to retain and connect these "bits." Perhaps most important, they need to learn what it feels like to be in charge of one's own brain, actively pursuing a mental or physical trail, inhibiting response to the lure of distractions.
Attention determines how and what an individual learns. [2] It enables us to make choices and maintain control over what we notice, absorb, and remember. Children with attention problems fall into two general categories: some are too mentally active, with their focus jumping from one thing to another, while others behave as if their brains were underactive. Those in the latter group frequently are termed "spaced out," but they are much less frequently diagnosed than the "hyper" ones, who respond impulsively to whatever can be touched or seen in their environments and have particular difficulty internalizing personal controls. [3] Those with serious disorders often grow up to be impulsive adults; ADHD is statistically linked with delinquency and antisocial behavior. If our society wants citizens who can reflect as well as respond, who can come up with solutions to the problems of a complex world, it must teach its children to stop, listen, and think as well as to react.
How can we help children learn to direct their mental energies? How much can the environment affect patterns of attention, listening, and problem-solving? Let us consider first what is known about attention and why physicians prescribe drugs for some children who lack it. Then we will start to take a look at what environments, both physical and mental, have to do with the way it develops -- or fails to -- during childhood.
What Is an Attention Deficit?
Attention, like learning disability, is not a single measurable quantity. Although psychologists are far from agreeing on an exact definition, they have generally believed, as far as learning is concerned, that selective attention -- the ability to concentrate and stay focused on a particular task -- is the critical issue. [4] But selective attention has proven hard to measure. Like memory, it is "task specific," changing according to the job the brain is asked to do and the underlying motivation to do it. For example, many teachers who complain that students can't pay attention and listen in class also notice that the same children will concentrate on a computerized video game for long periods of time. In these two situations there are clear differences between both motivational and cognitive factors such as auditory or visual attention, saliency (attention-grabbing quality) of the stimulus, requirements for memory, physical involvement, and the pace of the activity, all of which affect attention.
For all learners, attention varies from situation to situation, and it is difficult to determine the fine line between normal restlessness and pathology. Now that so many children seem out of sync with the attentional demands of their classrooms, the problem is compounded. Even the extreme diagnosis of "ADHD" -- which assumes that the child has some sort of organic brain dysfunction -- depends on rather vague criteria, since there are no surefire neurological tests to prove its existence.
To diagnose a child as pathologically inattentive most doctors depend mainly on behavior checklists filled out by teachers and parents; the official diagnosis is often subjective. A certain proportion of items like the following must be checked:
• failure to finish things he or she starts
• failure to listen
• difficulty in concentrating or sticking to an activity
• acting before thinking
• shifting between one activity and another
• difficulty in organization
• calling out in class/difficulty awaiting turns
To earn the additional designation "hyperactive," the child must also show excessive physical activity (e.g., run or climb excessively).
Since all children exhibit these behaviors at times, the diagnosis is supposed to be restricted to problems that are unusually severe for the child's age and level of mental development. Curiously, however, doctors are told that the child may seem perfectly normal during the office visit, since ADHD children are often able to control themselves in novel or one-to-one situations. [5]
Controlling Attention: From Inside or Outside?
Ritalin and other drugs prescribed for ADHD are variations on the type of stimulants, or amphetamines, banned in over-the-counter diet pills. They help heighten and sharpen attention -- even in many "normal" people. Some children with organic difficulties seem to benefit from carefully regulated doses that enable them to focus appropriately, listen more carefully to the teacher, and complete more work. In fact, moderate doses would have the same effect on almost anyone -- at least for a while -- and many doctors complain that the number of children treated is much larger than it should be. Some physicians, parents, and teachers are too eager, they say, to give children drugs with well-recognized negative side effects, instead of working to help them learn to manage their own behavior.
Many children diagnosed as having attention deficit disorder are extremely intelligent, but there is some reason to doubt the overall benefit of drug treatment alone in helping them use that intelligence productively. Students who take their medication do become more tractable, completing more repetitive "work" such as worksheets with fill-in answers and drills on math problems. In most studies conducted thus far, however, drugs per se do not make them score better on tests of academic achievement or of higher-level thinking and problem-solving. [6] Some studies have even shown that the level of dosage needed to make teachers approve a child's behavior is so high that it actually dulls reasoning ability. These findings raise questions, not only about the type of "work" dominating many classrooms, but also about the real source of the problem. [7]
Lasting improvement is generally not seen after the drug treatment is stopped. A few children appear spontaneously to "outgrow" attention problems around adolescence, probably because of nervous-system maturation, but many retain problems of self-control that persist into adulthood.
"Curing" attention problems seems to be close to impossible. Teaching students to talk through problems, thus developing conscious strategies for self-control, is the only therapy used thus far that appears to produce results lasting after drugs are discontinued. [8-10] In fact, this sort of "cognitive therapy" -- using language to control behavior -- has been shown to help even without drug treatment. Some professionals have gone so far as to suggest that the real disability is a lack of this type of teaching -- both at home and at school.
Misfitted Attention: What Is the Real Problem?
Since most of the "epidemic" of inattention cannot be linked to proven organic dysfunction of the central nervous system, other factors that create a misfit between the children's development and the demands of the schools are being considered. According to the newest research, a small percentage of problems called ADHD may be covering up basic anxiety or depression. [11] Many more may be related to other, environmental causes. Overall a confusing picture emerges.
In her book, When Children Don't Learn, Dr. Diape McGuinness expresses skepticism about the validity of the diagnosis itself. "Problems in the control of attention could result from deficiencies in the central nervous system, which could produce distractibility, failure to sustain attention to a task, inability to plan actions, and a diminished attention span. However, similar difficulties could be created by an environment that is either too overwhelming or insufficiently compelling [emphasis added]," she states. [12] Dr. McGuinness, who confesses she is irate about the amount of Ritalin being prescribed today, believes that many children thought to be "hyperactive" are really normally vigorous children "who refuse to abide by adult admonitions to sit still and conform to rules set by adults for their own convenience." She makes the point that children's bodies are designed by nature to be active, and the overly wiggly ones may really know what is good for them more than the docile types "who are overly conforming and remain for hours in sedentary positions."
Under some circumstances (such as in the doctor's office), even children labeled ADHD are able to control their attention -- but only if the situation is novel, one-on-one, and they get frequent and continuous rewards and reinforcement of some kind. For example, they can pay excellent attention to computer activities with frequent token rewards (e.g., a laser gun blows up a space invader every time the student gets a math problem correct), and their schoolwork improves noticeably when someone works individually with them. In one interesting study, children diagnosed ADHD were paid to respond quickly and accurately to a test on which they had previously scored quite poorly when no reward was offered. Much to the experimenter's surprise, promise of money brought their performance up to the level of a normal control group. [13]
These findings and others have led a number of professionals to begin rethinking their views. Dr. Russell Barkley, nationally noted authority and author of Hyperactive Children, recently told a large group of educators that he is changing his mind about what an "attention deficit" really is. [14] "If you have an attention deficit, shouldn't it show up everywhere? If language is impaired, we see language impairment anywhere the child needs to use language. How can this be an attention deficit? Don't we need to look for something else that explains this variation? Why do they do better with novel situations, with rich schedules of reinforcement [frequent rewards]? People are seriously questioning whether this is really an attention deficit."
One theory, according to Dr. Barkley, is that the ADHD children have particular trouble with what he calls "rule-governed behavior." When the environment demands adherence to a rule, especially one with few consequences, trouble begins. "So when a teacher says, 'He's not paying attention,' what she really means is he's not listening, he's not following the rule. 'I told him to go back to his desk, get out his math problems, and work on them, and he didn't do the rule.'
"It's been shown that when ADHD children are paying attention to what they like, they don't have an attention deficit," he emphasized. "So if they brought a car from home, or a transformer, or they're doodling war pictures on the corner of that reading workbook -- their attention span for war pictures is phenomenal! But it isn't for the stuff you ask them to do. The problem, then, is not attention, it's a disability in rule-following."
However, even these children can follow rules if there is an immediate reward, Dr. Barkley has observed. "In adults, we are the only animal that operates on a very sparse schedule of reward; I only get a paycheck once a month, but I show up at work every day. There is something fascinating about the human brain that allows it to be exquisitely sensitive to extremely sparse schedules of reward, but that is something that has to develop. Young children can't do it. You can tell a young kid you'll take him to Disneyland in February, and that won't do it. These ADHD kids are like younger kids; they need immediate feedback and reinforcement."
Why might this be the case? Dr. Barkley suggests, for some children, underlying differences in the motivational-control systems of the brain may not be operating normally; thus they need a much stronger external impetus to concentrate on the task at hand. They simply don't respond as other children do to "social approval."
"Somehow, neurologically, these children have a threshold for what rewards them that is set too high; it takes a more powerful reinforcer to get them to do what they are told. That is why they require the money, food, bikes, toys, privileges, bribes -- to work. Because the subtle rewards -- love of learning, grades, teacher approval -- don't motivate these kids at all. You can say 'good boy, good boy' all you want and that isn't going to work."
"They can understand what you say to them," he points out, "they just don't act on it. It's really a problem with how language governs behavior -- the connections between the linguistic and the motor systems." [15]
Dr. Barkley suspects there is a genetic cause for these brain differences, possibly related to the way chemicals (neurotransmitters) help different parts of the brain work together. Children who develop the most severe forms of ADHD so that they become openly "oppositional" and often delinquent, tend to come from families with a history of alcohol abuse, delinquency, and antisocial behavior, which he thinks may reflect some overall type of inherited problem. We can't blame parents for the fact that they have a difficult child, he insists, but we must acknowledge that a child's environment helps determine how the problem is expressed. As with bad table manners that seem to run in families, no one has been able to measure exactly how much living with impulsive adults in poorly structured situations contributes to the problem.
Obviously, no clear-cut answers about the "why" of attention problems are available. Perhaps neurology is just struggling to catch up with common sense, for it seems foolish to deny that the way a child is taught and shown to behave has a lot to do with whether or not he learns to manage himself without an immediate reward. A number of practical, real-life studies show that children's adult models may be a significant, but frequently unappreciated, variable. [16]
FURNISHING THE EXECUTIVE SUITE: HOW BRAINS LEARN TO PAY ATTENTION
Both physical and mental environments help develop the ability to pay attention. Because attention requires the use of many different areas of the brain, any severe trauma, "insult," or biochemical abnormality may affect it. As we all know, even transient emotional states can knock this delicately balanced block off the tower of learning abilities.
Attention systems grow in several directions in the brain: side to side, bottom to top, and inside to outside. Here's a brief summary of how they are formed.
Activating the Hemispheres
The side-to-side connections are mainly in the corpus callosum, that tough and busy band of fibers that carries messages between the hemispheres and lets the two sides of the cortex work efficiently together. Several prominent neuropsychologists believe that brains with attention and learning problems have trouble getting an idea into the appropriate hemisphere and keeping it there long enough to be processed efficiently.
One recent study measured electrical brain waves in right and left hemispheres of LD (in this case, reading disabled) children when they were doing different types of learning tasks; the measurements were then compared with brain-wave recordings from a group of good students doing the same activities. The good students showed the expected changes in hemispheric activation depending on whether the task was a verbal or nonverbal one, although overall they tended to favor left-hemisphere strategies. The LD children showed different patterns: (1) they had less overall left-hemisphere activation, even in verbal tasks, and (2) they showed significantly smaller shifts from one hemisphere to the other when the tasks required different processing strategies. [17]
If children have not had a chance to develop strong connections between the two sides or enough practice using left-hemisphere systems for careful listening, they certainly might have more trouble concentrating, getting their brains quickly and efficiently into gear for school tasks, and finding the best way to study and remember things they are supposed to learn. [18]
Three Levels of Attention
The up-and-down axis of brain maturation, which is probably the major route by which children learn to pay attention, may be particularly at risk in today's environments. Although, technically, this "attention circuit" cannot be separated from the hemispheres, since it crosses through them, it is, in many respects, a separate apparatus. Imagine, if you will, a circuit that runs from the base of your skull at the back of your head all the way up through the middle of the brain to the front of your forehead and back down again. This is similar to the main route from which higher-level systems receive information about where and how attention should be focused. These higher centers, in turn, decide what is to be done and then instruct the rest of the brain in how the behavior (including learning) is to be directed.
This attention loop has three layers that develop from bottom to top and inside to outside the brain. The first, primitive stage of the circuit lies near the top of the spinal cord, where it joins the skull, in brain structures that closely resemble those of other animals. It is responsible for basic alertness (e.g., staying awake when it is appropriate), screening out or letting in various types of stimuli (e.g., focusing without being distracted by background sights or sounds), filtering information, and getting the higher centers of the cortex "in gear."
Second come centers for emotion and memory, which are located in the middle of the brain in an area technically called the limbic system. In these "subcortical" areas, the incoming stimuli are connected with motivation (how important is it for me to pay attention to this right now?) and some centers for memory. I find it particularly interesting, although not intuitively surprising, that attention, emotion, motivation, and memory have such a close physical link in the nervous system.
Developmental influences on the limbic system are one of the great, barely unfolded mysteries of the brain. How do children acquire the neural foundations of motivation? No one really knows, but the central role of these midbrain connections imply that they must be important indeed.
At the very top of the circuit lie the frontal lobes of the cortex, comprising the frontmost parts of both right and left hemispheres. This part of the brain, which is the human animal's unique neural possession, is often called the executive of the brain because it is responsible for planning and regulating behavior. It consists of the motor cortex, which helps plan and implement physical movement, and the prefrontal areas, which, when (and if) fully developed, become the "boss" of thinking. (The terms "frontal" and "prefrontal" are used interchangeably.)
The neural groundwork for attention abilities is laid early in prenatal life, when the bottom layer of primitive "alerting" areas are developing. After birth the child must collaborate with nature and the motivational system to build the connections that put the thinking brain in charge. Because the higher centers can't take over immediately, young children are notoriously "stimulus-bound" -- at the mercy of any new sensory experience or idea. Thus they tend to be highly distractible.
During the years of childhood, especially between the ages of three and six, most youngsters work hard on learning to screen out both external and internal distractions and marshal their attention at will. Any environmental force that severely interferes with this important learning has the potential to disrupt the system. Sometime during adolescence, most brains are sufficiently mature to start to attend to future goals and use more complex forms of mental control (please notice, parents, I said "most"). It's a long process, indeed, and demands continued support from concerned and persistent (if often exasperated!) adults.
Attention and the Brain's Executive
Prefrontal development is not completed at least until late adolescence, or even adulthood. Thus, the way a child learns to use executive functions is doubtless highly dependent on the experiences the environment provides. Adults who show children how to put thought ahead of action, delay gratification, and use language as a tool for thinking and planning help provide the fundamental training ground for the brain's executive.
Curiously, this "highest" level of the brain's functioning does not seem to be measured by standard IQ tests. The rest of the cortex serves as the storehouse for taking in information, which it associates and connects into the intellectual data bank that constitutes a lifetime of learning. The frontal systems have a different responsibility: seeing that the data gets used effectively, the reason why they are referred to as the executive. When experts give advice about boosting mental skills, they are usually referring to the most efficient ways of filling up the storehouse. Unfortunately, they too often forget that merely trying to shovel in information will serve little purpose unless children also learn how to use their brains to stay mentally focused, put information into perspective, reflect on meaning, plan ahead, and follow through constructively -- the fundamental components of problem-solving. For this reason, "competency tests" that measure only the accumulation of data may seriously mislead us about children's real learning abilities. Without an efficient "executive," real-life competency is jeopardized.
Despite its critical importance in learning -- as well as in life -- there is little research on the way prefrontal development can be influenced. It appears that the way the brain learns to talk to itself may be a major factor in building its internal connections and learning to control the workings of both mind and body. [19] I will expand on this extremely important point in the next chapter.
For now, let us consider some of the interrelated factors that can cause trouble at any of the three levels of the attention system. Outright trauma, either before or after birth, is probably responsible only for a relatively small percentage of attention problems, but increasing numbers of children are currently seen as being at risk because of greater loads of environmental toxins and better survival rates for low-birthweight infants. Other more subtle factors, from "noise pollution" to biochemical effects of junk food, may tip the brain's attentional balances either before or after birth.
Several types of hazards in contemporary life should be specifically mentioned:
1. Toxic substances and foods that may predispose children to attention problems.
2. "Noisy" environments that cause children to tune out rather than tune in.
3. Sedentary lifestyles.
4. Failure by adults to act as constructive, thoughtful "coaches" for children.
HOW BRAINS GET "INSULTED": ENVIRONMENTAL HAZARDS FOR ATTENTION AND LEARNING
Before birth, some children suffer specific types of damage or so-called "insult" to attention-regulating systems. As we saw in Chapter 2, brains are at risk both before and soon after birth by overt damage from illness, accident, or exposure to toxins (e.g., lead, solvents, medications, etc.). Anything that deprives the brain of oxygen, particularly during times of rapid development, can also subtly jeopardize attention abilities. For example, children whose mothers smoked during pregnancy, who were premature, or who suffered various types of birth trauma tend to have a higher rate of attention problems and related learning disabilities than other youngsters.
Even after the foundation systems are in place, the brain can be disrupted by anything that interferes with the proper workings of the limbic system or the higher centers in the cortex, particularly the frontal areas. Sometimes these effects are so subtle that no one connects the cause with the resulting learning problem. One reason is that the brain has built-in mechanisms to protect itself, which may work well until they become overtaxed.
A good example of a built-in protection system is the so-called blood-brain barrier, which screens out brain-damaging materials that may be circulating in the rest of the bloodstream. Some potentially injurious substances are able to sneak across this barrier, and it can also be weakened, or made more permeable, by environmental factors, such as prolonged exposure to toxins or an unbalanced or inadequate diet.
Once across the barrier, troublesome agents can affect brain functioning in at least two ways that are, as yet, only generally understood. First, they may be directly toxic and create overt, permanent damage, as in the impairments inflicted on the fetal brain by alcohol. More subtly, they may cause temporary changes in the fine chemical balance that makes thinking possible. Brains can be either intolerant or frankly allergic to certain substances, but it is difficult to pin down the culprits.