When it’s hard to pay attention

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It’s 8.20 on a school day and 8-year old Josh isn’t ready for school. Each time he’s given a list of instructions, he completes the first one and then seems to wander off and get involved in something completely different. He is half-dressed, hasn’t had his breakfast or cleaned his teeth, and doesn’t know where his homework is from last night. His father is ready to leave for work and is frustrated that Josh is late – again! His dad complains that Josh has the attention span of a flea, is easily distractible, doesn’t "listen", and never finishes anything. He’s always been like this, but as he’s got older, the increasing demands of school are highlighting the problems and the strain results in lots of shouting and punishment for Josh and frustration for his parents.
Difficulties like these are not uncommon, and generally fall into the descriptive category of attentional problems. When a child of this age seems unable to maintain focus long enough to follow a simple series of instructions or finish a task; when he seems forgetful and disorganised a lot of the time – his parents and teachers might suspect that he has difficulties with attention and concentration. Often, the child manages reasonably well when in a one-on-one situation or when he is particularly interested in the activity, but without constant re-focusing, he wanders off less interesting tasks easily. This is often apparent when children have to settle down to homework tasks. When persistent difficulties with attention and distractibility have been present from early childhood, Attention Deficit Hyperactivity Disorder (ADHD) may be suspected. But Josh’s parents say that he doesn’t behave like other children they know who have ADHD – he isn’t "on the go" or hyperactive like they are – in fact, he seems a "bit of a daydreamer" and "lazy" rather than a "busy bee". The fact is that ADHD can be present in a predominantly Inattentive subtype – that is, the child does not manifest that hyperactivity and impulsivity associated with ADHD, but is inattentive and distractible. ADHD is a neurological disorder of the brain, which makes it harder for these children to stay on task without constant feedback and rewards. They need extra supports for sustaining attention and concentration and for maintaining self-control – they do not need labels of "unmotivated" or "spoiled".
The assessment of ADHD requires specialist knowledge. A child psychiatrist, a clinical psychologist and a paediatrician are trained to make this diagnosis, and will gather information from a number of sources in order to arrive at such a diagnosis. The pattern of inattention needs to be present across situations and lifelong. In some cases, the child’s behavior will be monitored over a period of time to see whether the diagnosis holds up across time. This is because children may be inattentive for a variety of reasons other than having ADHD. The treatment of ADHD should involve multiple strategies – learning strategies, parent management training specifically for ADHD, school accommodations and medication. A child psychiatrist or paediatrician is the best person to attend to the medication issues, and a psychologist can address the other issues. Teachers play an important part in the treatment of ADHD and can make an enormous difference to these children’s academic (and social) progress.
The cause of the inattention may not be ADHD, however. Other factors can result in inattentive behavior. Parents can think about these factors in their children’s lives and see if changing them makes a difference to the child’s inattention and concentration difficulties.
Those who are anxious find it difficult to pay attention for any length of time. Worrying that someone at home is ill or in any kind of danger, worrying about whether one will make the grade academically, worrying about being teased or bullied, worrying about whether someone will be there to collect you from school – these are all good reasons to be distractible or inattentive. How can you concentrate on the task at hand when these worries are running through your mind?
Children who have an intellectual disability also have a short attention span. A child whose intellectual functioning is significantly lower than his age-mates will struggle to keep focussed on any task. This is simply a function of the developmental state of his brain.
Some children whose intellectual functioning is in the average (or above average) range may suffer from a specific learning disability (SLD), for example, a language or mathematics disability, which can interfere with attention and concentration. A child with a specific learning disability often has attentional difficulties, which may be associated with the SLD itself, or with the anxiety that inevitably accompanies the SLD.
Those who are oversensitive or undersensitive to the sensations provided by their environments can struggle to maintain attention and concentration. For example, some children are acutely sensitive to noise and find background noises very distracting; others need to move constantly or fiddle with objects in order to achieve a satisfying level of sensory stimulation for their brains; and some children are sensitive to their clothing, finding labels or seams very irritating. Difficulties with integrating the sensory information from the world can interfere significantly with attention and concentration.
Developmental dyspraxia (Developmental Coordination Disorder) may present as though the child has attentional problems. Sometimes, difficulties with planning and sequencing their motor activities look like the disorganisation and distractibility associated with ADHD, and anxiety about not being able to keep up with peers can impact on the ability to stay focused.
Children who have been exposed to dangerous situations, for example, severe domestic conflict or other traumatic events, may be hypervigilant for signs of threat, and find it difficult to stay focused when they are scanning the environment for signals of danger. Thus, children who have experienced significant danger may present as restless and unsettled – unable to attend to tasks long enough to finish them.
When disruptive behavior has not been managed in appropriate and consistent ways, children may also find it difficult to stay focussed. When boundaries to keep behavior within safe and manageable limits are not consistently provided from infancy, children cannot learn to manage their own behavior and stay focused when they need to.
Given all of these alternative reasons for the presentation of inattention and distractibility, it is important to exclude them as possible reasons for a child’s attentional problems before ADHD is considered as the only possibility. However, this is not to say that ADHD cannot occur at the same time as these other problems, making the situation more complicated. What it does mean is that parents can check that their child’s attentional problems are not caused primarily by anxiety, learning difficulties, planning and sequencing problems, sensory integration difficulties, stresses associated with home life or social functioning, or simply poor self-management.

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Having acknowledged that many children struggle with inattention (for many different reasons) there are a range of ways in which parents and teachers can help inattentive children stay on task long enough to learn better and accomplish the tasks they need to. Remember that it’s the boring, mundane activities that cause problems with inattention – fun, new, interesting activities don’t usually pose such a problem. The everyday routines like getting ready for school or other outings, after-school activities, homework and the usual evening activities are where problems tend to occur. Bear in mind that school is a tiring business and that inattention is likely to be worse in the late afternoon and early evening.
In this article we will match the common difficulties with strategies to assist with them. These strategies can usefully be employed with all children – not just those who struggle with inattention.
First, inattentive children have trouble holding onto a lot of information or instructions at one time. Thus, they forget a series of instructions, possibly only remembering one; they lose track of the sequence of tasks, and may skip out important parts of a routine; and they can’t hold information in mind long enough to think about it and work it out. Therefore, these strategies are helpful: Give one instruction at a time – wait until the child has completed the task before giving the next one; when there is a routine to be followed, for example, going to bed, make a "comic strip" of pictures depicting the steps in the routine – this way the child can return to the strip to check out what needs to be done, and in what order; tell the child what to do – not what NOT to do – because it may be too hard to think about an undesirable behavior and turn it into a desirable behavior, it will be easier for the child to think directly about what you want them to do.
Second, concepts of time are especially hard for children with attentional problems, and they find it difficult to judge or allow for the time available within which to complete a task. Therefore, it’s very helpful to make time "visible" for them – use timers wherever you can to keep them aware of the passing of time. Inexpensive "wind-up" timers work well because you can hear and see them winding down, and they give a buzz when the time is up. For younger children or those with more severe difficulties, you can break time into smaller chunks when a complex task is demanded. So, you may give a set amount of time for each subtask, for example, brushing teeth gets three minutes, then getting into pyjamas gets three minutes and so on. Re-set the timer after each subtask is completed. Timers are also great for Timeout – when a child is sent to timeout for a fixed period, the timer keeps them (and you) aware of the passing of time. 
Third, rewards for success do not seem to be successful with children who struggle with inattention. The fact is that rewards and consequences do work with these children, but have to be implemented differently. The structures of the brain that are sensitive to positive and negative consequences do not operate as efficiently as they do in children without attentional problems. Consequently, it is harder for them to learn to associate particular behaviors with rewards or negative consequences. Children with attentional problems need rewards and consequences often, close in time to the behaviors they are intended for, and of strong significance for the child. Rewards need to be obvious and quickly available – for example, verbal praise or soft touches.  Parents need to be on the lookout for positive behaviors so that they can use praise often and quickly. Praise can also be connected to a reward system that has a payoff in some material reward in the future. This helps children learn to wait for rewards by providing quick, frequent smaller rewards along the way to the bigger one. 
Fourth, these children have trouble paying attention to speeches or explanations. Therefore, keep explanations to a minimum and, as has been advocated by the experts in the area – "act, don’t yak"! The more you talk, try to explain why a behavior is desirable, or "yak", the further away the rewards or consequences will be from the target behavior. It’s not that the child doesn’t understand you, it’s that the child finds it difficult to comply because her attention wanders so easily.
Fifth, inattention also means that a child finds it difficult to remember what will happen from one experience to the next. It can be hard to generalise knowledge from one situation to another. So, for example, a child may have been difficult to control at a friends’ party with the consequence that he was removed from the party and had the party treats confiscated as a consequence. Unfortunately, there is no guarantee that this lesson will be remembered when visiting the grandparents’ house, or attending the next party. This can be particularly frustrating because it feels as though you have to go through the drama all over again when the same thing happened recently. Parents come to know what settings or places are going to be problematic, so can anticipate problems and prepare accordingly. Here is a five-step plan that helps. One, shortly before the event, review one or two rules that apply to the situation with the child (be concise!) and have the child repeat them back to you. For example, one rule for visiting other people may be that the child is not to touch the party food before permission is given by the hosts, and another may be that the child greet others appropriately. Two, set up a small immediate reward for being successful and a small immediate consequence for failure. For example, polite greetings earn public praise, and waiting for treat foods earn an extra treat. Three, as you enter the situation, begin giving praise for success before any difficulties arise. For example, comment repeatedly on the fact that the child has not taken any party food. Four, deliver rewards and consequences immediately after the target behaviors. For example, lack of greetings result in the child having to stay beside the parent (when he would rather be off playing with other children) for five minutes. Five, remember not to engage in conversations about what is happening – the child knows what the deal is, and conversations simply drag out the situation and dilute the strength of the rewards or consequences.
Sixth, keep stimulation levels down when you can as the child’s nervous system has trouble trying to screen out extra sensory information that is interfering with paying attention. Keep your voice down when giving instructions, and don’t try to compete with the TV or other noise. When you’re speaking, make sure you have the child’s full attention, with a minimum of interfering noise, light, or movement around her. Shouting can be overwhelming for these children and they won’t even get the first part of what you say if you yell. You’re far better off to whisper – this will make her lean in towards you and concentrate harder.
So, with these pointers, your child will be better able to grasp what is being asked of him, and better able to keep his attention going long enough to get things done.


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