Working with Children Who
Show Attention Problems

By Stanley I. Greenspan, M.D.

One of my preschoolers can't seem to focus on anything. He is constantly distracted, even when our room is quiet. I've tried to calm him by touching him gently, but that doesn't work. Once in a while he'll get involved with a project but just as I think he's getting somewhere, he gets sidetracked. Can you help?

There are many different reasons why children have problems paying attention. One child might be visually oversensitive. For example, he'll be highly distracted by bright sunlight coming in through a window or too much color on a bulletin board. Another child who is oversensitive to smells might be distracted by the teacher's perfume or an odor coming from the cage where the animals are kept. Auditory sensitivity can be just as distracting. Some children are so sensitive to certain kinds of low-pitch sounds, such as motors, that if their classroom happens to be near the boiler room, a rumbling noise most people don't even notice will grab their attention. If we could get these children in a less distracting environment, they might do much better at attending.

We also see children who are under-reactive and may not focus when they hear a voice. Typically, they don't alert to sounds or to touch. A teacher might tap a child with this problem on the shoulder, and he will seem to be "living in his own world."

Focusing on Individual Differences

It's important to remember that children with developmental difficulties may have several problems at the same time. Auditory processing problems make it difficult for a child to make sense of the things he hears. If you give him three or four directions, he may only get the first two and seem not to be concentrating on what you have instructed him to do.

Visual-spatial processing problems provide still other deterrents to concentration. A child with this challenge doesn't need glasses; she just has difficulties organizing what she sees. For example, if you hide something in the child's room, instead of searching in each corner or looking under things, she may get stuck looking only in one part of the room. Children with this difficulty may be over focused some of the time and unfocused other times. They may have problems connecting what they see with what they hear, which hampers learning to read as well as attentiveness, and so they may appear lost or easily side-tracked

We also have inattentive children who are struggling with motor planning or sequencing, the ability to carry out complex actions, to plan and sequence ideas. This situation is even more common than processing problems. Let's take the example of a child who is trying to get dressed. There may be ten steps involved in this process. A child with sequencing trouble may be able to do only three or four steps at a time and easily gets lost on the way to his shoes or his shirt. In other words, for many things others do effortlessly, on automatic pilot, a child with sequencing problems has to remember each step.

Thinking About Attention

The mind has many different functions that contribute to attention. If we treat all intrusion on attention as one and the same thing, we can't help children master their own particular challenges. So by looking at inattention in terms of what contributes to it rather than as one global function, we are better able to identify the different origins of the problem in different children. If we figure out the underlying troubles, we can develop specific exercises to strengthen the underlying functions. This method offers a better way to help a child become more focused and attentive.

Looking Closely

Some children who are inattentive are self-absorbed and daydreaming, while others show an unusual amount of activity and may even be aggressive with others. Interestingly, a lot of overactive children turn out to be under reactive to things like touch and sound, and even to pain. They crave more sensations and so become very active in an effort to get more sensory input. They feel the need to be moving in space just to keep their own inner sense of movement going. In contrast, children who are overactive to their own movement are likely to be very cautious. They don't like to move much at all and none of them would turn out to be the daredevil who jumps from the top of the monkey bars.

It's important to note that worries and fears can cause children to be very active and inattentive. Some children may be showing sensitivity to medications or to foods or chemicals in their environment. Many children are overloaded when they feel overwhelmed with noise and commotion, or they're enduring an environment that's scary or abusive. In the end there's no substitute for trying to understand what's at work for each individual child by profiling her unique characteristics.

Taking the Team Approach

Teachers and parents are the key members of every team. They know the child best. They know the subtleties of what each child can and can't do — not just at school, but at home and with peers. Bringing in qualified professionals can help everyone better understand the child's strengths and areas of vulnerability. A child psychiatrist or clinical psychologist can look at the child's processing challenges, the family dynamics, the role of anxiety, and so on, and then make suggestions. With the help of additional team members observing in the classroom and talking with teachers and parents, we can tease out some of the special areas of trouble.


So far there has been no identification of a single gene or single neurochemical to explain what we call ADD or ADHD. And there doesn't seem to be one clear single origin emerging from the research. Maybe there is a unifying cause that we haven't yet found. But because these questions still remain open, I believe that the best way to approach attention and other developmental problems is to ask ourselves: What functions does the child have difficulty with? Is it motor planning and sequencing? Is it understanding what he's being told? Is it responding to touch or sound? Is it craving a lot of sensation or being active? Then we try to help each child work to master the troublesome functions.

Building on Strengths

While it's tempting to try to find a single answer to a problem, deciding a child "has ADHD" and needs to be medicated can lead us to miss out on opportunities to strengthen underlying capacities. Medicine helps some children and doesn't help others. By first strengthening a child's underlying functions, you can see what kind of progress she can make. Then you can get a very good sense of how much additional benefit you can get from adding medication.

Let's say a child has a typical planning and sequencing problem. She usually forgets what she's supposed to do next if she's getting ready for school. An older child with this problem may never quite get organized for the next school day. Stressing either child's ability to anticipate by using visualization "exercises" can be very, very helpful. Mommy or daddy can sit down each and every day (after some free play, which builds the child's trust and general intellectual-emotional skill) and talk about all the good things and all the challenging things that may happen tomorrow, about what the child thinks she'll like and won't like. Together they're building a picture of what's going to go on, just as if it were on TV. This picturing helps the child begin to anticipate, so she's now better able to plan and sequence. Or, if a child has problems sequencing and wants to go outside, build on her motivation to go outside, but give her a few things to do first. This helps her learn to plan and sequence and become more able to pay close attention.

You can also adjust your interaction to better meet the child's needs. For instance, talking or singing rapidly to a child with auditory-processing difficulties can cause him to tune out. Communicating slowly and calmly, in shorter segments, may help him to focus and attend. Since many children with auditory-processing difficulties are strong visually, try relating to them visually and verbally. Pick up a cup and point to it. Then point to the milk carton and say, "Milk?"

Making sure you use words along with actions and visual pictures works better for a child who is a strong auditory processor but weak in the visual area. Look for an area of strength to aid in mastering the individual child's developmental hurdles, and you are likely to see a growing capacity to pay attention. Rather than spending most of your time trying to correct a weakness, try spending at least 50% of your time together helping the child develop a sense of mastery around his natural strengths.

Stanley I. Greenspan, M.D., the author of The Child with Special Needs, is a clinical professior of psychiatry, behavioral sciences, and pediatrics at the George Washington University Medical School.

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