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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.
ADD
or ADHD
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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