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Can Children with ADHD Be Taught Better Attention Skills?
Over the past decade researchers have studied techniques for training individuals to pay better attention. Initially, these attempts were focused on adults with traumatic brain injuries who regularly demonstrate poor attention. More recently, researchers have applied similar techniques used with these adults to help children diagnosed with ADHD. A recently published study evaluates the effectiveness of one such attention training tool called Pay Attention! (Kerns, K., Eso, K, & Thomson, J. (1999). Investigation of a Direct Intervention for Improving Attention in Young Children With ADHD. Developmental Neuropsychology, 16, 273-295. This is a small scale study that is best thought of as a pilot investigation. The study addresses an interesting and important topic that has been the subject of virtually no prior research, however. For these reasons, I wanted to include it in this issue of ADHD RESEARCH UPDATE.
The authors provide a compelling rational for efforts to directly train children with ADHD to improve their attention skills. They note that although medication treatment is helpful to the majority of children with ADHD, many children continue to experience residual difficulties with attention. Thus, non-medical means to improve children's ability to attend could be quite useful for many children with ADHD. They also note that non-medical interventions for ADHD typically attempt to either 1) use behavioral strategies to increase a child's attentive behavior by providing incentives for better attending, or 2) provide children with compensatory strategies for dealing with their attention difficulties through such means as teaching better self-control or problem-solving strategies. Efforts to directly improve children's attention skills through a systematic training procedure, in contrast, has been the subject of virtually no research.
Pay Attention! is an attention training program specially designed for use with younger children (targeting ages 5-10 years) in an ADHD sample. The materials are modeled after the Attention Process Training (APT) system developed for adults a decade ago. It is based on the idea that there are several different components to attention. There are lower levels of attention, including basic functions such as being able to focus attention and sustain attention over time, and there are higher levels of attention, such as being able to alternate attention quickly between tasks, or to divide attention in order to perform multiple tasks. According to the theory behind the APT, higher levels of attention are dependent upon smooth lower level functioning. Pay Attention! was designed to train multiple levels of attention. In theory, then, this would target the different types of problems with attention that a child with ADHD may have.
The Tasks in Pay Attention! cater to the knowledge, skills, and concepts that are established in younger children. In an attempt to make the materials interesting and engaging to younger children, they are colorful and visually interesting. They also focus on familiar concepts such as family relationships (e.g., siblings, parents, grandparents), features of people (e.g., hair color, sex, clothing), and household characteristics (e.g., the purpose of particular rooms). Other constructs considered are the concepts of same and different, relative size, comparisons of visual features, and basic counting. Both visual and auditory stimuli are used, and the treatment tasks have been graded to determine whether or not the individual should move onto more challenging tasks.
In this study the authors were interested in examining the extent to which children's attention improved following a series of training sessions using the Pay Attention! program. The authors began with 2 groups of 7 children. Each group was comprised of children diagnosed with ADHD, and consisted of 4 boys and 3 girls. Five of the seven children in each group were taking stimulant medication throughout the study. (This is obviously a very small sample, which is why it is best to regard this study as a pilot investigation.)
Both groups participated in pre- and post-treatment testing on measures thought to reflect attentional functioning at the beginning and end of the study. A variety of measures of attention were collected, ranging from laboratory-based measures of attention to the more-commonly used method of having children's parents and teachers complete ratings of the child's attention. Both groups also participated in 2 half-hour sessions after school each week over the course of 8 weeks, with one group receiving the Pay Attention! training program and the other group participating in various types of computer game activities (see below).
During the half-hour sessions the group receiving treatment with the Pay Attention! program performed a variety of attention-training tasks such as quickly sorting cards into categories based on the color and picture presented on them. This was an activity that demanded careful attending in order to be successful. As the child accomplished these tasks they would be made progressively more difficult, so that ever- increasing demands for careful, sustained attention were made on the child. Auditory tasks followed a similar procedure (e.g., buzzing whenever the word ball is heard, versus buzzing whenever the name of something you might see in the sky is heard). These tasks also required the child to exercise careful sustained attention to be successful, and the tasks again became more difficult - and thus required greater focus - over time. The basic premise underlying the Pay Attention! program is that attentional abilities can be improved by providing structured opportunities for exercising and practicing particular aspects of attention.
The non-treated comparison group participated in computer based activities. This was a task that was interesting to children, and which required them to focus their attention. It did not, however, include a systematic effort to specifically provide training that would lead to improved attention abilities.
Results
Did The Program Work?
The results of this study are encouraging. Although the groups did not differ in IQ or performance in pre-testing, they both demonstrated improved performance on posttest measures of attention, particularly selective attention. This suggests the impact of a practice effect. However, children in the attention training treatment group demonstrated significant improvement above and beyond that of the comparison group on 4 of 6 groups of measures considered sensitive to attentional functioning. Both groups also demonstrated significant improvement on a measure of academic efficiency called Math Worksheets. Once again, however, the children receiving the Pay Attention! program showed significantly greater improvement than children assigned to the computer game condition. Children receiving the attention training program also tended to be rated as showing improvement in attentional functioning by their teachers. (The teachers did not know which group a child had been assigned to so these ratings should not have been biased).
In weighing the results of this study, there are several issues to be considered. First, as noted above, the very small number of children participating in this study clearly indicates the need for a replication with a much larger sample. Having said this, however, it is important to note that it is actually harder to obtain statistically significant results with such a small sample. The fact that several such results were found is thus impressive. It is also impressive to note that some significant improvements in attention were found even though the majority of children who participated were already on medication. The gains made, therefore, were above and beyond the benefits that children were presumably already receiving from their medication. Thus, combining this type of attention training program with medication treatment may offer potential benefits to many children.
Certainly, these results are encouraging enough to support the need for future investigations of this interesting program. In addition to employing larger samples, it will be important to include a longer follow up period to determine whether any initial improvements in attention as a result of the treatment are sustained over time.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.