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Teaching Attention Skills to Children with ADHD
In a prior issue of Attention Research Update, I reviewed the results of an interesting study in which children with ADHD received an intervention designed to teach them how to improve their ability to sustain attention. This was one of very few studies to test whether systematic procedures to directly train attention skills in children with ADHD (other than attention training via neurofeedback) could be successful. Results from this study appeared to be promising.
A second investigation of this topic was published in the November 99 issue of the Journal of Learning Disabilities (Semrud-Clikeman, M., An Intervention Approach For Children With Teacher- And Parent-Identified Attentional Difficulties. Journal of Learning Disabilities, 32, 581-590). Participants in this study were 33 children in grades 2 through 6 who were diagnosed with ADHD, and 21 matched comparison children. Teachers nominated children to participate in the study, based on their difficulty completing assignments and paying attention in class. (Note: Efforts were made to screen out children who had other diagnoses in addition to ADHD, so this was not a truly representative group of ADHD children.)
Parents were informed about a program to teach their child better attention skills. Those parents expressing interest in the program were contacted so that an ADHD evaluation for their child could be completed. Interestingly, of the 33 children identified with ADHD in this study, only 50% had been previously diagnosed and very few were receiving any treatment. Although this is not the focus of the study, these data highlight the unfortunate fact that many children who struggle with ADHD are never formally identified and receive little appropriate assistance.
Attention training was conducted in after-school groups of 4 to 5 children that met twice a week for 60 minutes each time over an 18-week period. The attention training system used was based on the Attention Process Training model (APT), developed for adults over a decade ago. This system is based on the idea that there are different components to attention: lower level components such as being able to focus and sustain attention over time and higher level components that involve the ability to allocate attention between different tasks.
The training program utilized both visual and auditory attention tasks. The visual attention tasks required children to find a target stimulus embedded in an array of distracters. Tasks were relatively simple at first (i.e. the child was required to find one type of figure among widely spaced figures ranging from somewhat similar to widely dissimilar) and became increasingly difficult (i.e. the child had to find a selected number of figures from among many closely spaced figures as quickly as possible). For the auditory task, children were required to count the number of times particular targets could be heard on a cassette tape. The easier tasks required children to keep track of how often they were presented with a particular letter from among a group of dissimilar options. In the more difficult tasks, children had to count the instances of words beginning with particular sounds. These are the kinds of repetitive, uninteresting tasks that children with ADHD typically have great difficulty performing accurately.
During each session, children reviewed their performance (i.e. speed and accuracy) from prior sessions and were required to set goals for their performance that day. In addition, the group discussed strategies to help each child meet his or her goals. Children attempted the task using the strategy they had selected, and then evaluated the effectiveness of the strategy based on their performance. When this evaluation indicated the strategy was not effective, the group leader helped the child revise the initial strategy and he or she would try again. Thus, the basis on which better attention skills were trained included repetitive practice in attention tasks, reviewing prior performance and setting new performance goals, and developing, monitoring, and, if necessary, revising strategies to achieve one’s performance goals. This active problem-solving approach is one that can be applied to a wide range of academic and behavioral objectives, not just the attention tasks that were the focus of this study.
Only 21 of the participants with ADHD received the intervention described above. The remaining children were unable to take part because of after-school scheduling conflicts. Prior to beginning the intervention, all 33 ADHD children and the 21 non-ADHD comparison subjects completed a test of visual and auditory attention that was different from those tasks used in the attention-training paradigm.
After the 18-week attention training intervention was completed, all children were given the visual and auditory attention tests a second time. To determine whether the attention-training program was successful, the authors compared the pre- and post-training performance of 3 groups: ADHD children who received the intervention (i.e. ADHD intervention group); ADHD children who did not receive the intervention (i.e. ADHD control group); and non-ADHD comparison children (non-ADHD control group).
Results
As expected, pre-test results indicated that children in both ADHD groups performed more poorly on the visual and auditory attention tests than the non-ADHD comparison children. The ADHD groups did not differ from one another, however, suggesting that their attention skills were equivalently impaired prior to the training program. In addition, parent and teacher ratings of attention problems for children in these groups were equivalent prior to the start of training.
At the post-test assessment, the ADHD control group continued to show poorer performance on both attention tasks than the non-ADHD control group. Children who received the attention-training program scored as well as the non-ADHD subjects and significantly better than the children in the ADHD control group. In fact, on the auditory attention task, children in the ADHD intervention group had slightly higher average scores, although this difference was not statistically significant.
Post-test behavior ratings from parents and teachers were not obtained.
Summary And Implications
Results from this study indicate that children with ADHD can perform as well as non-ADHD children on visual and auditory attention tasks following training in sustained attention and problem-solving skills. This is the second study published in recent years suggesting the potential benefits of direct attention training for children with ADHD.
These are encouraging results, but there are limitations to this study that the author notes are important to consider. First, because the sample did not include any children with diagnoses in addition to ADHD, as is true for many children with ADHD, this was not truly representative of the overall ADHD population. Therefore, it cannot be determined whether similarly positive results would have been obtained for children with ADHD and co-occurring problems. Second, there were very few females included in the study, making it unclear whether the beneficial impact of the training program would generalize to girls as well.
The most important limitation is the absence of any post-test assessment of children’s actual behavior and performance in the classroom. Although it is encouraging that children who received the training performed better on specific tests of attention, it is essential to know whether the training also had positive impact on classroom behavior and academic performance. It is certainly possible that it did, but it is also possible that there was no change in these more important outcomes. It would thus be very important to repeat this study to determine whether the attention-training paradigm used actually results in classroom gains.
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.