The Dimension
of Inattention
Among
Children
with School
Problems
Melvin D. Levine, MD, Betsy Busch, MD, and Cary Aufseeser, MEd
From the Division of Ambulatory Pediatrics, The Children ‘s Hospital Medical Center,
Boston
ABSTRACT. Within a population of children referred for
school-related problems, youngsters with significant
at-tention deficits were compared with children having other
types of learning problems. Using data from parent and
teacher questionnaires as well as results of multidiscipli-nary team assessments, each patient was assigned either
to a group with significant attention deficits or to one
with learning problems, but fewer, if any, problems with
attention. Disagreement between observation sources was
demonstrated. Children qualifying for the significant
at-tention deficit group were characterized by a greater
likelihood of having behavioral problems during the tod-dier and preschool years. They also had a higher preva-lence of minor neurologic signs and difficulty on tests of
language development. Their current behavioral and
ad-justment problems seemed to be more severe and
wide-spread than those of the youngsters with whom they were
compared. No major intergroup differences were
ob-served with regard to age at referral, socioeconomic
sta-tus, family history of learning and behavior problems,
perinatal health risks, or psychosocial difficulties. There
was considerable historic and symptomatic overlap
be-tween the two groups, suggesting that the clinical picture characteristic of significant attention deficits is relatively nonspecific and is either a primary or secondary finding
in a large proportion of a heterogenous population of
children experiencing difficulties in school. Pediatrics
70:387-395, 1982; attention deficit disorder,
hyperactiv-ity, learning disorders, school problems.
endure academic failure, peer rejection, adult
ostra-cism, and loss of self-esteem. Depression and
socio-pathy may be late complications.3 Although the
symptom picture is recognizable, there remains
con-siderable doubt regarding its specificity as a clinical
disorder.4 Is there a distinct entity of attention
deficit disorder? Or, do these symptoms represent
more or less nonspecific accompaniments of
child-hood maladaptation and failure? In the present
investigation, a referral clinic population of children
with school problems was studied to determine
whether a subgroup satisfying predetermined
cri-teria for significant attention deficits differed on a
number of historic variables and assessment
mea-sures from other youngsters with learning and
school adjustment difficulties.
Research was conducted over a three-year period
in the School Function Program at The Children’s
Hospital Medical Center in Boston. This clinic
pro-vides for the multidisciplinary assessment of
chil-then of normal intelligence between the ages of 5
and 13, who are referred by their parents, teachers,
or physicians because of problems in school.
METHODS
The diagnosis of attention deficit disorder is
in-creasingly widespread and accepted.’ Affected
chil-then conform roughly to a symptom complex that
encompasses such traits as impersistent or weak
concentration, poorly modulated activity, impulsive
behavior and learning, excessive distractibility,
dif-ficulty achieving satisfaction, impersistence at
tasks, and emotion lability.2 Many such youngsters
Received for publication July 7, 1981; accepted Oct 2, 1981.
Reprint requests to (MDL.) 300 Longwood Aye, Boston, MA
02115.
PEDIATRICS (ISSN 0031 4005). Copyright © 1982 by the
American Academy of Pediatrics.
Data were culled from three information sources:
a standardized parent questionnaire, a school
ques-tionnaire, and the diagnostic formulations of the
multidisciplinary team in the School Function
Pro-gram. The questionnaire data collection systems
have been standardized on community samples and
have been analyzed and described eisewheref7
Clinical findings were based on assessments by child
psychiatrists, pediatricians with experience in the
evaluation of learning problems, and
psychoeduca-tional specialists. Neurodevelopmental data were
generated primarily from a special pediatric
exam-ination for school-aged children. The latter has
been described elsewhere and includes assessments
2.0 SCHOOL QUESTIONNAIRE
2.1 K.sps t*ing out ofseat
2.2 Seems toactbefore thinking
2.3 Lsernsb.sa ona one-to-on. basis
2.4 Is unws ofown mistaker
2.5 Seems tohats too much energy
2.6 Hastrodels finishing a teak
2.7
2.8
Seems to ‘suer ottt#{149}tntermittently Is not eansitive topunishment
29 2.10
2.1 1
2.12
Ise impetsant for rewards or apsxoval
Iseasily distracted from work
Dossteaksatthe wrong times Hands end/or feet in motion
2.t3 Tiressaedydur,ngataak
2.14 Dosenotislenwork
2.15 Hssmsrked vstistion a, moods
2.16 Stares for long periods
2.17 Sesmsunderectiv.orlethxgic ;:- fsdowtot.keupanewtesit
ii; Maksscarslsse mistakes
220 Has trouble during unstructured time
different scale from school’s version. However, analogous
traits (such as weak attention, overactivity, distractibility, and impulsivity) are included in both inventories.
function, visual-spatial orientation,
temporal-se-quential organization, and language.3 The
neuro-developmental examination also allowed for the
direct observation of patterns of selective attention, so that traits such as distractibility, impulsivity,
and task impersistence could be observed directly
during the performance of age-appropriate tasks.
In order to study differences between children
with significant attention deficits and those with
school underachievement but less or no attentional
weaknesses, patients were assigned to an attention
deficit group based on criteria applied to the three
observation sources. The parent and teacher
ques-tionnaires both contained a series of behavior
prob-lem checklists, including inventories relating
specif-ically to selective attention and activity. These are
shown in Fig 1. Items were scored as 0, 1, or 2,
according to the degree of relevance to a child (with
a lower score indicating presence of the problem
and a 2, its complete absence). For all the parent
and teacher questionnaires, mean activity-attention
scores were calculated and compared to preexisting
norms derived from randomly selected community
samples. To qualify for inclusion within the
atten-tion deficit group, the children in the School
Func-tion Program had to satisfy at least two of the
following three criteria: (1) A mean score of less
than 1.0 on the parent questionnaire
activity-atten-tion rating. This would amount to an average of
“applies somewhat” on all items. This cutoff is
approximately 2 SD below the community mean.
(2) A mean rating of less than 0.50 on the teacher
questionnaire activity-attention rating. In such
in-stances at least half of the items would be rated
“more often than other children” by teachers. (3) A
consensus by the multidisciplinary team in the
School Function Program that a child did indeed
have a significant attention deficit. This
determi-nation was documented in a report emanating from
the clinic evaluation and representing the combined
observations during the neurodevelopmental
ex-amination, education testing, and a psychiatric
in-terview.
The criteria were thought to constitute
statisti-cally defensible and clinically valid standards for
significant attention deficits. Agreement by two of
three data sources was required to allow for the
possibility that children in a clinic setting may not
reveal the same degree of attentional weakness that
can be seen at home and in school. This also
per-mitted inclusion of cases in which there was
dis-agreement between the school and parents
concern-ing the existence of significant attention problems.
In such cases the clinic could cast the deciding vote.
Children with one or more missing data sources
were excluded from this study.
All data were coded and a computer program was
developed to enable comparison between the
sig-mficant attention deficit group and the remainder
of the children in the School Function Program.
80 PARENTOUESTIONNA$RE
li11k
i
8.1 H&P’S’ body isin consten,8.2 H,,/h.’ body i undice.
8.3 Hilt’.’ mind issms ovItactIve.
8.4 H’/ has tro,*Ie sflting 5w, a meal.
8.5 He/*does ihings without think,ng.
8.6 He/Il’. $tNts thfl9$. but domet f,ni, them.
8.7 Att#{233}mes.heI* doeant ,esm toheir what you say
8.8 Hsisia does thngs in the wong order.
8.9 He/d’. domes realize when he/she has made a mjstake
8.10 He/she has trouble f&hng asleep at mgIt.
81 1 Heft’. has troubte asteW atnight
812 H./i. yens often during the day. 813 Ha/shebreaks things around the home.
8.14 HI/I,. saints todo things the hrd may.
8.15 t4e/*sa stares attt for ng p.riod
.!:i6 Hi/the hair,, tooutida nodes for tong pererds. 8.17 4.1*. gltsd,stnscted ,eisy.
$18 Htkeachemea[
I
8.19 W/,. iihard tocontrol on a long cat trip.
82O Hs/. ca,t keep ho/her hands tohimsalt’hersalf.
8.21 P4.1*.. warns to wantth,n all the time lit ldom t.sfisdi.
Fig 1. Activity-attention sections of comprehensive be-havioral inventories completed by parents and teachers.
0-020 021-040 041-060 061-080 051-tOO
:::
BFROU201 QUESTIONNAme
tel (5o524)
to
51
4
2d[
The two subsamples were compared with regard to
their characteristics in nine categories: sex, age at
referral, social class, family history of dysfunction,
perinatal health, behavior patterns during the first
five years of life, current symptoms, school
perform-ance, and neurodevelopmental findings. A total of
646 children were studied. Of these, 220 qualified
for the attention deficit group, whereas 426 (ie, the
comparison group) were determined to have
learn-ing problems without significant attention deficits.
Although 36% of the youngsters qualified as
hay-ing significant attention deficits, only 9% of School
Function Program patients met criteria for all the
sources. Another 27% qualified because of
agree-ment by two of three observers. An additional 33%
met criteria from only one source. Of those
quali-fying on two of three criteria, there was an
approx-imately equal likelihood of any pairing of sources
(ie, teacher and parent; clinic and parent; or clinic
and teacher). Of interest was the fact that only 31%
of children in the School Function Program failed
to meet the attention deficit criteria of any source.
The distribution of mean parent and teacher
ratings among all referred School Function
Pro-gram children is shown in Fig 2. A continuum of
z
Ui
0
I
C)
U-0
Ui
:D
z
0-020 O2-O4O 00060 00-050 00-tOO Oi-2O 21-140 4-I6O st$-eO 0200
MEAN ACTIVtTY-ATTENTION RATING
Fig 2. Histograms depicting frequency distribution of
mean activity-attention ratings from parent and school
questionnaires. Note that for school questionnaire, a
“normal” score would be a 1.0, whereas for parent
inven-tory, appropriate behavior would be closer to 2.0 (see Fig.
1). Total sample size varies between these two
question-naires because of incomplete or missing data on some
subjects. Children lacking one or more information
sources were excluded from part of study that examined
differences between group with significant attention def-icits and remainder of referred populations, whereas all
available data are depicted here.
scores can be seen. On neither inventory could a
clear biphasic distribution be discerned. This
sug-gested that in a population of children with
aca-demic difficulties, varying numbers of attention
def-icit traits were perceived both at home and in
school.
Of the entire School Function Program sample,
23% were female and 77% were male. Twenty-six
percent of the girls and 37% of the boys met criteria
for significant attention deficits. A
x2
test for thissex difference was significant at the .01 level. There
were no significant differences between the groups
with regard to age at referral. On the average
chil-then with significant attention deficits were not
taken to the clinic at a younger or later age than
the remainder of the referred group.
Families were rated for social class by means of
a modified Hoffingshead-Redlich system.8 In the
total clinic population, 9% of parents were
profes-sionals, 24% held white collar positions, 56% were
blue collar workers, and 12% were on welfare or
were unemployed. When children with significant
attention deficits were compared with the
remain-der in the School Function Program, there were no
significant differences in social class distribution.
Thus, there was no evidence of strong
socioeco-nomic biases influencing perceptions or the rating
system.
RESULTS
Perinatal Health History
Considerable disagreement abounds with regard
to the relationship between perinatal health
stresses and the later occurrence of learning and
behavior problems.9”#{176} An attempt was made,
there-fore, to determine whether within this referral
pop-ulation those with prominent weaknesses in
selec-tive attention were more or less likely to have had
a history of difficulty during gestation, delivery, or
the first day of life. Parents completed a 42-item
inventory of perinatal health problems. A
compos-ite rating system was developed from which a
de-termination of “high perinatal risk” could be made.
Such conditions as hemorrhage during the first
trimester, prematurity, toxemia, difficult or
pro-longed labor, protracted jaundice, respiratory
dis-tress, and other prenatal and postnatal problems
could be indicated. In addition, children with
mul-tiple stresses of lesser severity could qualify as
having endured “high perinatal risk.”
Approxi-mately 40% of children seen in the School Function
Program were classified as “high perinatal risk.” In
comparing the significant attention deficit group
with the remainder of patients, no significant
dif-ferences were found in the likelihood of being in the
perinatal stresses was significantly more common in either group.
Family History
The extent to which genetic and familial factors
contribute to the pathogenesis of significant
atten-tion deficits is open to question.’1 In this study
parents were asked about specific behavioral,
lean-ing, and developmental problems within their
bio-logic families. It was found that 26% of the group
qualifying for significant attention deficits reported
a “hyperactive” family member (other than the
index child), as compared to 22% of the comparison
group, a difference that was not statistically
signif-icant. The prevalence of other behavior problems
in family members was 26% in the comparison group
and only 19% among those with significant attention
deficits. Approximately 42% of the comparison
group reported a family member who had been
retained in school, a rate nearly identical with that
found among those with significant attention
defi-cits. There also were no appreciable differences in
the prevalence of speech problems or various known
learning disorders.
Early Life Behavior Problems
This study afforded an opportunity to investigate
retrospectively the chronicity and onset of
mal-adaptive behaviors. As part of their questionnaire,
parents were asked to complete a section that
in-cluded 30 difficult behaviors that might have
ex-isted during specific intervals through the first five
years of their children’s lives. Included were
trou-bles with feeding, difficulties with sleep,
overactiv-ity, temper tantrums, social interactional problems,
and disturbances of mood or affect. For purposes of
analysis, three age intervals were studied (0 to 1
year, 1 to 3 years, and 3 to 5 years); the responses
were scored according to the number of
maladap-tive traits indicated in each interval. Patients
sub-sequently were divided into high, moderate, low,
and no reported problem groups.
The results are summarized in Table 1. It can be
seen that when children with significant attention
deficits were compared with the others, there was
a statistically significant tendency for those within
the significant attention deficit group to have had
the early onset of maladaptive behaviors. The
wid-est differences were detectable during the 1- to
3-year and 3- to 5-year intervals. Between 3 and 5
years of age, more than half of the significant
atten-tion deficit group were showing moderate to high
levels of problematic behavior, whereas this was
true for only 28% of the comparison cohort. Thus
there was a strong tendency for children with
sig-nificant attention deficits to manifest multiple
be-TABLE 1. Comparative Prevalence of Behavior
Prob-lems During First Five Years of Life
Age Interval and No. of Significant At- Remainder of
Problems tention Deficit
Group (%)
(N=209)#{176}
Clinic Sample (%)
(N=392)5
0-1 yr
None 24 36
Some 43 39
Many 33 25
1-3 yr
None 16 35
Some 38 41
Many 46 24
3-4 yr
None 13 33
Some 35 39
Many 52 28
A Reduced numbers reflect incomplete parent data.
havioral difficulties early in life. Approximately one
third showed this pattern during the first 12
months; this was not significantly greater than the
25% of the comparison group with infant behavioral
problems.
Current Behavior Problems
An effort was made to determine whether
chil-dren in the significant attention deficit group
showed a higher prevalence of current behavioral
and adjustment problems. A series of school age
behavioral inventories were completed by parents.
Problems were subdivided into four categories:
an-tisocial-aggressive; affective-dependent; somatic;
and social withdrawal!7 For each item on the
in-ventory, parents could indicate a score of 0
(defi-nitely applies), 1 (applies somewhat), or 2 (does not
apply). Total scores for each group of behavioral
items were computed and divided by the number of
items answered to yield a mean score for each
category (ie, similar to that derived for attention
deficit ratings). The means range from 0 to 2, with
the higher score suggesting fewer problems in that
category. In Table 2 are shown data for the group
with significant attention deficits, the comparison
group, and a community sample from which
nor-mative data were drawn.5’6 It can be seen that
youngsters meeting criteria for significant attention
deficits scored considerably lower on all categories of behavior.
Some items on the behavioral inventories
dis-criminated sharply between the two groups.
Diffi-culties with sleep occurred in 31% of the attention
deficit group and only 12% of the comparison
co-hort. Approximately 54% of youngsters with
signif-icant attention deficits were described as “not liked
by other children,” whereas this was true for only
TABLE 2. Scores on Categori es of Behavioral Inven-tory#{176}
Behavioral Category Significant
Attention
Deficit Group
(N = 220)
Remainder
of Clinic
(N = 420)
Commu-nity
Sample (N = 455)
Antisocial- 1.50 ± 0.5 1.73 ± 0.3 1.91 ± 0.2
aggressive
Affective- 1.15 ± 0.4 1.39 ± 0.4 1.64 ± 0.3
dependent
Somatic 1.57 ± 0.3 1.70 ± 0.3
Social withdrawal 1.34 ± 0.4 1.55 ± 0.4
1.88 ± 0.3 1.79 ± 0.3
SValues are means ± SD. In all instances P < .01 for
intraclinic comparison.
child who was very difficult to satisfy in 55% of the
youngsters qualifying for attention deficits and only
24% of the comparison group, a highly significant
difference. This is consistent with the observation
that insatiability often is a prominent symptom in
children with attention deficits.’2 Of interest was
the fact that there was no significant difference
between the groups in the prevalence of either
encopresis or enuresis.
School Data
Comparisons between teacher questionnaire
re-sponses in the group with significant attention
def-icits and the comparison sample are summarized in
Table 3. It can be seen that there were no
apprecia-ble differences in any areas of academic
perform-ance, except handwriting. There was no evidence
that children with significant attention deficits
ex-perienced greater delays than those with other
learning problems and better patterns of attention.
However, difficulties with written output commonly
were associated with attention problems. This
as-sociation was noted in an earlier study of children
with “development output failure”.3
Neurodevelopmental Findings
As part of their evaluation, all children in the
School Function Program underwent
neurodevel-opmental examinations. Comparisons between the
two groups are summarized in Table 4. Included
was an assessment of minor neurologic signs or
neuromaturational status, a major part of which
was the search for synkinetic or overflow
move-ments, commonly reported in association with
de-velopmental dysfunctions.’3”4 A composite rating
system was derived to score such synkinesis as
elicited on 12 motor tasks. Multiple synkinesias
(two or more) were found in 28% of youngsters
qualifying for the significant attention deficit group
and in only 12% of the comparison cohort
(P
< .01).As can be seen in Table 4, there was a trend toward
greater delay in both gross and fine motor function
within the significant attention deficit group. There
were no significant differences in
temporal-sequen-tial organization or in visual-perceptual motor
func-tion. However, there was a much higher prevalence
of delayed performance on several assessments of
receptive and expressive language among
young-sters with significant attention deficits.
Diagnostic Formulations
At the conclusion of the School Function
Pro-gram each multidisciplinary team convened to
share diagnostic findings and compile
recommen-dations. A determination was made of whether
there were relevant environmental stresses or
psy-chosocial problems interfering with the child’s
func-tion. This was derived from separate interviews of
the parents and child by a child psychiatrist, along
with the impressions of the pediatrician who
ac-quired the history. When the two groups were
com-pared, the prevalence of reported psychosocial
dif-ficulties was 55% in the attention deficit group and
TABLE 3. Selected Academic Items from School Ques.
tionnaire#{176}
Item Signif-
Re-icant mainder
Atten- of Clinic
tion (%)
Deficit Group (%)
Reading comprehension delay 39 40
Poor word analysis skills 43 43
Delayed spelling 48 48
Delayed arithmetic skills 33 31
Deficient in general knowledge 20 20
Poor written language 60 52
Poor handwriting 37 32
Ap < .05.
TABLE 4. Neurodevelopmental Findings
Neurodevelopmental Findings Signif-
Re-icant mainder
Atten- of Clinic
tion (%)
Deficit Group (%)
Multiple synkinesiast 28 12
Delay in gross motor function#{176} 22 17
Delay in fine motor function#{176} 22 15
Poor auditory sequential memory 35 32
Poor visual sequential memory 29 24
Trouble copying forms 34 28
Trouble copying from memory 37 29
Poor sentence comprehensiont 34 24
Trouble naming picturest 31 20
Trouble with verbal commandst 35 20
* P < .05.
47% among comparison children. This was not
found to be statistically significant. An attempt was
also made to determine the prevalence of specific
learning disabilities within each group. This was
based on psychoeducational testing as well as on
the neurodevelopmental examination and prior test
scores from school. It was found that 66% of
young-sters in both groups showed clear evidence of
disa-bilities. Thus, two thirds of youngsters with
signif-icant attention deficits, also were thought to harbor
information-processing handicaps. In the
compari-son group one third of students had neither
signif-icant attention deficits nor specific learning
disabil-ities. Presumably, this group was having academic
difficulty due to other psychosocial or educational
problems or, alternatively, was not really
manifest-ing learning problems, having been referred for
perceived deficiencies.
DISCUSSION
Inasmuch as attention deficits constitute a
com-mon set of attributes among many children with
school failure, increasing diagnostic precision, and
refinement of the concept is critical. Otherwise,
studies of etiologies, clinical manifestations,
prog-noses, and treatments will remain the reflected
images of arbitrary diagnostic criteria. The more
ambiguously defined the group of youngsters under
investigation, the more likely the generated data
will be poorly replicable and of dubious clinical
utility. Various investigations have pointed to a
high prevalence of perinatal risks,’ allergies,’6
sen-sitivities to food additives,’7 and family problems’8
among children with attention deficits. Others have
emphasized economic and cultural influences.19 Stifi
others have blamed these perceived problems on
the social biases of observers.#{176} Across such
inves-tigations there has been no consistency of
diagnos-tic criteria or sample selection. Observer biases and
the clinical settings for research therefore may have
strongly influenced epidemiologic and treatment
outcome findings.2’
The present study demonstrates some important
principles about the detection and selection of
chil-then with attention deficits. The first is that
ob-servers are apt to differ dramatically in what they
perceive when they live with, teach, or evaluate an
affected child. In this investigation there was
sub-stantial disagreement among parents, teachers, and
the clinic staff as to who had significant attention
deficits. There was unanimous agreement that 9%
of youngsters were manifesting the symptom
com-plex sufficiently to meet criteria. Another 30% of
the youngsters were felt by all observers not to have
significant problems with attention. The remaining
61% of the youngsters elicited disagreement
be-tween the three observation sources. Membership
in the subgroup of children with significant
atten-tion deficits would have differed dramatically if the
views of only one observation source were taken
into account. In many studies of children with
“hyperactivity” a teacher questionnaire, an
inter-view, or direct observations of the child constitute
sole source criteria for sample selection.
Clinically, it may be important to explore possible
sources of interobserver disagreement: First, it is
likely that diagnostic biases, social backgrounds,
personal hidden agendas, or the variable
observa-tional skills of persons completing questionnaires
constitute strong influences. Second, people may
differ in their attitudes toward questionnaires and
in the ways they complete them. Some parents, for
example, may exaggerate a child’s difficulties on a
behavior problem inventory in order to acquire
more sympathy or more services for the youngster.
Third, some children may manifest attention
defi-cits variably in different settings. A youngster may
be inattentive mainly in the highly verbal
atmo-sphere of a school, but be more focused and less
distractible at home. It is well known that some
youngsters behave angelically in a clinic or a
phy-sician’s office despite their demonic propensities at
home or in school. In some instances, the content
of the activity in which a child engages or the time
period during which he is scrutinized may modify
observations of selective attention. The process of
observing also may alter the way the child
func-tions. This clinical version of the Heisenberg
uncer-tainty principle must be acknowledged as a
limita-tion of diagnostic clinics.
In view of these possible sources of inconsistency,
it is critical that significant attention deficits be
attributed only after a review of data from multiple
observation sources. Contradictory perceptions
need to be accounted for and, in fact, may contain
important clues about the origins and everyday
patterns of a child’s attentional weaknesses.
It has been reported that some children have
learning disabilities plus attention deficits, some
have learning disabilities without attention deficits,
and still others show weak attention in the absence
of leaning disabilities.2’ It might be inferred that
there are these three discrete subgroups of children
with learning disorders. The present data would
indicate, however, that such categories may not be
so easily differentiated, or teased apart in a
popu-lation with school problems. There may indeed be
youngsters who appear to have “primary attention
deficits” without any other associated disabilities.
Such children have adequate language abilities,
good visual-spatial orientation, appropriate
mem-ory function for age, and good conceptual abilities.
sustained, selective attention and sometimes with
the modulation of activity. At the other extreme
are children who are able to concentrate and
regu-late activity, but who have perceptual, language, or
other cognitive handicaps that interfere with
lean-ing. One would anticipate that the former group
would have more difficulty with behavior and social
adjustment. The present study suggests that two
pure groups may well exist, but that mixed forms
are far more common. By inspecting the range of
activity-attention scores from both the parent and
teacher questionnaires, it can be seen that there
was a continuum of ratings, so that various degrees
of attention deficit were present in a large majority
of the clinic patients. Although cutoff criteria were
established and defended for purposes of this study,
drawing the line was difficult and could be clinically
misleading.
It is likely that some or all of the individual traits
associated with attention deficits also occur with
learning and adjustment problems of other types.4
It may be difficult to determine which came first.
For example, a child with a language disability may
become distractible and inattentive because
com-prehension is poor. As a result, concentration goes
unrewarded, and a youngster begins to focus on
stimuli that are more meaningful to him, although
they are viewed as distractions by adult observers.
On the other hand, a child who is chronically
mat-tentive to language may experience consequent
de-lays in verbal comprehension. Similarly, many
chil-dren with attention deficits are said to be impulsive.
It may be that some become impulsive because they
have difficulty performing tasks. If they cannot do
something well, they may prefer to accomplish it
quickly or “get it over with.” Therefore, there needs
to be continuing recognition of the lack of specificity
of individual signs described as part of the symptom
complex in attention deficits. The widespread
oc-currence of some of the traits over a population of
children with school problems is evidence of this.
Their pathophysiologic implications are likely to be
ambiguous.
In the present study perinatal stresses, family
histories of dysfunction, or socioeconomic levels did
not differentiate children with significant attention deficits. Such biosocial influences were represented
equally in the two subgroups. On the other hand,
children with significant attention deficits were
more likely to have had problems with behavior
early in life. Overactivity, emotional lability, trouble
with social interaction, and sleep difficulty were
particularly notable in the group with significant
attention deficits. In general, these tendencies
emerged during the toddler and preschool years,
rather than in infancy. Certainly, early life histories
may reflect observer biases. For example, parents
of some children were more severe in all of their
behavioral ratings; this may have produced an
ar-tificial subgroup perceived as “bad” in every way
(including selective attention). The use of multiple
sources of criteria for admission to the attention
deficit group helps minimize the impact of possible
parent biases.
If children with significant attention deficits have
a high likelihood of manifesting difficulties long
before their school problems become evident, the
early onset of maladaptive behaviors may be the
most stable predictor of later attention weakness in
school. Future prospective studies will need to
fol-low clusters of traits longitudinally to determine
which patterns are most predictive of significant
attention deficits.
In the current study, children with significant
attention deficits had many behavior problems in
areas extending beyond the pattern of poor
concen-tration, overactivity, etc. Somatic symptoms,
ag-gressive tendencies, signs of excessive dependency,
and poor relationships with peers were reported
much more commonly in this group. This again
raises the issue of whether there is a true difference
between such youngsters and those with generalized
poor behavior or so-called “conduct disorders.”4
From the present study, it is not possible to answer
that question. It is equally difficult to determine
whether a youngster’s galaxy ofmaladaptive
behav-iors came about as a result of repeated failure due
to attention deficits, whether there was
simultane-ous emergence of attentional weaknesses and
be-havioral difficulties stemming from a common
cause, or whether various forms of behavioral
maladjustment lead a child to “tune out.” Again, it
is likely that systematic prospective studies,
docu-menting the timing of emergence of various
behav-iors, will be critically important. In addition, it will
be relevant to ascertain the prevalence of
young-sters who show somatic symptoms, aggressive
be-haviors, and troubles with peer relationships but no
significant difficulties with attention, impulse
con-trol, and activity modulation. This phenomenon is
likely to be a rare occurrence, suggesting that there
is little purity with regard to the presence or
ab-sence of attention deficits.
Neurodevelopmental findings in this study are
likely to be of significance. There was a greater
prevalence of neuromaturational delay among
chil-dren with significant attention deficits. Multiple
synkinetic movements were common and may
sug-gest that inattention may be linked to a neurologic
substrate in some children with learning problems.
The higher prevalence of language disability in
the youngsters with significant attention deficits
also is relevant. Two tests of receptive language and
vocabu-lary were used. Of interest is the fact that the first
two required sustained listening and selective
atten-tion to verbal detail. The association between
dif-ficulty with these tasks and membership in the
significant attention deficit group has several
im-plications. First, assessments of language may be
unreliable in this population because such
exami-nations demand a high level of passive listening,
attention to detail, and persistence. Some children
who appear to have receptive language difficulties
during examinations actually may be failing
be-cause of generalized attention deficits. Conversely,
some youngsters who are said to have attention
deficits actually have underlying language
handi-caps that show up in school as weak auditory
atten-tion. Therefore, the possibility of a language
disa-biity would need to be ruled out in youngsters
manifesting attention deficits. This is consistent
with the finding of a recent study that during
com-prehensive neurodevelopmental examinations,
at-tentional weaknesses are most likely to be provoked
by language tasks.22
Significant therapeutic implications may emerge
from a refinement of the concept of attention
defi-cit. For example, if a youngster’s difficulty with
concentration is accompanied by evidence of a
lan-guage disabifity, individualized speech and language
therapy may enhance attention. If instead, such a
youngster were treated only with stimulant
medi-cation, underlying information processing problems
might be masked and remain untreated. Although
the attention-strengthening effects of the stimulant
might be beneficial, an underlying learning problem
could go unresolved and continue to produce
aca-demic difficulties. Analogously, a child whose
atten-tion deficits are embedded in a broader matrix of
psychosocial disorder may require intervention to
deal with environmental stresses and
preoccupa-tions as part of the effort to enhance selective
attention.
It is important to consider that an attention
deficit may have more than one cause or
contrib-uting factor. A youngster may have a primary
weak-ness of attention as well as psychosocial stresses at
home. That child may have been born with a
pre-disposition to attentional weakness, such that a
sibling growing up in the same home may show no
evidence of the problem. Similarly, when a
young-ster’s educational program and home environment
are optimal, a physiologic vulnerability to weak
attention may be minimized or even counteracted.
In those children with multiple contributing factors,
treatment will need to be delivered in several
mo-dalities. A child might benefit from counseling as
well as special education and also stimulant
medi-cation if he demonstrates evidence of serious
maladjustment, weaknesses of visual-spatial
proc-essing, and long-standing pervasive manifestations
of inattention.
Heterogeneity within groups of children with
at-tention deficits is likely to influence markedly
din-ical investigations of treatment. Future research
will need to include more detailed descriptions of
children under study in order to improve both
gen-eralizability and replication. Such characteristics as
the array of specific traits and associated behaviors,
the onset of clinical manifestations, the existence of
information processing problems and strengths, the
influence of psychosocial stress, and the presence of
neurologic findings will need to be included as part
of a clinical profile of patients under study. Such
factors are likely to influence prognosis with or
without intervention. There also will need to be
more careful scrutiny of which youngsters are likely
to have primary weaknesses of attention and which
are apt to have had their attention weakened
sec-ondarily. Differential treatment effects may reflect
these distinctions.
The results of this study suggest that the
symp-tom complex characteristic of attention deficits may
represent different phenomena in different children.
There may indeed be a relatively small group of
youngsters with so-called “pure” deficits of
atten-tion. More commonly the clinical picture is mixed,
and children with attention deficits demonstrate
marked heterogeneity. It is likely that an attention
deficit can be either a process or a disorder. The
process may be a concomitant or a result of other
behavior and learning problems. Future research on
the causes and management of attention deficits
needs to take into account the possibility that this
condition may be either a discrete neurologically
based dysfunction or a phenomenon analogous to
an inflammatory response. Just as the latter can
accompany trauma, infection, autoimmunity, and
other conditions, so attention deficits may appear
as a nonspecific host response. Poor impulse
con-trol, overactivity, weak concentration, and
insatia-biity may constitute the tumor, calor, rubor, and
dolor of child development!
ACKNOWLEDGMENT
This study was supported by a grant from The Robert
Wood Johnson Foundation, Princeton, NJ.
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INTERNATIONAL DEVELOPMENT ISSUES
The annual military bill is now approaching 450 billion US dollars, while
official development aid accounts for less than 5 per cent of this figure. Four
examples:
1. The military expenditure of Only half a day would suffice to finance the
whole malaria eradication programme of the World Health Organization, and
less would be needed to conquer river-blindness, which is still the scourge of
millions.
2. A modern tank costs about one mfflion dollars; that amount could improve
storage facilities for 100,000 tons of rice and thus save 4000 tons or more
annually; one person can live on just over a pound of rice a day. The same sum
of money could provide 1000 classrooms for 30,000 children.
3. For the price of one jet fighter (20 million dollars) one could set up about
40,000 village pharmacies.
4. One-half of one per cent of one year’s world military expenditure would
pay for all the farm equipment needed to increase food production and approach
self-sufficiency in food-deficit low-income countries by 1990.
Submitted by Student
From North-South: A Programme for Survival. Report of the Independent Commission on
