You may be concerned that your child is struggling to focus or follow instructions. Perhaps their school has mentioned that they are falling behind owing to lack of concentration.
You may be concerned about attention deficit hyperactivity disorder (ADHD/ADD), but there are many factors which can contribute to “ADHD-like” difficulties in focus and attention.
ADHD symptoms don’t necessarily point to a diagnosis of ADHD. There are many overlapping conditions.
There are also many lifestyle and environmental factors which are risk factors for developing attention deficits and/or symptoms of inattention.
Could it be ADHD?
ADHD (attention deficit/hyperactivity disorder) is considered by medical professionals to be a neurodevelopmental disorder. However, psychologists (who are not medical professionals!) prefer to describe it as a neurodevelopmental difference. It is a difference in the way the brain is “wired”. Many of us wish that the term “disorder” could be dropped completely. It is a condition which brings both strengths and weaknesses.
What is ADHD?
Key symptoms of ADHD can include:
- Being easily distracted
- Difficulty following directions
- Difficulty staying on task
- Impulsive symptoms such as touching and picking up all items in a shop
- Losing personal items such as keys or books
- Not paying close attention to details, making careless mistakes
- Problems staying organised and with time management
- Short attention span
- The ability to hyperfocus (focus on a task for hours on end, tuning out everything around you)
- High energy
Attention deficit disorder (ADD) is an outdated term. The DSM-V (Diagnostic and Statistical Manual, fifth edition) now categorises what was ADD as “ADHD – Inattentive Type”. It is still sometimes used informally to refer to someone who has difficulty staying focused but does not experience symptoms of hyperactivity.
Attention Difficulties: Unwanted Longer Term Side Effects
Unfortunately, if attention difficulties persist long-term without support, there can be unwanted side effects.
In my clinic I commonly see children whose attention and concentration problems have contributed to low self-esteem, social difficulties or (less commonly) mental health issues.
Attention Difficulties and Low Self-Esteem
If a child cannot focus or attend to instructions and tasks, there may be a resulting loss of self-esteem.
They may fall behind at school.
Or feel “stupid” because they can’t follow instructions, so they are not sure what they are supposed to be doing.
They may feel out of control, because they really want to do well at school, but they don’t know how.
Young children may quickly develop a learned helplnessness: “I can’t do this so I won’t try”.
Attention Difficulties and Social Interaction Problems
Social situations can be difficult when you have attention difficulties. You may get bored easily and struggle to stick with a task, which can be frustrating for others.
Attention difficulties and impulsiveness may go hand in hand, leading to a sense of unpredictability which may put off potential friends.
Attention Difficulties and Mental Health Problems
According to Mind, adults with ADHD are more likely to experience mental illness. Anxiety, depression and sleep problems are common.
In my experience this is not surprising, as the mental effort required to function well in a world not designed for you can be draining and stressful.
However, this need not be the case for those who receive appropriate treatment and support in daily life as a child.
Attention difficulties and impulsivity do not always go hand in hand, but young people who show impulsive behavior may be at risk of substance abuse issues or addiction in the future so early intervention is key.
Factors That May Contribute to Attention Difficulties
Before assuming ADHD, consider lifestyle and environmental factors which could be contributing to your child’s attention difficulties.
I usually advise parents to make changes where they can and review again in around 6 months.
You may find that small changes have a significant difference, enough to lessen or remove your concerns.
1. Attention Difficulties: Different Priorities
Starting their homework assignments might be important to you, but is it to them?
If you find that your child can concentrate very well on activities they enjoy, then it may not be a focus and attention problem but a lack of motivation.
2. Attention Difficulties, Stress and Anxiety
If a child is frequently in fight or flight the body prioritises survival. The brain only focuses on running from or fighting the perceived danger. Concentration and focus are significantly affected.
Read this article about the symptoms of anxiety to help you develop a plan.
3. Attention Difficulties: The Link With Sensory Processing Differences
If your child’s brain struggles to filter out background noise or is distracted by uncomfortable clothing, they will find it much harder to stay focused.
Your child may not have mentioned this to you.
They may not even be particularly aware of it themselves.
Spend some time exploring with them by asking questions like: Do you ever get distracted by noise in the classroom?
4. Lack of Sleep: The Connection With Attention Difficulties in Children
There is a strong connection between poor quality of sleep or not enough sleep and attention difficulties.
In one study children with fragmented sleep gave a lower performance on a variety of cognitive measures, particularly those associated with complex tasks.
5. Attention Difficulties and Lack of Exercise
The human body was built for physical activity. We were originally hunter-gatherers and moved for large portions of the day.
If children sit still for too long the body starts to initiate movement through fidgeting.
Movement regulates attention pathways in the brain.
6. Irregular Eating and Attention Difficulties
The body needs regular fuel for optimum cognitive function.
One study found that children who skipped breakfast achieved lower GCSE grades (the exams 16 students take at age 16).
Effective Treatments for Attention Difficulties
In my view, traditional treatments such as stimulant medications should not be considered until all the factors above have been explored and (if necessary) addressed.
A child psychologist or similar health care provider can help you with this process. They will develop a treatment plan and work through it with you, usually over a number of regular sessions.
When you look for a psychologist make sure they are a qualified clinical psychologist, counselling psychologist or educational psychologist, registered with the HCPC (Healthcare Professions Council).
You can find local child psychologists in the UK using the search function for the Association for Child Psychologists in Private Practice (ACHiPPP).
Treatment options include medication alone, psychological support alone, or medication plus psychological support.
Psychological support may include behavioural parent training, teacher training, adapting the child’s environment and altering their lifestyle.
In the UK, stimulant medication for ADHD in children and young people must be prescribed by a psychiatrist or paediatrician. This can then be transferred to the GP. Medication for ADHD is less commonly prescribed in the UK than in some countries such as the united states.
Attention Difficulties in Children: Case Study (Rose)
Rose is an eight year-old girl in a mainstream primary school. Rose loves dancing and gymnastics. She is a happy-go-lucky girl who flits between many activities and interests.
Teachers have struggled to keep Rose on task ever since she was in reception. Rose does not follow the teacher’s instructions, so she doesn’t know what she should be doing. As a consequence, Rose gets bored in class. She has begun to be disruptive, distracting others and acting the “class clown”. Rose has fallen behind academically despite being very able. This has begun to affect her self-esteem.
Although Rose’s classmates like her and enjoy her company, their parents are not keen to encourage friendship with her as she is disruptive in class and gets others into trouble by distracting them.
Rose’s parents engaged a clinical psychologist to help them understand Rose’s difficulties. The psychologist met with Rose and her family, and spent half a day observing Rose at school.
The clinical psychologist noticed that Rose was very fidgety in class. This was a strong hint that Rose’s body needed more movement and exercise in order to regulate itself. The clinical psychologist suggested the following strategies:
- Bounce on the mini-trampoline for 5 minutes before school
- Walk to school
- Teach Rose’s class teacher to do 2-minute “mini-movement breaks” four times a day with the whole class.
- Consider an occupational therapy consultation to explore further strategies to help the body move, such as a “wobble cushion”.
- Ensure teacher and teaching assistant are aware of Rose’s “early warning signs” that she is losing focus. The clinical psychologist spotted that these include playing with her hair and flicking her pencil. At these points, take a mini-movement break or send Rose on an errand. Alternatively, re-focus Rose. Call her name or touch her gently, then ask her to repeat the instruction or tell you about her progress with a task.
In addition, the clinical psychologist suggested:
- Seating Rose at the front of the class.
- Checking in with her more regularly than other children to ensure she has processed instructions.
- Breaking instructions down into smaller chunks.
Within 2 months Rose was noticeably more focused. She showed signs of catching up academically. Her friendships improved as she was less likely to get others into trouble. Her parents and teachers planned to continue the support strategies.
Attention Difficulties Example 2: Josh
Josh is a thirteen year-old boy who loves Marvel films, Doctor Who, Parkour and rugby.
Josh went to a small and nurturing primary school. He had support in class to stay focused, including the support of a TA to bring him back to the task when needed.
In secondary school Josh has struggled much more because the classes are larger and noisier. His parents have noticed that his grades have dipped, though he is still within the average academic range.
Josh’s school do not have major concerns about him but they noticed that he often drifts off into his own world in class. Josh reported that he finds lessons boring and struggles to stay motivated.
At home Josh manages homework by putting on music on his headphones and wearing a soft hoodie with the hood up, shutting out the world.
After meeting with Josh and his family, a clinical psychologist suggested a referral to an occupational therapist with a specialism in sensory processing issues.
The clinical psychologist spotted that Josh finds noisy environments difficult and tends to “tune out” when his nervous system gets overwhelmed. This is a successful way of coping with “brain overload” for Josh, but means that he isn’t attending or focusing in class.
The OT carried out an assessment. She found that Josh is much more sensitive than the typical teen to noise. She also found that he is sensitive to touch and his concentration has been affected by the scratchiness of his school shirt and tie.
The OT also identified that Josh was not getting enough sleep, so his nervous system could not recuperate fully.
Strategies implemented included:
- A soft underlayer to prevent Josh’s shirt rubbing on his skin.
- Use of noise cancelling headphones during certain noisy periods in lessons.
- The teachers moved Josh to the front row in all lessons and checked he had processed their instructions.
- Josh was invited to attend the school’s occupational therapy programme twice a week (providing movement and deep pressure exercises to regulate his nervous system).
- Josh was given guidance on “sleep hygiene”.
- Review progress in 6 months.
Josh’s focus and attention improved significantly with the strategies suggested. However, when GCSEs began and the academic demand increased, Josh started to struggle more.
He “tuned out” more often in lessons and this became an increasing problem.
Josh’s parents and teachers continued to implement the strategies. They also sought a neurodevelopmental assessment from a paediatrician to rule ADHD in or out, and to consider the pros and cons of medication.
Josh was diagnosed with ADHD.
The combination of adjustments to his lifestyle and school environment, along with stimulant medication, led to a successful outcome. Josh no longer tuned out in class and was successful in his GCSEs.
Attention Difficulties: Diagnostic Labels
In the UK assessment and diagnosis for neurological conditions such as ADHD usually starts at around six years of age upwards. Preschool-aged children are developing and changing at such a rate that a label would not be advisable or helpful. Even in older children it can be a good idea to “watch and wait”. Simple lifestyle interventions or adaptations to the environment may make all the difference in school-age children.
On the flip side, early identification of ADHD can help a child be better understood and supported. This can set the course for positive academic, social and emotional development. If you have concerns or see signs of ADHD I advise getting support early on. If you do not see improvements then a diagnostic assessment may be warranted.
What Does a Diagnostic Assessment Involve?
A health professional diagnoses ADHD and will distinguish between an inattentive presentation or hyperactive-impulsive type presentation, or a combined presentation. It is usually diagnosed by a paediatrician or child and adolescent psychiatrist, but clinical psychologists can also make a diagnosis of ADHD.
There is no single test for ADHD but there are specific criteria.
Your child’s doctor or health professional will take a full history and will ask you about the symptoms I have listed at the top of this article. They may observe your child in school.
Screening questionnaires are often used, but these should never be used as diagnostic tools by themselves.
Finally, there is a test called the Qb test which is used in some services. During the Qb test the child sits in front of a computer screen and clicks in response to certain shapes they see on the screen. Their responses are measured.
Brain Development and Attention Difficulties
Your child’s brain is not fully mature until at least age 25. Executive functioning – higher level thinking skills such as planning, organising and rational thinking – are not strong strong because the brain’s prefrontal cortex is highly under-developed.
What is more, it hasn’t yet built up strong connections with the limbic system (the emotion centre of the brain), which is needed for impulse control and inhibiting strong emotions.
What Should You Do If You Are Worried About Your Child’s Attention Difficulties?
First of all, ensure you work on lifestyle factors such as eating and sleep. This article on lifestyle habits in children and mental wellbeing will help you. Include daily activities which help regulate your child’s nervous system such as aerobic exercise and complex forms of exercise (dance, martial arts, gymnastics for example).
Secondly, aim to work in partnership with your child’s school. Ask them if they have noticed any attention difficulties, and if not, ask they to observe your child closely over a period of a couple of weeks.
They may have access to a specialist such as an educational psychologist who can provide input in this process. After this, ideally they will develop a written plan outlining supportive measures such as moving your child to the front of the class, checking in with them regularly and engaging in whole-class movement breaks.
Thirdly, seek support from a psychologist sooner rather than later. The psychologist will help you to understand what is causing the attention difficulties and develop a clear plan of action. They may refer you to a paediatrician for an ADHD assessment.
Find Further Help if You Are Concerned About Focus And Attention Difficulties
You can find further information and support from the following resources:
ADHD Foundation: https://adhdfoundation.org.uk/
UK ADHD Partnership: https://www.ukadhd.com/
Dr Lucy Russell is a UK clinical psychologist who works with children and families. Her work involves both therapeutic support and autism assessments. She is the Clinical Director of Everlief Child Psychology, and also worked in the National Health Service for many years. In 2019 Lucy launched They Are The Future, a support website for parents of school-aged children.
Through TATF Lucy is passionate about giving practical, manageable strategies to parents and children who may otherwise struggle to find the support they need.
Lucy is a mum to two teenage children. She lives in Buckinghamshire with her husband, children, rescue dog and three rescue cats. She enjoys caravanning and outdoor living, singing and musical theatre.
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