Attention and Concentration Challenges in Children and Young People

How long are you able to read something or think carefully about a topic without being distracted by something else? Do you feel satisfied with the length of time you can do this? Does it depend on the time of day or what you are doing? Has it changed over the years for you?

The questions above are about “attentional control” – in other words, our ability to keep our attention and thoughts focused on a chosen task, object or idea for a set period of time. Attentional control (one of our “executive skills”) may involve two separate neurological systems or set of neural networks – with one responsible for increasing and maintaining focus on relevant information and a second set responsible for suppressing urges to attend to irrelevant information (i.e., looking elsewhere, doing something else, changing the topic and thinking about something else). These two systems improve gradually from childhood to young adulthood (and start to decline again in middle to older adulthood- with some studies suggesting it is the “suppression systems” rather than the “focus systems” which fail first).

It seems that attentional control skills are important to our ability to learn and problem solve – there is a great deal of studies showing relationships between these skills and many different measures of cognitive and educational skills. Some psychologists have even theorized the reason for the well known “clustering” of cognitive skills in humans is that attentional control is what underpins many or most of them. This makes me wonder – if I could just stay focused well enough and for long enough, could I do well in almost anything?!

The opposite of good attentional control is inattention and distraction: when our thoughts and attention are involuntarily diverted away from the idea or task we were focusing on and onto other topics. Distractibility and inattention problems can lead to forgetfulness, slowness in completing tasks (sometimes thought of as a slow “cognitive tempo”), focus in completing study or other work tasks, organization difficulties and challenges maintaining focus in conversations, remembering instructions and a host of other problems.

Everyone (children, young people and adults) struggles with distractibility and inattention at times - especially in the face of challenges such as tiredness, boredom, pain and being in the presence of more interesting distractions. However some people have more significant difficulties with these processes than others. If we shift our focus to children and adolescents in particular, studies suggest about 20% of this age group have at least moderate difficulties with inattention and distractibility compared to others of a similar age, with 4-5% of them having severe difficulties.

Those with severe difficulties with attention and distraction are often thought of or diagnosed with having a psychological disorder - Attention Deficit Hyperactivity Disorder (ADHD). People with attention/distraction problems may meet the criteria of either Attention Deficit Hyperactivity Disorder – Predominantly Inattentive type (ADHD-I) or if they also have difficulties with hyperactivity/impulsivity (these problems often go together) they might be diagnosed with ADHD – Combined Type (ADHD-C - problems with attention/distractibility AND problems with hyperactivity/impulsivity).

To meet the criteria for ADHD-C or ADHD-I, young people need to have 6 or more of the symptoms below:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

• Often has trouble holding attention on tasks or play activities.

• Often does not seem to listen when spoken to directly.

• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

• Often has trouble organizing tasks and activities.

• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

• Is often easily distracted

• Is often forgetful in daily activities

(ADHD-C also requires children/young people have a minimum set of symptoms of hyperactivity/impulsivity, but I will not list these here as this is not the focus of this article.)
To be diagnosed with ADHD (C or I) these symptoms also need to have emerged before age 12, be present in at least two settings (ie not just school), cause significant impairment, not be better explained by another disorder and finally (and this is important) these symptoms above need to occur much more frequently than they do in other children of a similar age. Finally, according to DSM V guidelines, an ADHD diagnosis requires “multiple informants” (parents, teachers, self report) and “multiple methods of assessment”.

Whether or not they reach the level of a formal disorder, difficulties with inattention and distractibility can lead to serious challenges in other areas for young people. Some research has suggested that inattention specifically (above and beyond other challenges such as hyperactivity) might be an important factor contributing to learning difficulties, anxiety, challenging behaviours and social problems.

In addition, children with difficulties with inattention and distractibility often have other “executive skill” deficits. One deficit which has been extensively examined in the last few years in people with attention problems is working memory problems. Although studies have found a very large range for the number of children with ADHD who have working memory deficits – between 30 and 98%! - it seems to be generally accepted that working memory is very often a problem for at least a large number of young people who have attention/distractibility problems.

Problems with attention and distractibility (and working memory) can have long lasting effects beyond childhood. A New Zealand study found that attentional control as measured in childhood was a very important predictor of educational, social and work outcomes 20 years later.

It is worth noting however that many children/young people do improve their concentration and attention skills as they develop – with improvements often seen right up until early adulthood. However unfortunately some do not: a study published in 2018 followed 5000 children from childhood into adulthood and found that 1/3 children with symptoms of ADHD still had symptoms in adulthood. Another separate study found that children/teens with difficulties with attention and distractibility were more likely over the longer term to continue having these challenges than those who had childhood difficulties with hyperactivity and impulsivity.

It is important to note however that young people with problems with inattention and distractibility may not have difficulties all the time and in all settings. In fact, they may have some short periods in which they concentrate and attend extremely well. Some writers call this “hyperfocus” – and it is the subject of an important emerging area of research, with some suggesting that ironically people with attention/distraction problems may be able to “hyperfocus” more often and more effectively for short periods of time than those without attention/distraction problems. For this reason, it may turn out that problems with attention and distraction will be better thought of as an “attention regulation” problem rather than an “attention deficit” problem per se.

How do we assess problems with inattention and distractibility?

Given the potential negative outcomes associated with distractibility and inattention challenges, it would be ideal if we could confidently, accurately and quickly identify them in the children/young people we see. Unfortunately this is easier said than done. There are three methods for assessing problems in this area. The first is a clinical Interview, in which we can ask a list of questions about attention and distractibility problems. These include when they occur, how long they have been present for and how much they interrupt functioning. A good clinical interview of course would include asking for input from a range of people – the child/young person themselves as well as parents/family members and teachers for example.

While a clinical interview is an important way to collect information, it is of course subject to problems with bias. In my experience many parents/caregivers and young people themselves do not have a sound knowledge of developmentally normal level of attentional control for a child/teen’s age and situation - and therefore either under-estimate (I didn’t realise he should be better at focusing on his homework by now) or over-estimate (surely an X year old should be able to concentrate even when there is X going on in the background) a young person’s difficulties in this area. They may also misattribute problems – overlooking significant learning or emotional health/trauma/psychological difficulties and believing they are solely attention/distractibility problems.

A second potentially more useful method for measuring distractibility and inattention problems is to use rating scales. These are questionnaires (usually measuring both inattention/distractibility and hyperactivity/impulsivity challenges) for young people, parents/caregivers and others (eg teachers) – for example (eg SNAP-IV 26 - Teacher & Parent Rating Scale – available free online) in which children/young people’s scores can be compared to “norms”.

While rating scales can and do provide an additional layer of information compared to clinical interviews, we should be aware that they are also subjective measures and therefore also have potential bias problems.

For example, it is well known that rating scales in some situations often produce artificially high results. One study found that using rating scales, a sample of teachers rated a staggering 75% of their students as having attentional problems.

Another problem with rating scales is their low “interrater agreement” (who decides who has attention problems and who doesn’t) – low interrater agreement is found between parents/teachers and even between two parents of the same child. There are also some questions about reliability more generally – for instance some studies have found the number of psychological symptoms of the parents strongly correlated with how they rated their child.

None of these problems mean we shouldn’t use rating scales however it does mean they should be used in conjunction with clinical interview and using our clinical skills.

A third way of assessing attention issues is to use standardized cognitive or neuropsychological tests of attention. These consist of computer or pen and paper tasks which are usually simple but require close attention /avoidance of distraction for a set length of time (for example the Continuous Performance Test and the Test of Variable attention). Unfortunately both of these tests are subject to a high number of false positives (children with many kinds of learning challenges struggle with them, not just those with attention problems) and to high numbers of false negatives (some children with genuine inattention/distraction challenges “in real life” do not find these laboratory based tasks in these particularly difficult).

Overall therefore, unfortunately the assessment of inattention/distractibility issues presents ongoing challenges which have not yet been solved.

What causes inattention and distractibility difficulties?

It is widely acknowledged that inattention/distractibility difficulties are likely to have a biological basis of some kind. For instance, some studies estimate up to 85% of ADHD can be linked to genetic causes. There has been much wider acknowledgement over the past few years of the biological component of ADHD-I – and this has done a great deal to reduce stigma, reduce shame and encourage help seeking.

However, like all psychological disorders, studies suggest there are non biological and environment factors which may be contributing to at least the maintenance and severity of inattention/distractibility symptoms in some young people. For example, studies examining diet (sugar and energy drink intake for example), sleep, general health, levels of physical exercise, parenting behaviours and general psychological well being have suggested that all of these factors may influence the extent and severity of inattention and distractibility in at least some children and young people.

Are problems with inattention and distractibility made worse (or even caused) by use of technology?

One particular potential environmental influence on distractibility which has been the subject of much scrutiny in recent years is the usage of technology. In today’s world most of us are constantly breaking our attention from what we are doing or thinking about to look at or use technology. I’m sure your experience of this is so strong I don’t really need to cite the literature here – but just for your interest here is a selection of study results I’ve read recently: we look at our smart phones for up to 5-8 hours a day; students use their laptops for non class activities for 20% of the time spend in class; employees in some settings are able to focus on tasks for an average of only 60 seconds; Australian teens in some studies send an average of 80 text/in app messages each day - and so on!

I think it is reasonable to ask whether this regular and frequent breaking of sustained attention is having a long term effect on our attention skills. This is something I certainly have concerns about for myself. Many years ago, I would read for hours almost without blinking – now I’m lucky to get to the 15 minute mark before I check my phone.

Many people have studied this question and at first glance the research is concerning. Here are some of the studies I’ve read recently: A 2019 study found that preschoolers who had more than 2 hours of screen time per day (both gaming and passively watching video) reported more difficulties with inattention than children who had less than 30 minutes per day. Another study found that adolescents who met the criteria for internet gaming disorder had significantly more difficulties with inattention in objective testing than a control group. A 2018 study found that the more adults used their smart phone in an “absent minded/non goal driven” manner in any given day, the more problems they had on tests of inattention and distractibility on that day. Another 2018 study found that 15 and 16 year olds who were heavy social media users were more likely to develop difficulties with inattention over a period of two years compared to lower social media users. Children diagnosed with ADHD have been found in several studies to play more hours of video games per day than those who don’t. Other studies have found that those who spend more hours a day multi-tasking with media (ie using multiple technology devices/platforms at one time) have poorer attentional control than those who either use less technology altogether or who used one technology device/platform at a time. Other researchers point to the fact that there has a recent increase in ADHD diagnoses in countries with increasing technology use, and suggest these may be related.

However, before we get ready to throw all our kids’ (and our own!) devices in the bin, I think it is essential to note that the basis of all the research cited above is correlational. We do not have any studies (nor are we ethically likely to get any) which randomly assign children into a “use technology” or “don’t use technology” group and then follow them up to see the impact of varying amounts of technology on their attentional control skills. This means of course that we don’t know that it is the technology causing the attention problems. Instead it could be either that children/teen’s attention problems are causing the increased technology use (a possible mechanism is that kids with inattention/distractibility issues may be more drawn to tech and use it more frequently). Alternatively it could be that there is some third underlying factor which leads both to children using more technology use and to having more attention problems.

I also need to report that there have been some studies which have investigated this issue and failed to find a difference between high media users and those with attention problems. Given publication bias (without results, much harder to get published), it may be there were more of these we can’t read about. Finally, there have been a few studies in which action games actually improved the cognitive skills (including their attention skills) of the (adult) participants.

Therefore while technology use may play a part in contributing to attention/distraction difficulties in young people, my feeling is it is unlikely to be the primary or sole culprit in any given child – but just one piece in a complicated jigsaw.

By the way, it is interesting to note that the “young people can’t concentrate these days” is not a new concern: 2300 years ago Aristotle bemoaned that many people were too distracted by listening to others play the flute rather than focusing on the discussion they were having with others and in the early 1900’s an ironic cartoon emerged showed a couple ignoring each other while being distracted by their telegraph machines!

How to help young people with difficulties with inattention and distractibility

Given the large number of young people who struggle with this issue – and the potentially large and negative impact on their life – supporting young people to manage and improve their attention skills should be a key goal for health and education professionals. Unfortunately it is not always easy to know how to support this group. Most manualized and research programs for children with inattention/distractibility concerns are programs for ADHD more generally and tend to focus on the hyperactivity/impulsivity and/or disruptive problems than inattention/distractibility problems.

One exception (the Child Life and Attention Skills – Clas, 2007) has been shown to be effective (compared to treatment as usual) for inattention/distractibility issues but there is limited information publicly about the program other than it was based on “routine, scaffolding and reminders”.

However, as professionals who work with children we have a good understanding of behavioural and educational principles – and we can use these to find strategies to children with these difficulties.
Here are some ideas I use in support young people in this area - I hope some of them might be useful in your work with this group of young people.

1. Psycho-education

As always, when we are helping children and teens with their emotional and psychological challenges, it is helpful to explain to them what they are, why we want them to work on them and provide hope that they can improve/things can change. We also want to do this in a way which doesn’t induce shame or sadness and recognizes their strengths.

There are many ways to do this, depending on the age and situation of the child. Here are some sentences which can sometimes be useful.

Paying attention or concentrating means fixing our eyes, ears and thoughts on something. It also means saying “not now” when our brains try to get us to look at, listen to or think about something else.

Paying attention is a bit like shining a very bright torch light on something and keeping the torch very still – just on the one thing we are looking at.

Being able to pay attention or concentrate on something without getting distracted isn’t something we have to do all the time – but it is really important we can do it at least sometimes. When we are good at paying attention, it sometimes helps us to do other things – like school work, hobbies and sport, having good relationships/friendships and feeling good about ourselves.

Some people have more difficulties with attention/concentration than others. That’s not their fault, it’s just the way their brain is. But because the brain is a little bit like a muscle, we can slowly get a bit better at learning to focus, concentrate and pay attention if we practice.

2. Teach strategies for minimizing distractions

Once we have provided a basic level of psycho-education to young people about attention and concentration we can then start to teach them how to increase their concentration skills.

The first important strategy to help them do this is to try to help them minimize distractions – both external (visual, auditory) distractors and internal (mind wandering, other ideas /thoughts /feelings /sensations) distractors.

Minimizing distractions can make it easier for children and young people concentrate more effectively for slightly longer periods of time. Then, these periods of more effective concentration may also improve their concentration skills in an ongoing way through practice and positive self-concept effects (“I can do this”).

We might explain the minimizing of distractions to children/young people using words like the following:

“Distractions are things which we are tempted to look at, listen to, think about or do when we are focusing on something else. We have ‘inside our head distractions’ –ideas or feelings which seem more interesting or important to think about.

We also have “outside our head” distractions –things we can hear or see which seem more important to look at or listen to.

We can’t take our distractions away entirely, but when we want to concentrate we should try to make our distractions a little bit harder to see, hear, do or think about.

Here are some of the common ways to minimize distractions that children/teens often find helpful (with all of these dependent on the child/teen’s age and situation).

· Sitting closer to the focus (i.e., the teacher) to be able to less likely to see other input (minimizing visual distractions)
· Using white noise or using headphones (minimizing auditory distractions)
· Writing down thoughts/ideas/feelings which are repeatedly coming to mind to help “park” them for later (minimizing mental distractions)
· Closing their eyes when trying to think hard about a problem (minimizing visual distractions – incidentally one study found this significantly helped children solve maths problems)
· Closing doors when studying (minimizing visual/auditory distractions)
· Turning off or removing technology (phone away, tabs closed)

• Deleting apps/programs (from certain devices or altogether) to limit their use

• Using other apps and programs (Stay Focused, Freedom and others) to limit the use of other apps/programs when trying to study/do other tasks

· Writing down a plan for when other activities will occur (“parking” mental distractions)
· Turning off music, turning it down or using music without lyrics (minimizing auditory distractions)
· Removing clutter, toys, games, rubbish from the environment (minimizing visual distractions)

It can be helpful to sit with a child/teen for a period of time to see whether we can observe exactly what internal or external distractors seem to break their attention/distraction in what situations. This way we can try to tailor the strategies to the young person’s particular distraction tendencies.

3. Teach strategies to notice distraction and to build quick refocusing of attention

Minimizing distractions is a great first step but it is usually impossible (or inappropriate) to entirely remove all of them. Another important group of strategies therefore is to help children and teens notice when their distractions have diverted their attention and to as quickly as possible “refocus” back on the task at hand.

Here are some strategies which can be helpful for either the noticing of distraction or the quick “refocusing” of attention.

- Have young people set goals for how long tasks should take, and for them to check timers/use alarms to monitor their progress. When the time is up/alarm goes off – they can check whether they have been distracted
- Sometimes young people like using regular alarms or sounds (eg alarms going off every 10 minutes during intense homework periods) or signs “What am I doing right now” to act as refocus prompts
- If (and sometimes this is a “big if”!) it doesn’t damage child/parent relationships, parents may be able to provide code word prompts to “refocus” after agreed upon periods of time.

4. Teach strategies to reduce reliance on (or not “overtax”) working memory

Given that many children and teens with difficulties with attention and concentration will also have difficulties with working memory, and also given that working memory problems may actually lead to distraction (if they can’t mentally “access” the information they need to solve a problem/do a task, they will be more likely to become distracted), then it is often useful to provide strategies for reducing reliance on or avoiding the failure of working memory.

- Encourage them to write out the steps of complex problems rather than relying on mental strategies.
- Ask students to “say out loud” what they are trying to write before they write it (reduces reliance on working memory as “saying” often requires less mental effort than “writing”)
- Teach students to break tasks down into simpler tasks – (i.e., write what you know first, write essays using “little kid language”, write very short sentences first before adding extra complexity etc.).
- Having children /teens use visual task lists. For example, young children can have "picture lists" for everything, from steps to getting ready in the morning, what to do when doing tasks at school and the steps they need to take to clean their room.
- Older teens can (and usually should) use written lists for all to do items like homework and at home chores. By the way, it is not enough for lists to be written – we also need to build in prompts to actually look at these lists (posters, systems, reminders, alarms).
- Teach children/young people to recite phrases in their mind as they are walking to places (shoes on, shoes on, shoes on).

5. Encourage young people to avoid “overtaxing” their concentration and working memory and instead gradually increase the length of time they concentrate and focus

It is important that young people do not overtax their attention and concentration systems by trying to concentrate for too long or to attempt problem solving which requires high working memory skills. This will just lead to discouragement. Conversely however, it is usually important that young people DO gradually increase the length of time /working memory requirements of tasks in order to improve their skills in this area. Some writers call this "top down" (skill building) strategies compared to "bottom up" (working around the issue) strategies above.

An analogy I use with kids/teens might make this clearer.

Trying to improve our attention and concentration skills is like trying to build up our ability to run long distances. If we try to run a marathon before we are fit enough – we will exhaust ourselves and fail. However if we don’t push ourselves by trying to run just a little longer each time we train – we will never improve.

To run a marathon we have to do two things: a) gradually but b) consistently increase the amount of time we run as time goes by.

This means we want to have children and young people practice focusing their attention for gradually longer periods of time without them “maxing out” their attention. Strategies to do this might include:

- Get kids/teens to use the clock/timer to focus intensely for shorter periods of time and then have a restorative break (more on these breaks in a minute). They can record their times spent concentrating and set goals for new concentrating time periods as they improve.
- We can do the same but instead of using length of time as the metric, we can use length of material read or written (i.e., one paragraph, then one page, then two pages etc.

We can also help children and teens “practice” with increasing distractions and/or trying to beat their time in completing tasks. For example:

· Having a young person try to read as much of a story as possible in a short amount of time while we actively try to distract them. After each round ask the young person how many times they managed to re-focus and how they did this (e.g. I told myself “Ignore that, keep concentrating”).
· We might deliberately mess up a clinic room and then have a young person tidy it with our help, as quickly as they can and try to beat their time. To show the usefulness of visual lists and plans, we can do this with and without the plan to see if having the plan is useful.

6. Encouraging young people to have more restorative breaks

Research shows that it is not just “breaks” from concentrating which are important to renew our ability to refocus but instead restorative breaks – those in which we move away from what we are doing, move our body or change our focus entirely.

I find teens in particular do not often take restorative breaks when they are doing homework/study. They sit for hours at the same desk, often only working efficiently for several minutes at a time. They very frequently “break” from study tasks to use their phones/computers to do non-homework tasks but do take longer and more effective breaks.

Restorative breaks for young people might include:
- Exercise or stretching
- Being in a different room or place from where they are concentrating
- Doing an entirely different (possibly creative) task
- Being outside – and looking into the distance rather than at a screen.

We might ask young people to plan the length of time they are going to work without a break, and also plan how long (and how to make restful) their breaks.

7. Helping young people look after their health

Several studies found that making positive changes to children and young people’s diet, sleep and level of exercise resulted in improvements in attention and concentration skills. If we can assist families to make small change in each of these areas, it is likely this will help them manage I/D challenges and other cognitive difficulties.

8. Refer to health professionals for medication review

I haven’t discussed medications in this article as it is outside my scope of expertise. There has however been a great deal of research to show that pharmaceutical treatments can be very beneficial for many young people with severe difficulties with I/D, at least in some areas and at least in the short term. Like most medications, however there does appear to be some potential risks (eg possible side effects and long term “tolerance” effects) with these needing to be discussed thoroughly with an informed health care professional to help families weigh up these risks against the potential benefits.

9. Building of self reflection and monitoring skills in children/teens

Helping children/young people to get better at attention/concentration skills by giving them a list of strategies and forcing them to use them does not build long term skills in this area. Instead, we want them to be able to self monitor and improve in this area over a life time. To do this, it is important to ask children/young people to reflect on their attention/concentration in different situations and when using different strategies.
To do this we might ask them to rate (out of 10 for example) their attention/concentration in different situations and before and after using different strategies. We can ask them questions like: What helped? What made it better? Do you have any other ideas for how I can help you in this area? What would you like to do next?
Helping young people to reflect, monitor and plan their own strategies is likely to lead to more stable and more long term improvements.

10. Remembering to celebrate the uniqueness of individual children and young people

Finally, it is important to acknowledge that a tendency to struggle with inattention and distractibility is not entirely negative. The ability to break focus to notice “what is over there” may have been responsible for the survival of our species (for instance I imagine it was pretty important to prehistoric humans to break their attention on a plant to notice a tiger approaching!). In today’s world, the ability to flip quickly between many different ideas in a short period of time may also be vital for innovation and creativity.

I have worked with many amazing kids and teens with attention/concentration challenges who think in far more creative, interesting and amazing ways than many other children. Instead of just seeing these young people through a “defective” lens, we should affirm and capitalize on their unique and powerful strengths.

This doesn’t mean we don’t continue to work on helping them improve their attention and concentration skills, but we should acknowledge that this is a “marathon not a sprint” and that in the meantime, their strengths and unique approach to the world mean they are wonderful and valuable just as they are.

All the best with the work you do with young people in this area.

Kirrilie

If you work specifically with 4 to 11 year old children with attentional and concentration challenges, you might be interested in the lesson we have on Calm Kid Pro for this age group to help them understand and cope with their challenges in this area. Click here to find out more about Calm Kid Pro.