Problems with attention to classroom instruction and schoolwork are extremely common among students, and a recent survey of teachers indicated that approximately 16% of elementary school children display frequent inattention and/or poor concentration. When these problems are severe enough to warrant a diagnosis of AD/HD, the impact on children's educational success is often profound. Up to 80% of students with AD/HD exhibit academic performance problems and studies of young adults with AD/HD reveal a substantially higher history of grade retention, placement in special education, and school-drop out relative to their peers.
Even among children without a formal diagnosis of AD/HD, recent evidence highlights the adverse impact that attention problems have on academic achievement. For example, it has been found that teacher ratings of attention problems among non-diagnosed youngsters at the beginning of formal schooling predicted increasing academic difficulties over the next year. In related work, it was shown that that of 8 teacher-reported problem behavior syndromes, only teacher rated attention problems emerged as a unique predictor of academic achievement in a sample of 11-19 year old students. Thus, other behavioral and emotional problems known to be associated with academic difficulties did not seem to matter after attention problems were taken into account.
In some of my own prior work, my colleagues and I examined the role of
attention problems in the development of children's reading difficulties.
Students were followed from kindergarten through the end of fifth grade, and
attention problems during first grade predicted the development of reading
difficulties that were evident 5 years later, even after controlling for IQ,
other behavior problems, and prior reading achievement. In other words,
attention problems were found to predict diminished reading achievement even
among children who had no evidence of any primary reading disability.
You can find a more complete review of this study at www.helpforadd.com/yr1999/march.htm
(see the article titled "The impact of early attention difficulties on
children's reading achievement" ).
TWO NEW STUDIES
Study 1 - Does Tutoring Help Inattentive Children?
I've recently been working on two studies that follow up on my interest in this area. In the first study, my colleagues and I were interested in whether individual tutoring in reading during first grade would prevent the development of reading difficulties among inattentive children. Participants in this study were 891 children who were participating in a longitudinal study designed to test a comprehensive program for preventing the development of serious conduct problems among students at risk for such difficulties.
Half of the students received a comprehensive array of services that included social skills training, education in behavior management for their parents, and academic tutoring. The tutoring program focused on the development of early reading skills, specifically the ability to learn letter-sound combinations and sound out words. During first grade, students assigned to the treatment condition were given 2 30-minute tutoring sessions per week over the course of the school year. Students who had been assigned to the control condition did not receive tutoring, or any of the other intervention services.
Prior to beginning the tutoring, all students received individually
administered reading achievement tests so that their early reading ability
could be determined. IQ tests were administered to all students as well.
At the conclusion of first grade, reading achievement tests were
re-administered so that students' progress during the year could be
The first issue we examined was whether our prior results on the contribution of attention problems to the development of reading difficulties would be replicated. Replicating findings is always important, as it allows one to have far greater confidence that the results one has found reflect reality as opposed to possibly being a chance occurrence.
In this case, the results we had previously obtained were fully replicated as once again, children with higher levels of teacher rated attention problems during first grade made significantly less progress in reading over the year than other children.
We next examined the extent to which children benefited from the tutoring they received during the year. Not surprisingly, there was clear evidence that tutoring provided significant benefits, especially for children who had been poor readers to start with.
What we found that was less encouraging, however, is tutoring was clearly less helpful for children with attention problems. As children's level of attention problems increased, the benefits of tutoring steadily declined. In fact, among children whose attention problems approached a clinically elevated range, there was virtually no discernible benefit of tutoring.
This should not be interpreted as demonstrating that academic tutoring
cannot be helpful for children with attention problems. It does suggest,
however, that tutoring may need to be more intensive, and/or that it may need
to be specifically targeted to the special needs of children who are
inattentive. The research required to address these issues remains to be
Study 2 - Attention Problems and Below Grade Level Achievement in Multiple Academic Areas
In this second study, my colleagues and I examined the association between attention problems and academic achievement across a broader range of academic areas - i.e. reading, math, and written language.
Teachers across 8 elementary schools completed the Connors Teacher Rating Scale, a standardized behavior-rating instrument, on approximately 620 first grade students. In addition, teachers rated the academic achievement level of each student in reading, math, and written language on a 5-point scale ranging from far below grade level to far above grade level. All ratings were made during the last month of the year.
In addition to rating children's actual level of academic achievement,
teachers were asked whether they thought each child had failed to learn up to
his or her potential during the year, and, if so, to indicate why they
believed this had occurred. The different choices that were provided
included attention problems, behavior problems, family problems, emotional
problems, and specific learning disability.
The results were striking: among students in the top 15% on teacher rated attention problems, the percentage rated below grade level ranged from 76% in reading to 92% in written language. This strong association between attention problems and below grade level achievement was equally evident among Caucasian, African American, and Hispanic students. Overall, inattentive students represented between 35 and 40% of all students rated below grade level, even though they comprised only 15% of the total sample.
One problem with just looking at the percentage of inattentive students rated below grade level is that it is possible that co-occurring emotional and behavioral problems - rather than inattention specifically - might be contributing to poor academic performance. To examine whether this were the case, we conducted additional analyses in which a number of different factors were used to predict the odds that a child would be rated below grade level. These factors included: gender, ethnicity, and teacher ratings of oppositional behavior, anxiety, attention problems, and hyperactivity.
The results were once again striking: after taking all these factors into account, students in the top 15% on the attention problems scale were more than 5 times more likely to be rated below grade level in reading, math, and written language than other students. As before, these results held true within each ethnic group. What is particularly striking about these findings is that our sample was restricted to first graders, and one expects that the adverse impact of attention problems would become stronger in later grades when the demands for sustained attention increase.
In contrast to this strong effect for attention problems, high ratings of oppositional behavior, anxiety, and hyperactivity did not significantly increase the likelihood of below grade level achievement. In fact, high ratings of hyperactivity were actually associated with reduced risk of below grade level achievement. Although this is a somewhat surprising finding, it is consistent with other research in which it has been shown that the inattentive symptoms of ADHD, rather than hyperactive-impulsive, are what clearly impairs academic functioning.
Recall that teachers were also asked whether they thought each child had
achieved to his or her potential during the year and, if not, to indicate what
they thought had interfered with the child's learning. Teachers reported
that approximately 30% of students had not achieved to their potential and the
most frequently cited reason for this was attention problems, which were noted
in 58% of the cases.
SUMMARY AND CONCLUSION
Although a number of the inattentive children in the studies discussed above were likely to have had ADHD, it should be emphasized that none of the children were formally evaluated or diagnosed in these studies. Thus, the results presented apply to children with attention problems rather than to children specifically diagnosed with ADHD. What they seem to indicate, however, is that even among children without a formal ADHD diagnosis, attention problems frequently have a tremendously adverse impact on children's academic achievement. Among children who meet full ADHD diagnostic criteria, and who thus have attention problems that are often quite severe, the impact is likely to be profound.
These findings, which build on prior research from other investigators, emphasize the critical need to develop systematic procedures within schools for students whose attention problems are resulting in academic problems. Many children with attention problems but who may not also be disruptive often are not identified as requiring any special assistance. This can be true even among inattentive students whose problems are severe enough to warrant an ADHD diagnosis, and may be especially likely to occur for girls who are inattentive. As a result, these children may fail to acquire critical academic skills in the early grades, which put them on a path of academic struggles.
There is also a pressing need to develop effective academic interventions for inattentive students. As the results of our tutoring study suggests, methods that work well for students without attention problems will not necessarily be effective when significant attention problems are present. Although there are specialized instructional procedures for inattentive students that appear promising, research demonstrating that such interventions are associated with long-term gains in academic achievement is currently lacking.
This is also true for the impact of medication treatment on the long-term academic success of students with ADHD. Although such treatment has been shown to be profoundly helpful in many areas, there is currently little evidence that it results in substantially better academic outcomes, and there is a pressing need to develop intervention protocols that provide such benefits.
In this regard, I think these findings point to the importance of developing interventions that are intended to produce sustained benefits in children's ability to focus and attend. Instructional modifications, although helpful and important, try to compensate for a child's attention problems rather than alleviating those problems directly. Medication, although clearly yielding important short-term gains in attention for many children, does not produce any enduring gains in a child's ability to focus and attend.
A review of the attention training literature shows remarkably little work on interventions designed to produce sustained gains in children's attention, although promising results for training attention skills in children with AD/HD have been reported. (For a review of these studies, go to www.helpforadd.com/2001/feb.htm and www.helpforadd.com/yr2000/feb.htm ) Promising results of EEG biofeedback in reducing inattentive symptoms among AD/HD children have also been recently reported (Monastra, Monastra, & George, 2001) and are summarized at www.helpforadd.com/2003/january.htm The Interactive Metronome is another new technology that has also shown promise in enhancing children's attention and academic functioning.
(Note: Companies manufacturing neurofeedback devices and the Interactive Metronome have provided finanical support to Attention Research Update. I do not believe this has influenced my assessment of published research on these approaches, but do want to make you aware of this relationship.)
Research on these promising approaches, in conjunction with research geared
towards developing and implementing specialized instructional strategies for
inattentive students, may be required to help inattentive students achieve
closer to their potential. Lets hope that work in this important area
becomes more frequent in the near future. In the meantime, parents,
educators, and healthcare professionals should be especially vigilant in
monitoring the academic progress of children with ADHD, and do their best to
insure these children are provided with the level of assistance they may
require to keep up. Information on the educational rights for children
with ADHD can be found at www.helpforadd.com/rights.htm