by Dr. Jane Holmes Bernstein, CREN Guest Contributor
"A disturbance in attention is very much like fever. It is not a diagnosis; it is a symptom....Attention is actually very vulnerable to being undermined – by lack of sleep, too much to drink, too many things to think about at once, as well as brain injuries or disorders of all kinds. As a symptom, an attentional problem is sensitive but not specific."
(Dr. Jane Holmes Bernstein, 2017)
I am a developmental neuropsychologist and a clinician who works with children. When parents come to me they are typically concerned that something is getting in the way of their child being successful in school or the family or in the community. I use available knowledge about how the brain works to help me to understand how this child thinks and learns in all areas of life. I integrate the available findings into a diagnostic formulation and discuss this in detail in a feedback session with the child (when appropriate) and with the parents.
Initially, when parents meet with me they will often report that the child has “a memory problem” or “an attention problem” or “a language problem”. These descriptions reflect the way in which psychological processes like memory, language, or attention tend to be viewed by the general public in everyday conversation: each process is understood to have a dominant meaning that is typically undifferentiated. For the neuropsychologist, however, each of these processes is made up of a complex suite of sub-processes that depend on wide-ranging brain circuitry for their functioning. The goal of a clinical assessment is to clarify the actual nature of the behaviours (and the processes) that are the focus of the presenting complaint. That’s my job; that’s what I try to do.
Now, when someone goes to their General Practitioner (GP) with a fever, they expect him or her to take a history and (possibly) arrange for some tests. This is not surprising; they know that the body can spike a fever for many reasons. They go to the doctor to find out which one as the basis for the proper treatment.
In contrast, people will come to a neuropsychologist not just reporting that a child “not paying attention”, but expecting the clinician to “rule out (or rule in) Attention Deficit Hyperactivity Disorder (ADHD)”. A specific diagnosis is already in the frame. But a disturbance in attention is very much like fever. It is not a diagnosis; it is a symptom. Like fever, it tells you that something is going wrong but it does not tell you what. Attention is actually very vulnerable to being undermined – by lack of sleep, too much to drink, too many things to think about at once, as well as brain injuries or disorders of all kinds. As a symptom, an attentional problem is sensitive but not specific.
This “diagnosis” of ADHD is one of my pet peeves! Why? Because attention is not defined by “ADHD” – and a child who isn’t paying attention as expected is not necessarily in need of medication for an attention deficit! Attention (like “memory” and “language”) is not one thing; it depends on many things.
One, attention is not one thing: in the sense of being restricted to the ability to focus in on something (as in ‘‘paying attention’’); to focus in on something means you also have to be able to keep any information you don’t need – or want – out of awareness. One may indeed not be able to “pay attention’’ but one could equally well be unable to maintain attention because of an inability to screen out non-relevant stimuli. These are different problems and depend on different brain circuitry.
Two, attention is not one thing: in terms of how it is represented in the brain. Broadly speaking, there are two major neural networks that support attentional functioning; perturbations in the ‘‘anterior’’ as contrasted with the ‘‘posterior’’ circuitry lead to different behavioural manifestations of ‘‘attentional deficit’’ (Dennis et al., 2008; Posner, 1992; Posner & Fan, 2008).
Three, attention is not one thing: it is both actor and acted upon. One can have a primary deficit in attention that reflects disruption of brain networks that are believed to be critical to attentional functioning (the ‘glitch’ is in the attention system). One can also be unable to deploy attention effectively because of perturbations in other psychological systems (the ‘glitch’ is in the other system) – a secondary attention problem.
Four, attention is not one thing: it can be parsed into subcomponents, but it must also be appreciated at a system level. A deficit in attentional functioning can result from a ‘‘glitch” somewhere in the attentional system; it can also result from the inability to regulate the system as a whole. To be able to attend effectively you need to be able to regulate the ‘‘zoom-in’’ and ‘‘zoom-out’’ aspects of attention according to the needs of the moment. If you get stuck at the zoom-in end, you are likely to be seen as obsessive, perfectionistic, unaware of the big picture; if you get stuck at the zoom-out end, you are likely to be seen as distractible, tangential, or simply spacey.
The clinician must explore all of these possibilities in order to understand what psychological processes a child is dealing with. To do so, the clinician needs a framework for thinking that does not focus on the child alone but takes into account the context in which the child is doing the behaving. The clinical model within which I work is one that highlights the transactions between BRAIN-CONTEXT-DEVELOPMENT as the child matures (Bernstein 2000). Analysis of context is critical for interpreting the meaning of the observations made by the referring persons. “Context” is the classroom with its specific structures, demands and expectations; it is the environment and practices of the home, the family and the community; it is interactions with peers and adults; it is the cultural values and beliefs of the society. And, how these interactions shape the brain and behaviour changes dynamically as the child develops. The behaviours that parents and teachers ‘see’ – and thus interpret – are shaped by all of these. It is the job of the clinician – in the feedback session – to share his/her understanding of any or all of these variables to explain the child’s experience and the rationale for the intervention plan and specific recommendations.
Adapted from Bernstein JH. 2012. Clinical Encounters of the ADHD Kind: The Unique Role of Neuropsychology. Applied Neuropsychology: Child, DOI:10.1080/21622965.2012.702026
Bernstein JH. Developmental neuropsychological assessment. In KO Yeates, MD Ris & HG Taylor (eds.), Pediatric Neuropsychology. Research, Theory and Practice. Guilford Press, 2000.
Dennis, M., Sinopoli, K.J., Fletcher, J.M., & Schachar, R. (2008). Puppets, robots, critics and actors within a taxonomy of attention for developmental disorders. Journal of the International Neuropsychological Society, 14(5), 673-690.
Posner M. I. (1992). Attention as a cognitive and neural system. Current Directions in Psychological Science, 1(1), 11-14.
Posner, M.I. & Fan J. (2008). Attention as an organ system. In J. R. Pomerantz (Ed.), Topics in integrative neurosciences: From cells to cognition (pp. 31-59). New York, NY: Cambridge University Press.
Dr. Jane Holmes Bernstein grew up in England. After college she worked in Algeria with Voluntary Service Overseas teaching English as a foreign language. She returned to graduate with a Ph.D. from Edinburgh University in Scotland and then went to the US as a postdoctoral fellow in the Aphasia Research Center at the Boston VA Medical Centre. Subsequently she moved to Boston Children’s Hospital where she is now a Senior Associate in Psychology/Neuropsychology in the Department of Psychiatry and a Faculty member of the Centre for Neuropsychology. She is also an Associate Professor of Psychology in Psychiatry at Harvard Medical School and a licensed psychologist provider in Massachusetts. In 2004 she stepped down as director of the Neuropsychology Programme at Children's Hospital and since then has been dividing her time between teaching and research responsibilities at Boston Children’s Hospital, professional work with children in the Republic of Trinidad and Tobago in the West Indies, and international clinical consultation and teaching.
In Trinidad and Tobago she works with the Cotton Tree Foundation and the Immortelle Centre for Special Education where she has, with both local and US colleagues, developed a Service Learning Programme providing psychological services to children and families. She is involved in the training of Masters students in psychology at the University of the West Indies at St Augustine and provides ongoing professional development for early career psychologists locally.