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Evolving research on attention deficit disorders is going beyond the typical hyperactive, disruptive child to find ways to better identify the quietly drifting student, as new screening tools and cognitive therapies seek to help both types of students.
Children with attention deficit disorders are impulsive, and often exhibit developmental delays in balance, motor control, emotional regulation, and behavior. They frequently show difficulty concentrating, sitting still in class, and otherwise acting in age-appropriate ways.
Known formally as attention deficit hyperactivity disorder, or ADHD, the condition affects 5 percent to 8 percent of American children of both sexes, making it one of the most common childhood disorders. So why are boys diagnosed three times as often as girls? The answer, in part, is that experts find girls with attention deficits are more likely to be considered inattentive rather than hyperactive, leading to fewer of the classroom disruptions that can trigger a teacher referral.
Studies show students with inattentive, but not necessarily hyperactive, ADD tend to be older when they are diagnosed, yet girls in particular can develop more cognitive difficulties later on, even in areas of ability typically considered strong for girls.
One 2010 study, published in the journal Pediatrics, found that of the 5,000 Minnesota students ages 19 and younger studied, 51 percent of boys and 46.7 percent of girls with ADHD had reading disabilities, compared with only 14.5 percent of boys and 7.7 percent of girls who were typically developing. That finding was of particular concern because girls tend to have lower instances of reading problems overall.
In addition, separate studies have shown girls with attention deficits are at higher risk of eating disorders, self-cutting, substance abuse, and suicide than typically developing girls or even boys with ADHD.
Part of the problem, according to Sam Goldstein, an assistant clinical professor of psychiatry at the Neurology, Learning, and Behavior Center at the University of Utah in Salt Lake City and an expert on ADHD, is that educators and therapists often focus on problems of attention or behavior, rather than underlying problems with executive brain function and impulse control.
“ADHD is not a problem of paying attention,” Mr. Goldstein said. “Poor impulse control, inattention to task, restlessness are the main symptoms, but the best predictor of later outcomes is impulse control.... It’s the fallout of living with a disability that makes you unable to meet the expectations of those around you.”
Thus, a student who sits quietly but cannot prevent herself from being distracted by class noises, or cannot concentrate long enough to read a full text passage, may have a more significant impairment than one who can’t sit still and talks out of turn in class but can get through homework.
For the most part, ADD is still diagnosed using behavioral and academic observations, and Mr. Goldstein advises educators to be on the lookout for students who don’t respond to environmental cues—knowing when to do a task or interact with another student. Such unresponsiveness can signal underlying cognitive problems.
Dr. Stewart Mostofsky, a pediatric neurologist and the director of the Laboratory for Neurocognitive and Imaging Research at the Kennedy Krieger Institute in Baltimore, is also studying neurological tests that may help identify students with ADD more accurately. His research, published in February in Neurology, found children with attention deficit disorders have lower ability than other children to control voluntary and involuntary hand movements.
“Even simple basic motor control is not as good [in ADD children] as it is in typically developing children,” Dr. Mostofsky said. With further studies, he said, “that may help us diagnose children who are going undetected as well as to identify at a very early age which children might be particularly responsive to which interventions.”
Preventive Brain Training
In the meantime, some schools are experimenting with cognitive training, which research shows can help students of both sexes improve working memory and attention, even when they don’t have a specific ADHD or ADD diagnosis.
Take, for example, Glenwood School for Boys and Girls, a private residential school outside Chicago for kindergarten through 8th grade students who are homeless or experiencing family and income instability. Ninety-five percent of the 120 students live in poverty, and 70 have been identified as having some type of processing or attention problem. Glenwood has implemented cognitive training for all its students.
For 30 minutes, four or five times a week, each elementary grade class uses the school’s computer lab to play through a set of 20 cognitive games called BrainWare Safari, offered by the Learning Enhancement Corp., a Chicago education software firm. Before beginning the program, teachers explain to students how the brain learns and tell them “you can strengthen the brain like you would a muscle,” said Anne Budicin, the director of the learning and resource center at the Glenwood School.
She said the games during computer class also provide a safety net for students whose problems aren’t as apparent.
“I’ve really noticed improvement with our younger students in focus and attention,” Ms. Budicin said. “We’ll have a student diagnosed with ADHD who is on grade level in everything and so is not getting extra help from the resource room, but is still getting the BrainWare in the [computer] lab.”
Games require students to begin by clicking to the beat and managing other distracters that can compete for working memory. To an adult watching over their shoulders, the games look at once both simple and insidiously difficult.
In one, a list of numbers and letters flashes on the screen, then disappears, to be replaced by a screen full of various numbers and letters.
Sixth grader Fatima—the school didn’t allow the use of students’ last names—paused to click the mouse five times to a beat before searching for her series. She had to find the numbers and letters on the screen and also identify them in alphabetical or numerical order, forward or backward, depending on the auditory instructions. The game required Fatima to listen to directions, keep and manipulate the series in her head, avoid becoming distracted by the beat, and finally find and organize the series.
It took her three tries to succeed, and she breathed a sigh and smiled when she completed the game. “It has helped me focus,” Fatima said of the games.
Some students with severe attention deficits are assigned specific memory and focus games, Ms. Budicin said.
She described one student repeating 2nd grade, who was diagnosed with attention deficit disorder but who could not take medications because of drug-related problems at birth. Instead, the student came in before school each morning to play some of the computer games before going to class.
“Just coming in the mornings, sitting down and doing the [games], and having to focus, I think it just made his brain calm down,” Ms. Budicin said.
She said the school is still researching the long-term effects of the program. But one early study of 96 students in the 2008-09 school year, she said, found students who played the games improved in academic and cognitive function, compared with a control group, on the Woodcock-Johnson tests, a set of normative assessments of cognition.
Mr. Goldstein said cognitive exercises may be as important as medication in helping students overcome attention problems.
“While [medicine] reduces symptoms, it doesn’t change the underlying condition,” he said. “You still have to teach a student with ADHD planning, cue recall, organization. …These kids need more stimulation, not less, but they need it in a very structured way.”
A version of this article appeared in the May 25, 2011 edition of Education Week as Studies Focus on Quieter ADD Pupils