Attention Issues
Attention is intimately tied to a hierarchy of needs. The most basic needs are biological needs which aim to keep the organism alive. When these needs are not satiated attention will be focused on attaining biological safety/security related needs. Some examples of biological needs are food, water, sleep, movement as it relates to fight or flight, comfort, and temperature. The main point to remember here is that attention will be pulled by stimuli in the environment that may lead to the fulfillment of these basic needs. Only after the basic needs are satisfied will a child turn their attention to other objects in the world. Biological safety needs provide the greatest control over attention. After these needs are met attention is much more under the control of a child’s individual physical and sensory preferences. The usual progression is to move from biological safety needs, to aesthetic sensory-motor needs, and finally to needs for social affiliation and interaction.
One of the major deficits, in autism spectrum disorders, is a deficit of social relating. Children with autism do not reference other people as often as typically developing children and they are not as influenced by the desires of others. After basic biological safety needs have been met the child with autism moves into fulfilling basic sensory-motor needs. Many children with autism get stuck at this level of need fulfillment and never move into valuing social affiliation and interaction. This occurs because of the complexity inherent in social relations. If something is too difficult to understand it will be ignored by the child. Because of this halt in development the typical way of controlling and directing attention by society through social influence is not very effective with children who have autism.
For many children with autism attention is mainly pulled by, novelty (related to needs for safety) and sensory/motor stimulation. Many children are described as having attention deficit symptoms. This is somewhat of a misnomer, because the children usually do not have a deficit of attention resources. The problem is usually related to the child’s attention not being under the control of social influence and the child’s difficulty with shifting attention. It is common for a child to be able to focus attention on a video game or television show (which provides sensory stimulation) to the point that their attention is not easily redirected away from the activity. In regard to the heuristic model described above the ping pong ball is vacillating virulently between the child and the video game and it does not break out of its path when a parent calls the child’s name. What we want to happen is for the child to direct a few ping pong balls at the parent to be able to perceive the parents request.
If we envision this ping pong ball beginning at the perceiver (sense of I) it must travel out through the various senses to the object of interest and back again. If the senses of touch, hearing, or sight, provide interference along the path of attention, attention will be distorted and disrupted through that particular sensory path and it will be more likely that the child will rely on an alternative sensory/perceptual pathway when attending.
Many children with autism have a disturbance in their auditory sensory/perceptual pathway. When this is the case it is more difficult for the child to attend to information that is traveling through the auditory pathway and the child may place up barriers along that pathway further blocking attention along that path as they mainly rely on an alternative route. Some very forceful and salient signals may be able to grab some attention now and then but for the most part it is a blocked path.
Children with autism, because of their sensory issues, as described earlier, tend to stick with what they know and tend to repeat experiences with which they are familiar. This is in part a strategy to decrease the sensory stimulation coming in. Or said another way, this is a strategy to decrease the variety of sensory experience that can influence and pull their attention. This is a strategy for self-soothing.
When a behavior is first learned, or a new experience is encountered, attentional resources must be used to learn the new behavior or to process the new experience. After the behavior has been learned, less attention is needed to perform the behavior. Eventually, no attention is needed to perform the behavior. The behavior becomes automatic much like a reflex. The same happens with new experiences. At first a lot of attentional resources are needed to process the new experience. Eventually most of the experience can be ignored and attention resources are freed up. Many people find the process of purposefully directing attention difficult, almost painful in a mental sense. As behavior becomes automatic a soothing feeling accompanies the performance of the behavior. Comfortable environments are usually familiar environments because very little is pulling the attention.
A state of attention free awareness is a very comfortable feeling that many typically developing people strive for through exercise, self-hypnosis, yoga, and Zen training. Many children with autism have this feeling most of the time. The problem with living in this attention free world becomes apparent to the child when biological safety needs are no longer satiated. At that time they must direct attention to all the behaviors necessary to satisfy the physiological need. This usually means socially relating to someone who is able and willing to help satisfy the needs. This is often one of the few times when a parent of a child with autism can see socially directed attention. This is also a good time to build socially directed attention, problem solving abilities, and adaptive skills as described above.
By observing a child’s attention and the objects the child attends to, the therapist can gain insight into objects and activities that the child finds enjoyable and important. Recognize the items and the activities the child attends to and join with the child. If the therapist can place themselves into the activity (existing chain of events), the therapist can teach the child the value of socially relating and help the child to improve social communication.
Attention is very responsive to shaping procedures. As a child tries to get his or her needs met in their environment, attention is directed toward objects, people, movements and sensations. At the moment that the child receives the desired item or interaction their attentional state is rewarded. If the child is looking off in the distance when the parent or therapist hands them the desired item, to the child staring into space caused the item to appear. In other word’s we have just increased the behavior of attending to perceptual experiences coming from staring off into the distance. If a child is flapping his/her hands in the air when they receive the desired item flapping their hands is what caused the item to appear. When the child wants the item again the child will start to flap his/her hands. My main point here is that parents and therapists have to be extremely aware of the child’s attention and only provide desired items and activities when attention is socially appropriate and functional.
Typically developing children naturally look at the face and find the subtle nuances of the face intriguing. As a result of being naturally drawn to looking at the face and facial expressions they learn that subtle facial expressions predict vocal and physical behaviors. Since subtle facial expressions predict verbal and physical behavior, facial expressions become valuable in-and-of-themselves, because they predict positive and negative verbal and physical behavior on the part of the caregiver. Typically developing children learn that they can predict and control their environment and solve immediate contingencies present in the immediate environment, by learning to read nonverbal communication. The child gains control over the uncontrollable. Through reading nonverbal subtle behaviors they learn to alter their own behavior in response to the nonverbal behavior of others. In doing so they learn to say and do what others require to achieve desired goals.
Children with autism are not naturally drawn to looking at the face and hence miss out on many of the social cues that the face provides. Selectively teaching the child the value of referencing and attending to the face sets the stage for the child with autism to be able to predict the presence of contingencies and solutions to obtain desired outcomes. For this reason selectively setting up the environment and systematically making facial referencing productive for the child is a very valuable first step in training attention. Facial expression should also be purposefully exaggerated when first teaching a child with autism to reference the face. Sensory and perceptual organization difficulties may make the more subtle changes in facial expressions too subtle to be noticed by a child with autism. Exaggerating facial expression and tying them very clearly to outcomes will help a child with autism to cue in to the value of facial referencing.
Once a child’s attention has been conditioned to reference the face, the face can be used as a cue to other nonverbal behaviors. For example, once a child’s attention is drawn to the face because of the vast amount of information it provides, the face can be used to convey yes, no, maybe, danger, impending reward, confusion, fear, joy, anxiety etc.
The face and eyes can also direct the child’s attention to the hands which can further gesture to the child. The face can show anticipation as the eyes and the head look down to the hand, and as the child looks down to the hand, the hand can open with a desired item. As the child’s eyes go down to the hand and the hand opens we have purposeful joint attention. From here when the hand opens, the index finger can come out turning into a point toward an up-side-down cup at the end of the finger. As the child’s eyes reference the hand, the novelty of the finger coming out will draw the attention, as the child’s attention is focused the therapist picks up the cup offering a desired item. This procedure can be done in many situations moving the point farther away from the object as attention becomes more focused and is used to follow the therapist’s social cues.
Teaching a child to attend to and reference the face and then to attend to a variety of facial and physical gestures provides the child with autism with the tools necessary to be able to navigate social interactions. In early stages of therapy attention towards other people will be extremely valuable. Attention is captured by the environment through the value of achieving desired outcomes. As attention is captured for longer and longer periods of time, the ability to sustain attention grows and the value of sustained attention becomes apparent. Sustained attention can then be used on tasks society finds valuable like reading, writing, math and the acquisition of knowledge about society and the world.
Therapists also have to be careful to watch for the percent of attention that is engaged at the time the child receives a desired item or activity. Many people, including children with autism, only provide as much attention as is necessary to accomplish a given task. This may have to due with the painful nature of purposeful attention. Imagine a man watching a football game and his wife coming in and asking what she should make for dinner. Most likely she is going to get an answer that was born out of very little attentional resources. Why? At the time the wife asked the question the man’s attention was engrossed in a winning touchdown. Said another way, the football game was strongly pulling his attention and was fulfilling his immediate sensory/motor needs. His physiological and safety needs were satiated because he is eating peanuts and drinking beer and is not very hungry. Of the pool of full attention (100 % of the man’s attention) 98% of his attention remained tied to the unsatiated sensory/motor needs of watching the football game. He threw 2 ping pong balls at his wife. One to perceive the question and one to answer “what ever you want, honey.” With so little attentional resources directed at this social interaction it is very likely that the man will not even remember the conversation.
What can change in this situation which would result in his wife having more of his attention? She could shut off the TV and invoke an angry almost frantic response. Here 60% of his attention will be directed at the game and what he is missing, with the other 30% directed at thoughts about how unfair his wife is. The wife may at this point have 10% of his attention. Had she planned ahead and asked him at a time when there wasn’t a football game on and when he was hungry and wondering what’s for dinner, she would have had his undivided attention. The point here is that the environment and timing issues have to be managed exactly to provide periods of undivided attention. There is a saying that practice makes perfect. I believe that perfect practice makes perfect. In other words children need to practice socially directed sustained attention and achieve desire goals for full attentional effort. After full sustained attention has been practiced in a distraction free environment with optimal desires driving the child’s attention, sustained attentional processing can be slowly generalized to include distractions and decreased incentives.
A key element in building attention is to focus on building attention first and tying sustained attention to social contingencies. Socially directed attention is much more difficult to develop after a child has been randomly successful with inattentive behavior. Therapists should always be aware that lower levels of attention are often successful to varying degrees regardless of whether they are aware of it or not. If the therapist is not aware of the child’s state of attentional awareness it is very likely that they are inadvertently increasing inattentive behavior by not focusing on providing desired items only for attentive behaviors. If a child is not paying attention it is because they have been taught from the beginning to not pay attention.
Children with autism just like children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) have the key attention deficit of not attending to what society wants them to attend to. I would like to reiterate that they do not have global attention deficits. They have attention deficits to information society deems important. Another key feature of ADHD is impulsivity. Impulsivity is basically choosing immediate rewards over delayed rewards. The final symptom of ADHD usually involves some form of hyperactivity. Attention problems, hyperactivity, and impulsiveness all are very interrelated. Hyperactivity leads to impulsiveness and inattention. Inattention leads to impulsiveness. The solution with children with ADHD and autism is to teach and reward delayed gratification over immediate gratification and to systematically reward attention to objects and information society values. Saying that someone has attention deficit is an explanatory fiction. ADHD means nothing more than the person does not value what we want them to value and the person usually overvalues immediate rewards over long term rewards.
Therapy should systematically teach delayed gratification and increase the value of objects and information society values. Delayed gratification can be taught easily by presenting a choice of rewards to a child after successful completion of a task. This should be a focus that runs through all programs. When a child is at the level where they can understand token systems or make a choice between two objects they can be offered a choice. Would you like one E&M now or 5 after you stand up? A little later the question might be would you like to swing for 10 seconds right now or five minutes after this next program? I child’s ability to delay rewards and to choose rewards that they have to wait for and work for can be systematically increased. This can be integrated into a token economy system. If we have control over desired items we are expanding the child’s ability to attend for longer and longer periods of time and also to delay gratification.
At the same time we work on attention by changing the stimulus qualities of the objects in their environment. If we want a child to pay attention to letters or numbers the letters and numbers have to predict natural rewards or enjoyable activities. Natural pairing of the non-preferred objects with preferred objects in such a way that the non-preferred object predicts the appearance and attainment of the preferred objects will lead to improved attention for the non-preferred object. The same should be done for social interactions. First exciting social interactions can lead to preferred items eventually boring uninteresting social interactions lead to preferred items. We develop systematic plans for children to move them from attending to what they want to attending to what society values. Attending to what society values will lead to increase rewards for the child in the future.