What is attention?

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It seems that in the DSM 5-dominated world of psychiatry, it is considered a given that attention can be measured and evaluated, and that it may be impaired due to reasons which are unknown but are thought to be at best multifactorial and at worst purely brain-related, thus returning to the age-old idea of “minimal brain damage”. Moreover, this presumed impairment has become the leading paradigm of an “disease,” one that affects a growing number of children and adolescents, and recently also adults: ADHD, or Attention Deficit Disorder, with or without hyperactivity.

I would like to examine this widely accepted idea more closely.

Attention in the diagnostic approach of the DSM-5:

If we look at the diagnostic criteria of attention in ADHD outlined in the DSM-5, as well as read the additional literature and comments of its partisans, we will necessarily come to three conclusions:

1) To diagnose ADHD, DSM-5 presents us with two lists of criteria, each comprising nine different symptoms. The “Inattention” list includes four items having to do with the child’s difficulties with his schoolwork, which gives us a clue about what it is we are trying to determine or identify.  Also, regarding the item “has trouble organizing tasks,” it is by no means clear that the issue of planning necessarily has anything to do with inattention. It is also worth noting that the authors of the DSM-5 made sure to specify that we must distinguish between this difficulty of organizing and what is called the “Oppositional defiant disorder,” which refers to persistent and manifest rebelliousness. Yet how do we distinguish between a lack of attention to schoolwork and, for example, latent, episodic or temporary oppositional behavior? This approach in fact allows the DSM-5 to “diagnose” inattention in a student who simply cannot do his homework by himself – the inattention of the “poor student.” The selected traits can really be summed up as absent-mindedness and distraction, plus the latter is conflated with distractibility, i.e. the characteristics of being easily distracted by any stimulus external to the task.

We know that distraction does not exclude concentration and that a pedestrian who is lost in his thoughts can easily manage to cross the road when the light turns green – he is focused and distracted at the same time. Likewise, the diagnostic criteria does not say anything about either the context in which the child manifests these symptoms or the conflicts that may accompany them. It is enough for them to appear in two different places. The ADHD child of the DSM-5 is essentially a child whose attention is evaluated in isolation; he does not exist in relation to others, which makes him bear the responsibility for his pathological behavior alone. To conclude, we could agree with Bernard Jumel(1): “In the presentation of these nine criteria of inattention, which ignore both the question of what attention is and what its conditions are, the only aspects of behavior retained here have in fact little to do with attention.” Instead of inattention, the DSM-5 criteria identify what classical clinical psychiatry called instability – the latter had multiple triggers, was highly context-dependent and could fall within the range of normal as well as pathological variation.

2) The DSM-5 completely ignores the tradition and methodology of psychological evaluation. In general, the ADHD advocates argue that the diagnosis is clinical and psychological tests are of no use. A particular feature of the interview questionnaires created by experts (such as the Conners scale) is that they list criteria that tally with the DSM, but crucially – and with few exceptions — are not meant to be observed in the context of a two-way relationship, which is nonetheless crucial in psychological evaluation and psychometrics. Here, we could even argue that in extreme circumstances the clinician could formally make a diagnosis without ever actually being in contact with the child.

What is worse, the fact that any child’s attention will fluctuate depending on the time and context is highlighted as an argument against the use of individual testing in diagnosis. Therefore, if a child does better on tests, has better concentration and becomes more attentive in the framework of a close relationship, the DSM-5 advises us to ignore this. One of the leading authorities on ADHD, Dr. Russell Barkley, has argued that neither WISC III nor the “freedom from distractibility” (FDD) factor should be used to assess attention because they saturate these tests too heavily, due to the close relationship the WISC test establishes between the child and the psychologist; it is however obvious that this relationship is a crucial clinical element and bound to cast a different light on the child’s difficulties. In fact, an experienced psychologist or an educator using a WISC test are much more likely to say something relevant about the child’s inattention than these questionnaires, which are based on the DSM-5, focus on behavior alone and suffer from the bias of subjective judgment. This is especially true if these practitioners have been psychoanalytically trained and are thus able to gain a deeper and wider perspective. For the theoreticians of these tests, the question of attention has indeed always been a difficult one, and the fourth version of the WISC scale no longer includes any tests to assess attention specifically. This is to ensure scientific rigor because no test can measure attention per se, not even the so-called “cancellation tasks.” To conclude, the diagnostic method adopted by the DSM-5 in the case of ADHD represents a power grab led by a number of psychiatric experts who wish to justify their own hypotheses, especially in terms of the alleged brain etiology.

3) The last comment concerns the position of ADHD in the DSM-5. ADHD is listed under the category of “Attention-deficit and disruptive behavior disorders,” which in a sense lumps together, under the same name, ADHD and behavior disorders. This is symptomatic because neither the CIM-10 classification established by the WHO, nor the French CFTMEA do the same. The CIM-10 does not consider ADHD itself a behavior disorder, and for the CFTMEA “Attention disorders without hyperkinesia” belong in the larger category of cognitive and learning disorders. It therefore seems that attention itself is not a priority for the DSM-5 and what matters instead are the behavior disorders it is equated with.

A few brief comments on attention

There is no scientific definition of attention and no test can discriminate a subject’s level of attention sufficiently and “purely.” Neuropsychologists do not agree on the conception of attention – some see it as determined by the structural organization of perception, others wish to separate attention from perception and instead define it psychologically. Without going into too much detail regarding this debate, I am instead going to try and articulate a few of arguments based on the (revised) ideas of A.R. Luria(2), one of the pioneers of modern neuropsychology.

The “two” types of attention

In a newborn, there exists an elementary form of attention, which manifests itself in the way the baby reacts and turns or, in the hours immediately following birth and probably due to its still being flooded by the mother’s hormones, in the reactions of imitation which have been revealed by experimental observation. Some see this so-called involuntary attention as the basis and beginning of directed, structured, organized and selective behavior. In certain autistic symptoms, as well as organic diseases, this reflexive elementary attention is disturbed.

However, what we commonly call attention is in fact voluntary attention, which includes an object to which action is directed, an expectation, a mental tension and an action. This type of attention is gradually acquired in the course of the child’s mental development and especially the development of language; it takes over from the first type of attention, which is less attractive. In its origins, voluntary attention is always constructed through social interaction and its object is designated by the other, especially the adult; it is designated as desirable and named using language and its signifiers. As his linguistic abilities evolve, the child slowly interiorizes this attention. Attention is therefore developed together with language and language is developed together with attention.

– What is essential is this originally social, joint character of voluntary attention, which to a certain degree remains unchanged. The attention of child working by himself on his homework, with no adult present, is still a joint attention because the homework can for example be connected to the demand or desire of the adult, who embodies the Other. The child may also like to please this adult, or perhaps rebel against him; it matters little whether we think of this other as his interiorized parents, as an imago, as his internal language, etc.… There is thus no voluntary attention that could be understood in isolation. Yet it is also true that the child must make space for this joint attention: he or she must have some psychic space available to it.

– Voluntary attention always concerns an object. There is not attention without an object, and it fluctuates depending on this object — on its desirability, accessibility or value, on the words that describe it, on the memories it evokes, on the fantasy it embodies, as well as many other things.

4) Attention is not vigilance; on the contrary, a child that is too vigilant can no longer pay attention. A child disappointed, abused or abandoned by an adult can become hyper-vigilant and have problems concentrating because he has no attention left to allocate to the adult’s parallel demand. To focus on such demand would mean to let go, to no longer be on guard.

As a tentative conclusion, I wanted to give you a sense of the complexity of the notion of attention (which adds to the complexity of clinical situations), but also of the sheer inadequacy of the DSM-5 criteria in this field. It would be unfortunate if the question of attention were reduced to its DSM-5 description and if the ADHD label were to make a particular diagnostic and therapeutic attitude the new norm.

(1) JUMEL, B. Les troubles de l’attention chez l’enfant. Paris: Dunod, 2014.

(2) LURIA, A. The working brain. New York: Basic Books, 1973.

Patrick Landman

January 27, 2017

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