4. Attention and concentration problems in ADHD
Problems with maintaining attention for longer periods of time during tasks or leisure activities is one of the 9 most accurate symptoms of ADHD in adults.1
- 4.1. Manifestations of attention problems in ADHD
- 4.2. Groups of attention problems in ADHD
- 4.3. Cause of attention problems in ADHD - motivational problems?
- 4.4. Age development of attention problems in ADHD
- 4.5. ADHD without attention and concentration problems
- 4.6. Attention problems as stress symptoms
4.1. Manifestations of attention problems in ADHD
- Slip of the pen
Attention span shortened or impaired
- For children
- Often has difficulty maintaining attention on a task/game for extended periods of time (DSM IV / 5)
- Frequently avoids / has an aversion to / is often reluctant to engage in tasks that require prolonged mental effort (DSM IV / 5)
- For adults
- Boring tasks increase distractibility2
- For children
- Task switching issues
Listening is difficult
- Attention span is too short to follow instructions to the end
(Tendency to interrupt, on the other hand, is impulsivity problem)
- Attention span is too short to follow instructions to the end
Implementation of instructions is difficult
- Adults: overload due to lack of ability to structure tasks2
- When structuring tasks, the attention already wanders into the details
Tasks are often not completed
- Frequently fails to carry out instructions of others completely and cannot complete schoolwork, other work, or duties at work (DSM IV / 5)
- In the middle of task the focus changes to another thing
- Example cleaning4
- The floor is wiped, up to the table
- There the focus changes to clearing this out
- Going into another room to put something away, you find the open closet and the clothes in front of it and start putting them away.
- You only remember to mop the floor when you come into the living room and are surprised to find the bucket and the mob at the table..
- While at work, you search for something on the internet and magically get trapped there…
- Example cleaning4
- In the middle of task the focus changes to another thing
- Attention can not be maintained for a long time
- Tasks with short and frequently changing requirements are preferred
- Tasks that require prolonged concentration and effort are unpleasant and are readily avoided
4.2. Groups of attention problems in ADHD
We divide attention problems in ADHD into 3 groups:
- Distractibility: increased change in attentional focus; problems keeping attention on an object when needed
- Attention switching problems: problems detaching attention from an object when it is required
- Concentration problems: difficulty paying attention to one object for a prolonged or sustained period of time when required, even in the absence of distraction
These three groups represent different manifestations of attention problems, all of which are typical of ADHD. All three groups occur more frequently in ADHD than in non-affected individuals.
Distractibility is to be distinguished, depending on the cause, into those
- In relation to external, external stimuli
- Is more often distracted by external stimuli (DSM IV / V)
- Can not overhear conversations at the neighboring table
- Can’t look away when a TV is on in a pub
- By internal incidental thoughts (mind wandering, daydreaming, drifting away, autopilot, sometimes also (medically incorrectly) referred to as dissociation)
22.214.171.124. Distractibility by external stimuli
Distractibility is a change in attention due to an external stimulus. ADHD sufferers show increased distractibility more often than non-affected individuals.
This form of distractibility by external stimuli initially seems to be a direct consequence of the stimulus filter being too wide open (increased sensitivity). However, against the background of the deviant regime of attention control it is questionable whether the stimulus filter disturbance is the essential cause. Since it is primarily the degree of personal interest or the resulting motivation that determines whether attention is directed or distractible, and not only distractibility but also directionality is temporarily increased (task switching problems) while at the same time the basic mechanisms of attention and its directing are technically functioning, this could rather indicate that the attention problems in ADHD are a consequence of a change in motivational control than genuine deficits of attention itself or mere consequence of reduced perceptual filtering.
Distractibility is one of the 9 most accurate symptoms of ADHD in adults.1
ADHD sufferers are distracted by unimportant stimuli from the environment, but selective attention is hardly affected.5 The latter is only partially covered by the results of our symptom test. Task switching problems (problems with switching/selecting attention) occur less frequently in ADHD than distractibility, but are equally less frequent in non-affected individuals, so that the frequency difference of distractibility and task switching problems between ADHD-affected and non-affected individuals is approximately identical.
126.96.36.199. Daydreaming / Mind Wandering / Absence of Thought
Daydreaming is not a form of distractibility by external stimuli. Rather, attention wanders without external cause. Mind wandering or absent-mindedness are equivalent terms.
Daydreaming can be measured with the Mind Wandering Questionnaire (MWQ).
255 adult ADHD sufferers were differentiated into hi-level daydreamers and lo-level daydreamers according to the MWQ score of more or less than 24. Daydreaming is thus not specifically associated with the ADHD-I subtype without hyperactivity (“Träumerle”), but correlates significantly with6
- Higher inattention
- Higher hyperactivity
- Worse executive functions
- More general mental problems
- Higher emotional dysregulation
- More impaired quality of life
i.e. with increased ADHD symptoms in general.
Increased mind wandering (daydreaming) was also found in children with ADHD. Daydreaming was able to detect ADHD in a group of ADHD sufferers and non-affected persons with a sensitivity of 0.71 and a specificity of 0.81.7
One interesting report cites partial brain sleep as a possible cause of some SCT symptoms or daydreaming.8
One study found daydreaming in adults to be a symptom independent of ADHD that correlated with anxiety but not depression.9
A study using event-related EEG measurements during tasks with high and low demands on working memory and sustained attention, and during periods of mind wandering and task focus found in ADHD sufferers:10
- weaker decrease in alpha power
- with high demands on the working memory
- for sustained attention requirements
- weaker increase of theta power and weaker phase consistency
- with demands on the working memory
- with low requirements for sustained attention
- weaker decrease of beta power
- with low demands on working memory
- weaker decrease in alpha power during mind-wandering episodes
- in the task of sustained attention
- lower consistency of theta phase during mind wandering episodes
- in the task of working memory
4.2.2. Attention switching problems
188.8.131.52. Task switching issues
Task switching problems describe a difficulty in turning one’s attention to another object in response to an external demand, that is, in response to an extrinsic demand to stop an activity or occupation one is currently engaged in in order to attend to the new demand. Consequence is the difficulty to stop an activity or behavior when one should.
Task switching problems are an ADHD symptom.11 It is difficult for the person to detach his attention from things that personally interest him so much that they motivate him12 - and especially if the request for task switching is extrinsic and refers to things that do not address the personal interest of the person concerned.
Task switching problems are therefore a consequence of the altered attentional control regime, which in turn is controlled by the motivational state.
Task switching problems are one of the 9 most accurate symptoms of ADHD in adults.1
Manifestations of task switching problems in ADHD:
- Problems with spontaneously putting down something that is busy and turning to something else
- Difficulty to switch task after external request
- Difficulty paying attention to externally given new topic
- For a new activity, advance notice is preferred
- 10/15 minutes notice time can help
- Difficulty getting previous activity out of mind
- Difficulty completing engagement with a thought/topic/problem
- New demand from outside, while still busy with something else inside, easily triggers stress / impulsive reactions
One concerned person asked his co-workers, when they come to his office, to enter without knocking, but then not to address him, but simply to sit in a chair next to the door, look out the window, and wait until he can finish what he is doing.
This (without such an agreement certainly impolite) behavior saved him from having to react immediately and saved him from having to take a deep, annoyed breath, as he used to do, when employees came in and wanted something from him, even though he was still busy with something else.
The symptomatology of task switching problems was still clearly preserved even under stimulants.
184.108.40.206. Hyperfocus: extreme concentration
Hyperfocus is a very strong ability to concentrate when performing activities involving things that are of great personal interest to the individual. This is often accompanied by a reduced ability to perceive distracting stimuli.
Hyperfocusing is a well-known symptom of ADHD that also occurs in autism and schizophrenia.13
Hyperfocus is not really a problem as far as there is not a strong lack of perception of external stimuli in this state. It is definitely advantageous to be able to concentrate particularly intensively on certain things. Nevertheless, it is a specific feature of ADHD, which is why it is a symptom. In addition, those affected cannot control hyperfocusing.
ADHD sufferers can show very good attention and concentration (up to hyperfocus) when personal interest exists,14 once they have started an activity that gives them satisfaction, because the reward that then immediately arrives keeps the reinforcement center active. However, this interest is much more difficult to achieve because of the smaller number of dopamine D2 and D3 receptors in the striatum.15
Anyone who has experienced an ADHD sufferer in hyperfocus, in which even highly monotonous activities are carried out in a highly concentrated manner for hours on end, provided that the personal interest of the sufferer is aroused, and in which external stimuli irrelevant to the current interest are very well blanked out, can confirm this from his own observation. Against this background, one could assume that in ADHD it is not the ability to pay attention and concentrate per se that is disturbed, but the directing of attention. However, in our opinion, this description also falls somewhat short. We think that in ADHD the mechanisms of attention control are not impaired either, but that the control of attention control is impaired. Compared to a car, neither the driving itself (attention) nor the steering mechanism (where does it go) is impaired, but the driver is the problem - he steers the (fully functioning) car (attention) towards an inappropriate destination. (The driver here is not the affected person, but a symbol for the instance of the affected person’s attentional control that is impaired in ADHD.) The orientation of attention is subject to an inappropriate regime: that of a existence-threatening stress situation. In such a situation the ADHD-typical attention would be helpful (stress benefit). More on this below.
The so-called hyperfocus - another name is “flow”13 - is a state in which ADHD sufferers (contrary to the typical symptoms) are able to persistently engage with a topic in a concentrated manner, free of frustration intolerance or distractibility.
Hyperfocus is the state from which autism spectrum disorder sufferers are unable to disengage enough and into which ADHD sufferers are unable to bring themselves enough.16 What the two disorders have in common is that the self-regulatory ability to direct attention is impaired.
If it is about topics that particularly fascinate the respective affected person, they can suddenly occupy themselves with a very specific topic for hours, days, nights17 and have a very steep learning curve here. With less interesting topics, on the other hand, the learning curve with ADHD is typically slowed down or delayed.18
An ADHD sufferer reported: “I was once involved in a task in an open-plan office that fascinated me very much. I didn’t even notice that colleagues had spoken to me several times. This would certainly not have happened to me in a less exciting task.”
The other ADHD sufferers we interviewed unanimously expressed that they are very familiar with the state of hyperfocus when something really interests them. They further confirmed that in this state they are able to permanently occupy themselves with a topic without being burdened by concentration problems, attention problems, distractibility or frustration intolerance. The problem is that the required interest is not sufficiently controllable.
All people can concentrate better on things that interest them. However, non-affected people can motivate themselves much better to concentrate on less exciting things than ADHD sufferers.19 This is not a question of character or effort, but simply a question of ability.20 To the extent that ADHD sufferers lack this ability, it is a symptom of ADHD. Brown quotes a sufferer with the beautiful image of mental erectile dysfunction. If something is sufficiently interesting to motivate, one can act. If there is no personal interest, you can do whatever you want - it won’t work.19
We do not share Barkley’s interpretation that21 hyperfocus is a form of perseveration,22 i.e. a form of accompanying disorder. A concomitant disorder does not enable hours of concentrated work if the subject is only exciting enough. Rather, hyperfocus is a healthy response to intense interest. It suggests much more that the intensity of interest in ADHD differs from non-affected individuals. It can be significantly lower (resulting in attention problems) or significantly higher (resulting in task switching problems or hyperfocus).
4.2.3. Concentration problems as ADHD symptoms
Concentration is the purposeful focusing of attention on a specific object, as opposed to the distractibility of attention problems.
Concentration problems may result from an attention span that is too short. This too low attention span seems to exist independently of distractibility problems.
Concentration problems are a major symptom of ADHD. Problems with maintaining attention for longer periods of time during tasks or leisure activities is one of the 9 most accurate symptoms of ADHD in adults.1 According to others, concentration problems are less common in ADHD compared to attention problems.23
One consequence of a shortened attention span may be that the affected person avoids or has an aversion to engaging in tasks that require prolonged mental effort. A short attention span also increases the difficulty of following instructions to the end.
4.3. Cause of attention problems in ADHD - motivational problems?
The basic (technical) functionality of attention and attention control is not impaired in ADHD. Attention problems in ADHD are a consequence of attention and motivation control following other motives. The regime, the scales by which attention directing is done, is altered. It corresponds to that of people who are subject to extreme, life-threatening stressors and is “technically” healthy in that such a response pattern is helpful to survival in the face of existential threat. Altered attention can be thought of as a healthy response to severe stressors, just as fever is a healthy immune response to pathogens. The disorder in ADHD is that this attentional regime is applied even though there are no adequate stressors. Comparable in this picture would be a fever reaction without an existing pathogen or trigger.
Children with ADHD often show normal attention skills when doing things they like, but have difficulty with externally imposed demands that do not engage their interest.24 Control is increasingly subject to personal motives. It is not the basic ability to pay attention that is disturbed, but the ability to control it (to direct it to something as well as to detach it from something).25
A person affected: “The phrase - See, you can if you want to - is one of the most frequently heard phrases of my childhood and youth. It was terrible: I wanted to, but I just couldn’t. It was only when I reached a certain level of interest or annoyance with my parents that I finally managed to do what I actually wanted to do, but which to my own sorrow interested me so little: Getting homework done, or doing other boring things. And of course I felt infinitely guilty for that.”
ADHD varies between temporarily reduced distractibility (task switching problems or, rather rarely, so-called hyperfocus) and temporarily increased distractibility. When which deviation occurs depends crucially on whether there is sufficient personal interest in the activity or occupation currently being performed. ADHD sufferers need higher incentives to feel the same level of motivation as non-affected persons. If intrinsic interests or extrinsic incentives such as rewards are high enough to trigger motivation, the attentional and inhibitory performance of ADHD sufferers is sometimes indistinguishable from that of non-affected individuals.
Inattention may be masked - especially in adults - by anxiety or compulsive coping strategies.26
4.4. Age development of attention problems in ADHD
Inattention does not appear as early as kindergarten or the first years of school.27 Some sources even mention 14 or 15 years for the first manifestation.28 A very early first manifestation of inattention is described in fetal alcohol syndrome.29
Inattention remits less frequently and more weakly in adulthood than hyperactivity and impulsivity.30 However, the view that inattention always remains high in adulthood27 will have to be discussed.
4.5. ADHD without attention and concentration problems
Attention problems are one of the most prominent ADHD symptoms after hyperactivity.
Nevertheless, these are not present in all affected persons. DSM IV, which (unlike the current DSM 5) still defined subtypes, described with the ADHD-HI subtype affected persons who had predominantly hyperactive-impulsive symptoms and hardly any attention problems. This subtype without attention problems is found primarily in children and is often likely to be a precursor to ADHD-C. This is because, in principle, due to the development of the human brain, attention problems do not become apparent until the age of 7,27 even, according to some, until the age of 14 or 15,28 unless as a symptom of other disorders, e.g., fetal alcohol syndrome.29
This has sometimes been interpreted to mean that the pure ADHD-HI subtype (hyperactivity only, no inattention) occurs only up to this age.31 More likely, the pure ADHD-HI subtype is often a precursor to ADHD-C in children, but there is still a significant proportion (almost 10%) of adults without severe attention problems but with significant other ADHD symptoms.
Of 1433 subjects in our ADxS.org symptom test with a positive ADHD test (screening) result (of whom 1390 were 20 years and older), 102 were found to have no concentration/attention problems (1 of whom was younger than 20 years), or 7.1% (as of June 2020). 21 showed no distractibility (1.5%), 162 no task switching problems (11.3%).
Among non-ADHD sufferers, the rate of those affected by distractibility was significantly higher than for concentration problems or task-switching problems, so that diagnostic accuracy (the difference in measures of concentration problems, distractibility, and task-switching problems) was approximately equal between ADHD sufferers and non-ADHD sufferers in each case.
It is disputed whether relevant problems with inattention that have occurred once can subside or remit in adulthood.3233 If ADHD does not necessarily persist throughout life, i.e., in 30 to 50% of all those affected in childhood it completely remits in adulthood, then inattention also remits. This suggests that inattention can remit. Statistical data confirm that inattention remits less frequently than hyperactivity, or that the reduction in symptom severity is lower in inattention. Nevertheless, in 18-20-year-olds who still had ADHD, remission of attention problems was found in 10% to 15%.30 A study of 144 adults who had been diagnosed with ADHD as children found that 3.3% had a purely hyperactive form of ADHD, that is, hyperactivity without attention problems.34
Possibly, inattention as one of the strongest symptoms is the one that is felt the longest.
We know quite a few affected persons who show a great abundance of the typical ADHD symptoms and also respond positively to stimulants, but have little or no problems in the area of attention. Affected persons who show several symptoms of an overreactive (i.e. inappropriately overreacting to the external situation) stress response system suffer from the remaining symptoms even if attention problems are not among them.
There is no doubt that there are (former) sufferers in whom the inattention and hyperactivity of their childhood and youth have remitted. For only about 50% of all affected persons do the symptoms persist into adulthood.
Indisputably, there are sufferers who have no hyperactivity at all (ADHD-I).
Other way around:
Hyperactivity usually turns into an inner drive in adulthood. This is somewhat less unpleasantly noticeable, but no less stressful for those affected.
People who had a pure ADHD-HI (without attention problems) as children and adolescents, and whose hyperactivity has changed to a pure inner restlessness typical for adults, and thus now no longer attract negative attention due to hyperactivity, and have always had no attention problems, may be more pleasant for their environment and are therefore probably more often not suspected of having a stressful disorder. However, if the burden of the other symptoms persists, these people also have a right to help and treatment.
Therefore, we represent the hypothesis that there is a (small) circle of ADHD sufferers in whom attention problems are rather weakly pronounced or have also diminished completely. The test diagnostics pursued by some physicians and therapists, which solely target sustained attention deficits, or which exclude ADHD without attention problems35 is therefore misleading according to this view and could not cover just under 10% of adult ADHD sufferers.
According to this view, the decisive factor is not whether certain individual symptoms of the symptom cluster are present, but whether
- A large amount of the symptoms occur from the symptom totality
- Whose occurrence independently (outside) of acute stressful situations (e.g. bullying, family problems) justifies a diagnosis.
This is consistent with the model presented by Barkley 36, according to which ADHD sufferers can be identified from non-affected persons quite reliably on the basis of the number of frequent occurrences of 18 symptoms. See the text in the introduction of this paper.
As a rule, attention problems are a central symptom of ADHD. However, even if this is rather the exception, the possibility of ADHD without attention problems should not be disregarded even in adults.
⇒ Neurophysiological correlates of attention problems in ADHD
4.6. Attention problems as stress symptoms
Distractibility, attention problems and susceptibility to disturbances are typical symptoms of severe stress.37383940 Concentration problems are a typical symptom of severe stress, even outside ADHD.4137423843
Nearly every mental disorder is associated with attention problems,44 ex:
- Panic disorders
- Obsessive Compulsive Disorder
Stress reduces the voluntary controllability of attention (the “searchlight of attention”). In the extreme case of a shock, the ability to control attention is almost lost.45
For an understandable overview of attention, see <http://www.neuropaedagogik.de/html/aufmerksamkeit.html>.
Luna-Rodriguez, Wendt, Kerner Auch Koerner, Gawrilow, Jacobsen (2018): Selective impairment of attentional set shifting in adults with ADHD. Behav Brain Funct. 2018 Nov 10;14(1):18. doi: 10.1186/s12993-018-0150-y. PMID: 30414619; PMCID: PMC6230251. ↥
Biederman, Lanier, DiSalvo, Noyes, Fried, Woodworth, Biederman, Faraone (2019): Clinical correlates of mind wandering in adults with ADHD. J Psychiatr Res. 2019 Oct;117:15-23. doi: 10.1016/j.jpsychires.2019.06.012. ↥
Andrillon, Windt, Silk, Drummond, Bellgrove, Tsuchiya (2019): Does the Mind Wander When the Brain Takes a Break? Local Sleep in Wakefulness, Attentional Lapses and Mind-Wandering. Front Neurosci. 2019 Sep 13;13:949. doi: 10.3389/fnins.2019.00949. eCollection 2019. ↥
Figueiredo, Lima, Erthal, Martins, Corção, Leonel, Ayrão, Fortes, Mattos (2020): Mind-wandering, depression, anxiety and ADHD: Disentangling the relationship. Psychiatry Res. 2020 Jan 21;285:112798. doi: 10.1016/j.psychres.2020.112798. PMID: 31991281. n = 78 ↥
Bozhilova, Kuntsi, Rubia, Asherson, Michelini (2022): Event-related brain dynamics during mind wandering in attention-deficit/hyperactivity disorder: An experience-sampling approach. Neuroimage Clin. 2022 Jun 1;35:103068. doi: 10.1016/j.nicl.2022.103068. PMID: 35696811; PMCID: PMC9194650. n = 48 ↥
Luna-Rodriguez, Wendt, Kerner Auch Koerner, Gawrilow, Jacobsen (2018): Selective impairment of attentional set shifting in adults with ADHD. Behav Brain Funct. 2018 Nov 10;14(1):18. doi: 10.1186/s12993-018-0150-y. ↥
Volkow, Wang, Newcorn, Kollins, Wigal, Telang, Fowler, Goldstein, Klein, Logan, Wong, Swanson (2011): Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway; Mol Psychiatry. 2011 Nov;16(11):1147-54. doi: 10.1038/mp.2010.97. ↥
Brown (2015): ADHD – From Stereopypic to Science in Educational Leadership, 10/2015, S. 52 – 56, Seite 54; Brown ist Leiter der Yale Clinic for Attention and Related Disorders in New Haven, Connecticut ↥ ↥
Barkley: Taking Charge of Adult ADHD ↥
Conway (2015): Attention Deficit Hyperactivity Disorder: Integration of Cognitive, Neuropsychological, and Psychodynamic Perspectives in Psychotherapy, am Ende des Kapitels “Das Eva-Projekt” unter Verweis auf Sugarman (2006): Attention deficit hyperactivity disorder and trauma1. The International Journal of Psychoanalysis, 87: 237–241. doi:10.1516/F2BD-QXEU-NENX-QL3N ↥
Weibel, Menard, Ionita, Boumendjel, Cabelguen, Kraemer, Micoulaud-Franchi, Bioulac, Perroud, Sauvaget, Carton, Gachet, Lopez (2019): Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults. Encephale. 2019 Oct 11. pii: S0013-7006(19)30250-7. doi: 10.1016/j.encep.2019.06.005. ↥
Dagegen: Stahl (2013): Chapter 12: Attention deficit hyperactivity disorder and its treatment. In: Stahl’s essential psychopharmacology, 4. Ausgabe, Seite 486 ↥
Mak, Chan, Chan, Tang, Lai, Wong, Leung, Hung, Lam, Lee (2018): Diagnostic Outcomes of Childhood ADHD in Chinese Adults. J Atten Disord. 2018 Sep 27:1087054718802015. doi: 10.1177/1087054718802015. n = 144 ↥
z.B. Rossi in http://www.adhs.ch/adhs-das-wichtigste-auf-einen-blick-2/ ↥
Hebold (2004): Stress und Stressverarbeitung bei Kindern und Jugendlichen, in: Schluchter, Tönjes, Elkins (Hrsg.), (2004): Menschenskinder! Zur Lage von Kindern in unserer Gesellschaft. Band zur Vortragsreihe des Humanökologischen Zentrums der BTU Cottbus, Seite 86 ↥ ↥
Laessle, Hansen-Spinger (2010): Stressinduzierte Herabsetzung der Aufmerksamkeit bei jungen Erwachsenen mit ADHS-ähnlicher Symptomatik, Kurzbericht, Zeitschrift für Klinische Psychologie und Psychotherapie, 39 (4), 213–216 ↥