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
  • 4.2.1. Distractibility
    • 4.2.1.1. Distractibility by external stimuli
    • 4.2.1.2. Daydreaming / Mind Wandering / Absence of Thought
  • 4.2.2. Attention switching problems
    • 4.2.2.1. Task switching issues
    • 4.2.2.2. Hyperfocus: extreme concentration
  • 4.2.3. Concentration problems as ADHD symptoms
• 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
  • For children:
    • Often fails to pay attention to details or makes careless errors in schoolwork, work, or other activities (DSM IV, DSM 5)
  • For adults:
    • Aversion to instructions for action²
    • Lack of concentration when reading through longer tasks²
    • Overwhelm longer instructions
• 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
• Task switching issues
  • For children:
    • Does not seem to listen when others address him/her (DSM IV / 5)
    • In thoughts still somewhere else
  • For adults
    • Speed of switching between tasks (task switching) reduced³
    • Are still busy with own thoughts from previous task²
    • Can no longer get out of thought loops
• Listening is difficult
  • Attention span is too short to follow instructions to the end
    (Tendency to interrupt, on the other hand, is impulsivity problem)
• 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
  • Children:
    • Frequently fails to carry out instructions of others completely and cannot complete schoolwork, other work, or duties at work (DSM IV / 5)
  • Adults:
    • 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 caught there…
• Concentration problems
  • 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.

4.2.1. Distractibility¶

Distractibility is to be distinguished, depending on the cause, into those

• In relation to external, external stimuli
  • Distractibility
    • 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)

4.2.1.1. Distractibility by external stimuli¶

Distractibility is a change in attention due to an external stimulus. ADHD sufferers are more likely to show increased distractibility 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 since 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.

4.2.1.2. 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 (“dreamerle”), but is significantly correlated with⁶

• Higher inattention
• Higher hyperactivity
• Worse executive functions
• More general mental problems
• Higher emotional dysregulation
• More impaired quality of life

thus with increased ADHD symptoms in general.

Increased mind wandering (daydreaming) was also found in children with ADHD. Daydreaming could be detected by 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 in 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¶

4.2.2.1. 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 task switching request is extrinsic and refers to things that do not address the person’s personal interest.
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.

4.2.2.2. 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 an advantage to be able to concentrate particularly intensively on certain things. Nevertheless, it is specific to 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 is present,¹⁴ once they have started an activity that gives them satisfaction, because the reward that is then immediately received 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 ever experienced an ADHD sufferer in hyperfocus, in which even highly monotonous activities are performed 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 their own experience. 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 affected person’s impaired instance of attentional control 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) can persistently engage with a topic in a concentrated manner, free of frustration intolerance or distractibility.

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

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 can 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 matter of character or effort, but simply a matter 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 can 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 directing 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 for 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 response 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

ADHD fluctuates 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 individuals. 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 noticeable 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, although the ADHD-HI-only subtype is often a precursor to ADHD-C in children, 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. Nonetheless, 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, i.e., 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 sufferers who show a wide range of the typical ADHD symptoms and also respond positively to stimulants, but have little to no problems in the area of attention. Affected individuals who show multiple symptoms of an overreactive (i.e., inappropriately overreacting to the external situation) stress response system suffer from the remaining symptoms even when 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 stand out negatively 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
  and
• 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 by 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 disruptiveness are typical symptoms of severe stress.^37383940 Concentration problems are a typical symptom of severe stress, even outside of ADHD.^4137423843

Nearly every mental disorder is associated with attention problems,⁴⁴ ex:

• Depression
• Psychosis
• Tourette
• Mania
• 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>.