Dr Jay Seitz

I asked in an earlier blog, The social construction of mental illness, why attention deficit disorders in children, adolescents, and adults are uncommon, if non-existent, in other cultures such as East Asian societies?  Why is there such a rash of these disorders in often high-functioning individuals across the US?  The concept of attention is much maligned and there seems to be some confusion about what it actually is as well as the role it actually plays in humans.

There are two fields that study attention: Cognitive psychology, which since the 1950s, seeks to understand the nature of human thought processes; and cognitive neuroscience, which is even a newer field, which investigates the brain bases of human mental processes like thought, attention, memory, language, consciousness, perception, and so on.

Let’s start with the doyen of human mental processes, William James (the brother of Henry James, the novelist), early prognostications on the subject:

“Everyone knows what attention is. It is the taking possession by the mind in clear and vivid form, of one out of what seem several simultaneously possible objects or trains of thought…It implies withdrawal from some things in order to deal effectively with others.” (The Principles of Psychology, 1890).

Or, to put it in the language of science, something like selecting targets from competing inputs. That is, it involves increasing neural thought activity in one’s area of concern and decreasing or inhibiting other thought processes that are not in one's immediate area of concern.  For example, deciding what you would like to have for dinner and selecting a way to get there: Recipes, leftovers, quick stop at the store, pushing some buttons on the microwave, and the like.  That is, we frequently choose to focus our attention on a specific activity (improving our golf swing) and pay less attention to the immediate environment such as a noisy neighbor or an annoying itch on our leg.

There are many varieties of attention, however, such as concentrating on one thing while ignoring others (typing on one’s Blackberry and ignoring the conversation next to you), doing two things at once (talking on a cell phone while driving) or sustaining an activity over time (e.g., reading a book).  Of the latter, we may even find that we need to be vigilant about an anticipated knock on the door or an infant’s cry–-a special kind of sustained attention.  Yet, some processes of attention are preconscious, meaning the mind carries them out without conscious awareness (avoiding obstacles as we walk down a busy sidewalk) and automatic (one’s morning ritual after arising from bed).  These preconscious and automatic processes often and characteristically go awry.  For instance, when we are having a stressful day and are overwhelmed, but more commonly we refer to these not so infrequent moments as cognitive slips when the order of, or choosing of alternatives, breaks down: You inadvertently place a box of cereal in the refrigerator and carry the milk to the pantry cabinet.

Let's look at some ways that "attention" gets misunderstood:

From a neural perspective, attentional processes are widely distributed in the brain and it would be rather remarkable for these to break down en masse or even en part (if they did, we wouldn’t be talking about the waxing and waning of attentional processes anymore but more severe causes such as a stroke or a severe epileptic seizure or the like).  On the other hand, there is some evidence that the maturation of the frontal lobes is not completed until late adolescence so adolescents with attentional issues may be demonstrating the normal development of the brain, rather than underlying pathology.  Parenting skills and providing a healthy home and social environment may be more relevant during this period than reflexive use of medication or psychotherapy.  Moreover, there are many kinds of “attention” and each of these attentional processes involves different cognitive processes and underlying brain systems as well as their activation or inhibition.  Attention is not unitary.

The parietal lobe, for instance, is involved in switching among visual tasks (reading the newspaper or surfing the web); the pulvinar nucleus of the thalamus in focusing on a target from an array of choices (choosing the chocolate cake from the dessert menu); areas of the thalamus and the visual cortex for awareness of one’s immediate environment; frontal and parietal areas for focusing on color, form, and location information; the interplay of frontal areas, the basal ganglia, and the anterior cingulate cortex (which translates decisions into actual physical activity) for searching for appropriate targets (Which book should I choose from my bookshelf?) and it’s even more complicated because the left frontal areas are more concerned with semantic content (Which book will help me better understand Middle East politics?) and the right posterior areas are more concerned with the features of objects (Apple or a pear?); the dorsolateral prefrontal cortex for holding this information in immediate memory; and various areas of the frontal cortex for sustained vigilance.

If someone complains of an “attentional deficit” or a “problem concentrating” just exactly what is being stated?  These attributions are almost meaningless without a knowledge of the cultural and environmental context in which they occur.  Not to mention an individual’s personality and disposition as well as the impact of psychosocial stress and lifestyle choices on an individual.

There is also an issue about which sensory modalities are involved.  Since attention can be focused on what people say or what they look like or the feelings they arouse in us or the touch of someone’s hand on our shoulder or the aroma of freshly brewed coffee.  Or, the taste of a favorite meal or the physical feedback we receive from internal receptors in our bodies.  Inattention deficit in what sense?  Problem concentrating on what?  Often, these questions are never asked by mental health professionals but taken at face value.

Indeed, theories of attention are derived from studies of individuals with obvious and pronounced damage to the brain as well as studies of normal individuals and how their brain systems interact in sundry types of everyday attentional processes (i.e., focal, divided, and sustained attention as well as preconscious and automatic processes of attention).  There is no hard scientific evidence, that I am aware of, for the collapse of cognition or its brain basis in common, everyday complaints of inattention or problems in concentration.

Insomnia, drugs (both the licit and illicit kind, such as excessive use of caffeine or sleeping pills), psychosocial stressors (work, school, family, and financial stress), and diet and physical exercise (or lack of it) can have a significant impact on cognition.  There are even suggestions that infection or immune activation may break down cognitive processes and hormonal changes in the body have also been documented (e.g., estrogen suppression in women).  Indeed, the augmentation or suppression of neurotransmitter systems (e.g., acetycholine, involved in memory; dopamine, involved in needs and desires) can affect cognitive function and have many causes and consequences.  Yet, it is uncommon for these possibilities for “attention deficit” or “problems in concentrating” even to be considered in the diagnosis and treatment of attentional issues.  The focus is on symptoms, not underlying causes.

In Part II, I’ll examine the psychopharmacology of attention and the role of psychiatric treatment including psychotherapy.  In Part III, I will look at normal overactivity (particularly in males) and consider the special case of situational hyperactivity, especially in children.

Some suggested readings:

Fuster, J. M. (2003).  Cortex and mind: Unifying cognition.  Oxford: Oxford University Press.

Gazzaniga, M. S., Ivry, R. B., & Mangum, G. R. (2002).  Cognitive neuroscience: The biology of mind (2nd ed.).  NY: W. W. Norton (Chapter 6: Attention and selective perception).

Kolb, B., & Whishaw, I. Q. (2003).  Fundamentals of human neuropsychology (5th ed.).  NY: Worth (Chapter 22: Attention, mental images, and consciousness).

Sternberg, R. S. (2006).  Cognitive psychology (4th ed.).  Belmont, CA: Thomson Wadsworth (Chapter 3: Attention and consciousness).