Clinical Reference Systems: Pediatric Advisor 10.0
Attention Deficit Disorder (Short Attention Span)
Also called ADD, ADHD, or hyperactivity, a short attention
span occurs in 3% to 5% of children, most of them males.
A normal attention span is 3 to 5 minutes per year of a
child's age. Therefore, a 2-year-old should be able to
concentrate on a particular task for at least 6 minutes, and
a child entering kindergarten should be able to concentrate
for at least 15 minutes. (Note: A child's attention span
while watching TV is not an accurate measure of his or her
If you suspect that your child has a short attention span,
ask another adult (a teacher or day care provider, for
example) if they have observed this also.
- A child hasn't learned to listen when someone talks,
wait his turn, complete a task, or return to a task
if interrupted. (These can be normal characteristics
of children less than 3 or 4 years old.)
- 80% of boys and 50% of girls are also hyperactive. A
child who has symptoms of hyperactivity is restless,
impulsive, and in a hurry.
- 50% of children also have a learning disability. The
most common learning disability is an auditory
processing deficit (that is, they have difficulty
remembering verbal directions). However, the
intelligence of most children with ADD is usually
- Similar conditions
Disruptive children, children who don't mind, and
aggressive children are sometimes included under the
broad category of hyperactivity. Many problem
2-year-olds are considered "hyperactive." These
children should be looked upon as children with behavior
problems and approached with appropriate discipline
Attention deficit disorder (ADD) is the most common
developmental disability. "Developmental" means that
the disability is caused by delayed brain development
(immaturity). This delay results in poor self-control,
requiring external controls by the parents for a longer
period of time. Often this type of temperament and
short attention span is hereditary. A small percentage
of children with ADD are reacting to chaotic home
environments, but in most cases the parents' style of
child-rearing has not caused the disability. Minor
brain damage has not been proven to be a cause of ADD
but scientists are conducting research into this area.
- Expected course
Children with ADD on a developmental basis can improve
significantly if parents and teachers provide
understanding and direction and preserve the child's
self-esteem. When these children become adults, many of
them have good attention spans but remain restless, have
to keep busy, and, in a sense, have not entirely
outgrown the problem. However, not only does society
learn to tolerate such traits in adults, but in some
settings the person with endless energy is prized.
Children with severe ADD may need vocational counseling
Call Your Child's Physician for Referral to a Child
Psychiatrist or Psychologist If:
- Your child shows unprovoked aggression and
- Your child has repeated accidents.
- Your child has been suspended or expelled from school.
- Your child can't make or keep any friends.
- You have "given up" hope of improving your child.
- You can't stop using physical punishment on your child.
- You are at your wit's end.
Living with a Child Who Has Attention Deficit Disorder
Attention deficit disorder is a chronic condition that needs
special parenting and school intervention. If your child
seems to have a poor attention span and is over 3 years of
age, these recommendations may assist you in helping your
child. Your main obligations involve organizing your
child's home life and improving discipline. Only after your
child's behavior has improved will you know for certain if
your child also has a short attention span. If he does,
specific interventions to help him learn to listen and
complete tasks ("stretch" his attention span) can be
initiated. Even though you can't be sure about poor
attention span until your child is 3 or 4 years of age, you
can detect and improve behavior problems at any time after 8
months of age.
- Accept your child's limitations.
Accept the fact that your child is intrinsically active
and energetic and possibly always will be. The
hyperactivity is not intentional. Don't expect to
eliminate the hyperactivity but merely to bring it under
reasonable control. Any criticism or other attempt to
change an energetic child into a quiet or model child
will cause more harm than good. Nothing helps a
hyperactive child more than having a tolerant, patient,
- Provide an outlet for the release of excess energy.
This energy can't be bottled up and stored. Daily
outdoor activities such as running, sports, and long
walks are good outlets. A fenced yard helps. In bad
weather your child needs a recreational room where he
can play as he pleases with minimal restrictions and
supervision. If no large room is available, a garage
will sometimes suffice. Your child should not have too
many toys, for this can cause him to be more easily
distracted from playing with any one toy. The toys
should be safe and relatively unbreakable. Encourage
your child to play with one toy at a time.
Although the expression of hyperactivity is allowed in
these ways, it should not be needlessly encouraged.
Don't initiate roughhousing with your child. Forbid
siblings to say, "Chase me, chase me," or to instigate
other noisy play. Encouraging hyperactive behavior can
lead to its becoming your child's main style of
interacting with people.
- Keep your home well organized.
Household routines help the hyperactive child to accept
order. Keep the times for wake-up, meals, snacks,
chores, naps, and bed as regular as possible. Try to
keep your environment relatively quiet because this
encourages thinking, listening, and reading at home. In
general, leave the radio and TV off. Predictable daily
events help your child's responses become more
predictable. ADD symptoms are made worse by sleep
deprivation and hunger. Be sure your child has an
early bedtime and a big breakfast on school days.
- Try not to let your child become fatigued.
When a hyperactive child becomes exhausted, his
self-control often breaks down and the hyperactivity
becomes worse. Try to have your child sleep or rest
when he is fatigued. If he can't seem to "turn off his
motor," hold and rock him in a rocking chair.
- Avoid taking your child to formal gatherings.
Except for special occasions, avoid places where
hyperactivity would be extremely inappropriate and
embarrassing (such as churches or restaurants). You
also may wish to reduce the number of times your child
goes with you to stores and supermarkets. After your
child develops adequate self-control at home, he can
gradually be introduced to these situations. Be sure to
praise your child when he plays independently rather
than interrupting you when you are talking to guests or
are on the telephone.
- Maintain firm discipline.
These children are unquestionably difficult to manage.
They need more carefully planned discipline than the
average child. Rules should be formulated mainly to
prevent harm to your child and to others. Aggressive
behavior, such as biting, hitting, and pushing, should
be no more accepted in the hyperactive child than in the
normal child. Try to eliminate such aggressive
behaviors, but avoid unnecessary or unattainable rules;
that is, don't expect your child to keep his hands and
feet still. Hyperactive children tolerate fewer rules
than the normal child. Enforce a few clear, consistent,
important rules and add other rules at your child's
pace. Avoid constant negative comments like "Don't do
this," and "Stop that."
- Enforce rules with nonphysical punishment.
Physical punishment suggests to your child that
physically aggressive behavior is OK. We want to teach
hyperactive children to be less aggressive. Your child
needs adult models of control and calmness. Try to use
a friendly, matter-of-fact tone of voice when you
discipline your child. If you yell, your child will be
quick to imitate you.
Punish your child for misbehavior immediately. When
your child breaks a rule, isolate him in a chair or
time-out room if a show of disapproval doesn't work. The
time-out should last about 1 minute per year of your
child's age. Without a time-out system, overall success
- Stretch your child's attention span.
Encouraging attentive (nonhyperactive) behavior is the
key to preparing your child for school. Increased
attention span and persistence with tasks can be taught
at home. Don't wait until your child is of school age
and expect the teacher to change him. By age 5 he needs
at least a 25-minute attention span to perform
adequately in school.
Set aside several brief periods each day to teach your
child listening skills by reading to him. Start with
picture books, and gradually progress to reading
stories. Coloring pictures can be encouraged and
praised. Teach games to your child, gradually
increasing the difficulty by starting with building
blocks and progressing to puzzles, dominoes, card games,
and dice games. Matching pictures is an excellent way
to build your child's memory and concentration span.
Later, consequence games such as checkers or tic-tac-toe
can be introduced. When your child becomes restless,
stop and return for another session later. Praise your
child for attentive behavior. This process is slow but
invaluable in preparing your child for school.
- Buffer your child against any overreaction by neighbors.
Ask neighbors with whom your child has contact to be
helpers. If your child is labeled by some adults as a
"bad" kid, it is important that this image of your child
doesn't carry over into your home life. At home the
attitude that must prevail is that your child is a good
child with excess energy. It is extremely important
that you not give up on him. Your child must always
feel loved and accepted within the family. As long as a
child has this acceptance, his self-esteem will survive.
If your child has trouble doing well in school, help him
gain a sense of success through a hobby in an area of
- From time to time, get away from it all.
Exposure to some of these children for 24 hours a day
would make anyone a wreck. Periodic breaks help parents
to tolerate hyperactive behavior. If just the father
works outside the home, he should try to look after the
child when he comes home, not only to give his wife a
deserved break but also to understand better what she
must contend with during the day. A baby sitter one
afternoon each week and an occasional evening out can
provide much-needed breaks for an exhausted mother.
Preschool is another helpful option. Parents need a
chance to rejuvenate themselves so that they can
continue to meet their child's extra needs.
- Utilize special programs at school.
Try to start your child in preschool by age 3 to help
him learn to organize his thoughts and develop his
ability to focus. However, you should consider
enrolling your child in kindergarten a year late (that
is, at age 6 rather than 5) because the added maturity
may help him fit in better with his classmates.
Once your child enters grade school, the school is
responsible for providing appropriate programs for your
child's attention deficit disorder and any learning
disability he might have. Some standard approaches that
teachers use to help children with ADD are smaller class
size, isolated study space, spaced learning techniques,
and inclusion of the child in tasks like erasing the
blackboard or passing out books (as outlets for
excessive energy). Many of these children spend part of
their day with a teacher specializing in learning
disabilities who helps improve their skills and
If you think your child has ADD and he has not been
tested by the school's special education team, you can
request an evaluation. Usually you can obtain the help
your child needs with schoolwork by working closely with
the school staff through parent-teacher conferences and
special meetings. Your main job is to continue to help
your child improve his attention span, self-discipline,
and friendships at home.
- Medications are sometimes helpful.
Some stimulant drugs can improve a child's ability to
concentrate. You may want to discuss the use of drugs
with your child's physician. In general, medications
should not be prescribed before school age. They should
also not be prescribed until after your child has been
evaluated by a doctor and a school psychologist or
special education teacher, an individualized educational
plan (I.E.P.) is in effect at school, and you have
followed the suggestions in this handout. Medications
without special education and home management programs
have no long-term benefit. They need to be part of a
broader treatment program.
Barbara Ingersoll, Your Hyperactive Child (New York:
Melvin D. Levine, Keeping a Head in School: A Student's
Book About Learning Abilities and Learning Disorders
(Cambridge, MA: Educators Publishing Service, 1990).