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Attention
-your firm and flexible friend

Picture posed by model (see p1)

Sandwell speech and language therapist Nibbhaya contemplates the skills involved in attention control and shares his work in progress, a new model for clinical use. Although his inspiration comes primarily from children with autism, the model can be applied to any client group - and to ourselves.

erhaps the first thing you notice about another person when you meet them is whether they are with you or not. This skill of engaging in your topic of thought and conversation is known as joint or shared attention (Ellis, 1990). An example of successful joint attention is when a child looks at a toy, then makes eye contact with an adult, smiles then looks back at the toy as if to say, Look at this great toy or hey you, I like this. When a child enters education they are required to have the skill of joint attention because they need to attend to the topics chosen by teachers. Some children do not have this listen and do skill at school entry. Reynells developmental framework of attention (1980, see figure 1) is frequently used by speech and language therapists when deciding to treat delays in attention development associated with a communication difficulty. Often the attention of a child with a delay is single channelled. Treatment including sound lotto, sound matching, comprehension and memory games is aimed at gaining and sustaining the childs attention until they can follow instructions of a certain length. Children with autism have been described as having tunnelled attention (Jordan, 1997). Superficially, the presentation of children with either single channelled or tunnelled attention is the same. To use a Hanen term (Manolson, 1992), they both have their own agenda. However, autistic childrens attention sometimes appears to be strongly influenced by their interest. Attention span can be of very long duration and is therefore disordered rather than delayed. GN is a child with tunnelled attention. She has a restricted range of interests, particularly liking rabbits. In free play it is very difficult to share her games because her attention is on one thing to the exclusion of others. She is insistent about the type of play and there is very little sharing of interest. I observed a quite different quality of attention in DS, a child diagnosed with autism. (This was before June 2001 when I was given a Buddhist name, Nibbhaya, to replace my old name of James.) When DS saw me in school he said, James, James Bond, and went on to make connections about the fictional character. He also said hello, but could not sustain his attention to my response long enough to take another turn. His attention rested only briefly and lightly on me. There was no joint attention, and he seemed vague or not present, his attention drifting in verbalised free association.

Read this
if you want a clinical tool for attention control to engage with your clients to like other people more

Descriptive model
Having observed qualities of attention control other than those described in the literature, I decided to develop a descriptive model to cover them, as more specific descriptions should lead to more awareness about attention control and more specific treatment strategies. The spiritual practices of meditation and reflection are ways of cultivating and sustaining attention and could give clues to finding suitable methods of describing attention control. Sangharakshita (1980), a Buddhist with fifty years of meditation

Nibbhaya

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experience, described the quality of attention needed for the skill of reflecting on a topic. Reflection, he said, requires attention that is both directed and flexible: directed onto an object - for example, a friend - yet flexible enough to move onto other objects of thought - for example, events in their lives. Reflection and joint attention share the same skill. In joint attention this would be bearing of attention onto the object of someone elses thoughts as expressed verbally or non-verbally. The attention of DS was too flexible for interaction and that of GN too rigid. As opposites a continuum can be drawn between two extremes (figure 2). There are other children whose attention is quite rigid but moves quickly from one object to another. For them to be described another dimension is needed - the degree that attention is rested on an object. That allows for DS having light attention as well as flexible. GN has firm attention as well as rigid. The model can now be completed using two continua (figure 3). The rigid-flexible continuum relates to the number of objects in awareness, whilst the light-firm continuum relates to the extent that one object is attended to. Four possible qualities of attention can now be described, one for each quadrant. Examples are given of everyday uses of each quality to demonstrate how attention control varies: 1. Light and rigid This is similar to levels 2 and 3 in Reynells framework. A production line worker would need this quality of attention in order to inspect items as they pass before them on a conveyer belt. 2. Light and flexible Attention is freely associating from one item to the next without control as, for example, when day dreaming. 3. Firm and rigid Attention is fixed onto one object for long periods of time, the type of control used in ball sports.

4. Firm and flexible The attention that would be used by a chairperson in a meeting. They have the aims of the meeting continually in mind, but need to be flexible enough to let discussion roam to related items. At this level attention control is a very conscious act.

When a child enters education they are required to have the skill of joint attention because they need to attend to the topics chosen by teachers.

It is interesting to note that the first three examples do not involve other people in communication so, although the first may have developmental relevance and all have their uses, clinically their absence is not a problem. The problem for interaction occurs when the client does not have the fourth quality in their repertoire. In going from the world of the clinician to the world of the child, there seem to be two main approaches in gaining joint attention. The first is for the therapist/adult to undertake activities that grab a childs interest in a certain way as described. The second approach is to teach the child the tools required to enable them to gain

the attention of another person, for example through pointing behaviour: SB appeared to have very little intention to interact. He used a lot of jargon with varied intonation that did not seem at all communicative. Whilst I was looking at his father, he suddenly said, excuse me. I looked at him and he was making strong eye contact. He then started using jargon. Because he does not use pointing or gaze to refer to something it appears as if he is talking without communicative intent. He does not refer to anything non-verbally. He may be using a strategy, in jargon, for gaining joint attention but it is idiosyncratic, incomplete or both. The method of following the childs interest and commenting on it as well as imitating their behaviour is a sort of middle way, and is the basis for Intensive Interaction (Hewett & Nind, 1998). With children who appear to have very little interest in others this would be the primary method: BS and ST are in nurseries but do not initiate contact with others, and respond only very briefly to high interest activities like blowing bubbles or balloons. When treating clients I often hear views from adults such as teachers, therapists and parents. One view is that children who have idiosyncratic interests in things to the extent that joint attention is not gained do so as a function of their personality and, as such, they should not be treated. I disagree. We are in a privileged position. One of awareness. We are aware that people have different interests and then make our choice as to what to attend to. That is, we have an informed choice. Children with such attention control may not be making an informed choice. Therefore it is our responsibility, where possible, to give them the tools they need to make that choice. I choose to define humans as social creatures, so the lack of development in attention and therefore interaction is a breakdown in activity*. One head teacher had the view that evolutionary theory would explain that there would be people who are not sociable. Again, if a person with austistic spectrum disorder is aware of their own social skills and is happy to make a choice to avoid interaction then I wouldnt want to intervene. The degree of participation* would be a personal choice. Reading the accounts of adults with autistic spectrum disorder could be the best way of deciding the degree of distress* experienced by people with autism in regard to interaction, and would therefore aid the forming of a philosophy of intervention. For individual children hypotheses about the causes of distress can be made. Distress may be significantly due to interaction difficulties, and teenage children with Asperger Syndrome may become depressed as a result of difficulties with social skills (Ellis, 1990).

Figure 1 Reynells levels of attention

Level 1 (0-1 year) Extreme distractibility when childs attention flits from one object, person or event to another. Child can concentrate on a task of his own choosing. His attention is single-channelled and he must ignore all extraneous stimuli. Child cannot listen to adults directions while he is playing but he can shift his whole attention to the speaker and back to the game with the adults help. Child must still alternate his full visual and auditory attention between the speaker and the task but he now does this spontaneously. Childs attention now twochannelled, that is, he understands verbal instructions related to the task without interrupting his activity to look at the speaker. His concentration span may still be short but he can be taught in a group. Auditory, visual and manipulatory channels are fully integrated and attention is well established and sustained.

Level 2 (1-2 years)

Level 3 (2-3 years)

Level 4 (3-4 years)

Level 5 (4-5 years)

Level 6 (5-6 years)

(Based on Reynells levels of attention as quoted in the Speechmark publication Working with Childrens Language by Jackie Cooke & Diana Williams.)

Figure 2 Early model of attention

Rigid/inflexible.......................free associating

Figure 3 The latest model

LIGHT

RIGID

FLEXIBLE

FIRM

Rigorous rationales
Having made an attempt to describe the different attention skills of clients in terms of the model in figure 3, I found myself considering these as an outcome of the different theories of the underlying
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Reflections
causes of autistic spectrum disorder. Such a consideration is one of impairment*. It is similar to asking what the level of breakdown is in speech and language difficulties so that specific interventions may be designed. Instead of only treating surface behaviours - although this can be valid - treatments for the underlying skills may be developed, ideally leading to more rigorous rationales for intervention. It may be that children with different attention difficulties have different underlying aetiologies including: 1. weak central coherence 2. executive dysfunction 3. weak Theory of Mind 4. high anxiety. There is therefore no These would be suitable of my clients be described with reason to share experifor older/able children reference to their attention control? ence. Further assesswith good comprehen Do I consider the relative merits ment would be sion of the concepts of treating surface symptoms and / required - for example, involved. I suggest gainusing the Sally Anne ing parental consent or underlying causes? Test (Baron-Cohen et before undertaking I already use reflection to improve al, 1985) - to establish teaching of meditation. my practice - could meditation the status of this skill, Teaching should come be my next step? although my colfrom someone who is leagues already a meditation and I have found results from this teacher, so outside agencies such as Buddhist centres test inconsistent. There are levels may need to be involved. of the Theory of Mind skill, and the Intervention aims at gaining and establishing Sally Anne Test evaluates one level: joint attention through moving away from the that other people have beliefs of extremes of attention control to achieve more their own about events or things. balance. The following are some ideas for interIn the test two dolls are used. In vention under the different qualities of attention. front of them and the child, an item is put into one of two boxes. 1. Light and flexible One doll, Sally, then leaves and Therapy was devised for DS before the model Anne puts the item into the other illustrated in figure 3 was developed. I observed box. Sally is brought back in. The that he could not engage with a speakers interchild is asked which box Sally will action for more than a single turn. In group work look into for the item. If the child he was described by the teacher as being in a understands that others have their world of his own. His therapy required him to own beliefs (in this case based on answer closed questions in tasks of increasing the experience of sight) then the length. To begin with he answered yes or no child will say that Sally will look in the first box when I labelled noun pictures correctly or incorwhere she saw the item placed. Developmentally, rectly. With consistent correct responses the task this skill is expected to develop by four years. was extended to functions, simple sentences, and If a client has not got skills to infer what goes on so on. He was inconsistent at the level of nouns in the minds of others - a theory of mind - then an initially. By the time he was able to respond to approach based on the Metta Bhavna meditation sentences he was also able to take two to three may help develop empathy. This meditation is turns in conversation with his teacher. used to develop positive mental states such as Taking theories on executive dysfunction into compassion and kindness. Simply put, you develop account, therapy could be aimed at a graded prothe desire for the well-being of yourself and others. gramme with the aim of achieving goals. Tasks People you feel neutral about, for example would be made that control what is required to strangers, and people you feel ill will towards are achieve goals, for example choosing, sorting and brought to mind in order to develop kindness prioritising. They may simply be memory tasks to unconditionally. Over time one result is that begin with then, later, involve an obstacle where when you meet people you tend to respond to a change of plan is required. For example: The them more out of good will than previously. task is to get from A to B on a map but there are After preparing yourself you bring others to mind. natural barriers such as rivers and mountains. In my experience thinking about others doing the Give a choice of items that could be used to most basic human things, for example, washing enable the journey to be continued. up, shopping, talking, as well as experiencing the 2. Firm and rigid pain and joy that we all do, has helped develop a Interestingly, the same method was used with GN as growing appreciation that others are alive too, with DS. She went through the same steps. By the not two-dimensional cardboard cut-outs. Therefore, time she was able to respond to simple sentences similar exercises could be developed in the guessing there was an observable difference in her quality of of what people do when they are not in the presattending to me. She appeared to be checking ence of the client (see for example Wendy Rinaldis what my attention was on. The method is likely to self / other awareness material (1995; 2001)). have been successful with both extremes because 4. high anxiety the task requires a balance between the two. The Another reason why attention control can be rigid game also involves the adult making mistakes and is high anxiety. This can be reduced with a structured this can delight children and grab their interest. routine and strategies such as visual aids or gesIncreasing the awareness of the interests of others ture to help comprehension of language and through social activities may be appropriate here. events. Meditation can also be used to relax. Also consider using a childs interests as a reward for Probably those practices that involve observing the attending to an adults choice of activity. However, process of breathing would be most appropriate. children with rigid and firm attention may attend to

Could the odd interaction of any

1. weak central coherence In the case of firm/rigid attention the theory of weak central coherence may be the primary or significant impairment. Central coherence is the ability to see the wood for the trees, to be able to put information together, to get the gist of communication or the thread in a story. Weak central coherence would result in attention to bits of information. One item would be attended to rather than putting many together. This theory may fit for the child who has good rote learning skills, or the child who remembers small details on a journey. PJ looked at a picture of someone being mugged. He ignored the main event in favour of examining a clock. For me this does not explain why one item is chosen over another. Why is the child interested, say, in a hat as opposed to a face? The answer may be in the childs perceptual preferences. Sensory experience of one kind, for example sight, may be more salient than experience through the other senses. For PJ the movement of a clocks second hand was alluring. Perhaps for GN the touch of rabbits fur is attractive. 2. executive dysfunction In the case of light/flexible attention the theory of executive dysfunction may be applicable. Executive functions are those skills that modulate behaviour towards a goal. They therefore manage behaviour over time. They are, amongst others, the skills used to develop and carry out plans. The strategies used to carry out those plans are monitored and altered as necessary. If one has not got a goal in mind, or the goal is held weakly, then the mind will wander, attaching to anything that comes into consciousness whether from outside the client (such as another person coming into view) or internally (for example, memories). This appeared to be the case with DS.

If a client has not got skills to infer what goes on in the minds of others - a theory of mind then an approach based on the Metta Bhavna meditation may help develop empathy.

3. weak Theory of Mind A weak Theory of Mind is also posited as a reason for lack of interaction. This is where the client does not appreciate that others have their own perspective, views and feelings about experience.

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..resources...resources....resources...
the reward to the exclusion of the activity. The teaching staff of GN negotiated with her that she could have her toy rabbits on Fridays but she was observed on a Tuesday to ask for them frequently. Her understanding of words of time may not yet be established. Lastly, to facilitate more flexible thinking try a sorting activity where the items can be sorted by different qualities, for example cards of different shapes and colours. Begin by sorting into colours then change task to sorting by shape. The same task can be done with clothes, coins or books. 3. Light and rigid The Manolson (1992) approach of following the interests of the child and commenting on them as well as imitating the child would be applicable here as it may be with firm and rigid. With DA, a nursery age child, I copied his physical play such as kicking legs out whilst sitting on a chair, and then began to initiate my own movements. DA soon began to copy me. This was extended to following my commands verbally with an increasing number of information carrying words.

Workplace conflict
Practical assistance with workplace conflict, drawn up as a result of research, aims to provide organisations with a useful template or checklist for strategy development. Free copy of Practical Assistance for Employers in relation to the Recognition, Prevention and Management of Workplace Conflict from Lawrence Allison, tel. 020 7957 4344, or see www.lawrenceallisontraining.com.

Deaf directory
The largest and most comprehensive guide to organisations which provide services to deaf and hard of hearing people, and to the professionals who work with them, has been updated for 2002/3. The Directory of Services for Deaf and Hard of Hearing People costs 34.99 from RNID Information Line on 0808 808 0123 (T 0808 808 9000).

Mind mapping online

A web-based service aims to help students learn faster and get better exam results using mind mapping techniques. Mindwarp Pavilion has created over 15,000 mind maps from the best selling undergraduate textbooks in fields such as medicine, education, psychology, sociology and writing skills. Different packages allow subscribers options such as testing themselves and benchmarking progress against their peer group. Mind maps are an established accelerated learning technique and use a series of headings and sub headings that branch out like a family tree. Each separate heading triggers the memory bank to recall information stored there. From 16.99 per year, see www.mwpavilion.com.

Photocopiable materials
Black Sheep Press has added to its collection of photocopiable therapy materials, with Talking About...friends, new concepts in pictures (long / short; more than / less than; same / different), revisions of older packs including prepositions, and publication of more materials in Welsh. www.blacksheep-epress.com, tel. 01535 631346.

Work in progress
Several of the children referred to are either diagnosed with autism or are in the process of multiagency assessment. The cases mentioned also have a very wide range of ability. Although not peculiar to autism, difficulty with joint attention is one of the main features of children with autistic spectrum disorder. There is no reason not to use the model with any client group or ourselves for that matter (how difficult is it to keep a goal in mind when leading a meeting?!) I hope this work in progress will enable clinicians and researchers to have a simple way of describing attention control, design intervention and measure progress.

Fragile X information
Two new education booklets are available from the Fragile X Society. An introduction to educational needs (3rd ed) and Education and severe learning difficulties have been mailed to all Directors of Education and special schools in the UK, and the Society is encouraging members to distribute them as widely as possible. www.fragilex.org.uk.

Leading for results

The Open University Business School is launching a professional development course nationwide following successful pilots in the NHS. Leading for Results is a 12-16 week parttime, distance learning programme which aims to develop individuals into leaders who can create a cohesive, motivated, wellmanaged and well-led workforce where all employees are striving for the same ends. Details: Nicci Carr, 01908 659196, e-mail n.carr@open.ac.uk.

References
Baron-Cohen, S., Leslie, A.M. & Frith, U. (1985) Does the autistic child have a theory of mind? Cognition 21 (1), 37-46. Ellis, K. (Ed) (1990) Autism. Professional perspectives and practice. London: Chapman and Hall. Frith, U. (1989) Autism. Explaining the Enigma. Oxford: Blackwell. Hewett, D. & Nind, M. (1998) Interaction in Action. Reflections on the use of Intensive Interaction. London: David Fulton Publishers. Jordan, R. & Powell, S. (1997) Autism and Learning. London: David Fulton Publishers. Manolson, A. (1992) It Takes Two To Talk. Ontario: Hanen Centre Publications. Reynell, J. (1980) Language Development and Assessment. Lancaster: MTP Press. Rinaldi, W. (1995) SULP for Primary and Infants. Guildford: Learn-Communicate. Rinaldi, W. (2001) SULP-R. Windsor: NFER-Nelson. Sangharakshita (1980) Publication in preparation by Windhorse Publications, Birmingham. Note: *Categories originally developed by the World Health Organisation and modified in Sandwell.

Computers as communication aids

Sensory Software offers one day training courses to introduce therapists, teachers and other professionals to using computers as communication aids and for familiarisation with its AAC suite. The courses are free at the base in Malvern, and cost from 150 plus expenses elsewhere. Details of training and products, tel. 01684 578868, www.sensorysoftware.com.

Free curriculum resources

The number of registered users of Clicker Grids for Learning has hit 10,000. The Crick Software website for Clicker 4 and Wordbar users provides over 300 free sets of Clicker Grids and Wordbars on a host of different topics and themes. www.clickergrids.com.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2002