Attention Research Update
"Helping parents, professionals and educators stay informed about new research on ADHD"
David Rabiner, Ph.D. Senior Research Scientist, Duke University
Can contact with nature enhance attentional functioning in children with ADHD? Recently, I came across an interesting and unusual study in which this hypothesis was explored (Taylor et al., (2001). Coping with ADD: The surprising connection to green play settings. Environment and Behavior, 33, 54-77.)
The notion that exposure to nature might improve attention problems in children is based on the Attention Restoration Theory, which proposes that natural environments can assist attentional functioning. According to this theory, humans have two types of attention: voluntary attention (also known as directed attention); and involuntary attention. Voluntary attention is the form of attention employed in attending to tasks or situations that require sustained attention and are not inherently easy to attend to. After prolonged and intense use, voluntary attention becomes fatigued.
In contrast, involuntary attention is said to be easy and does not require effort -- think of settings or activities in which remaining focused and attentive seems to happen naturally, without any deliberate effort. In Attention Restoration Theory, it is proposed that natural environments assist in recovery from directed attention fatigue, in part because they draw on involuntary attention rather than directed attention. These ideas led the researchers to propose that attention deficit symptoms would be more manageable after activities in green settings than after activities in other settings.
Participants in this study were parents of 96 seven- to twelve-year-old children diagnosed with ADHD (approximately 75% boys) who volunteered to complete a survey related to their child's activities and play settings. In the first section of the questionnaire, parents were asked to identify up to two after-school and weekend activities after which they felt their child functioned especially well ("After ________ my child's ADD symptoms are much less noticeable than usual") and up to two activities they felt left their child functioning especially poorly ("After ________ my child's ADD symptoms are much more noticeable than usual"). Approximately two-thirds of the parents were able to identify at least one activity that they believed diminished or enhanced their child's inattentive symptoms.
Next, parents were presented a list of different after-school and
weekend activities and asked to rate each activity in terms of its
effect on their child's attentional functioning. These ratings
were made on a 1 ("more worse") to 5 ("much better") scales. A
rating of 3 was neutral and indicated that parents did not feel their
child's attention problems were noticeably different after
participating in the activity. Twenty-five activities were rated:
11 indoor activities, 6 outdoor activities in man-made settings, and 8
activities conducted in green outdoor spaces.
To examine whether children's ADHD symptoms -- specifically problems with attention -- are diminished after activities in green settings, the authors compared activities that parents believed were associated with subsequent increases or decreases in their child's symptoms. Of the 20 activities judged by independent raters as unequivocally occurring in natural settings (e.g. playing in the woods), 17 (i.e. 85%) were nominated as "best" activities, meaning that after participating in these activities, parents felt their child's symptoms were noticeably diminished. Only 3 of these activities (i.e. 15%) were felt to be associated with a subsequent increase in ADHD symptoms. In contrast, of the activities nominated as "worst" (i.e. symptoms are worse immediately after these activities), 57% were activities that were likely to occur indoors or in man-made outdoor settings. Thus, "green" activities were significantly more likely to be nominated as "best" than "not green" activities.
The authors also examined parents' ratings of their child's ADHD symptoms after participating in a wide range of activities that occurred in both natural and non-natural settings. They reasoned that if nature is supportive of children's attentional functioning, activities conducted in green outdoor settings should receive higher ratings than activities conducted in indoor settings or man-made outdoor settings. Results were consistent with the hypothesized pattern as "green" activities received higher ratings (i.e. average rating of 3.54 on a 1 to 5 scale) than activities occurring in the other two contexts (i.e. 3.22 for indoor activities and 3.24 for activities in man-made outdoor settings). These differences were statistically significant.
To be more certain that these support an association between "green" activities and enhanced attentional functioning, the authors considered a number of alternative possibilities. For example, one alternative explanation for these results is that "green" activities enhance attentional functioning not because they occur in natural settings, but simply because they occur outdoors. If this were the case, however, then parent ratings of "green" activities and outdoor activities in man-made settings should not differ. As discussed above, however, "green" activities were rated more positively than other outdoor activities. (Remember, higher ratings indicate that parents felt their child's symptoms were better after participating in the activity.)
They also considered whether "green" activities may help diminish ADHD symptoms not because they occur in natural settings, but rather because they are more likely to involve physical activity. Active green activities (e.g. playing in a tree house) did not receive higher ratings than passive green activities (e.g. reading a book in a park). Thus, they did not find evidence that participating in "green" activities and better attentional functioning are associated because of the physical activity involved.
The authors also considered whether "green" activities are qualitatively different from activities that occur in non-green settings, and that this could explain their results. To examine this, they identified activities that were similar across the three settings and considered whether parent ratings still differed. Even for similar types of activities, parents still rated those occurring in "green" settings as more likely to be associated with a subsequent reduction in ADHD symptoms.
Finally, they considered whether activities in green settings may be associated with better attentional functioning simply because they are more likely to be preferred activities. According to parents' ratings of their child's preferences, however, this did not seem to be the case. Many activities that were reported to be strongly preferred by children (e.g. watching TV and playing video games) were regarded by parents as leading to an increase, rather than a decrease, in their child's symptoms.
SUMMARY AND IMPLICATIONS
Results from this interesting study are consistent with the authors' primary hypothesis that spending time in natural settings enhances the attentional functioning of children with ADHD. Based on these findings, the authors suggest that increasing the amount of time spent in green settings, particularly before times when sustained attention to tasks such as homework will be required, may offer a helpful addition to traditional treatments.
Although the authors are to be commended for their efforts to begin researching this interesting hypothesis, it is important to recognize that limitations in this study prevent any firm conclusions. One important limitation they acknowledge is that the design of their study was correlational, meaning that time spent in green settings was shown to be related to better attentional functioning. Correlational data, however, cannot establish causal relationships. This remains true despite efforts made by the authors to rule out alternative explanations of their findings. Evidence of causation can only be established by experimental studies.
Thus, the next step in this program of research would be an experiment in which children were randomly assigned to spend time in "green" and "non-green" activities, and then be measured on their subsequent functioning on tasks demanding sustained attention (e.g. schoolwork) by individuals who were not aware of what activity the child had just completed.
If it were found that children's attention to these activities was significantly better after time spent in green vs. non-green settings, then more direct support for the benefits to attention of spending time in green settings would be provided. In the absence of this experimental evidence, no firm conclusions about the role of nature in enhancing attentional functioning can be drawn. (For example, it is possible the current results could be explained by the fact that parents believe that spending time in natural settings is good for children, and thus believe that children do better after contact with nature even though this is not objectively true.)
It is important to emphasize that highlighting this need for additional experimental research is not a criticism of the interesting work the authors have presented. The study they conducted is a reasonable first step in trying to establish a relationship between time spent in natural settings and diminished ADHD symptoms. It is, however, only a first step and should be clearly recognized as such.
Until more definitive evidence in support or refutation of their
hypothesis is available, this work highlights the possibility
that some activities -- whether they are "green" activities or not --
may be reliably associated with a subsequent reduction in children's
ADHD symptoms. It could be profitable, perhaps, for parents to
think about how their child appears after engaging in different
activities, and whether there are particular activities after which
attentional functioning seems to improve. Trying to identify what
these activities have in common, and working to incorporate any common
features into a larger part of their child's day, would seem unlikely
to cause any harm and might turn out to be quite helpful.
Although it is generally assumed that children with ADHD tend to think poorly about themselves, there have actually been relatively few studies in which the self-concepts of children with and without ADHD have been compared, and the results of those studies have been mixed. Thus, some researchers have reported that children with ADHD regard themselves less favorably in a number of different domains than other children, while other researchers have not found these differences.
A related area of research has examined the appraisals that children make of their own performance immediately following their participation in a laboratory task. Thus, in these studies, researchers have examined how the self-appraisals of ADHD children vary in situations where their actual level of performance is objectively known. Regardless of whether the tasks have involved academic or social activities, boys with ADHD tend to report they did better than what was shown to actually be the case. Boys without ADHD, in contrast, evaluate their performance more accurately.
Findings from these laboratory studies have led some researchers to speculate that boys with ADHD (unfortunately, girls with ADHD have not been included in this research) have "positive illusory self-concepts". It has been argued that holding unrealistically positive views about themselves may serve an important protective function for boys with ADHD, by allowing them to cope with repeated failures without adverse psychological consequences. Other psychologists have suggested, however, that this "self-protective" strategy may interfere with the remediation of their problems if it leads them to deny that they have problems at all.
Although these are interesting speculations, it is important to recognize that there has been no previous research in which the self-concept of children with ADHD has been examined in relation to their actual abilities and competencies. The laboratory studies mentioned above deal with children's appraisals of their performance on specific tasks, and findings from these studies may not generalize to the more enduring views children hold of themselves. Thus, the question of whether children with ADHD have inflated self-concepts has not been systematically examined.
Do boys with ADHD actually have "positively illusory self-concepts" as some have suggested? This question was examined in a study published recently in the Journal of Abnormal Psychology (Hoza, B. et al, 2002, 111, 268-278.) Participants in this study were 268 boys between the ages of 7 and 13. The majority of these boys (195) had been diagnosed with ADHD and was participating in an intensive summer treatment program. The remaining 73 boys did not have ADHD and were included as comparison subjects. Unfortunately, as has often been the case in research on ADHD, females were not included as participants.
Participants' self-perceptions were assessed using the Self-Perception Profile for Children (SPPC), a widely used instrument that assesses children's views of themselves in five specific areas: academic performance, social competence, physical appearance, athletic competence, and behavioral conduct. In addition to these domain-specific ratings, the SPPC also includes items designed to assess children's general feelings of self-worth. The idea behind this measure is that children have domain-specific self-perceptions that can vary from one area to another, in addition to more general feelings about themselves that are not domain-specific.
To assess the boys' actual competencies in the different domains assessed by the SPPC, their teachers completed a teacher version of this measure. Teachers' responses to the same sets of items were regarded as providing an "objective" assessment of how the boys were actually doing in each domain, and provided a benchmark against which boys' self-ratings could be compared. When a child's self-ratings were higher than the ratings provided by his teacher in a particular domain, it suggests that the child's self-perceptions in that domain were inflated. Similarly, if a child's self-ratings were lower than those of his teacher, it suggests that the child was being unrealistically negative. When child and teacher ratings corresponded, it was assumed to reflect the fact that the child had an accurate perception of his competence. (Note: The teacher measure did not include items reflecting children's feelings of general self-worth because these reflect a child's views of self that are independent of specific areas of competence, and thus can not be compared to an "objective standard".)
The researchers predicted that, although the self-perceptions of ADHD boys might not differ from those of comparison boys in an absolute sense, they would be inflated relative to the "objective" ratings provided by teachers. In other words, they expected to find that ADHD boys had "positive illusory self-concepts". Furthermore, they expected the greatest inflation would be found in those domains that were most problematic for the boys. Thus, for boys with ADHD who also had significant learning problems, their self-concept in the academic domain was expected to show the greatest inflation. For ADHD boys who were also highly aggressive, the greatest inflation was expected in the behavioral and social domains. For ADHD boys who were depressed, no domain-specific predictions were made. These boys, however, were expected to report the most negative feelings about themselves on the general self-worth scale.
To determine whether boys with ADHD overestimate their competence relative to the comparison boys, the authors first compared the size of the discrepancy between self- and teacher-ratings for children in the two groups. Results indicated that boys without ADHD tended to rate themselves similarly to the way in which their teachers had rated them in all domains. Boys with ADHD rated themselves as more competent than their teachers had rated them in the academic, social, and behavioral domains. The discrepancy between self-ratings and teacher-ratings for ADHD boys was significantly higher than that for comparison boys in every domain. In other words, their ratings of their own competence were inflated relative to how their teachers regarded them.
It is interesting to note that the self-competence ratings for boys in the two groups did not differ in an absolute sense. Thus, the ratings made by boys with ADHD were equivalent to those given by comparison boys, indicating that ADHD boys did not regard themselves as either more or less competent than the other boys. As noted above, however, comparisons to the teacher ratings indicated that, for boys with ADHD, these views of themselves are overly positive and do not reflect the opinions of their teachers that are presumed to be more objective.
The researchers next examined whether ADHD boys who had additional problems with aggressive behavior, academic achievement, or depression tended to overestimate their competence in these specific areas. It was predicted that boys with ADHD would overestimate their competence to the greatest extent in the domains that were most problematic for them.
As predicted, ADHD boys with aggressive-behavior problems overestimated their competence to the greatest extent in the behavioral and social domains. Not only was the discrepancy between self- and teacher-ratings for these boys greater than for non-ADHD comparison boys, it was also greater than the discrepancy for ADHD boys without aggressive-behavior problems. For ADHD boys with co-occurring learning problems, the greatest overestimate was found for ratings of academic competence. Compared to non-ADHD boys and ADHD boys without significant learning difficulties, these boys had significantly larger discrepancies between self- and teacher-ratings.
The situation for ADHD boys who also were depressed was somewhat different. These boys were the only group to underestimate their physical appearance, rating themselves as less attractive than their teachers rated them. Relative to comparison boys, they overestimated their competence in the behavioral domain, but to a lesser extent than ADHD boys without depressive symptoms. In the social and academic domains, their self-ratings were not inflated. On the global self-worth scale, they had significantly lower scores than boys without ADHD and ADHD boys who were not also depressed.
SUMMARY AND IMPLICATIONS
The major findings of this study were: ADHD boys overestimated their self-perceptions more than comparison boys in scholastic, social, and behavioral domains relative to how their teachers regarded them; and, examination of ratings provided by boys in the different subgroups indicated that they overestimated their competence the most in those domains in which they were most impaired. Thus, even though they did not rate themselves more favorably than comparison boys in an absolute sense, boys with ADHD perceived themselves to be far more competent than their teachers did. The primary exception to this was for ADHD boys who were also depressed, as these boys regarded themselves negatively in several areas, including their feelings of global self-worth.
As noted earlier, some researchers have argued that these inflated self-perceptions serve a self-protective role for boys with ADHD, buffering them from the adverse psychological consequences associated with daily struggles and difficulties. This explanation suggests that ADHD boys may not be deliberately overstating their capabilities, but may be "deceiving themselves" in an effort to avoid feelings of inadequacy. Alternatively, the authors suggest these findings may represent either a conscious attempt at impression management (i.e. wanting to present themselves favorably to others), or the fact that they lack the necessary knowledge about what constitutes successful vs. unsuccessful behavior.
What are the implications of these results for treatment? There is a lack of clarity on this issue in the literature. Some have suggested that if ADHD boys overestimate their actual competence, their self-perceptions need to be altered to more accurately reflect the reality of their situation. Proponents of this view argue that, unless boys with ADHD develop an accurate appraisal of their abilities and how others perceive them, they will not be motivated to work on changing their problematic behavior. Others have expressed concerns that such "humility training" could be damaging to boys' self-esteem. Clearly, there is no simple answer to this question, and research that specifically examines the treatment implications of these findings would be important to conduct.
As with any study, it is important to be careful not to generalize the results of this research beyond what is reasonable. First, the findings obtained apply only to boys with ADHD, and whether ADHD girls show the same tendency to overestimate their competence is not known. Second, it should not be assumed that these findings apply to all boys with ADHD. Thus, many boys with ADHD -- even those who are not also depressed -- will regard themselves quite negatively, rather than overestimating their competence as was reported here. This may be especially true as boys with ADHD move into adolescence, and replicating this study with a teenage population would be an important extension of this research.
We also do not know what the implications of these findings are for the immediate or longer-term adjustment of boys with ADHD. Does the tendency to overestimate one's competence create more trouble for these boys because it eliminates the motivation to work on their difficulties? Or, does it protect them from becoming discouraged and despondent? Questions like this can only be answered by following boys over time, and examining their ongoing adjustment in relation to the types of discrepancies between self-perceptions and ratings provided by others that were the focus of this study. This is difficult work, but the results of such a longitudinal study would be extremely interesting and informative.
Information presented in Attention Research Update is for
informational purposes only, and is not a substitute for professional