About ADHD

Attention Deficit Hyperactivity Disorder (ADHD)

Shelia Birkinbine, Alissa Fritz, Lesa Lamb, and Danielle Roller

Brief Description of ADHD:

For a child to be diagnosed with attention deficit hyperactivity disorder (ADHD) they must have difficulty with inattentiveness, over-activity, impulsivity, or a combination of the three. These difficulties must be greater than normal when compared to children their age and at their developmental stage. At this point in time, it is the most commonly diagnosed behavioral disorder in children. A cause has not been found for ADHD but imaging studies have shown the brains to be different between a child diagnosed with ADHD and a typical child. A majority of children with this disorder have concomitant developmental or behavioral disorders. Although guidelines for diagnosing ADHD have been set, it is both misdiagnosed and goes undiagnosed. The following is the DSM-IV criteria for diagnosing ADHD:

I. Either A or B:

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat when sitting still is expected.

2. Often gets up from seat when remaining in seat is expected.

3. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4. Often has trouble playing or doing leisure activities quietly.

5. Is often "on the go" or often acts as if "driven by a motor".

6. Often talks excessively.

             Impulsivity

1. Often blurts out answers before questions have been finished.

2. Often has trouble waiting one's turn.

3. Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV. There must be clear evidence of clinically significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

IA. ADHD, Combined Type: if both criteria IA and IB are met for the past 6 months

IB. ADHD, Predominantly Inattentive Type: if criterion IA is met but criterion IB is not met for the past six months

IC. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion IB is met but Criterion IA is not met for the past six months.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.


Prevalence:

On average, ADHD affects 3-5% of school age children with more boys being diagnosed than girls. The chart below breaks down the prevalence by state for all individuals (ages 4-17) who have ever been diagnosed with ADHD: (this chart is confusing to me - you might want to put in something here to explain more clearly or maybe take out?)
 

State	Diagnosed	State	Diagnosed	State	Diagnosed
Alabama	14.3	Louisiana	14.2	Oklahoma	11.0
Alaska	9.2	Maine	9.6	Oregon	8.8
Arkansas	13.1	Maryland	11.9	Pennsylvania	10.2
Arizona	7.6	Massachusetts	9.8	Rhode Island	11.1
California	6.2	Michigan	9.9	South Carolina	12.0
Colorado	7.6	Minnesota	7.8	South Dakota	8.1
Connecticut	7.8	Mississippi	9.9	Tennessee	11.3
Delaware	14.1	Missouri	10.8	Texas	7.7
District of Columbia	7.7	Montana	8.5	Utah	6.7
Florida	11.6	Nebraska	9.0	Vermont	9.9
Georgia	9.2	Nevada	5.6	Virginia	10.2
Hawaii	6.3	New Hampshire	8.5	Washington	9.5
Idaho	8.3	New Jersey	9.0	West Virginia	13.3
Illinois	6.2	New Mexico	7.1	Wisconsin	9.9
Indiana	13.2	New York	9.2	Wyoming	9.1
Iowa	9.7	North Carolina	15.6
Kansas	10.0	North Dakota	10.0
Kentucky	12.4	Ohio	13.3

(http://www.cdc.gov/ncbddd/adhd/prevalence.html)

Summary of ADHD’s affect on language and literacy:

• Comprehension: Both oral and silent reading comprehension is intact. However, the rate at which they comprehend text is slower than their age-matched peers. Although their rate of comprehension is reduced, their accuracy of responses to comprehending complex sentences is not impacted.
• Fluency: The reading rate and accuracy, rapid word reading efficiency and rapid naming speed is impacted is impacted.
• Vocabulary: Vocabulary is reduced. Due to their inattention, their ability to acquire language and new vocabulary is impacted.
• Writing/Spelling: Writing skills are impacted in terms of adequacy, structure, grammar, and lexicon. Their expressive narrative texts tend to be short in length and contain more errors than their age-matched peers.
• Language discourse: Sentence imitation and word articulation is impacted, as well as inappropriate pragmatic knowledge, such as not responding to questions/requests, providing less detailed feedback to the listener, lack of cohesion of verbal output, and/or using nonspecific vocabulary. Overall expressive language is more impacted than receptive language. It should be noted, however, that their pragmatic knowledge is not impaired, but rather their pragmatic performance behaviors exhibited.

References:

Ghelani, K., Sidhu, R., Jain, U., & Tannock, R. (2004). Reading comprehension and reading related abilities in adolescents with reading disabilities and attention-deficit/hyperactivity disorder. Journal of Dyslexia, 10, 364-385.

Ghelani et al. (2004) examined reading comprehension in adolescents with a reading disability and/or ADHD using both oral and silent reading passages. They also investigated the characteristics of reading component skills in these disorders. The performance of four groups of adolescents (RD, ADHD, ADHD and RD and normal controls) were compared on reading comprehension tasks as well as on reading rate and accuracy tasks. Both silent and oral reading comprehension was measured using the Gray Oral Reading Tests-4th Edition (GORT-4) and the Gray Silent Reading Tests (GSRT). Text reading rate and accuracy was measured using the Rate and Accuracy subtests of the GORT-4. Rapid word reading efficiency was measured using subtests of the Test of Word Reading Efficiency (TOWRE). Lastly, the Letters, Digits, Colors, and Objects subtests from the Comprehensive Test of Phonological Processing (CTOPP) were used to assess rapid naming speed. Oral and silent reading comprehension: Only the RD group had lower scores on both oral and silent reading comprehension measures compared to the normal controls and the ADHD group. However, these scores were within normal range. Text reading rate and accuracy: RD, ADHD, and RD + ADHD had significantly lower scores on text reading rate and accuracy compared to normal control group. Mean scores for RD and RD + ADHD were within the more severe range. Also, RD and RD + ADHD were significantly lower on text reading rate and accuracy relative to the ADHD group. Rapid word reading efficiency: RD, ADHD and RD + ADHD were significantly slower on both sight word and nonword reading efficiency tasks compared to the normal control group. However, the scores for the ADHD group remained within the average range. Rapid naming speed: RD and RD + ADHD were significantly impaired on both naming composites compared to the normal controls. The ADHD group displayed significantly lower scores relative to the normal controls when naming colors and objects, but not when naming letters and digits. This study highlights the need to include a number of different reading skill measures when conducting reading assessments rather than relying solely on measures of untimed isolated sight word reading and decoding. Reading comprehension tasks that assess reading rate, oral decoding, and prosody, as well as silent reading tasks that reflect classroom reading should be included in assessments. Slower reading rates found in the RD and ADHD + RD groups may prevent these students from keeping pace with the amount of required reading. Therefore extra time provisions for students who have both inattention and reading difficulties are critical as they require more time to decipher print.

Kim, O. & Kaiser, A. (2000). Language characteristics of children with ADHD. Communication Disorders Quarterly, 21(3), 154-165.

Kim and Kaiser (2000) examined the language characteristics of 11 children with ADHD and 11 typically developing children ages 6-8. Both groups were assessed on semantic, syntactic, and pragmatic language abilities using the Attention Deficit/Hyperactivity Disorder Test, the Standford-Binet and the WISC-III (for intellectual measures), the Peabody Picture Vocabulary Test- Revised (PPVT-R), the Test of Language Development-2 (TOLD-2), the Test of Pragmatic Language (TOPL), and the Pragmatic Protocol. Results of the study showed that children with ADHD performed significantly lower than controls on sentence imitation and word articulation (TOLD-2), overall speech and language quotient and speaking quotient (TOLD-2), and pragmatic performance. It is important to note that no significant difference was found between the groups with regards to pragmatic knowledge. Inappropriate pragmatic performance behaviors exhibited by those with ADHD included not responding to questions/request, interrupting, providing less feedback to the listener, lack of cohesion of verbal output, and/or using non-specific vocabulary. Overall, findings from the study suggest that children with ADHD are more likely to have deficits in expressive language than receptive language. As noted by Kim and Kaiser (2000), “behavioral characteristics of children with ADHD- such as short attention span and insensitivity to social cues- may contribute to pragmatic difficulties of children with ADHD” (p. 159). Furthermore, the authors point out that inattentiveness itself can lead to language impairments because if one is not able to pay attention well, then they are less likely to develop language normally.

Re, A.M., Pedron, M., & Cornoldi, C. (2007). Expressive writing difficulties in children described as exhibiting ADHD symptoms. Journal of Learning Disabilities, 40(3), 244-255.

Re, Pedron, and Cornoldi examined the expressive writing skills of children who were identified by their teachers as having symptoms of ADHD. Three groups of children of various ages with symptoms of ADHD were matched to control groups. The groups were given different expressive writing tasks. In the first task, the subjects were asked to write a description of an image. The task was given to 24 students in the sixth- and seventh-grade. The second task involved subjects that were younger in age and involved them giving a verbal description. In the third task, different experimental and control groups from the first two tasks were asked to write a narrative text. The researchers found that on all three tasks, the children identified as having ADHD symptoms scored lower than the control group. The researchers used four parameters to measure performance on the tasks, which were adequacy, structure, grammar, and lexicon all of which the ADHD group performed lower on. It was also found that the ADHD group’s texts were shorter and contained more errors. The overall conclusion made by the researchers were that children who have ADHD symptoms do have difficulty in writing and these difficulties exist in both spelling and expression. They also concluded that these difficulties are not dependent on age or task.

Wassenberg, R., Hendriksen, J., Hurks, P., Feron, F., Vles, J. & Jolles, J. (2010). Speed of language comprehension is impaired in ADHD. Journal of Attention Disorders, 13 (4), 347-385.

Wassenberg et al. (2010) compared the ability to comprehend complex sentences of participants with ADHD combined type and normal controls. Participants included fifteen children aged 7-11 and 15 adolescents aged 12-16 with combined type ADHD. These participants were then matched for age, gender, and parental level of education with 30 control subjects. Complex language comprehension was assessed using the Assessment Battery for Children-Language (ABC-L) and an adapted version of the Token Test (TT-A). Example sentences used to measure complex language comprehension included: ‘Put the red circle between the yellow rectangle and the green rectangle,’ and ‘The girl who worked at the zoo came to Margaret’s school to give a presentation. Who gave the presentation?’. In analysis, experimenters controlled for level of verbal intelligence, level of working memory, and presence of dyslexia in order to increase the internal validity of the study. Specific aims of the current study were to assess accuracy and speed of complex language comprehension as well as any age-related differences in complex sentence comprehension in individuals with ADHD. The primary finding of the study was that those with ADHD comprehend language at a slower rate than age and gender matched controls without ADHD. Accuracy of responses to complex sentence comprehension were not found to be different across the two groups however. Furthermore, the experimenters found no significant interaction between ADHD and age on either accuracy or speed of complex language comprehension measures, suggesting that ADHD is not simply a developmental delay, but is actually a permanent disability. These results are clinically relevant in several ways. As noted by Wassenberg et al. (2010), children and adolescents with ADHD may need more time to process complex instructions in the classroom or therapy setting, such as “Take out your workbook, open to page 34, and start working on assignment B” (p. 9). The author suggests that these results should be taken into consideration within such settings, and children and adolescents with ADHD should be provided with extra time to process complex oral instruction as well as increased opportunities to ask for repetition.

Websites:

• http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/
• PubMed Health provides a definition of ADHD, along with causes, incidence, risk factors, symptoms, treatment, and expectations. The website is simplified, where a parent could easily read through and understand the information. This website is a great starting point for parents who have questions about ADHD.
• http://kidshealth.org/teen/school_jobs/school/adhd.html
• Kids Health is a great website to share with children and their families who have been diagnosed with ADHD. The website has a tab for parents, for kids, and for teens. It also has a listening option where the text is read out loud and it can also be displayed in Spanish. The site is for health overall but has easy access to find the articles and information on ADHD. This site is a great resource for speech-language pathologists since it could be used for many other disorders as well.