Reconceptualizing ADHD in the classroom Implications for Educators

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Reconceptualizing ADHD in the classroom
Implications for Educators

• Rosemary Tannock, PhD
• The Hospital for Sick Children
• Toronto, CANADA

Disclosures Novartis Research funds Lilly
Consultant, Research funds
Toronto, November 27th 2003
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ADHD Challenges for Educational Systems

• Education costs 3 to 6 times greater
  (Forness et al., NIH Concensus, 2000)
• Prevalence (1 or 2 children in every class)
• Association with learning social problems
• Meaning for educational programming is unclear
• What type of exceptionality/special needs?
• What are the Standards for level of service
  instruction?
• What are the required teacher qualifications?

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Current paradox ADHD
Clinical Perspective Construct behavioral
disorder Diagnosis Treatment behavioral
symptoms
Neuroscientific Perspective Construct
neurobiological disorder Diagnosis treatment
neurobiological /or
neuropsychological features
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Reconceptualizing ADHD for the classroom Overview

• Overlap with LD
• Oral language, reading, arithmetic, written
  expression in children with ADHD
• Significance of inattention
• Significance of working memory problems

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Medical/Psychiatric Learning Disorders

• are characterized by academic functioning that
  is substantially below that expected given the
  persons chronological age, measured
  intelligence, and age-appropriate education.
  (DSM-IV-TR, APA, 2000)
• Note No requirement for evidence of impairment
  in basic psychological processes

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Legal/Educational Specific Learning Disability

• a disorder in one or more of the basic
  psychological processes1 involved in
  understanding or in using language, spoken or
  written, which may manifest itself in an
  imperfect ability to listen, think, speak, write,
  spell, or do mathematical calculations(Individu
  als With Disabilities Education Act, June 4,
  1997, 602.26a. Emphasis added)1 The
  psychological process criteria are not
  specified. Also, most US states have
  operationalized the phrase - disorders of- as a
  discrepancy between ability (IQ) and achievement

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Controversy in the Definition of LD

• federal/legal/educational approach
• Discrepancy
• Heterogeneity
• Exclusion
• Biobehavioral systems approach
• Manifest disability
• Cognitive/psychosocial traits
• Environmental variables
• Biological variables
• Premise IQ tests not necessary for the
  identification of LD do not contribute to
  intervention planning

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Significant overlap between ADHD
language/learning disorders(Reviews Cantwell
Baker, 1991 Tannock Brown, 2000)

• Epidemiological clinical studies indicate that
  the rates of overlap are greater than expected by
  chance between ADHD
• language disorder 8 - 30 (often unrecognized)
  
• reading disorder 15 - 40
• math disorder 10 - 25 (often overlooked)
• disorder of written expression (common but
  unstudied)
• developmental coordination disorder 10 - 50
  
  (rarely considered)

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Early emergence of overlap of ADHD oral
language problems
Gross-Tsur et al., 1991 Ornoy et al., 1993
Szatmari et al., 1989 Tripp et al., 1999

• Delayed onset of oral language
• 6 - 30 ADHD group1 - 6 of control group
• Most preschoolers (80) exhibiting
• soft neurological signs language impairments
  inattention/hyperactivity,
• meet diagnostic criteria for ADHD most have
  learning disorders (RD) at school age

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Longitudinal pathway of overlap between ADHD
oral language problems (McGee et al., JAACAP
1991)

• Epidemiological prospective longitudinal study
  of youngsters with difficult to manage behavior
  plus language difficulties at age 3
• manifested as ADHD reading disorders in
  school-age
• had worst outcome in terms of literacy and
  psychopathology in adolescence, compared to those
  with difficult to manage behavior or language
  difficulties, alone.

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The Canadian SceneLongitudinal course of
overlap between oral language behavior problems

• Preschool children in Ottawa with early language
  delay behaviour problems (ADHD) show higher
  rates of psychopathology in adolescence young
  adulthood (Beitchman et al, 1982, 1997)

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Language Impairments in ADHD often not recognized

• High rate (58) of undetected language
  impairments in children referred for mental
  health services in Ontario
• Subtle but impairing language problems may be
  obscured by more salient behavioral symptoms
• (Cohen et al., 1993, 1998a, 1998b)

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Behavior problem or communication problem in
ADHD?CONTEXT PSYCHOEDUCATIONAL ASSESSMENT
Child What are we gonna do next? Huh?
Whats in there? Whats that?
(tries to grab test materials) Adult
Youll see in a sec.
(reaching into case for next set of test
materials) --- a few minutes
later, child interrupts testing --- Child
Wheres the umthe thingsumwheres the
um bugs? Adult Pardon? What
bugs? There are no bugs here.
Now, look at this next page and-
(child interrupts whining then gets louder)
Child - The bugs. You said Ill see the
bugs. I dont wanna do this.
I wanna see the bugs the um
secs the insecs!
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Language Correlates of ADHD

• several behaviour symptoms used in ADHD diagnosis
  implicate memory and language-related deficits
• fails to follow through on instructions
• does not appear to be listening
• blurts out answers, talks excessively
• forgetful of routines

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What does the Research Literature Show? Studies
of Expressive Language

• word retrieval difficulties
• poor conversational skills
• weak message coherence
• weak sentence formulation
• language in elicited responses less
  well-formed than spontaneous language
• poor organization of narratives

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Listening Comprehension is impaired in ADHD even
in the absence of comorbid language impairments
McInnes, et al., J Abnormal Child Psychology
(2003)

• community sample of 77 boys
• ADHD, ADHDLI, LI, normal
• main objective...
• listening comprehension for spoken
  explanations (expository passages)
• facts and inferences
• ability to detect errors in explanations and
  descriptions
• verbal and spatial working memory abilities

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Main Findings McInnes, et al., J Abnormal Child
Psychology (2003)

• ADHD group (normal basic language
  skills)performed as well as peers in
  comprehending facts
• but were
• poorer at comprehending inferences - took
  longerto explain their understanding
• poorer at detecting errors in sequence of
  instructions
• had significantly poorer verbal and spatial
  working memory and poorer spatial memory span
• Also, teacher ratings of inattention symptoms
  were significantly related to comprehension of
  the passages

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ADHD ReadingBrock Knapp, 1996
Cherkes-Julkowski et al., 1995 Rucklidge
Tannock, 2002

• Decoding
• only if have concurrent phonologically-based
  reading disabilities
• Rate
• slow reading of single words non-words, of
  short passages despite good phonological
  abilities
• Comprehension
• Weak reading comprehension for science texts
  despite adequate decoding skills
• unclear whether problems attributable primarily
  to slower reading rate

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Dual-pathways to reading problems in
adolescenceMcGee et al, JCPP 43(8) 2002
Teacher ratings
Hyperactivity Ages 9 -11
ADHD Age 5-8
Inattention Ages 9 -11
Inattention Age 15
Word Reading Age 15
Word Reading Age 7-8
Data from Australian Temperament Project
Dunedin Multidisciplinary Health Development
Study
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ADHD Arithmetic Computation A neglected issue

• Numeracy skills
• predict employment and earnings
• related to health evaluation decision
  making (e.g., Charette et al.,
  1998 Parsons Bynner, 1997
  Rivera-Batiz, 1992 Woloshin et al., 2001
  International Adult Literacy
  Survey Green Riddell, 2001)

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Arithmetic Computation Impairments in ADHD
SubtypesFaraone et al., J Am Acad Child Adolesc
Psychiatry 37185-93, 1998
aControls gt Inatt, Combined
a
a
a
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ADHD Mathematics

• Computation
• Weak, even in absence of specific math disability
• Multi-step computation appears particularly
  problematic
• Word problems
• Difficulty with irrelevant information
• Problematic even for youngsters with
  sub-threshold inattention (sub-clinical ADHD)

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Disruptive Talk or Private Speech ADHDCONTEXT
D ARITHMETIC IN LAB CLASSROOM
(Child with ADHD (9yrs old) seated alone at table
with set of math computation problems to be
completed in 10-min) Child Hmm. Two plus three
(counting on fingers) thats two,
three, four, five! (writes, erases,
writes again) Twenty-nine take away. This is
hard! (stands up) Twenty-nine, twenty-eight, um
twenty-six.. uh-oh! (erases vigorously, sharpens
pencil, turns to next page) Wow!
Lots!(whispered. Turns back to previous page)).
OK. And three..nine, tenah!
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Private speech, behavior math computation in
ADHD (Benedetto Tannock, J Attention
Disorders, 1999)

• During a 10-min self-directed arithmetic
  computation task, children with ADHD
• Use immature strategies (finger counting, add-on)
  
• Use immature (externalizing) self-talk
• Exhibit low productivity
• Are more inattentive fidgety

Compared to peers matched on age, IQ, math
achievement,
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ADHD Written Expression

• Anecdotally, the most common and impairing
  problem at school. Characterized by.
• Low productivity, poor fluency
• Slow effortful /or fast careless approach
• Poor written spelling
• Untidy, uneven, illegible handwriting
• Poor written sentence construction
• BUT.No systematic research to date

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The presence of even a fewinattentive behaviors
in early childhood should be viewed as a
developmental risk factor (Warner-Rogers et
al., JLD,332000) (Rabiner Coie, JAACAP,
392000)
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The presence of even a few inattentive behaviors
in early childhood should beviewed as a
developmental risk factor (Warner-Rogers et
al., J Learning Disabilities,332000) (Rabiner
Coie, JAACAP, 392000)

• Grade 1-2
• below average academic skills
• oral language, reading, written language, number
  concepts and computation
• poor classroom adjustment
• low confidence, need for repeated instructions
• Kindergarten
• poor reading achievement in Grade 5

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Significance of Inattentionfor cognitive
processesChhabildas, Pennington, Willcutt, J
Abnorm Child Psychol, 2001

• Inattention symptom cluster is the strongest
  predictor of neuropsychological impairments
• vigilance, processing speed, inhibition
• Hyperactivity/impulsivity not associated with
  neuropsychological impairments

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Working Memory

• Helps the mind focusan attention controller

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Working Memory

• Multi-component cognitive system that allows us
  to temporarily hold and manipulate information
  on-line for a brief period (second).
• Permits us to maintain information temporarily in
  a readily accessible form while simultaneously
  processing new information, often in the presence
  of distracting and irrelevant information.
• This continually updated internal on-line
  record of relevant information guides decision
  making and overt behavior (responses) during an
  activity, rather than immediate sensory cues in
  the environment.
• Plays a crucial role in a wide variety of complex
  cognitive activities (e.g., mental arithmetic,
  reading comprehension)

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Working Memory(Baddeley, 1986 Fuster, 1995
Goldman-Rakic, 1996 Miyake Shah, 1999)

• Multidimensional construct
• Processes
• On-line maintenance (span)
• Manipulation (updating, shifting)
• Modality/representation
• Auditory/Verbal
• Visual/Spatial

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Working memory(Brunel et al., 2001 Fuster,
2001 Gao, Krimer, Goldman-Rakic, 2001 Gutkin et
al., 2001

• operates over periods of seconds
• not localized in the brain, but rather comprises
  transiently activated neural networks in
  prefrontal cortex and other brain regions
• Persistent neuronal firing in the absence of a
  stimulus
• Influenced by chemical neurotransmitters
• Dopamine, noradrenaline

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Working memory attentionDe Fockert, Rees,
Frith, Lavie Science, 2911803-6, 2001 Conway,
Cowan, Bunting, 2001 Strayer Johnston, 2001
Working memory
attention

• The greater the working memory load, the more the
  individual will be distracted by irrelevant
  information.
• Implications individuals with WM impairments
  will be more readily overloaded distractible

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Driven to Distraction (Strayer Johnston,
2001)

• Dual-task studies to assess effects of cellular
  phone conversations on driving performance
• Driving performance impaired by
• Concurrent tasks that placed demand on verbal
  working memory (e.g., in-depth conversation)
  diverted attention to those activities
• Not by listening to radio or books-on-tape

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Working memory the cocktail party phenomenon
(Conway, Cowan, Bunting, 2001)

• Humans exhibit the ability to attend to only part
  of a noisy environment, yet highly pertinent
  stimulus, can suddenly capture attention
• In approx 33 individuals
• Those with low working memory capacity (span)

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Working memory language acquisition (Baddeley,
Gathercole Papagno, 1998 Adams Gathercole,
2000 Willis Gathercole, 2001)

• Ability to maintain unfamiliar sound patterns (in
  the phonological loop) while more permanent
  memory records are constructed, plays a crucial
  role in vocabulary acquisition
• Children with limitations in working memory
  exhibit narrower repertoire of words syntactic
  constructions, shorter utterances, poorer
  sentence repetition

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Working Memory ComprehensionDaneman
Merickle, 1996 Goel Dolan, 2001 Haenggi,
Kintsch Carpenter, 1995)

• Ability to manipulate ( maintain) information is
  essential for comprehension
• visual-spatial working memory critical for
  inferential comprehension
• neural substrates for visuo-spatial processing
  form the basic representational building blocks
  used for logical reasoning in 3-term relational
  arguments
• A is in front of B A is in front of C thus, B
  is...

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Hypotheses

• Individuals with low working memory ability
  (maintain/manipulate) will exhibit
• Greater distractibility, poorer sustained
  attention
• Weaker oral language abilities
• Poorer inferential comprehension

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Inattention, working memory, academic
achievement

• Community sample in the UK
• Low working memory predicts below-average
  performance on national curriculum in language
  arts and math, in 6 - 7 year-olds (Gathercole
  Pickering, 2000)

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Potential Impact of WM Weaknesses on Language
Functioning

• May forget what one was going to say
• May get confused when given complex instructions
  or explanations
• Expressive language may not be cohesive or
  coherent
• E.g., disorganized story-telling
• Difficulty with turn-taking and topic shifts

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Impact of Working Memory Deficits on Academic
Performance

• Difficulty thinking through problems or engaging
  in extensive reasoning in ones head
• Difficulty understanding meaning of a sentence
  while decoding an unfamiliar word
• Difficulty implementing necessary subskills in
  the writing process while concurrently organizing
  and writing text
• Difficulty maintaining all relevant information
  in a problem and monitoring progress

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Working Memory is impaired in ADHD (Martinussen
Tannock, under review)

• Visual-spatial span working memory
• associated with severity of inattentive symptoms
  (Barnett et al., 2001 Brito et al., 1999
  Karatekin Arsarnow, 1998 Kempton et al., 1999
  Mariani Barkley, 1997 Martinussen et al.,
  World Congress Psychiatric Genetics, 2002
  Mealer et al., 1996 Willliams et al., 2000
• Verbal working memory
• inconsistent findings may be associated with
  comorbid language-based learning disorders

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Inattention, working memory, academic
achievement

• Low working memory predicts below-average
  performance on national curriculum in language
  arts and math, in 6 - 7 year-olds (Gathercole
  Pickering, 2000)

It may be the combination of Inattention
Working Memory that is problematic in ADHD
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Proposed relationship between working memory,
attention, language, reading
Neurobiological Substrate
Biological factors
WorkingMemory Deficits
Inattention
Hyp/Imp
Environmentalfactors
Language
Reading
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However a cautionary note

• To date, there is no cognitive measure that can
  be used to rule in or rule out ADHD
• ADHD is a heterogeneous disorder
• Variation in symptoms
• Variation in co-existing disorders

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BUT!

• Working memory is a critical construct to
  understand because
• WM deficits are associated with learning problems
• WM implicated in ADHD but not specific to ADHD
• Seems to play a role in helping the mind focus
  (de Fockert et al., 2001)

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Clinical and Educational Implications

• ADHD children (with normal basic language
  decoding skills) are likely to have problems in
  some aspects of working memory in higher level
  language comprehension could these problems
  account (in part) for.
• some behaviour symptoms
• reading comprehension difficulties
• pragmatic/ social language problems
• achievement problems in higher grades

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Major points ADHD

• ADHD is a biologically-rooted neurocognitive
  disability
• ADHD is more usefully conceptualized as a type of
  learning disability - rather than just a
  behavioral problem
• It is frequently accompanied by one or more
  specific LDs
• Oral language, academic, cognitive function
  should be routinely assessed in ADHD

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Major points Inattention Working Memory

• Inattention in K/G1 should be viewed as a
  developmental risk factor
• Most classrooms will have several students who
  have one or more of the following difficulties
• ADHD, reading,math, language comprehension,
  anxiety, depression defiance,aggression
• Many of these students are likely to have
  problems with working memory, which impedes
  learning

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What are the treatment targets?DSM-IV medical
perspective
Brain Abnormalities
Inattention Hyperactivity Impulsivity
Genetic Environmental Factors
?
Cognitive function, learning, academic
achievement
Treatment targets
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Emerging neuroscience/educational perspective
Brain Abnormalities
Specific cognitive processes
Genetic Environmental Factors
Inattention, Hyperactivity, impulsivity Learning,
Academic achievement
Treatment targets
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Implications for the Classroom

• Target
• Language, cognitive academic problems
  associated with ADHD
• as well as
• behavioral symptoms

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Thank you for your attention!
Questions