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Reconceptualizing ADHD in the classroom Implications for Educators


Reconceptualizing ADHD in the classroom Implications for Educators Rosemary Tannock, PhD The Hospital for Sick Children Toronto, CANADA Disclosures: – PowerPoint PPT presentation

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Title: Reconceptualizing ADHD in the classroom Implications for Educators

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
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
  • What are the required teacher qualifications?

Current paradox ADHD
Clinical Perspective Construct behavioral
disorder Diagnosis Treatment behavioral
Neuroscientific Perspective Construct
neurobiological disorder Diagnosis treatment
neurobiological /or
neuropsychological features
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

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

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

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

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
  • developmental coordination disorder 10 - 50

    (rarely considered)

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
  • meet diagnostic criteria for ADHD most have
    learning disorders (RD) at school age

Longitudinal pathway of overlap between ADHD
oral language problems (McGee et al., JAACAP
  • Epidemiological prospective longitudinal study
    of youngsters with difficult to manage behavior
    plus language difficulties at age 3
  • manifested as ADHD reading disorders in
  • had worst outcome in terms of literacy and
    psychopathology in adolescence, compared to those
    with difficult to manage behavior or language
    difficulties, alone.

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)

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)

Behavior problem or communication problem in
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!
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

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

Listening Comprehension is impaired in ADHD even
in the absence of comorbid language impairments
McInnes, et al., J Abnormal Child Psychology
  • 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
  • verbal and spatial working memory abilities

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
  • 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

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
  • Comprehension
  • Weak reading comprehension for science texts
    despite adequate decoding skills
  • unclear whether problems attributable primarily
    to slower reading rate

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
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)

Arithmetic Computation Impairments in ADHD
SubtypesFaraone et al., J Am Acad Child Adolesc
Psychiatry 37185-93, 1998
aControls gt Inatt, Combined
ADHD Mathematics
  • Computation
  • Weak, even in absence of specific math disability
  • Multi-step computation appears particularly
  • Word problems
  • Difficulty with irrelevant information
  • Problematic even for youngsters with
    sub-threshold inattention (sub-clinical ADHD)

Disruptive Talk or Private Speech ADHDCONTEXT
(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!
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
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

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,
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

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

Working Memory
  • Helps the mind focusan attention controller

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)

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

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
  • Influenced by chemical neurotransmitters
  • Dopamine, noradrenaline

Working memory attentionDe Fockert, Rees,
Frith, Lavie Science, 2911803-6, 2001 Conway,
Cowan, Bunting, 2001 Strayer Johnston, 2001
Working memory
  • The greater the working memory load, the more the
    individual will be distracted by irrelevant
  • Implications individuals with WM impairments
    will be more readily overloaded distractible

Driven to Distraction (Strayer Johnston,
  • 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

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)

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

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
  • A is in front of B A is in front of C thus, B

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

Inattention, working memory, academic
  • 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)

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

Impact of Working Memory Deficits on Academic
  • 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

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

Inattention, working memory, academic
  • 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
Proposed relationship between working memory,
attention, language, reading
Neurobiological Substrate
Biological factors
WorkingMemory Deficits
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

  • 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)

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

Major points ADHD
  • ADHD is a biologically-rooted neurocognitive
  • 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

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

What are the treatment targets?DSM-IV medical
Brain Abnormalities
Inattention Hyperactivity Impulsivity
Genetic Environmental Factors
Cognitive function, learning, academic
Treatment targets
Emerging neuroscience/educational perspective
Brain Abnormalities
Specific cognitive processes
Genetic Environmental Factors
Inattention, Hyperactivity, impulsivity Learning,
Academic achievement
Treatment targets
Implications for the Classroom
  • Target
  • Language, cognitive academic problems
    associated with ADHD
  • as well as
  • behavioral symptoms

Thank you for your attention!
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