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ADHD AND EMERGENTLITERACY: INFLUENCE OFLANGUAGE FACTORSCynthia A. Riccio a & Sandra J. Jemison aa The University of Alabama , Tuscaloosa,Alabama, USAPublished online: 28 Jul 2006.

To cite this article: Cynthia A. Riccio & Sandra J. Jemison (1998) ADHDAND EMERGENT LITERACY: INFLUENCE OF LANGUAGE FACTORS, Reading& Writing Quarterly: Overcoming Learning Difficulties, 14:1, 43-58, DOI:10.1080/1057356980140103

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ADHD AND EMERGENT LITERACY: INFLUENCE OFLANGUAGE FACTORS

Cynthia A. Riccio and Sandra J. JemisonThe University of Alabama, Tuscaloosa, Alabama, USA

Language-based learning disability and attention-deficit hyperactivity dis-order (ADHD) frequently co-occur. Theoretical frameworks for understandingthe relationship between ADHD and learning disabilities, and particularlyreading disability (RD), are reviewed. Attentional factors per se may not resultin difficulty attaining basic reading skills; some children with ADHD may alsohave linguistic deficits and particularly phonological processing deficits. Giventhe frequency of co-occurring ADHD and RD, children referred for either con-dition should be assessed for the other. ADHD frequently occurs with specificlanguage impairment (SLI). A comprehensive assessment must include lin-guistic factors, particularly phonological processing. Collaboration and consul-tation of various professionals in the assessment process are necessary. Finally,the implications of this research with an emphasis on the need for appropriateintervention for children with co-occurring ADHD and problems in acquisitionof reading skills are discussed.

Attention-deficit hyperactivity disorder (ADHD) is one of the most fre-quent reasons for referral of children for evaluation (Barkley, 1990;Felton & Wood, 1989). Over the course of its history, ADHD has beenknown by various terms and, at times, conceptualized as having sub-types (attention deficit disorder without hyperactivity, attention deficitdisorder with hyperactivity; American Psychiatric Association [APA]1980) or not having subtypes (APA, 1987), and more recently with areturn to subtypes (predominantly inattentive, predominantly hyper-active, combined type; APA, 1994). In the interest of consistency,ADHD is used throughout this article with subtypes indicated only ifspecified by the study reviewed.

What is now called ADHD was originally conceptualized in conjunc-tion with learning disabilities as minimal brain damage (Epstein,Shaywitz, Shaywitz, & Woolston, 1991). It has gradually been recon-ceptualized as a developmental behavior disorder distinct from thedevelopmental learning disabilities (APA, 1980, 1987, 1994). Despitethis separation in theory, it is not uncommon that children with ADHDdemonstrate academic underachievement, at times sufficient for iden-tification as having a specific learning disability and most frequently inthe area of reading (e.g., Dykman & Ackerman, 1991; Elbert, 1993).

Address correspondence to Cynthia A. Riccio, Educational Psychology MS 4225,Texas A&M University, College Station, TX 77843-4225, USA.

Reading & Writing Quarterly: Overcoming Learning Difficulties, 14:43-58 1998 43Copyright C 1998 Taylor & Francis

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44 C. A. RICCIOANDS.J. JEMISON

Estimates of co-occurrence of ADHD and learning disability range from10% (August & Holmes, 1984) to 92% (Silver, 1981), with many studiesreporting approximately 50% co-occurrence. For example, Wood andFelton (1994) found that 45% of the third graders with reading prob-lems also met criteria for ADHD. In another study, Elbert (1993) foundthat 54% of children with ADHD met the criteria for specific learn-ing disability. Variability in the reported prevalence of ADHD withlearning disability has been attributed to differences in the wayin which learning disability is defined or the way in which ADHD isassessed (Shaywitz, Fletcher, & Shaywitz, 1994).

It could be argued that the underlying cause of learning disability isless important than the implementation of an appropriate interven-tion. Intervention choice and planning, however, may well be influencedby one's beliefs or perceptions of causality. For this reason, it is criticalthat special educators, regular educators, school psychologists, andothers who work with children diagnosed with ADHD have an under-standing of the interactive effects of ADHD, acquisition of basic readingskills, and linguistic factors. Hypotheses specific to the relationshipbetween ADHD and learning disabilities are presented briefly. Recentresearch as it relates to these hypotheses and specific to reading dis-ability (RD) are reviewed. Furthermore, factors that have been found tobe shared by children with RD as compared to children with co-occur-ring ADHD and RD (ADHD/RD) are discussed. Implications of theresearch reviewed as it applies to assessment and intervention for chil-dren with ADHD and co-occurring reading problems are presented.

ADHD: RELATIONSHIP TO RD

Researchers have investigated genetic factors and neurological factorsto try to explain the frequent co-occurrence of ADHD and RD. In addi-tion to research suggesting that ADHD/RD may be due to genetic fac-tors, other hypotheses have been generated with regard to the rela-tionship between learning disability and ADHD. The first two of thesehypotheses deal with unidirectional causal relationships. In contrast,the third, offered by Rowe and Rowe (1992), postulates a reciprocalrelationship between reading achievement and inattention.

Heredity

Research specific to ADHD and RD has indicated that genetic trans-mission may be a factor in both ADHD and RD (e.g., Biederman et al.,1986; Biederman et al., 1992; Lubs et al., 1993). Studies on the familial

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ADHD AND EMERGENT LITERACY 45

transmission of ADHD and RD have suggested that whereas both dis-orders are heritable, each may occur independently (Faraone et al.,1993; Gilger, Pennington, & DeFries, 1992; Gillis, Gilger, Pennington,& DeFries, 1992; Smith, Pennington, Kimberling, & Ing, 1990). In rela-tion to the sizable number of children who evidence ADHD/RD, othergenetic research has suggested that this co-occurrence may be heri-table. For example, in the Colorado Reading Project, with 61 identicaltwins and 43 same-gender fraternal twins, a relationship was foundbetween reading and hyperactivity measures for 70% of the partici-pants (Light, Pennington, Gilger, & DeFries, 1995). It also was foundthat for the children with ADHD/RD, approximately 45% of the deficitin reading was due to genetic factors that also influenced the hyperac-tivity. Researchers concluded that the co-occurrence of RD with ADHDwas due at least partly to genetic influences (Light et al., 1995). In con-trast, the results of Faraone and colleagues (1993) indicated thatADHD/RD was attributable to a higher than expected marriage-mating of individuals with learning disabilities to individuals withADHD.

As with other research, different methods have been used to iden-tify and define RD and different criteria have been used to diagnoseADHD (Shaywitz et al., 1994). As such, additional research in the areaof heredity as a factor is needed before any definitive conclusions canbe reached. Furthermore, it may be of scientific interest to determinethe genetic and neurological bases or causes of these disorders, butthis information is not likely to lead directly to interventions in theschool setting.

Inattention as the Cause

With more of an emphasis on addressing intervention, it has beenhypothesized that the lower levels of achievement of children withADHD are the result of the attentional problems, impulsivity, hyper-activity, and cognitive difficulties associated with ADHD. Zentall(1993) suggested that academic problems were secondary to ADHDbecause of the higher need for stimulation of children with ADHD.Based on this premise, appropriate intervention might be directed toameliorating those behaviors associated with ADHD. Consistent withthis, Zentall (1993) suggested that additional physical stimulationduring learning activities (e.g., through the use of interactive com-puter programs) may improve attention, and, therefore, ultimatelyaffect academic achievement. Although there is evidence that over thelong term some children with ADHD demonstrate low achievement,

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46 C. A. RICCIO AND S. J . JEMISON

there is no evidence that ADHD or inattention per se directly causesproblems in initial academic skill acquisition to the extent presentwith specific learning disability (Baker & Cantwell, 1990).

Academic Difficulty as the Cause

Another hypothesis suggests that the learning disability (processingdeficit) and subsequent failure experience result in impaired concen-tration or inattention. Frith (1995) postulated that the attentional andbehavioral deficits occur as secondary manifestations of reading diffi-culties. Following this line of causality, the child with reading difficul-ties is unable to complete successfully the tasks asked of him or her,becomes frustrated or overwhelmed by the academic demands, and asa result appears inattentive and distractible, possibly demonstratingbehavioral problems as well. Educators and professionals who supportthis premise may be more inclined to design and implement directintervention to the learning disability and academic areas as opposedto the behavioral symptomatology.

Reciprocal Relationship

Whereas the latter two causal hypotheses (i.e., inattention and aca-demic difficulty) are unidirectional, there is a reciprocal relationshipbetween inattentiveness and reading achievement that is mediated bypsychosocial factors (Pennington, Grossier, & Welsh, 1993; Rowe &Rowe, 1992). Rowe and Rowe (1992) examined data from 5,000 stu-dents, aged 5 to 14 years. When socioeconomic status, age, and genderwere controlled, results indicated that student inattentiveness nega-tively affected reading achievement, attitude toward reading, andreading at home with parents. However, this was a reciprocal ratherthan unidirectional relationship. High reading achievement in con-junction with a positive attitude toward reading and reading at homelead to increased attentiveness in the classroom. Thus, not only wasinattentiveness found to influence reading achievement, but readingachievement was also found to affect attentiveness. Furthermore, ithas been suggested that the presence of a mild language disorder andassociated RD in conjunction with environmental factors may result inthose behaviors characteristic of ADHD (Pennington et al., 1993).

CO-OCCURRENCE OF ADHD AND RD (ADHD/RD)

Extensive research has been conducted to explain the relationship be-tween and the co-occurrence of ADHD and RD. Studies have attempted

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ADHD AND EMERGENT LITERACY 47

to identify deficits that are specific to ADHD or RD or their co-occur-rence (ADHD/RD). To accomplish this, researchers have compared somecombination of children with RD (no ADHD), children with ADHD(no RD), and children with ADHD/RD. More recent studies thathave included RD, ADHD, ADHD/RD groups are presented in Table 1.Some of these studies are discussed briefly, with shared results high-lighted.

Separation of Attention-Reading Difficulty

Three studies from the Bowman Gray Learning Disabilities Projectaddressed the ability of linguistic and attentional variables to predictreading achievement (Wood & Felton, 1994). In the first study re-ported, 204 first graders were tested to determine baseline levels andwere then followed in grades 3 and 5. Results indicated an increasedprevalence of ADHD at follow-up; however, there was no predictive orconcurrent relationship between identification as ADHD and testedreading performance. Thus, it was concluded that ADHD had no sig-nificant predictive or concurrent relationship to word identification orpassage comprehension. In the second study, 60 third graders withimpaired reading were reevaluated in grades 5 and 8. As with thefollow-up of first graders, diagnosis of ADHD was not found to be pre-dictive of later reading ability (Wood & Felton, 1994). Similar findingshave been reported by other researchers as well (e.g., Shaywitz et al.,1994).

In their third study, Wood and Felton (1994) reported on the follow-up of adults ages 20-44 years who had previously been identified ashaving reading problems during childhood. These adults were com-pared to a control group of adults with normal reading ability. Non-word reading and rapid naming tests were the only measures that dis-tinguished those adults who had been previously identified inchildhood as having an RD from the control group. Variables of readingimpairment and ADHD (based on review of childhood records) werefound to predict adult educational outcome and reading level. Thus,Wood and Felton concluded that ADHD may impair long-term outcometo a greater extent than it impairs reading acquisition (Wood & Felton,1994). This more global pattern of low achievement in children diag-nosed as ADHD has also been found in other studies (e.g., Elbert,1993).

A number of studies have focused on phonological processing andword attack skills (e.g., Ackerman & Dykman, 1993; Elbert, 1993; Hyndet al., 1995; Pennington, et al., 1993; Wood & Felton, 1994), rapidnaming (e.g., Ackerman & Dykman, 1993; Felton, Wood, Brown, Camp-

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TABLE 1 Selected Studies of Children with Reading Disability (RD), Attention Deficit HyperactivityDisorder (ADHD), and Comorbid ADHD/RD

Study Participants Results

Felton, Wood, Brown,Campbell, & Harter(1987)

Benezra (1988)

Felton & Wood (1989,Study 3)

McGee, Williams,Moffitt, & Anderson(1989)

Kupietz (1990)

Robbins (1992)

Ackerman & Dykman(1993)

8-12 years old (N= 45)ADHD, RD

7-12 years old (AT =84)ADHD, RD, Control

First graders (N = 485)ADHD, RD

13 years old (N= 100)ADHD, RD, ADHD/RD

7 to 12 years old (AT =35)RD, ADHD/RD, Control

6-12 years old (N =68)LD, ADHD, ADHD/LD

7.5-12 years old (2V =119) ADHD, RD, slowlearner

Deficits in rapid naming were found to be associated with RD; deficits in verbalrote learning and memory were found to be associated with ADHD; no specificeffects were found to be attributable to RD with ADHD.

Children in the RD group demonstrated significant deficits on recall of verbalitems.

Word reading was found to be strongly related to rapid naming; attentionalproblems were associated with deficits in verbal memory on specific tasks.

The ADHD group did not differ from the control group in verbal learning; boththe ADHD/RD and RD groups had problems in verbal learning skills and lowerverbal skills overall.

All groups were compared on a sustained attention task; the control group madethe least errors; both the RD and ADHD/RD groups made significantly moreerrors. Correct responses increased with age for the RD group, but thisimprovement was not evident with the ADHD/RD group.

Both the ADHD and the ADHD/LD groups had significantly more problems withself-regulation; children in the ADHD/LD group had more problems than theother two groups.

When age and Verbal IQ were taken into account, phonological processing wasfound to be the best predictor of single word reading; attentional problems werenot related to reading skill.

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Pennington, Grossier,& Welsh (1993)

Wood & Felton (1994,study 1)

Wood & Felton (1994,study 2)

Wood & Felton (1994,study 3)

Hynd et al. (1995,study 1)

Hynd et al. (1995,study 2)

Narhi & Ahonen(1995)

7-10 year olds (N = 70)ADHD, RD, ADHD/RD,Control group

First graders (N = 204)Follow-up in grades 3, 5

Third graders (N = 60)RD, ADHD/RD

20-44 years old,(W=105)RD,ADHD/RD, Control

6-15 years old (N = 34)RD, ADHD/RD

8-12 years old (N = 34)RD.ADHD

8-12 years old (N= 73)RD,RD/ADHD,ADHD

Both the ADHD and the ADHD/RD groups performed lower on executive functionmeasures; the ADHD/RD and the RD groups performed lower on phonologicalmeasures.

No predictive or concurrent relationship was found between identification asADHD and reading performance

Diagnosis of ADHD was not found to be predictive of later reading ability.

Nonword reading and rapid naming tests were the only measures thatdistinguished adults with a history of RD; those with ADHD had a more globalpattern of lower achievement.

No differences were found on neurocognitive measures; only differences foundwere on behavioral measures of ADHD.

Children in the RD group demonstrated relative deficits in areas of phonologicalprocessing, expressive language, and vocabulary skills.

Rapid naming problems were found to be associated only with the children in theRD and RD/ADHD groups.

Note. LD = learning disabled.

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50 C. A. RICCIO AND S. J . JEMISON

bell, & Harter, 1987; Narhi & Ahonen, 1995), speech fluency-rate (e.g.,Ackerman & Dykman, 1993), memory span (e.g., Ackerman & Dykman,1993; Benezra, 1988), expressive language and vocabulary (e.g., Hyndet al., 1995), and verbal learning tasks (e.g., McGee, Williams, Moffitt,& Anderson, 1989). In two studies (Ackerman & Dykman, 1993; Hyndet al., 1995), children with RD (no ADHD) were compared to childrenwith ADHD/RD. No significant group differences were found other thanon the behavioral measures related to ADHD.

Across studies, it was concluded that language and verbal abilities,particularly phonological awareness and processing, affected theacquisition of basic reading skills and were not directly related toADHD. Taken together, the results of these studies indicated thatalthough the presence of ADHD affected long-term educational out-come, ADHD did not affect the development of reading skills. Rather,these findings underscore the importance of linguistic factors in emer-gent literacy and were consistent with other research specific tolearning disabilities (e.g., Scarborough, 1990).

Influence of Language Factors

Research strongly suggests a relationship between RD and languageprocessing difficulties (e.g., Catts, 1991; Gillon & Dodd, 1994; Scarbor-ough, 1990). As evidenced by the research already reviewed and otherstudies (e.g., Dykman & Ackerman, 1991), it has been suggested thatchildren with RDs often demonstrate impairments across a variety oflanguage tasks, including phonological awareness, rapid naming,vocabulary and expressive language tasks, and verbal memory. Fur-thermore, research indicates an increased prevalence of learning dis-ability and ADHD among children with early language impairment(Baker & Cantwell, 1990; Cantwell & Baker, 1991).

Not surprisingly, research has also consistently indicated that alarge percentage of children diagnosed with ADHD demonstrateddeficits in auditory-linguistic areas. Regardless of whether the studiesrepresent follow-up assessment of preschoolers with specific languageimpairment (SLI) or language evaluations on clinical referrals, co-occurrence rates with ADHD ranged from 15% (Baker & Cantwell,1982) to 49% (Cohen & Riccio, 1994), with many of these children alsoidentified as having a specific learning disability. Thus, the co-occur-rence of SLI in children with ADHD may contribute to the co-occur-rence of reading problems in these children. Research has furtherdemonstrated that for many of the children with both ADHD and SLI,

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ADHD AND EMERGENT LITERACY 51

the language problems are not identified, and interventions specific tothe language problems are not implemented (Gibbs & Cooper, 1989.For a review of related studies, see Riccio & Hynd, 1995.)

As with hypotheses regarding the relationship between ADHD andlearning disability, the presence of the component behaviors of ADHD(inattention, hyperactivity, impulsivity) may be secondary to the lan-guage impairment (August & Garfinkel, 1990; Gordon, 1991; Weinberg& Emslie, 1991). Others have suggested that the ADHD and SLI mayco-occur as a result of the interaction of genetically based characteris-tics of the child (e.g., temperament) with psychosocial factors (Love &Thompson, 1988). Regardless of the causality of the co-occurrence ofADHD and SLI, the evidence for the frequent co-occurrence is suffi-ciently strong that it has been suggested that children with both con-ditions comprise a sizeable and distinct subgroup of those childrenidentified as ADHD (Beitchman, Tuckett, & Batth, 1987). Given theimpact of linguistic factors on emergent literacy, it would seem rea-sonable for these children to be considered at risk for reading difficul-ties.

In summary, identifying the cause of the language impairment orreading difficulty that occurs in some children with ADHD may or maynot be relevant to the educational outcome of these children. Althoughthere is emerging evidence that the co-occurrence of ADHD and RDmay be genetically determined (e.g., Biederman et al., 1992; Faraoneet al., 1993; Light et al., 1995), this does not directly affect the choiceof appropriate interventions. The importance of the role of phonolog-ical processing and language factors in the acquisition of reading skillsis a consistent finding for children with RD and for those children withADHD/RD. Psychosocial or environmental factors may also contributeto the co-occurrence of ADHD and delays in emergent literacy (Love &Thompson, 1988; Pennington et al., 1993; Rowe & Rowe, 1992). Assuch, these factors may interact with genetic factors, positively or neg-atively, to affect the outcome of these children. Finally, research sug-gests that there may be a reciprocal as opposed to a unidirectionalcausal relationship between inattention and reading achievement(Rowe & Rowe, 1992).

IMPLICATIONS

It is imperative that assessment of children referred for possible ADHDbe sufficiently comprehensive to identify or rule out potential co-occur-ring SLI, RD, and other potential conditions. This underscores the needfor the active collaboration of speech-language pathologists, school psy-

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52 C. A. RICCIO AND S. J. JEMISON

chologists, and regular and special educators in the assessment process.The involvement of speech-language pathologists in the screening andevaluation process, either directly or as consultants, would seem bene-ficial in assessing language skills. Similarly, although referral forADHD may be based on behavioral concerns, the reciprocal relationshipbetween attention and reading achievement (Rowe & Rowe, 1992)makes it imperative that academic areas be assessed as well.

Similarly, comprehensive assessment, including behavioral do-mains, would seem appropriate for children referred because of diffi-culty in early acquisition of reading skills or delayed language devel-opment. Behavioral problems can be easily assessed through the useof rating scales completed by both a parent and teacher to identifyany co-occurring behavioral difficulties; alternatively, behavior can beassessed using direct observational methods. This is particularlyimportant given that research has indicated an additive phenomenonof those deficits associated with ADHD in combination with those asso-ciated with RD in children with both conditions (Felton et al., 1987;Robbins, 1992).

Consistent with this, concurrent academic, language, and behav-ioral interventions are needed for those children with ADHD/RD (e.g.,Merrell, 1990; Rowe & Rowe, 1992). In particular, Rowe and Rowe(1992) argued that, given the reciprocal nature of the relationshipbetween inattention and reading achievement, strategies must bedesigned and implemented to address both areas simultaneously. Forexample, while using a direct instruction method or language enrich-ment activity to supplement whole language instruction, behaviormanagement techniques can be used to increase attention to task ortask completion.

To conceptualize simultaneous interventions for the co-occurrenceof RD in children with ADHD, however, professionals working withthese children need to not only "reframe the current focus on ADHD"(Reid, Maag, Vasa, & Wright, 1994, p. 132) with regard to eligibility forspecial education services, but also with regard to intervention plan-ning. Intervention should be addressed as part of regular educationprogramming rather than relegated solely to the arena of special edu-cation. This is particularly important because many of the childrenwith ADHD may not require or be eligible for special education ser-vices. Furthermore, appropriate intervention for ADHD may result insubsequent improvement in reading and other academic areas.

The primary methods of intervention for ADHD are stimulant med-ication, behavioral management, and parent training, with a combina-tion of these found to be most effective (Johnson, Handen, Lubetsky, &Sacco, 1994; Pelham, 1993; Pelham, Carlson, Sams, & Vallano, 1993;

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ADHD AND EMERGENT LITERACY 53

Satterfield, Satterfield, & Cantwell, 1981). The assumption that ad-dressing the inattention (e.g., through medication) is sufficient inter-vention to allow these children to develop appropriate reading skills iscalled into question by more recent research reviewed herein (e.g.,Wood & Felton, 1994) and the lack of predictive ability of attentionalproblems for reading achievement. Furthermore, research has indi-cated that stimulant medication results in improved classroombehavior but may not result in improvements in academic functioning(Rapport, Denney, DuPaul, & Gardner, 1994).

Others have also questioned the use of medication specifically foraddressing academic difficulty. Cotter (1987) recommended thatmedication be used as an intervention only after careful evaluationof both behavior and achievement and only in conjunction with ap-propriate academic intervention; similar considerations have beenrecommended by the American Academy of Pediatrics (1987). Con-cerns specific to the use of medication and the limited knowledge ofeducators regarding medication (Kasten, Coury, & Heron, 1992) havealso been raised. Teachers need to be better informed of the potentialside effects of medication with communication established betweenschool, home, and the physician regarding effectiveness and any prob-lems that may be medication related. Monitoring medication effects(positive and negative) can be easily accomplished through the com-pletion of behavior rating scales on a quarterly basis. Additional con-cerns are discussed in more detail by Kasten et al. (1992) and Reid etal. (1994).

Medication and other interventions designed to address the behav-ioral components of ADHD may, however, be beneficial in conjunctionwith specialized instruction. For example, Richardson, Kupietz, andMaitinsky (1986) studied the reading achievement of 42 children withADHD/RD. Their results indicated that achievement improved as aresult of special reading instruction. It also was found that the extentto which interventions specific to increasing the child's attention span(e.g., medication) were effective was related to the child's response tothe specialized reading instruction (Richardson et al., 1986). Thiswould further support the need to address academic and behavioralconcerns concurrently.

The research has further suggested the potential of environmentalor psychosocial influences and particularly parental involvement toaffect achievement (e.g., Rowe & Rowe, 1992). In fact, research has sug-gested that the largest gains from an emergent literacy program wereassociated with the active involvement of the child's primary caregivers(Whitehurst et al., 1994). In the studies reviewed, parent involvementin emerging literacy was accomplished by soliciting parent participa-

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54 C. A. RICCIO AND S. J. JEMISON

tion in listening to the child read at home or having the parent verifythat the child had engaged in a reading activity at home (Cox, 1987;Rowe & Rowe, 1992; Whitehurst, et al., 1994). Similar findings haveemerged relative to parent involvement in behavioral management forchildren with ADHD (e.g., Newby, Fischer, & Roman, 1991; Pisterman,Firestone, McGrath, & Goodman, 1992). Given the impact of parentalinvolvement on both behavior and reading at home as mediating fac-tors in achievement, it has been recommended that intervention pro-grams need to be designed to provide the opportunity for parents totake an active role (Cox, 1987; Newby et al., 1991; Pisterman et al.,1992; Rowe & Rowe, 1992; Whitehurst, 1994).

SUMMARY

Research has consistently indicated that a large percentage of childrendiagnosed with ADHD have also demonstrated deficits in auditory-lin-guistic areas and frequently demonstrated difficulty with mastery ofbasic reading skills, potentially leading to identification of an RD.Taken together, results of the studies reviewed herein consistentlyindicated that children with reading problems demonstrate similardeficits regardless of whether they have a co-occurrence of ADHD. Fur-thermore, the studies reviewed consistently indicated that readingproblems were not predicted by the presence or severity of attentionproblems. Instead, findings consistently implicated linguistic factorsas most predictive of reading problems. Finally, psychosocial and envi-ronmental factors have also been found to affect achievement.

Therefore, it is important that the myriad factors that may con-tribute to the co-occurrence of ADHD and RD be considered throughassessment and interventions. For children with ADHD who experi-ence difficulty in developing basic reading skills, the research suggeststhat in both the assessment and intervention planning phases, there isa need to attend to linguistic factors (e.g., phonological processes, rapidnaming, vocabulary skills) and basic reading skills rather thanfocusing on ameliorating the behavioral components of ADHD alone. Assuch, active collaboration of speech-language pathologists, school psy-chologists, teachers, and parents is needed to improve the academicprognosis of these children (Riccio & Hynd, 1995). Collaboration andcomprehensive assessment are needed initially in the assessmentprocess to identify co-occurring deficits. Furthermore, collaborationand consultation should continue throughout the intervention plan-ning and implementation to ensure that interrelated deficits in lan-guage areas and basic reading skills are effectively addressed. Throughactive collaboration, the educational outcome of students with co-occur-

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ADHD AND EMERGENT LITERACY 55

ring ADHD, linguistic deficits, and early reading difficulties may beimproved.

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