ADHD and Learning Disorders

Abnormal Behavior Problems

Fall 03

Attention Deficit/Hyperactivity Disorder (ADHD)

What comes to mind when you hear ADHD?

ADHD

HyperactivityDisorganized/forgetfulAthletic, evolutionary advantageOver-diagnosedNot a real disorder

ADHD Subtypes

Not all children with ADHD are hyperactive!2 clusters of symptoms:

Hyperactivity/Impulsivity and Inattention

3 Subtypes of ADHDADHD/HIADHD/IAADHD/C

ADHD Prevalence and Course

4% to 12%Boys:girls 3:1 to 8:168% continue in adulthoodPersistence of inattention

Decline in hyperactivity/impulsivity

Comorbidity

ODD/CDLearning DisordersDepressionAnxietyBipolar Disorder

Associated Features

Academic failure/underachievementPeer rejection, low self-esteemOccupational underachievement

Fired, job change

DisorganizedSmoking, drug useCar accidents, tickets

A Real Disorder?

Symptoms are atypicalFunctional impairmentsAssociated features

Symptoms can be measured reliably>90% test-retest reliability

Moderate inter-rater reliability

Genetics and ADHD

Meta-analytic estimate h2=.73No single gene believed to be responsibleAction and interaction of genes and

environment are not well understoodAndrogenic effect among ADHD/IA

boys??

Treatment of ADHD

Stimulants90% responseHelpful with impulsive aggressionNot addictive if used appropriatelyMTA

EnvironmentalParent EducationStructured environment

Over/Under-Diagnosed?

Increase in diagnosesDisorder du jourPolitical decisionsCommunity-based studiesTreatment adherence

Evolutionary Advantage?Better Athletes?

Cognitive deficitsFidgety, impulsiveSocial deficitsEvidence from motor studies

Learning Disorders

History

Rutter and Yule (1975)Poor readers with low IQ had more global

neurodevelopmental abnormalities, but better acquisition of reading and spelling than children with average ability language but with delays in language and speech

Defined

No universally accepted test or battery of testsDiscrepancy between IQ and achievement

“Wait to fail” standardHigh reliance on exclusionary criteria for

Diagnosis

Prevalence

The overall prevalence of LD is estimated to be between 2 and 10%Approximately 5% of children have

identified LD in public schools

Why increase in prevalence rates?

Better researchLongitudinal, focus on individual factors (e.g. reading)Not based on school diagnosis, large population

studiedReading

specific diagnostic criteria5% 1976 to 17% 1994 having difficulties

Increase in diagnosis among girlsIncreased awareness and understanding of

educational, professional, social impact

Gender Differences

Boys>GirlsAmong those with LD:

Females generally have a lower IQ, and perform more poorly in math and reading, better in writing

Males tend to perform better in math

Associated Features

Social skills, demoralization, low self-esteem

Dropout rate as high as 40%ConductAttentionInternalizing symptomsImportant predictors of classroom failure

Associated Features

More likely to be rejected, on-task behavior, off-task behavior, conduct disorders, distractibility, and shy/withdrawn behavior

8-39% comorbidity with ADHD

Course

Evidence for a deficit model rather than developmental lagChildren identified in 3rd grade as poor

readers in bottom 10% in 5th and 8th74% of children identified in 3rd grade still

behind at 9th

49% classified as poor readers in adulthood

Genetics

Pennington, 199540% of LD children have LD parents40% of their siblings are LD

The “Mathew Effect”Arguments against IQ

Cumulative effect of RD affects cognitive development over time

Older students may not maintain discrepancyNot a 1:1 relation between IQ and achievement

Specific skills (e.g. phonology) may be more important

                                                                                                                                                           

                                                              

                                                                                             

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                            

                                                                                                             

 

                                            

                                            

                                            

                                            

                                            

                                            

                                                                                                                                                           

                                                              

                                                                                             

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                            

                                                                                                             

 

                                            

                                            

                                            

                                            

                                            

                                            

A Brief Look at the Specific Disorders

Mathematics

Difficulty learning simple computational skills and numerical operations Math facts: addition, subtraction and

multiplicationOperations: making change, telling time, and

understanding and using devicesVisuo-spatial confusionTranslation between paper and knowledge

Mathematics

DevelopmentallyInformal- learning equivalency, magnitude,

language, manipulation, judgment, conservation

Formal- aspects of numbers, operationsAbstract- concepts, going beyond mimicry

Written Expression

Physical aspects of writingSpellingPutting concepts on paper

ReadingDyslexia

Gough Simple View of Reading:

Comprehension=Listening Comprehension * DecodingC=LC*D

Reading

DyslexiaDecoding difficulties, intact listening

comprehension

HyperlexiaGood decoding skills, poor comprehension

“Garden Variety”Poor decoding and comprehension

“The disabilities you can see may be easier to deal with than

the ones you can’t”

Puzzles

I O U

Puzzles

I O U

I F-N N-E N-R-G

Decoding

O U Q-T. U R A B-U-T. S A 3-L 2 C U! I-L B U-R-S 4-F-R N F-R.

I M 2 O-L 4 U.

L! U-R O-D-S!

N U R S-N-9. F U R B-Z, I-L 1 O-A. M-N-U-L S N-C-Q-R. E S N N-L-S-S. S N-L-S-S-T S N-2-8-F N Y-S. I F D Q-R!

D N

Decoding

Why was the man’s name?

What did he think of the woman?

What kind of Dr. was he seeing?

What was the woman’s excuse?

Comprehension

`Twas brillig, and the slithy toves  Did gyre and gimble in the wabe:All mimsy were the borogoves,  And the mome raths outgrabe.

"Beware the Jabberwock, my son!  The jaws that bite, the claws that catch!Beware the Jubjub bird, and shun  The frumious Bandersnatch!"

Comprehension

He took his vorpal sword in hand:  Long time the manxome foe he sought --So rested he by the Tumtum tree,  And stood awhile in thought.

And, as in uffish thought he stood,  The Jabberwock, with eyes of flame,Came whiffling through the tulgey wood,  And burbled as it came!

Comprehension

One, two! One, two! And through and through  The vorpal blade went snicker-snack!He left it dead, and with its head  He went galumphing back.

"And, has thou slain the Jabberwock?  Come to my arms, my beamish boy!O frabjous day! Callooh! Callay!'  He chortled in his joy.

Comprehension

`Twas brillig, and the slithy toves  Did gyre and gimble in the wabe;All mimsy were the borogoves,  And the mome raths outgrabe.

Comprehension

Why was the Jabberwock killed?

What else was there to beware of?

What kind of tree did he rest by?

Diagnosis

What does the discrepancy standard boil down to?1-2 standard deviations below mean

Specific Skills assessmentsOther contributing factors

Home and school environment, attention

Treatment

Megavitamins Colored lenses Special diets Sugar-free diets Body stimulation or manipulation

Basics

Heterogeneous disordersAccurate assessment Individual tailoring

Basic skills, fluency, comprehensionResearch needed to help parse

Treatment

RemediationsResolving underlying difficulties

CompensationsBypass the problem

Keyboarding, changing expectations, strategies

Treatment

Sound-Based StrategiesPhonics, Phonemic Awareness, Letter-sound

relationshipsRemove the “cuh” sound from cart

Whole languageDecoding through context, emphasis is on

comprehension and fluency

NVLD (Non-verbal Learning Disorder)Not recognized by DSMMany have multiple etiological insults

rather than developmental conditionsPrevalence approximately 1-10% of LD

childrenShould this be recognized as a specific

disorder?