Reconceptualizing ADHD in the Reconceptualizing ADHD in the classroomclassroom

Implications for EducatorsImplications for Educators

Rosemary Tannock, PhDRosemary Tannock, PhD

The Hospital for Sick ChildrenThe Hospital for Sick Children

Toronto, CANADAToronto, CANADA

Toronto, November 27th 2003

Disclosures:Disclosures:Novartis: Research fundsNovartis: Research fundsLilly: Consultant, Research Lilly: Consultant, Research fundsfunds

ADHD: Challenges for Educational ADHD: Challenges for Educational SystemsSystems

Education costs 3 to 6 times greaterEducation costs 3 to 6 times greater (Forness et al., (Forness et al., NIH ConcensusNIH Concensus, 2000), 2000)

– Prevalence (1 or 2 children in every class)Prevalence (1 or 2 children in every class)– Association with learning & social problemsAssociation with learning & social problems

Meaning for educational programming is Meaning for educational programming is unclearunclear– What type of exceptionality/special needs?What type of exceptionality/special needs?– What are the Standards for level of service & What are the Standards for level of service &

instruction?instruction?– What are the required teacher qualifications?What are the required teacher qualifications?

Current paradox: ADHD Current paradox: ADHD

Clinical PerspectiveClinical PerspectiveConstruct: Construct:

behavioral disorderbehavioral disorderDiagnosis & Treatment: Diagnosis & Treatment:

behavioral symptomsbehavioral symptoms

Neuroscientific PerspectiveNeuroscientific PerspectiveConstruct: Construct: neurobiological disorderneurobiological disorderDiagnosis & treatment: Diagnosis & treatment: neurobiological &/orneurobiological &/or neuropsychological features neuropsychological features

Reconceptualizing ADHD for the classroomReconceptualizing ADHD for the classroom OverviewOverview

Overlap with LDOverlap with LD

Oral language, reading, arithmetic, written Oral language, reading, arithmetic, written expression in children with ADHDexpression in children with ADHD

Significance of inattentionSignificance of inattention

Significance of working memory problemsSignificance of working memory problems

Medical/Psychiatric: Learning DisordersMedical/Psychiatric: Learning Disorders

“…“…are characterized by academic are characterized by academic functioning that is substantially below that functioning that is substantially below that expected given the person’s chronological expected given the person’s chronological age, measured intelligence, and age-age, measured intelligence, and age-appropriate education.” appropriate education.” (DSM-IV-TR, APA, 2000) (DSM-IV-TR, APA, 2000)

Note: No requirement for evidence of Note: No requirement for evidence of impairment in “basic psychological impairment in “basic psychological processesprocesses

Legal/Educational: Legal/Educational: Specific Learning DisabilitySpecific Learning Disability

“…“…a disorder in one or more of the a disorder in one or more of the basic basic psychological processespsychological processes11 involved in involved in understanding or in using language, spoken understanding or in using language, spoken or written, which may manifest itself in an or written, which may manifest itself in an imperfect ability to listen, think, speak, write, imperfect ability to listen, think, speak, write, spell, or do mathematical calculations…”spell, or do mathematical calculations…”(Individuals With Disabilities Education Act, June 4, 1997, (Individuals With Disabilities Education Act, June 4, 1997, §602.26a. Emphasis added)§602.26a. Emphasis added)

1 1 The “psychological process criteria” are not The “psychological process criteria” are not specified. Also, most US states have operationalized specified. Also, most US states have operationalized the phrase - “disorders of”- as a discrepancy between the phrase - “disorders of”- as a discrepancy between ability (IQ) and achievementability (IQ) and achievement

Controversy in the Definition of LDControversy in the Definition of LDfederal/legal/educational approach federal/legal/educational approach – DiscrepancyDiscrepancy– HeterogeneityHeterogeneity– ExclusionExclusion

Biobehavioral systems approachBiobehavioral systems approach– Manifest disability Manifest disability – Cognitive/psychosocial traitsCognitive/psychosocial traits– Environmental variablesEnvironmental variables– Biological variablesBiological variables

Premise: IQ tests not necessary for the identification of LD Premise: IQ tests not necessary for the identification of LD & do not contribute to intervention planning& do not contribute to intervention planning

Significant overlap between ADHD Significant overlap between ADHD & language/learning disorders& language/learning disorders

(Reviews: Cantwell & Baker, 1991; Tannock & Brown, 2000)(Reviews: Cantwell & Baker, 1991; Tannock & Brown, 2000)

Epidemiological & clinical studies indicate that the rates of Epidemiological & clinical studies indicate that the rates of overlap are greater than expected by chance between ADHD overlap are greater than expected by chance between ADHD &…&…

• language disorderlanguage disorder: 8% - 30% (often unrecognized) : 8% - 30% (often unrecognized)

• reading disorderreading disorder: 15% - 40%: 15% - 40%

• math disordermath disorder: 10% - 25% (often overlooked) : 10% - 25% (often overlooked)

• disorder of written expressiondisorder of written expression (common but unstudied)(common but unstudied)

• developmental coordination disorderdevelopmental coordination disorder: 10% - 50%: 10% - 50% ( ( rarely consideredrarely considered))

Early emergence of overlap of Early emergence of overlap of ADHD & oral language problemsADHD & oral language problems

Delayed onset of oral language:Delayed onset of oral language:– 6% - 30% ADHD group6% - 30% ADHD group

1% - 6% of control group1% - 6% of control group

Most preschoolers (80%) exhibitingMost preschoolers (80%) exhibiting

soft neurological signs &soft neurological signs &language impairments & inattention/hyperactivity,language impairments & inattention/hyperactivity,

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

Gross-Tsur et al., 1991; Ornoy et al., 1993; Gross-Tsur et al., 1991; Ornoy et al., 1993; Szatmari et al., 1989; Tripp et al., 1999Szatmari et al., 1989; Tripp et al., 1999

Longitudinal pathway of overlap between Longitudinal pathway of overlap between ADHD & oral language problemsADHD & oral language problems

(McGee et al., JAACAP 1991)(McGee et al., JAACAP 1991)

Epidemiological prospective longitudinal study of Epidemiological prospective longitudinal study of youngsters with “difficult to manage behavior” youngsters with “difficult to manage behavior” plusplus language difficulties at age 3 language difficulties at age 3::

manifested as ADHD + reading disorders in manifested as ADHD + reading disorders in school-ageschool-age

had worst outcome in terms of literacy and had worst outcome in terms of literacy and psychopathology in adolescence, compared psychopathology in adolescence, compared to those with “difficult to manage behavior” or to those with “difficult to manage behavior” or language difficulties, alone.language difficulties, alone.

The Canadian Scene:The Canadian Scene:Longitudinal course of overlap between Longitudinal course of overlap between

oral language & behavior problemsoral language & behavior problems

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

Language Impairments in ADHD Language Impairments in ADHD often not recognizedoften not recognized

High rate (58%) of undetected language High rate (58%) of undetected language impairments in children referred for mental impairments in children referred for mental health services in Ontario health services in Ontario

Subtle but impairing language problems Subtle but impairing language problems may be obscured by more salient may be obscured by more salient behavioral symptomsbehavioral symptoms

(Cohen et al., 1993, 1998a, 1998b)(Cohen et al., 1993, 1998a, 1998b)

Behavior problem or Behavior problem or

communication problem in ADHD?communication problem in ADHD?CONTEXT: PSYCHOEDUCATIONAL ASSESSMENTCONTEXT: PSYCHOEDUCATIONAL ASSESSMENT

Child: “What are we gonna do next? Huh? What’s in there? What’s that?” (tries to grab test materials) Adult: “You’ll see in a sec.” (reaching into case for next set of test materials) --- a few minutes later, child interrupts testing ---

Child: “Where’s the um…the things…um…where’s 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 I’ll see the bugs. I don’t wanna do this. I wanna see the bugs… the um… secs… the insecs!”

Language Correlates of ADHDLanguage Correlates of ADHD

several behaviour symptoms used in ADHD several behaviour symptoms used in ADHD diagnosis implicate memory and language-diagnosis implicate memory and language-related deficitsrelated deficits

– fails to follow through on instructionsfails to follow through on instructions– does not appear to be listeningdoes not appear to be listening– blurts out answers, talks excessivelyblurts out answers, talks excessively– forgetful of routinesforgetful of routines

What does the ResearchWhat does the Research Literature Show? Literature Show?

Studies of Expressive LanguageStudies of Expressive Language word retrieval difficultiesword retrieval difficulties

poor conversational skillspoor conversational skills

weak message coherenceweak message coherence

weak sentence formulationweak sentence formulation

language in elicited responses lesslanguage in elicited responses less well-formed than spontaneous language well-formed than spontaneous language

poor organization of narrativespoor organization of narratives

Listening Comprehension is impaired in Listening Comprehension is impaired in ADHD even in the absence of comorbid ADHD even in the absence of comorbid

language impairmentslanguage impairments McInnes, et al., J Abnormal Child Psychology (2003)McInnes, et al., J Abnormal Child Psychology (2003)

community sample of 77 boyscommunity sample of 77 boys

ADHD, ADHD+LI, LI, normalADHD, ADHD+LI, LI, normal

main objective...main objective...– listening comprehension for spoken listening comprehension for spoken

explanations (expository passages) explanations (expository passages) – facts and inferencesfacts and inferences

– ability to detect errors in explanations and ability to detect errors in explanations and descriptions descriptions

– verbal and spatial working memory abilitiesverbal and spatial working memory abilities

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

ADHD group ADHD group (normal basic language skills)(normal basic language skills)performed as well as peers in comprehending performed as well as peers in comprehending factsfacts

but werebut were

poorer at comprehending inferences - took longerpoorer at comprehending inferences - took longerto explain their understandingto explain their understanding

poorer at detecting errors in sequence of instructionspoorer at detecting errors in sequence of instructions

had significantly poorer verbal and spatial working had significantly poorer verbal and spatial working memory memory andand poorer spatial memory span poorer spatial memory span

Also, teacher ratings of inattention symptoms were Also, teacher ratings of inattention symptoms were significantly related to comprehension of the passagessignificantly related to comprehension of the passages

ADHD & ReadingADHD & ReadingBrock & Knapp, 1996; Cherkes-Julkowski et al., 1995; Brock & Knapp, 1996; Cherkes-Julkowski et al., 1995;

Rucklidge & Tannock, 2002;Rucklidge & Tannock, 2002;

Decoding Decoding – only if have concurrent phonologically-based reading only if have concurrent phonologically-based reading

disabilitiesdisabilities

Rate Rate – slow reading of single words & non-words, & of short slow reading of single words & non-words, & of short

passages – despite good phonological abilitiespassages – despite good phonological abilities

ComprehensionComprehension– Weak reading comprehension for science texts Weak reading comprehension for science texts

despite adequate decoding skillsdespite adequate decoding skills– unclear whether problems attributable primarily to unclear whether problems attributable primarily to

slower reading rateslower reading rate

InattentionInattentionAges 9 -11Ages 9 -11

InattentionAge 15

Word ReadingWord ReadingAge 15Age 15

Word ReadingWord ReadingAge 7-8Age 7-8

HyperactivityHyperactivityAges 9 -11Ages 9 -11

Dual-pathways to reading problems in Dual-pathways to reading problems in adolescenceadolescence

McGee et al, JCPP 43(8) 2002McGee et al, JCPP 43(8) 2002

Data from Australian Temperament Project & DunedinData from Australian Temperament Project & DunedinMultidisciplinary Health & Development StudyMultidisciplinary Health & Development Study

““ADHD”ADHD”Age 5-8Age 5-8

ADHD & ADHD & Arithmetic ComputationArithmetic Computation

A neglected issueA neglected issue

Numeracy skills :Numeracy skills :• predict employment and earningspredict employment and earnings• related to health evaluation & related to health evaluation &

decision making decision making

(e.g.,(e.g., Charette et al., 1998;Charette et al., 1998; Parsons & Bynner, 1997; Parsons & Bynner, 1997;

Rivera-Batiz, 1992; Woloshin et al., 2001; Rivera-Batiz, 1992; Woloshin et al., 2001;

International Adult Literacy Survey: Green & Riddell, 2001) International Adult Literacy Survey: Green & Riddell, 2001)

Arithmetic Computation Impairments Arithmetic Computation Impairments in ADHD Subtypesin ADHD Subtypes

Faraone et al., Faraone et al., J Am Acad Child Adolesc PsychiatryJ Am Acad Child Adolesc Psychiatry 37:185-93, 1998 37:185-93, 1998

80

85

90

95

100

105

110

115

120

WISC-FSIQ WISC-3rdFactor

WRAT-Arithmetic

Computation

WRAT-Wordreading

COMBINED(182)

HYP/IMP (28)

INATTENTIVE (92)

CONTROL (135)

aa aaControls >Controls > Inatt, Combined Inatt, Combined

aa aa

ADHD & MathematicsADHD & Mathematics

ComputationComputation– Weak, even in absence of specific math Weak, even in absence of specific math

disabilitydisability– Multi-step computation appears particularly Multi-step computation appears particularly

problematic problematic

Word problemsWord problems– Difficulty with irrelevant informationDifficulty with irrelevant information– Problematic even for youngsters with Problematic even for youngsters with

sub-threshold inattention (sub-clinical ADHD)sub-threshold inattention (sub-clinical ADHD)

Disruptive Talk or Private Speech & ADHDDisruptive Talk or Private Speech & ADHDCONTEXT D: ARITHMETIC IN LAB CLASSROOMCONTEXT 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) that’s 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, ten…ah!

Private speech, behavior & math Private speech, behavior & math computation in ADHDcomputation in ADHD

(Benedetto & Tannock, J Attention Disorders, 1999)(Benedetto & Tannock, J Attention Disorders, 1999)

During a 10-min self-directed arithmetic During a 10-min self-directed arithmetic computation task, children with ADHDcomputation task, children with ADHD– Use immature strategies (finger counting, Use immature strategies (finger counting,

add-on) add-on) – Use immature (externalizing) self-talkUse immature (externalizing) self-talk– Exhibit low productivityExhibit low productivity– Are more inattentive & fidgetyAre more inattentive & fidgety

Compared to peers matched on age, IQ, & Compared to peers matched on age, IQ, & math achievementmath achievement,,

ADHD & Written ExpressionADHD & Written Expression

Anecdotally, the most common and impairing Anecdotally, the most common and impairing problem at school. problem at school.

Characterized by…….Characterized by…….– Low productivity, poor fluencyLow productivity, poor fluency– Slow & effortful &/or fast & careless approachSlow & effortful &/or fast & careless approach– Poor written spellingPoor written spelling– Untidy, uneven, illegible handwritingUntidy, uneven, illegible handwriting– Poor written sentence constructionPoor written sentence construction

BUT….No systematic research to dateBUT….No systematic research to date

““The presence of even a fewThe presence of even a fewinattentive behaviors in early inattentive behaviors in early

childhood should be viewed as a childhood should be viewed as a developmental risk factor”developmental risk factor”

(Warner-Rogers et al., JLD,33:2000) (Rabiner & Coie, JAACAP, 39:2000)

““The presence of even a few inattentive behaviors in The presence of even a few inattentive behaviors in early childhood should beearly childhood should be

viewed as a developmental risk factor”viewed as a developmental risk factor”

(Warner-Rogers et al., J Learning Disabilities,33:2000)(Warner-Rogers et al., J Learning Disabilities,33:2000)

(Rabiner & Coie, (Rabiner & Coie, JAACAP,JAACAP, 39:2000) 39:2000)

Grade 1-2:Grade 1-2:– ““below average” academic skills below average” academic skills

oral language, reading, written language, number concepts and oral language, reading, written language, number concepts and computationcomputation

– poor classroom adjustment poor classroom adjustment low confidence, need for repeated instructionslow confidence, need for repeated instructions

Kindergarten:Kindergarten:– poor reading achievement in Grade 5 poor reading achievement in Grade 5

Significance of InattentionSignificance of Inattentionfor cognitive processesfor cognitive processes

Chhabildas, Pennington, Willcutt, J Abnorm Child Psychol, 2001Chhabildas, Pennington, Willcutt, J Abnorm Child Psychol, 2001

Inattention symptom cluster is the Inattention symptom cluster is the strongest predictor of neuropsychological strongest predictor of neuropsychological impairments impairments – vigilance, processing speed, inhibitionvigilance, processing speed, inhibition

Hyperactivity/impulsivity Hyperactivity/impulsivity notnot associated associated with neuropsychological impairmentswith neuropsychological impairments

Working MemoryWorking Memory

Helps the mind focusHelps the mind focus

“an attention “an attention controller”controller”

Working MemoryWorking MemoryMulti-component cognitive system that allows us to Multi-component cognitive system that allows us to temporarily hold and manipulate information “on-line” for a temporarily hold and manipulate information “on-line” for a brief period (second).brief period (second).

Permits us to maintain information temporarily in a readily Permits us to maintain information temporarily in a readily accessible form while simultaneously processing new accessible form while simultaneously processing new information, often in the presence of distracting and information, often in the presence of distracting and irrelevant information. irrelevant information.

This continually updated internal “on-line” record of This continually updated internal “on-line” record of relevant information guides decision making and overt relevant information guides decision making and overt behavior (responses) during an activity, rather than behavior (responses) during an activity, rather than immediate sensory cues in the environmentimmediate sensory cues in the environment. .

Plays a crucial role in a wide variety of complex cognitive Plays a crucial role in a wide variety of complex cognitive activities (e.g., mental arithmetic, reading comprehension)activities (e.g., mental arithmetic, reading comprehension)

Working MemoryWorking Memory(Baddeley, 1986; Fuster, 1995; Goldman-Rakic, 1996; (Baddeley, 1986; Fuster, 1995; Goldman-Rakic, 1996;

Miyake & Shah, 1999)Miyake & Shah, 1999)

Multidimensional constructMultidimensional construct

– ProcessesProcesses: : On-line On-line maintenancemaintenance (span) (span)Manipulation Manipulation (updating, shifting)(updating, shifting)

– Modality/representationModality/representation::Auditory/VerbalAuditory/VerbalVisual/SpatialVisual/Spatial

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

2001; Gutkin et al., 2001; 2001; Gutkin et al., 2001;

operates over periods of secondsoperates over periods of seconds

not localized in the brain, but rather comprises not localized in the brain, but rather comprises transientlytransiently activated neural networks in activated neural networks in prefrontal cortex and other brain regionsprefrontal cortex and other brain regions– Persistent neuronal firing in the absence of a Persistent neuronal firing in the absence of a

stimulusstimulus

Influenced by chemical neurotransmittersInfluenced by chemical neurotransmitters– Dopamine, noradrenalineDopamine, noradrenaline

Working memory & attentionWorking memory & attentionDe Fockert, Rees, Frith, Lavie: De Fockert, Rees, Frith, Lavie: ScienceScience, 291:1803-6, 2001; , 291:1803-6, 2001; Conway, Cowan, Bunting, 2001; Strayer & Johnston, 2001Conway, Cowan, Bunting, 2001; Strayer & Johnston, 2001

Working Working memorymemory

• The greater the working memory load, the more the The greater the working memory load, the more the individual will be distracted by irrelevant information.individual will be distracted by irrelevant information.

• Implications: individuals with WM impairments will be Implications: individuals with WM impairments will be more readily overloaded & distractiblemore readily overloaded & distractible

““Driven to Distraction” Driven to Distraction” (Strayer & Johnston, 2001)(Strayer & Johnston, 2001)

Dual-task studies to assess effects of Dual-task studies to assess effects of cellular phone conversations on driving cellular phone conversations on driving performanceperformanceDriving performance impaired byDriving performance impaired by– Concurrent tasks that placed demand on Concurrent tasks that placed demand on

verbal working memory (e.g., in-depth verbal working memory (e.g., in-depth conversation) & diverted attention to those conversation) & diverted attention to those activitiesactivities

– Not by listening to radio or books-on-tapeNot by listening to radio or books-on-tape

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

Humans exhibit the ability to attend to only Humans exhibit the ability to attend to only part of a noisy environment, yet highly part of a noisy environment, yet highly pertinent stimulus, can suddenly capture pertinent stimulus, can suddenly capture attention attention

– In approx 33% individuals… In approx 33% individuals… – Those with Those with low working memory capacitylow working memory capacity

(span)(span)

Working memory & language Working memory & language acquisitionacquisition (Baddeley, Gathercole & Papagno, 1998; (Baddeley, Gathercole & Papagno, 1998;

Adams & Gathercole, 2000; Willis & Gathercole, 2001)Adams & Gathercole, 2000; Willis & Gathercole, 2001)

Ability to maintain unfamiliar sound patterns (in Ability to maintain unfamiliar sound patterns (in the “phonological loop”) while more permanent the “phonological loop”) while more permanent memory records are constructed, plays a crucial memory records are constructed, plays a crucial role in vocabulary acquisitionrole in vocabulary acquisition

Children with limitations in working memory Children with limitations in working memory exhibit narrower repertoire of words & syntactic exhibit narrower repertoire of words & syntactic constructions, shorter utterances, & poorer constructions, shorter utterances, & poorer sentence repetition sentence repetition

Working Memory & ComprehensionWorking Memory & ComprehensionDaneman & Merickle, 1996; Goel & Dolan, 2001; Haenggi, Daneman & Merickle, 1996; Goel & Dolan, 2001; Haenggi,

Kintsch & Carpenter, 1995)Kintsch & Carpenter, 1995)

Ability to manipulate (& maintain) Ability to manipulate (& maintain) information is essential for comprehensioninformation is essential for comprehension

visual-spatial working memory critical for visual-spatial working memory critical for inferential comprehensioninferential comprehension– neural substrates for visuo-spatial processing form neural substrates for visuo-spatial processing form

the basic representational building blocks used for the basic representational building blocks used for logical reasoning in 3-term relational argumentslogical reasoning in 3-term relational arguments

A is in front of B; A is in front of C; thus, B is...A is in front of B; A is in front of C; thus, B is...

HypothesesHypotheses

Individuals with low working memory Individuals with low working memory ability (maintain/manipulate) will exhibitability (maintain/manipulate) will exhibit

– Greater distractibility, poorer sustained Greater distractibility, poorer sustained attentionattention

– Weaker oral language abilitiesWeaker oral language abilities– Poorer inferential comprehensionPoorer inferential comprehension

Inattention, working memory, & Inattention, working memory, & academic achievementacademic achievement

Community sample in the UKCommunity sample in the UK

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

Potential Impact of WM Weaknesses Potential Impact of WM Weaknesses on Language Functioningon Language Functioning

May forget what one was going to sayMay forget what one was going to say

May get confused when given complex May get confused when given complex

instructions or explanationsinstructions or explanations

Expressive language may not be cohesive or Expressive language may not be cohesive or

coherentcoherent

– E.g., disorganized story-tellingE.g., disorganized story-telling

Difficulty with turn-taking and topic shiftsDifficulty with turn-taking and topic shifts

Impact of Working Memory Deficits on Impact of Working Memory Deficits on Academic PerformanceAcademic Performance

Difficulty thinking through problems or engaging in Difficulty thinking through problems or engaging in

extensive reasoning in one’s headextensive reasoning in one’s head

Difficulty understanding meaning of a sentence while Difficulty understanding meaning of a sentence while

decoding an unfamiliar worddecoding an unfamiliar word

Difficulty implementing necessary subskills in the Difficulty implementing necessary subskills in the

writing process while concurrently organizing and writing process while concurrently organizing and

writing textwriting text

Difficulty maintaining all relevant information in a Difficulty maintaining all relevant information in a

problem and monitoring progressproblem and monitoring progress

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

Visual-spatial span & working memoryVisual-spatial span & working memory– associated with severity of inattentive associated with severity of inattentive

symptomssymptoms (Barnett et al., 2001; Brito et al., 1999; Karatekin & Arsarnow, 1998; (Barnett et al., 2001; Brito et al., 1999; Karatekin & Arsarnow, 1998; Kempton et al., 1999; Mariani & Barkley, 1997; Martinussen et al., Kempton et al., 1999; Mariani & Barkley, 1997; Martinussen et al., World Congress Psychiatric Genetics, 2002; Mealer et al., 1996; World Congress Psychiatric Genetics, 2002; Mealer et al., 1996; Willliams et al., 2000Willliams et al., 2000

Verbal working memoryVerbal working memory– inconsistent findings & may be associated inconsistent findings & may be associated

with comorbid language-based learning with comorbid language-based learning disordersdisorders

Inattention, working memory, & Inattention, working memory, & academic achievementacademic achievement

Low working memoryLow working memory predicts below- predicts below-average performance on national curriculum average performance on national curriculum

in language arts and math, in 6 - 7 year-oldsin language arts and math, in 6 - 7 year-olds (Gathercole & Pickering, 2000)(Gathercole & Pickering, 2000)

It may be the It may be the combinationcombination of of InattentionInattention & &

Working MemoryWorking Memory that is problematic in that is problematic in ADHDADHD

Proposed relationship between working Proposed relationship between working memory, attention, language, & readingmemory, attention, language, & reading

BiologicalBiologicalfactorsfactors

NeurobiologicalNeurobiological SubstrateSubstrate

WorkingWorkingMemoryMemoryDeficitsDeficits

EnvironmentalEnvironmentalfactorsfactors

However… a cautionary noteHowever… a cautionary note

To date, there is no cognitive To date, there is no cognitive measure that can be used to rule in measure that can be used to rule in or rule out ADHDor rule out ADHD

ADHD is a heterogeneous disorderADHD is a heterogeneous disorder

– Variation in symptomsVariation in symptoms

– Variation in co-existing disordersVariation in co-existing disorders

BUT!BUT!

Working memory is a critical construct to Working memory is a critical construct to understand because:understand because:

– WM deficits are associated with learning WM deficits are associated with learning problemsproblems

– WM implicated in ADHD WM implicated in ADHD but not specificbut not specific to to ADHDADHD

– Seems to play a role in helping the mind focus Seems to play a role in helping the mind focus (de Fockert et al., 2001)(de Fockert et al., 2001)

Clinical and Educational ImplicationsClinical and Educational Implications

ADHD children (with normal basic language & decoding ADHD children (with normal basic language & decoding skills) are likely to have problems in some aspects of skills) are likely to have problems in some aspects of working memory & in higher level language comprehensionworking memory & in higher level language comprehension

could these problems account could these problems account (in part)(in part) for…. for….

some behaviour symptomssome behaviour symptoms

reading comprehension difficultiesreading comprehension difficulties

pragmatic/ social language problemspragmatic/ social language problems

achievement problems in higher gradesachievement problems in higher grades

Major points: ADHDMajor points: ADHDADHD is a biologically-rooted neurocognitive ADHD is a biologically-rooted neurocognitive disabilitydisability

ADHD is more usefully conceptualized as a type ADHD is more usefully conceptualized as a type of learning disability - rather than just a of learning disability - rather than just a behavioral problembehavioral problem– It is frequently accompanied by one or more specific It is frequently accompanied by one or more specific

LDsLDs

Oral language, academic, & cognitive function Oral language, academic, & cognitive function should be routinely assessed in ADHDshould be routinely assessed in ADHD

Major points: Major points: Inattention & Working MemoryInattention & Working Memory

InattentionInattention in K/G1 should be viewed as a in K/G1 should be viewed as a developmental risk factordevelopmental risk factor

Most classrooms will have several students who Most classrooms will have several students who have one or more of the following difficulties:have one or more of the following difficulties:– ADHD,ADHD, reading,math, language comprehension, reading,math, language comprehension,

anxiety, depression defiance,aggressionanxiety, depression defiance,aggression

Many of these students are likely to have Many of these students are likely to have problems withproblems with working memoryworking memory, , which impedes which impedes learninglearning

What are the treatment targets?What are the treatment targets?DSM-IV medical perspectiveDSM-IV medical perspective

GeneticGenetic&&

EnvironmentalEnvironmental FactorsFactors

BrainBrainAbnormalitiesAbnormalities

InattentionInattentionHyperactivityHyperactivityImpulsivityImpulsivity

Cognitive function, learning, Cognitive function, learning, academic achievementacademic achievement

Treatment targets

?

Emerging neuroscience/educational Emerging neuroscience/educational perspectiveperspective

Genetic Genetic &&

EnvironmentalEnvironmental FactorsFactors

BrainBrainAbnormalitiesAbnormalities

Specific Specific cognitive processescognitive processes

Inattention, Inattention, Hyperactivity, impulsivityHyperactivity, impulsivity

Learning, Academic achievementLearning, Academic achievement

TreatmentTreatment targets targets

Implications for the ClassroomImplications for the Classroom

Target Target

Language, cognitive & academic Language, cognitive & academic problems associated with ADHDproblems associated with ADHD

as well as as well as

behavioral symptomsbehavioral symptoms

QuestionQuestionss

Thank you Thank you for your attention!for your attention!