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Rethinking ADHD in the Classroom

ADHD impedes academic achievement

One of the most critical findings from recent cross-sectional and longitudinal research is that children with ADHD are at high risk for academic failure, grade repetition, placement in special education, and high-school drop-out (see Table 4-1, below).1-4

Additional research suggests that the association between ADHD and poor academic achievement starts early in a child's school career (that is, kindergarten for many students).5-9

Table 4-1: Educational Attainment in ADHD

Educational Outcome ADHD vs. Non-ADHD Peer Group

Low achievement at school:1-3

Grade repetition
Low academic grades (Cs and Ds)
Achievement scores (reading, math)
Placement in special education

 

two-fold risk
two- to four-fold risk
8% to 10% lower
two- to four-fold risk

Early school leaving:2-3

Highest level completed
High school dropout

 

one to two years lower
three-fold risk

Tertiary level attainment (college):4

College grade point average (GPA)

 

0.7 lower GPA

Language and literacy in ADHD

Language functioning in children with ADHD

Deficits in language functioning associated with ADHD can be classified into three areas:

  • pragmatic language
  • higher-level language comprehension and expression
  • basic language abilities

Weaknesses in pragmatic language

Children with ADHD are often described as poor communicators, even though they seem on the surface to have normal verbal expression and basic language skills. Specifically, their communication problems arise due to weaknesses in the "pragmatics of language."10-11

Pragmatic language refers to how language is used in everyday interactions with others. It requires the ability to self-regulate one's own communication (planning what to say, when to say it, and how to get the message across, while respecting the rules of turn-taking in conversations). Communication breakdowns in ADHD children may be explained by poor self-regulation of language use.

The pragmatic language difficulties, which can often be identified as behaviour problems by parents and teachers, include:

  • blurting out answers in class
  • interrupting others
  • talking excessively when it is inappropriate
  • problems in modulating voice volume

Problems with voice modulation

Children with ADHD often speak much louder than social norms for a given situation and fail to modulate their voice volume.12 From the listener's perspective, it may appear that these children are being rude or "in your face." However, these problems likely reflect their immature motor system, which is involved in the fine muscle adjustments involved in voice modulation, as well as in other fine motor control activities such as handwriting.

Also, children with ADHD are often highly verbose in that they speak for much longer at a stretch, and with many brief pauses. Speakers often pause briefly during their utterances in order to re-think, re-formulate, and re-organize the information and language to be used in forthcoming utterances. However, the within-turn pauses in the speech of children with ADHD appear to be too short to permit thought, organization of information, or speech planning. Moreover, they are too short to permit others interceding or being able to take a turn.

Weaknesses in higher-level language

Children with ADHD also exhibit weaknesses in the "higher-level" language functions. These functions are necessary for comprehending and producing lengthy and complex spoken and written language. They involve learning complex language strategies used to construct cohesive and coherent units of information. Not surprisingly, processing tasks associated with higher-level language are most difficult for children with ADHD because of the high demands on working memory skills. Research has found that children with ADHD display weak performance in the following types of tasks:

Language comprehension:

  • comprehending inferences13
  • identifying errors in instructions13
  • making judgments about comprehension efficiency14
  • comprehending information in science textbooks14
  • comprehending cause-effect relationships and goal-directed actions of characters in stories15-18

Language expression:

  • retelling a narrative in an organized and coherent manner19
  • elaborating verbally on their ideas20
  • making clear explanations on request20,21
  • answering questions concisely using specific vocabulary20

Weaknesses in basic language skills

Many children with ADHD will have deficits in basic language skills.22,23 These basic language skills involve the development of age-appropriate vocabulary, grammar, and syntax, which in turn will affect their classroom work.22,23 Specifically, these children will struggle with oral language and reading skills.

Educational Implications of Language Weaknesses

  • Children with ADHD may have communication breakdowns that negatively affect their social interactions (for example, working in a cooperative group, participating in a whole-class discussion).
  • Children with ADHD may have considerable difficulty communicating their ideas in an organized and coherent manner (for example, justifying a solution for a math problem, explaining or retelling a story).
  • Students may need external organizers or support systems to help them understand the text structure and to help them construct coherent written texts.

ADHD and reading

Studies have shown that behaviour problems in kindergarten, particularly those involving symptoms of inattention, are predictive of later academic underachievement in reading, even after accounting for other co-existing behaviour problems (for example, hyperactivity), early reading skills, and intellectual ability.6,24

Children who exhibit behavioural difficulties in kindergarten and who have initial reading difficulties are also less likely to make improvements in the primary grades in reading achievement compared to children who exhibit only initial reading problems. This finding strongly suggests that early intervention efforts need to address both behaviour-related concerns and early literacy weaknesses.9,24

Children with ADHD may exhibit a range of reading profiles. Approximately 15% to 40% of children with ADHD exhibit a co-existing specific reading disability.22 ADHD children with a co-existing reading disorder display the cognitive weaknesses associated with both of the individual disorders.25,26

These students exhibit:

  • core linguistic weaknesses associated with reading disorder (for example, poor phonological skills and word attack skills, slow letter/digit naming speed)
  • executive function deficits associated with ADHD (for example, poor working memory and inhibitory control)

Some children with ADHD, particularly those with attention problems, have also been found to exhibit poor orthographic processing.25,27 Orthographic processing refers to the ability to represent the visual properties of the words. A typical task assessing orthographic processing asks children which letter string is a correctly spelled word (for example, blame/blaim or streat/street). Orthographic processing is important to the development of both reading and writing outcomes, and thus it is important for children to be able to create a precise orthographic word form in working memory.27

Text recall and comprehension in children with ADHD

Children with ADHD may also exhibit mild to more severe impairments in text recall and comprehension, depending upon their decoding skills, oral reading fluency, and knowledge of reading strategies. For example, students with ADHD have been found to:

  • have slow reading of single words and nonwords28
  • have difficulty recalling information from stories19
  • be less sensitive to story structure15
  • have difficulty organizing events and identifying causal events in narratives15
  • have difficulty retelling stories in a well organized and cohesive manner19
  • have difficulty monitoring comprehension of orally presented information13
  • have difficulty making inferences13

Adolescents with ADHD without co-existing reading disorder have been found to exhibit subtle weaknesses in text reading rate and text accuracy and have performed slightly more poorly than non-ADHD peers on silent reading comprehension.28

Educational Implications of Research on Children with ADHD and Reading Difficulties

  • Inattentive children in kindergarten and Grade 1 should be considered at risk for later reading problems, even when their reading-related foundation skills may be in the typical range.24 Frequent progress monitoring will help to ensure that these students demonstrate appropriate levels of growth in core reading skills.
  • Children with reading, attention, and behaviour problems require instructional interventions of sufficient intensity and duration that address both types of difficulties. For example, instructional programs that are highly structured, systematic, explicit, and promote high levels of engagement have been shown to be beneficial for children with reading and behavioural difficulties.29,30

In particular, children with ADHD and reading difficulties would likely benefit from:

  • intensive instruction that promotes high levels of engagement and participation (for example, using small group instruction or structured peer-assisted learning programs)30,31
  • instruction that provides students with multiple opportunities to respond and receive explicit and systematic feedback (for example, error corrections and feedback statements regarding performance)29,30
  • instruction that incorporates systematic direct instruction in pivotal reading-related skills and provides students with specific strategies to use to become independent readers30
  • instruction that helps students attend to the orthographic units in written words

ADHD and written expression

Children with ADHD often exhibit significant weaknesses in written expression.32 Anecdotally, problems with written expression are one of the most common and impairing problems at school for children with ADHD.

Problems with written expression in children with ADHD are often characterized by:

  • low productivity, poor fluency
  • slow and effortful and/or fast and careless approach
  • poor written spelling
  • untidy, uneven, illegible handwriting
  • poor planning and disorganization
  • poor written sentence construction
  • poor story composition (missing story elements, missing reasons or conclusion)

Figure 4-1: Neuropsychological Model of Written Expression33

 

As described in Figure 4-1, many of the difficulties that characterize children with ADHD (for example, poor orthographic coding, poor fine motor skills, weaknesses in executive functions and working memory) are considered to be core components of neuropsychological models of written expression and thus it is not surprising that children with ADHD may find the process of text generation (composition) to be daunting.

The model in Figure 4-1 illustrates the extent to which the process of text generation carries a significant cognitive load. Specifically, text generation requires high levels of advanced planning and organization, and the ability to concurrently store and manipulate multiple elements of information at the same time (for example, text structure and sequence, topic knowledge, ideas, spelling).

Educational Implications of Research on Children with ADHD and Written Expression

  • To increase output, the teacher may need to give the student support for both the transcription aspects of writing and the composition process.
  • To help with the transcription process, the student may benefit from assistive technology (for example, speech-to-text software, word processing).
  • To help the student with composition, the teacher may provide:
    • highly explicit strategy instruction regarding the writing process (planning, understanding text structures, use of transition words, thesis statements) (see Chapter 6, "Facilitating the Academic Success of Students with ADHD: Student Learning Strategies")
    • software to facilitate the planning process (for example, outlining and graphic organizer software)
    • concrete reminders of key action steps in the text generation process (for example, think sheets, cue cards). These supports are gradually phased out as the student becomes familiar with the steps

Numeracy skills in children with ADHD

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Numeracy skills in children with ADHD are often significantly below those of their peers. Data from a recent national longitudinal study reported that the mathematics achievement scores of students with symptoms of ADHD were 8% to 10% lower than that of their non-ADHD peers.1

Academic underachievement in numeracy is not solely due to the behavioural symptoms that students with ADHD exhibit in the classroom. Rather, children with ADHD are often perceived by their classroom teachers to exhibit skill deficiencies in numeracy.34 This strongly suggests that in order to optimize academic achievement, children with ADHD need academic instruction that targets their skill deficiencies and takes advantage of their potential strengths.

Research has shown that children with ADHD tend to exhibit the following types of math weaknesses:35-38

  • procedural errors (for example, subtracting larger number from smaller number, failing to carry a number)
  • tendency to rely on finger counting rather than direct retrieval of facts
  • more overt (out-loud) self-talk to guide actions (rather than using inner speech)
  • slow computation speed
  • difficulty retrieving number facts fluently and accurately
  • difficulty ignoring irrelevant information in word problems
  • difficulty solving math problems with multiple procedures or steps

Students with ADHD may have difficulty approaching a problem-solving situation in a systematic manner and also may have difficulty evaluating the success of specific strategies. For example, they may have a limited number of strategies in their repertoire and these strategies may be less sophisticated or inefficient. Students with ADHD often need to be able to learn how to be active and strategic learners.

In addition, learning mathematics requires students be able to access prior knowledge in order to apply this knowledge to a new, more advanced mathematical concept.39 Children with ADHD may have difficulty with using prior knowledge for several reasons. They may lack important pre-skills and/or may have the requisite prior knowledge but may have difficulty retrieving this information in an efficient and organized manner. Children with ADHD may also struggle with the language and processing demands of word problems. For example, Table 4-2 illustrates how subtle changes to the language of a word problem can alter both the problem type and the type of computation needed to solve the problem.

Table 4-2: Characteristics of Word Problems: Linguistic, Situational, and Mathematical Features

Word Problem Problem Type Required Arithmetical Operation
1.  John had three marbles. Then Nina gave him six more marbles. How many marbles does Jim have now?
change addition
2.  John had some marbles. The he gave six marbles to Nina. Now John has three marbles. How many marbles did John have in the beginning?
change addition
3.  John has three marbles. Nina has six marbles. How many marbles did they have altogether?
combine addition
4.  John and Nina have nine marbles altogether. John has three marbles. How many marbles does Nina have?
combine subtraction
5.  John has nine marbles. Nina has six marbles. How many marbles does John have more than Nina?
compare subtraction
6.  John has nine marbles. He has six more marbles than Nina. How many marbles does Nina have?
compare subtraction

 

Educational Implications of Research on Numeracy and ADHD

  • Teachers may wish to use several useful strategies that support students who are experiencing math difficulties.40 These include:
    • rewriting problems in a simpler language
    • pointing out key words and key concepts
    • minimizing copying from boards by providing students with hand-outs
    • using multiple representations and providing links to "real-world" situations
  • Students may need:
    • explicit instruction in problem-solving strategies (for example, counting on, how to use a table, drawing a picture)
    • more instructional supports to learn a strategy (for example, more guided practice, opportunities for review, feedback, and help with monitoring strategy use and application) (see Chapter 6, "Facilitating Academic Success in Students with ADHD: Instructional Supports")
  • Math problems requiring multiple procedures and/or multiple operations may be quite challenging for a student with ADHD and additional instructional supports and guidance may be required to facilitate success (for example, cue cards, mnemonics, guided practice, and frequent progress monitoring).
  • To help students gain understanding of key math concepts, vocabulary and facts, more intensive instruction and/or increased opportunities for engagement (for example, peer tutoring, small group instruction) may be needed.
  • Assessment of mathematical understanding often requires a student to explain his or her ideas either orally or in written language (for example, asking the student to explain the problem in their own words or explain processes and results and justify solutions). As students with ADHD may have difficulty organizing their oral or written output and explaining relationships among concepts, they may need more guided questioning and supportive dialogue to demonstrate their level of understanding of mathematical concepts.

ADHD and social-emotional abilities: implications for the classroom

Children with ADHD often experience more social and emotional problems than their non-ADHD peers.41-44 Although ADHD is often viewed in the classroom as a behaviour management issue, interpersonal deficits are common to all subtypes of ADHD and occur in both boys and girls.43-44 These deficits are often the consequence of poor social skills acquisition, limited insight into social interactions, and/or poor control and regulation of behaviour.45

Children who exhibit hyperactive-impulsive symptoms often experience peer rejection.46 This is often the result of their aggressive behaviour, lack of insight, and failure to develop social problem-solving skills. As well, the use of language for social engagement may be impaired. This impairment may appear as either poorly learned conversational skills or, when the skills are evident, limited ability to perform the skills in a social context.

Social and emotional problems also appear in children who are predominantly inattentive, without the hyperactivity and impulsivity.46 Again, social problems are associated with the failure to develop appropriate social skills and in some cases are also associated with anxiety or depression. Because these children are usually quiet and withdrawn, teachers may not recognize social problems. Yet, these children are often shunned or even bullied by their peers.

It is important to recognize that these maladaptive classroom behaviours and poor peer interactions by ADHD children are not intentional behaviours, but rather the consequence of neurocognitive weaknesses, specifically in executive functions. These weaknesses may manifest themselves in the classroom as:

  • blurting out answers
  • acting without thinking
  • getting up or moving around in the middle of a lesson
  • difficulty remembering the classroom rules
  • misunderstanding instructions

Poor peer interactions may include:

  • aggressive play
  • interrupting conversations
  • failing to take turns
  • overly loud speech

Comorbid psychiatric disorders

Social and emotional skills in ADHD may also be affected by the presence of one or more comorbid disorders. Children with ADHD often present a complex diagnostic picture, with approximately 50% to 80% of children diagnosed with ADHD meeting criteria for other co-existing psychiatric diagnoses (see Chapter 1 for more detailed information).47,48

Co-existing Diagnosis Rate among Children with ADHD
Anxiety disorder 38%
Conduct disorder 14%
Oppositional defiant disorder 40%

There are many programs available to teachers to help children develop social skills, though the success of these programs is limited. However, research shows that the most effective programs need to be embedded in the environment in which the child is having difficulty, such as the classroom.

For teachers who are unable to bring in a full curriculum, there are classroom practices that can make a big difference. Researchers have pointed out that children who feel connected to their school and classroom are more likely to engage in pro-social behaviour and to achieve academically. Teachers can make children feel connected by creating positive learning environments. (See Chapter 7, "Behaviour Support Strategies," for more information.)

Educational Implications of Social Skills Weaknesses in ADHD

It is important to:

  • Teach, model, and scaffold the child's ability to exhibit pro-social behaviours to increase the occurrence of appropriate behaviours: teach a behaviour you want to replace the one you do not want.
  • Provide high levels of positive feedback to reinforce pro-social behaviours (for example, "Thank you for raising your hand").
  • Be proactive by being aware of which students are at risk and gathering information to develop a good assessment. Recognize and support the student's competencies and promote protective factors that the children may have difficulty achieving on their own.

The high risk triad: inattention, poor working memory and academic underachievement

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There is a triad of related difficulties that children with ADHD often exhibit. As illustrated in the diagram below, attention problems are related to weaknesses in both working memory and academic achievement. In turn, these two variables relate to each other. For instance, studies indicate that children with working memory deficits — regardless of whether or not they have ADHD — tend to perform worse on tests of academic achievement than those students without such impairments.50

Figure 4-2: Triad of Problems in ADHD

 

Beyond behaviour: factors affecting school success for children with ADHD

In the classroom, two common characteristics of students with ADHD are their struggle to achieve and their low productivity (that is, they often have difficulty completing tasks or assignments). As indicated in the preceding sections, children with ADHD often experience significant weaknesses in many academic domains. Hence, the academic problems experienced by children with ADHD are not just due to their behavioural symptoms, but are also associated with their difficulty developing academic skills (for example, reading) and supportive academic enablers (for example, study skills, level of engagement).34

For example, researchers have demonstrated that academic grades in reading for children with ADHD are predicted both by academic skills and by teachers' ratings of students' academic enablers (for example, level of engagement, study skills). This finding suggests that academic achievement in children with ADHD may be enhanced by increasing the student's engagement in the task (for example, using instructional techniques that enhance engagement) and by using various instructional strategies to boost academic skills (for example, peer-assisted learning strategies, instructional supports, study strategies, and organizational techniques).

A second group of factors influencing academic success for students with ADHD is weakness in memory and executive functions.51,52 It has generally been found that children with ADHD who have poor working memory and executive function capabilities often underachieve academically51,52 (see also Chapter 3, "Rethinking ADHD from a Cognitive Perspective").

These findings are important because they suggest that interventions to support learning and academic success for children with ADHD need to address both potential cognitive and academic skill weaknesses and not just focus on the reduction of the behavioural symptoms.



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