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One of the key aspects of ADHD that parents and clinicians
need to be aware of is that there are a number of other difficulties that
often co-occur in children with ADHD.
For example, children with ADHD are more likely to be diagnosed with
other externalizing behavior problems such as Oppositional Defiant Disorder
and Conduct Disorder.
Children
with ADHD are also more likely to experience difficulties with depression and
anxiety, and to have specific learning difficulties. Such co-occurring
problems are not evident in all children with ADHD, and a variety of factors
contribute to why some children with ADHD experience one or more of these
additional difficulties while others do not. Correctly identifying these
additional problems is essential to providing effective treatment. These
co-occurring problems often play an important role in the long-term success
experienced by children with ADHD, and may not be substantially helped by
interventions that are typically prescribed for ADHD alone.
Another
reasonably common, but often overlooked, problem that can go along with ADHD
is language impairment. Language difficulties (significant problems in either
the production or understanding of language) are more common in children with
a wide variety of psychiatric disorders, and this is also the case in
children with ADHD. In addition, both ADHD and language difficulties are
likely to play a role in the academic struggles that many children with ADHD
experience. Therefore, it is important
to know which difficulties are typically experienced by children with ADHD,
are specific to ADHD alone, and are indications of language impairment. Such
knowledge could prove helpful in ensuring that a child receives treatments
that are most likely to meet his or her needs.
Examining
the academic and cognitive functioning in ADHD children with and without a
co-occurring language deficit was a fundamental issue addressed in a paper
published in the Journal of Child Psychology and Psychiatry (Cohen N.J.,
et al., 41, 353-362, 2000). Participants in this study included 166 children
between the ages of 7 and 14 (approximately 75% boys) who had been brought by
their parents to a mental health center. Of these children, 105 were
diagnosed with ADHD, and the remaining 61 were diagnosed with some other
psychiatric disorder. As part of the evaluation process, participants were
also administered a number of standardized tests of language functioning to
determine whether or not they also met criteria for a co-occurring language
impairment. Of the 105 children with ADHD, 36 were diagnosed with language
impairment as well. Among the 61 children with a psychiatric diagnosis
besides ADHD, approximately 50% had a co-occurring language disorder. The
specific nature of the language deficits was not described, but problems in
both expressive and receptive language were included.
Following
this battery of language tests, participants were given a series of tests
designed to evaluate their academic and cognitive functioning. These included
tests of reading, spelling, math achievement, IQ, and working memory. The
authors then compared the performance of children in 4 different groups:
those with ADHD and no language impairment; those with ADHD and a language
impairment; those with a psychiatric diagnosis besides ADHD with no language
impairment, and those with a psychiatric diagnosis besides ADHD and a
language impairment. These comparisons enabled the authors to determine which
academic and cognitive difficulties may be specific to ADHD, which may be
specific to language difficulties, and which may be specific to neither ADHD
nor language impairments, but may be likely to occur in children with any
type of psychiatric problem.
Results
For
the academic achievement measures, ADHD and language difficulties were both
significantly associated with lower achievement scores. Thus, children with
ADHD did worse than children with a psychiatric diagnosis besides ADHD, and
children with ADHD and language impairment did worse than children with
another psychiatric diagnosis and language impairment.
Of
particular interest, however, are comparisons between the ADHD groups with
and without language impairment. For each academic achievement area, ADHD
children with a language impairment did substantially worse than those
without. The figures are shown below. (Note: On the tests administered, a
score of 100 is average, and any score between 90 and 109 is considered to
fall within the average range. In the table below, LI stands for language
impairment. Basic reading refers to the ability to sight read single words.
Word attack refers to the ability to correctly sound out nonsense words such
as "glurp".)
ADHD alone ADHD + LI
Basic
reading 109 102
Reading
comprehension 97 95
Spelling 94 88
Math
computation 85 82
Word
attack 86 74
For
children with ADHD alone, the average achievement scores for each area fell
within the normal range. In contrast, scores for children with ADHD who also
had a language disorder were substantially below average. In all cases, the
magnitude of the difference between the groups is significant.
Similar
results were found for intellectual ability. Children with ADHD alone had
significantly higher IQ scores than those with ADHD and language impairment
(108 vs. 96). This was largely because the ADHD + LI children received poor
results on the verbal portions of the IQ test. Children with ADHD + LI also
performed worse on the various memory tests that were administered.
Summary And
Implications
The
results of this study highlight the importance of screening for language
difficulties among children who are being evaluated or treated for ADHD.
Compared to ADHD children who did not have language difficulties, children
with ADHD + LI performed significantly worse on measures of academic
achievement, intellectual functioning, and working memory. Although not
directly tested in this study, it is reasonable to hypothesize that
successfully addressing the academic difficulties of children with ADHD + LI
requires interventions that focus directly on their language impairment in
addition to difficulties attributed to their primary symptoms of ADHD. Thus,
for these children, bringing their ADHD symptoms under control is not
expected to be a sufficient intervention. For some children with ADHD alone,
in contrast, interventions that focus more exclusively on the core ADHD
symptoms of inattention, hyperactivity, and impulsivity could be quite
adequate.
Screening for associated
language difficulties is not a frequent component in ADHD evaluations, and is
most often excluded when primary care physicians conduct the evaluation.
Should parents have any concerns about their child’s expressive or receptive
language functioning, a thorough screening for language difficulties is worth
pursuing. In addition, for children already are being treated for ADHD but
who continue to struggle academically, results from this study suggests that
language difficulties may be a strong contributor to this problem. A speech
and language evaluation may be worth considering in such instances.
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