Understanding Language Impairments in Children with ADHD

1. Understanding Language Impairments in Children with ADHD Carol Westby, PhD (mocha@unm.edu) Lee Robinson, MS (lee_robinson@byu.edu Brigham Young University ASHA 2007

2. Body function&structure(Impairment) Activities (capacity) (Limitation) Participation (performance) (Restriction) Environmental Factors Personal Factors International Classification of Functioning Condition (disorder/disease)

3. DSM-IV Criteria for ADHD • I. Either A or B: • A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: • Inattention • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. • Often has trouble keeping attention on tasks or play activities. • Often does not seem to listen when spoken to directly. • Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). • Often has trouble organizing activities. • Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). • Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). • Is often easily distracted. • Is often forgetful in daily activities.

4. B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: • Hyperactivity • Often fidgets with hands or feet or squirms in seat. • Often gets up from seat when remaining in seat is expected. • Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). • Often has trouble playing or enjoying leisure activities quietly. • Is often "on the go" or often acts as if "driven by a motor". • Often talks excessively. • Impulsivity • Often blurts out answers before questions have been finished. • Often has trouble waiting one's turn. • Often interrupts or intrudes on others (e.g., butts into conversations or games). • C. Some symptoms that cause impairment were present before age 7 years. • D. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). • E. There must be clear evidence of significant impairment in social, school, or work functioning.

5. Based on these criteria, three types of ADHD are identified: ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months. ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months NOTE: Predominantly hyperactivity/impulsivity and combined types have particularly be associated with deficits in executive functioning and working memory. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

6. Children Ryan, age 6, on medication ADHD – predominantly hyperactive-impulsive ?comorbid Asperger’s Jason, 8, on medication ADHD – predominantly hyperactive/ Impulsive (may be moving to combined type) Zach, age 15 ADHD – predominantly inattentive; Sluggish cognitive tempo; Comorbid language/learning disability

7. Parent Concernsfor Zach Talks really loud a lot of time, I think he is a little obnoxious. Doesn’t really have hardly any friends at all. He tries really hard. Doesn’t understand doesn’t realize that he not acting the same way as other kids at school. Talks about Zach is cool. Zach is always in the story. It is getting better It might be that he’s really consumed with himself still cause that’s a younger child. E: Is he aware of not having friends Yeh, Said that he doesn’t have any friends.

8. Parent Concernsfor Ryan Biggest concern we have for him in school is his social acceptance and his ability to interact socially. Anything that would give him skills in being able to when a friend expresses a different opionion than his, being able to say, “well, that’s OK, but this is my opinion.” When somebody has a toy he wants or isn’t sharing a turn, being able to approach that and in a socially acceptable manner, say, “I’ve waited 5 minutes; can I have a turn now.” Give him tools that he can apply in situations when usually the alternative would be to lash out, or kinda spit, or take the toy.

9. Hyperactivity song by Mark Lowry They might tame the wind, They might calm the sea, But they’re never harness my energy. I’m the poster boy for hyperactivity! It’s not my fault! The world’s not keeping up with me.

10. Sluggish Cognitive Tempo Qualitatively different problems with attention Spacey, daydreamy, easily confused, stares a lot Under- rather than over-active Lethargic, sluggish, slow moving Slow information processing Social withdrawal Greater risk for anxiety Reduced response to stimulants

11. Research Evidence on Effectiveness of ADHD Treatments • Medication more effective than psychosocial treatments in the short-term • Medication combined with psychosocial treatments the most effective • Best supported psychosocial treatments involve: • Contingency management/reinforcement approaches • Parent training • Integration of home and school-based approaches Multimodal Cooperative Group (2004). National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. Pediatrics, 113, 762-769.

12. Research Evidence on Effectiveness of ADHD Treatments • Limitations of medication treatments • Problems with compliance to medication regimens • Limitations of psychosocial treatments • Failure to maintain post-treatment benefits • Failure to generalize to broader areas of life functioning • Failure to achieve long-term gains in academic achievement • Persistent deficits in executive functions, motivational deficits, and impairments in self-regulation 70-80% of adolescents with ADHD have significantly impairing symptoms

13. Need Revised diagnostic criteria Outcome measures that capture real-world functioning Improving long-term efficacy and effectiveness outcomes in ADHD: A treatment development workshop. March 12-13, 2007, Rockville, MD.

14. Evidence-Based Practice Professional Expertise Clinical Decision Making Research Evidence Client Evidence

15. Barkley’s Definition of ADHD ADHD consists of developmental deficiencies in the regulation and maintenance of behavior by rules and consequences. These deficiencies give rise to problems with inhibiting, initiating, or sustaining responses to tasks or stimuli and adhering to rules of instructions, particularly in situations where consequences for such behavior are delayed, weak, or nonexistent. Barkley, R. (1990). Attention-deficit hyperactivity disorder: A Handbook for diagnosis and treatment. New York: Guilford, p.71.

16. Aspects of Executive Functioning Deficits in Behavioral Inhibition Result in deficits in Deficits in Nonverbal Working Memory Sense of time Schema formation Anticipatory set/hindsight forethought Complex imitations Deficits in Verbal Working Memory/ Internalization of Speech Rule-governed behavior Reading comprehension Moral reasoning Deficits in regulation of affect. arousal, motivation Emotional control Perspective taking Motivation/ persistence Analysis and synthesis Creativity Deficits in Problem-Solving Barkley, R.A. (2005). ADHD and the nature of self-control. New York: Guilford. Deficits in Goal-Directed Behavior

17. Other Disorders • Associated disorders: disorders that are a direct result of the ADHD • A result of the deficits in executive function; which may include deficits in theory of mind • Comorbid disorders: disorders that exist in addition to the ADHD

18. ADHD and Associated Disorders • Types of communication problems • Pragmatic deficits • As evaluated by the DSM-IV • Difficulty taking turns • Interrupt • Don’t listen to what is said • Excessive talking • Difficulties in introducing, maintaining, changing topics; failure to adjust language to listener • Scores on CCC-2 scales, Inappropriate Initiation and Social Relationships, differentiated children with ADHD from controls • No difference between children with ADHD and controls on speech, syntax • Discourse organization Bruce, Thernlund, & Nettelbladt, 2006;Cameratia & Gibson, 1999; Geurts, et al, 2004; Nixon, 2001)

19. ADHD and Associated Disorders • Reading problems • Failure to monitor comprehension • Failure to understand main ideas • Difficulty with inferencing • Failure to use language to regulate behavior and plan • Motor development and motor planning (Barkley, 2005; McInnes, Humphries, Hogg-Johnson, & Tannock, Purvis & Tannock, 1997)

20. Deficits in Identifying Emotions • Children with ADHD (7-13 years with no comorbid disorders) • less accurate than typical children in identifying the emotions of happiness, sadness, anger, and fear in pictures and in the tone of voice of an adult reading a sentence (Cadesky, Mota, & Schachar, 2000) • When shown photographs depicting joy, anger, disgust, and sadness in varying intensities, exhibited particular difficulty in identifying anger and sadness( Pelc, Kornreich, Foisy, & Dan, 2006). • Significant correlation between interpersonal problems and impairment in decoding emotional facial expressions. • Adults with ADHD had more difficulty identifying emotions compared to those adults without ADHD (Rapport, Friedman, Tzelepis, & Van Voorhis, 2002).

21. Narrative Comprehension in Children with ADHD • Fewer causal connections in stories • Difficulty establishing a goal (less frequent mention of initiating event) • Difficulty using causal, goal-based story structures to guide ongoing comprehension and later recall • Use more ambiguous reference • Include more extraneous information • Children with ADHD-only answer fewer inferential questions than children without ADHD • Children with ADHD +LI answer fewer literal and inferential questions (Flory, et al, 2006; Lorch, et al, 2006; McInnes, Humphries, Hogg-Johnson and Tannock, 2003; Renz, et al, 2003)

22. ADHD and Comorbid Disorders • Externalizing disorders identified more with predominantly hyperactive-impulsive and combined types • Conduct disorder • Oppositional defiant disorder • Internalizing disorders identified more with predominantly inattentive type • Anxiety/depression • Speech/language disorders affecting phonology, syntax, semantics • Dyslexia (deficits in decoding and syntax)

23. Assessing Elements of EF Underlying ADHD

24. Stroop Task Black Blue Red Yellow Green Orange

25. Stroop Day-Night Test

26. Animal Stroop: Name the body of the animal

27. Animal Stroop Task

28. Types of Cohesion

29. Types of Cohesion

30. Persuasive Writing Should Animals be used in a Circus I think that animals at the circus should be able to do tricks because it is fun to see it and it looks very dangerous. Other people might not think that is a good idea, because the people are doing dangerous things. But they are triand to do that. It is fun to see it. Becuase people are doing dangerous things like, makking lions jump through hoops. It is dangerous and scary to see it, but people are trained to do it. It looks cool. People have a lot of fun. People always cheer after ever trick. They are so happy to come. In conclusion I think it is cool to have animals do tricks. Because it is fun to see it, and it has dangerous actors in it. People have a lot of fun there.

31. Types of Answers to QRI Questions • Failure to link ideas across a passage – making relational inferences • Failure to make causal inferences • Failure to parse syntax • Excessive elaboration or overreliance on prior knowledge • Failure to know a key vocabulary word • No response – did not answer Dewitz, P., & Dewitz, P.K. (2003). They can read the words, but they can’t understand: Refining comprehension assessment. The Reading Teacher, 56:5, 422-435.

32. The Octopus – 5th gradeConcept Questions • What is an octopus? • A big creature with 8 legs • Why does an animal attack another animal? • Wants to eat it • What are animal defenses? • Pine needles, claws • What is animal camouflage? • So things can’t see it • Prediction • Octopus attacking humans

33. The Octopus – 5th grade • Explicit questions • What is the favorite food of the octopus? (crabs) • How does the octopus move forward very rapidly when it is frightened? Pushes water from its body • What does the ink-like fluid do to the water? Makes it dark (not specific enough) • What is one color that an octopus can change to? Pink and blue

34. The Octopus – 5th grade • Implicit • What is this passage mainly about? An octopus and what it does when it’s scared or excited (relational inference across text) • Why doesn’t an octopus completely change color when it sees a crab? Don’t know (causal inference across text) • What color does an octopus probably become when it sees an enemy? Dark(relational inference from text) • Why might the shy octopus attack another creature? If hurt (over reliance on prior knowledge)

35. Theory of Mind & Emotion Understanding Belief understanding does not guarantee emotion understanding; emotion understanding does not guarantee empathy; and empathy does not guarantee sympathy as manifested by kindness to people who are sad. Davis, M., & Stone, T., (2003). Synthesis: Psycholgical understanding and social skills. In B. Repacholi & V. Slaugher (Eds.), Individual differentes in theory of mind: Implications for typical and atypical development (pp. 306-352). New York: Psychology Press.

36. Pons,R. Harris, P., & M. de Rosnay (2004). Emotion comprehension between 3-11 years : Developmental periods and hierarchical organization. European Journal of Developmental, 1, 127-152 Wellman, H.M. & Liu, D. (2004). Scaling of theory-of-mind tasks. Child Development, 75, 523-541.

37. Sad Mind Reading: The Interactive Guide for Emotions

38. Perceptual-language distance I II III IV perceptual Matching Perception Selective Analysis of Perception Reordering Perception Reasoning about Perception language distance Blank, M., Rose, S.A., Berlin, L.J. (1978). The language of learning: The preschool years. New York: Grune & Stratton.

39. Johnny has been playing with this truck for a long time, all morning, and now Jimmy wants a chance to play with it. What can Jimmy do or say so he can have a chance to play with the truck? Peter broke his mom’s favorite flower pot and his mom might be mad at him. What could Peter say or do so that his mom will not be mad? Early Childhood (Alternative Thinking) Spivack, G., Platt, J.J., & Shure, M.. (1976). The problem-solving approach to adjustment. San Francisco: Jossey-Bass.

40. Middle Childhood (Means-End Thinking) Child is told the beginning and end of a story and is asked to fill in the middle, tell what happens in between, or tell how the ending got to be that way. Al (Joyce) moved into the neighborhood. He (she) didn’t know anyone and felt very lonely. The story ends with Al (Joyce) having many good friends and feeling at home in the neighborhood. What happens in between Al’s (Joyce’s) moving in and feeling lonely, and when he (she) ends up with many good friends. Spivack, G., Platt, J.J., & Shure, M.. (1976). The problem-solving approach to adjustment. San Francisco: Jossey-Bass.

41. Adolescence(Consequential Thinking) George is in training. The football coach has a rule that all members of the team get to bed early during the week. George gets invited to a Tuesday night social in the next town by a girl he likes a lot. If he goes, he’ll end up getting to bed rather late. He would really like to go. Tell everything that goes on in George’s mind and then tell what happens. Spivack, G., Platt, J.J., & Shure, M.. (1976). The problem-solving approach to adjustment. San Francisco: Jossey-Bass.

42. Conflict Resolution • John’s teacher assigned him to work with three other boys on a project for the science fair. The boy’s decided to build a model airplane that could actually fly. All of the boys, except one, a boy named Bob, worked hard on the project. Bob refused to do anything and just let the others do all the work. This bothered John very much. Now I’d like you to tell the story back to me. • Now I’d like to ask you some questions about the story. • What is the main problem? • Why is that a problem? • What is a good way for John to deal with Bob? • Why is that a good way for John to deal with Bob? • What do you think will happen if John does that? • How do you think they both will feel if John does that? Nippold, M.A., Mansfield, T.C., Billow, J.L. (2007). Peer conflict explanations in children, adolescents, and adults: Examining the development of complex syntax. American Journal of Speech-Language Pathology, 1, 1798-188.

43. Ways social skills affect academics • Teacher-student relationships • Teacher may spend more time addressing child’s behavioral issues then teaching child academic concepts • Peer relationships • Child not selected for peer work groups • Child does not fully participate in learning groups • Ability to make inferences from texts • If child does not understand emotionality and temporal-cause/effect relationships in social situations, cannot use this information to build mental models for texts

44. Specific targets/outcomes Emotional Understanding Problem Solving Temporal sequence & cause and effect Non-verbal cues

46. Underlying Principles:Explicit teaching • Repeated exposures • Variety of contexts • Practice in safety

48. Semantic memory: memory for words and concepts Procedural memory: memory for how to do something Episodic memory: memory for subjective experiences throughout time; ability to perceive the present moment as both a continuation of the past and as a prelude to the future. Plan, Do, Review = Episodic Memory Journal writing Facilitates episodic memory Take it home and share with the family Culturally appropriate Developing episodic memory McGuigan, F., & Salmon, K. (2004). The time to talk: The influence of the timing of adult-child talk on children’s event memory. Child Development, 75, 669-686. Tulving, E. (1993). What is episodic memory? Current Directions in Psychological Science, 2, 67-70.

49. Outcomes focus on participation • Capacity goal • Zach will identify when his clinician is indicating boredom. • Participation goal • Zach will make and keep a friend • Zach will invite a friend to a movie, arranging time, place and transportation

50. Emotional understanding Problem Solving Temporal, cause/effect relationships Noverbal cues