QJER logo 2
[ Contents Vol 17, 2001 ] [ QJER Home ]

Attention deficit hyperactivity disorder and reading achievement

Kathy B. Baker
Attention Deficit Hyperactivity Disorder (ADHD) is a disorder that affects one in 30 children, to differing degrees, for the entire life-span. Family life, social conformity, mental health and success in school and the workforce are compromised due to the impact of the disorder. A significant number of ADHD children have also been diagnosed as learning disabled, with reading disability being the most common co-morbid learning disability. Whether the reading difficulties experienced by ADHD children are unique, in that they are due to the specific action of ADHD characteristics, or are separate disabilities is currently under debate. However, it is likely that the reading disabilities experienced by ADHD children are the result of the impact of the core characteristics of the disorder on executive functions.


This paper provides a 'snap-shot' of current perceptions regarding the nature of Attention Deficit Hyperactivity Disorder (ADHD), an overview of current medical and educational interventions for the disorder, and describes a reading intervention designed to address the impact of executive function deficits in the reading process. The intervention strategy uses a combination of cognitive training, strategy training and medication in a multimodal intervention to improve the reading behaviour of ADHD children and promote associated reading achievement.

HISTORY OF ADHD

The symptoms of ADHD were observed and documented in the mid-1800s, with symptoms noted as appearing similar to central nervous system damage or disease (Barkley, 1989). However, the first well-documented descriptions of the disorder and an attempt to understand and explain the symptoms occurred in England in 1902 when George Still labelled the set of behaviours as 'defects in moral control' (Barkley, 1989, p. 39). Still described those affected with the disorder as aggressive, defiant, resistant to discipline, highly emotional, evidencing little self-control, with many participants in his sample also exhibiting excessive activity and poor sustained attention to task.

Since these early identifications of the disorder both the label and the diagnostic requirements have changed several times. The current publication of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published in 1994 saw further changes to the labelling of the disorder with three subtypes being established. The subtype ADHD-Predominantly Inattentive Type (ADHD-PI) allows a distinction of the disorder where inattention is the principal source of problems. ADHD-Predominantly Hyperactive-Impulsive Type (ADHD-PHI) distinguishes the disorder where the main problem area is hyperactivity-impulsivity with some or none of the symptoms of inattentive behaviour. The ADHD-Combined Type (ADHD-C) is used to describe the disorder where both inattention and hyperactivity-impulsivity are evident. The combining of hyperactivity and impulsivity reflect current findings where these two symptoms are beginning to be seen as one behaviour dimension rather than two separate problem areas. (Barkley, 1996).

CORE CHARACTERISTICS OF ADHD

The three core characteristics of ADHD - hyperactivity, impulsivity and inattention - are pervasive with significant situational fluctuations. Situations that involve novelty and immediate gratification are likely to cause a reduction in these behaviours, while boring repetitive activities will prompt an increase in hyperactivity levels and a decrease in attention (Saunders & Chambers, 1996). ADHD impacts on sustained and selective attention, causing children with ADHD to be more disorganised and forgetful than other children of the same age. Deficits in impulsivity make it difficult for ADHD children to reflect on and reconsider their actions so they often enact thoughts without the consideration of consequences (Grainger, 1997; Gross, 1997). Hyperactivity presents across a dimension ranging from fidgeting to inappropriately excessive motor activity (Barkley, 1996), and is a clear indicator of ADHD with the severity of this characteristic not indicative of the severity of the disorder (Gross, 1997).

PREVALENCE OF ADHD

ADHD is a disorder that affects a significant proportion of the population (Baker, 1996). However, variations in cited prevalence rates occur both within and between countries depending on a number of factors, including the diagnostic criteria used, age and gender of the population, socio-economic status and urban living (Barkley, 1996). According to the National Health and Medical Research Council (1997) ADHD affects 2-6 per cent of Australian children. Prevalence of ADHD in the United States of America ranged from 20 per cent of the general population (Gross, 1997) to 3-6 per cent of children if DSM-IV guidelines are adhered to (Barkley, 1996). Prevalence rates in Britain are significantly lower than those cited for both Australia and America (1.5%), due to the exclusion of children who have a co-morbid disorder such as conduct disorder (Grainger, 1997).

The great majority of children diagnosed as ADHD are boys, making up 60-90 per cent of children classified with the disorder. This occurs despite studies showing that males and females have the same genetic predisposition to the disorder (Hay & Levy, 1996). Gross (1997) believes that ADHD occurs with equal frequency in both males and females with differences in the manifestation of the disorder between genders resulting in the differing prevalence rates. Females with ADHD are less likely to be hyperactive (Gross, 1997), aggressive, sensation seeking (Goodman & Poillion, 1992), and present with conduct disorders, but are more likely to be socially withdrawn (Baker, 1994). As a result females tend to be less visible than males and so do not prompt the same number of referrals as their male counterparts (Epstein, Shaywitz, Shaywitz & Woolston, 1991). The difference in prevalence rates between genders is an important issue as it affects the behavioural and educational support available to unidentified ADHD females.

LONG-TERM EFFECTS OF ADHD

ADHD is a disorder that is most commonly associated with children, particularly within the context of schooling. However, ADHD continues to affect individuals into adulthood with only 11 per cent of ADHD children developing adequate coping strategies by adulthood (Baker, 1994). The continuing presence of ADHD symptoms into adulthood is likely to impair both home and work adjustment (Barkley, 1989). It is likely that ongoing symptoms of ADHD will impact on family in the form of stressed parenting and ultimately dysfunctional families and family breakdown (National Health and Medical Research Council, 1997). ADHD adults show a higher rate of unemployment (Gordon, 1994) and when employed are rated by employers as being less independent, less capable of complet ing set tasks, less amenable to co-workers and more likely to lose their job (Baker, 1994). As well, ADHD adults are more likely to be in low-status jobs (Baker, 1994) and to change jobs more frequently (Wodrich, 1994).

ADHD adults also have a high co-morbidity rate of conduct disorders as well as depression and anxiety disorders, and when ADHD occurs concomitantly with Conduct Disorder (CD), these persons have an increased risk of developing personality disorders (Hay & Levy, 1996). Attempted and successful suicide rates are also higher (Wodrich, 1994), as are substance abuse rates (Hay & Levy, 1996), police contact in relation to traffic offences and speeding (Gordon, 1994), and court involvement related to theft and physical aggression (Wodrich, 1994). For ADHD adults who experienced ADHD symptoms concomitantly with learning disorders and CD as children, the possibilities of achieving a near normal adult life is further diminished with these individuals most likely to have greater on-going problems in adulthood (Gordon, 1994).

ADHD AND SCHOOLING

During the years of schooling the impact of ADHD is evident both educationally and socially, symptoms of which include academic underachievement as well as peer rejection and difficulty conforming to rules and behaviour expectations. The precise nature of the impact of ADHD on learning is unclear as yet. The symptoms include poor organisational skills, poor sequential memory, deficits in fine and gross motor skills, and unproductive cognitive styles (Saunders & Chambers, 1996). Affected children are more likely than other children to experience problems with reading, spelling and written language (Zentall, Gohs & Culatta, 1983). By adolescence approximately 50 per cent experience school failure or fail at least one subject, one third will not finish high school (Zentall et al., 1983) and only a minority attempt tertiary education (Baker, 1994). The overlap of learning disabilities (LD) and ADHD is significant with 11 per cent of ADHD children also diagnosed with a LD and 33 per cent of LD children also presenting as hyperactive (Epstein et al., 1991). Reading disabilities in particular occur concomitantly with ADHD (Cantwell & Baker, 1991).

TREATMENT

According to the literature, effective strategies are those that are multimodal and take into account the variability and complex nature of the disorder and the particular needs of each individual. No single treatment is sufficient to maximise reduction of symptoms across settings (Baker, 1994; Barkley, 1989; Gordon, 1994), nor can treatments be considered to cure the disorder (Barkley, 1989). It is recommended that treatments be viewed as long-term management (Baker, 1994). Strategies that are able to occur across a variety of settings will be more successful in managing the disorder as children affected by ADHD have difficulty in generalising behaviour to new settings (Baker, 1994; Barkley, 1989).

ADHD has been found to be highly heritable. The Australian Twin ADHD Project, begun in 1991, showed that between 75 per cent and 90 per cent of ADHD is inherited (Hay & Levy, 1996). This being the case, it is likely that more than one member of the immediate family will be affected by the disorder, with at least one parent having the disorder also a possibility. Since the outcome of the disorder is significantly influenced through environmental factors relating to the home and family pattern of interaction (Barkley, 1996; Wodrich, 1994), treatment packages should consider family support, including training in behaviour management and counselling support. Stimulant medication, specific developmental issues, behaviour management and educational management should also be considered as part of a multimodal approach to treatment (National Health and Medical Research Council, 1997).

MEDICATION

Stimulants are the most frequently used form of drug treatment for ADHD (Barkley, 1989; Gordon, 1994). They are also the most safe and consistently effective medication, with 96 per cent of patients responding favourably (National Health and Medical Research Council, 1997). The benefits of stimulant drug therapy lie in their immediate impact on inattention, impulsivity and hyperactivity. A reduction in these behaviours occurs, with hyperactivity often reducing to within normal limits (Gordon, 1994). As a result ADHD children may become more co-operative and be better able to sustain their compliance. Enhanced academic performance in the areas of accuracy and productivity may also result (Barkley, 1989; Gordon, 1994). However, gains in academic achievement, where higher levels of difficulty are achieved, do not result from use of the medication (Barkley, 1989). In order for higher levels of academic achievement to occur other academically orientated treatments need to occur as an adjunct to medication (Grainger, 1997).

CURRENT EDUCATIONAL INTERVENTIONS

There are a number of interventions thought to assist the learning of ADHD children, ranging from general interventions able to be applied across the curriculum and designed to improve on-task behaviour, to interventions used for specific learning needs. Tables 1 and 2 provide a summary of these interventions.

Table 1: General interventions for ADHD children

General interventionSource
Allow for active respondingBarkley, 1989
Allow movement between and during tasksZentall, 1993
Use tasks with embedded stimulationZentall, 1993
Use novelty such as gamesas well as changes in settings, resources and presentation modesZentall, 1993
Use reinforcement such as a token economy to reward on-task behaviourFiore, Becker & Nero, 1993
Provide tasks that have an appropriate level of difficultyZentall, 1993
Maintain a structured schedule as far as possibleOstoits, 1999
Be consistent with instruction methodsOstoits, 1999
Use tasks with multisensory featuresOstoits, 1999
Use visual/graphic representations of information and conceptsFrench & Andretti, 1995
Provide activities that can be divided into smaller tasksZentall, 1993
Teach organisational and study skillsYehle, 1998
Highlight important information in directionsYehle, 1998
Provide a supportive and risk-taking learning environmentYehle, 1998
Support for verbal responses during class interactions such as 'think time', verbal or visual scaffolding Saunders & Chambers, 1996

Table 2: Task/subject specific interventions for ADHD children

Task/subject specific interventionSource
Mathematics
Peer Tutoring

Hook & DuPaul, 1999
Handwriting
Colour added to difficult stroke sequences

Zentall, 1993
Spelling
Colour added for difficult stroke sequences
Computer Assisted Instruction

Zentall, 1993
Fitzgerald, Fick & Milich, 1986
Reading
Pre-reading and post-reading strategies to improve comprehension
Qui etly reading aloud during Silent Reading to maintain attention
Using a marker to maintain place when reading
One-to-one and small groups instruction in specific reading skills
Self-assessment of taped oral reading to improve auditory discrimination
Use of predictable 'join-in' texts to improve auditory discrimination

Warren & Flynt, 1995
Ostoits, 1999
Ostoits, 1999
French et al., 1995
French et al., 1995
Warren et al., 1995

THE IMPACT OF ADHD ON EXECUTIVE FUNCTIONS

The high incidence of co-morbidity between ADHD and Reading Disability (RD) suggests an association, though the nature of the relationship is unclear. However, it is likely that the learning difficulties experienced by ADHD children are unique in that they are due to the impact of ADHD core characteristics on executive functions, and not the result of a specific learning disability. Executive functions have been described as those functions that allow for analysis of information, reflection on current knowledge, planning and organization, self-monitoring (Douglas, 1980), mobilising attention, and inhibiting responding (Purvis & Tannock, 1997). They allow self-regulation (Barkley, 1996) and are necessary for the initiation and maintenance of goal directed behaviour (Akhutina, 1997).

Support for the idea of executive function deficits in ADHD children is found in work where ADHD children have been identified as having difficulty carrying out strategies when working on tasks (Douglas, 1980), being less able to communicate the strategies they use to others (Saunders et al., 1996) and lacking the metacognitive abilities needed for the planning and evaluation of current cognitive strategies. Cited difficulties with memory (Conte, 1991; Saunders & Chambers, 1996) are further indications of executive function deficits since working memory is considered to be one aspect of these functions.

Barkley (1996) has developed a theoretical model of ADHD that provides further insight into the role of executive functions in causing ADHD behaviours. This model is represented in figure 1. The model places inhibition as the primary executive function that affects four other executive functions, that of working memory, self-regulation of affect/motivation/arousal, internalisation of speech, and reconstitution. These secondary functions are dependent on inhibition for their optimal operation. However, the quality of the primary function of inhibition can be influenced through changes in quality of any or all of the second order functions, with all the executive functions being interactive.

THE IMPACT OF EXECUTIVE FUNCTION DEFICITS ON READING

Reading is a meaning constructing process that involves the reader in a continuous series of hypotheses and revisions. This process is monitored by executive control functions through the use of metacognitive strategies such as rereading a text section. Monitoring behaviour allows the reader to assess progress toward the goal of understanding the text (Garner, 1994; Rosenblatt, 1994; Ruddell & Unrau, 1994; Rumelhart, 1994). Successful reading relies on the active use of the reader's past life experiences and knowledge, including knowledge of text content and structure, and reading strategies suitable to monitor meaning construction and repair meaning when meaning loss is detected (Ruddell & Unrau, 1994).

Figure 1

Figure 1: Barkley's (1996) model linking inhibition, executive function and motor-control fluency

An analysis of the executive function deficits experienced by ADHD children indicate that these deficits would impact on the reader's ability to recall and apply relevant background knowledge, as well as the capacity of executive control functions to monitor the meaning construction process. Motivation to initiate and maintain reading effort would also be difficult to achieve. The result is likely to be an underachieving child who views themself as a non-reader and reading as a threatening and unenjoyable experience. A model based on Barkley's model of executive function deficits is displayed in figure 2. This model shows the impact of executive function deficits on the reading process.

Figure 2

Figure 2: The effects of executive function deficits on the reading process

REDUCING THE IMPACT OF EXECUTIVE FUNCTION DEFICITS

Reading instruction for underachieving ADHD children is likely to be successful if it addresses the impact of executive function deficits on the reading process as well as deficits in knowledge and use of reading strategies. Strategic knowledge includes knowledge of a variety of meaning repair and monitoring strategies as well as knowledge of how and when to apply these strategies, and the value of strategic behaviour. The multimodal intervention designed by the author employs a combination of the cognitive training approaches of self-instruction, self-monitoring and self-reinforcement, strategy training, medication, memory prompts, and stimulant medication. The simultaneous application of these components aims to positively influence the executive functions compromised by ADHD and address deficits in reading strategy knowledge.

First, the intervention enhances the executive function of inhibition through the direct action of stimulant medication, self-instruction and self-monitoring. Stimulant medication causes a reduction in 'disinhibition' creating a delay in responding. Self-instruction, which is the self-verbalisation of the steps undertaken when engaged in a task (Conte, 1991), acts to cause a delay in responding as it directs the child to engage in thoughtful responses. In using self-instruction the student focuses on the self-statements needed to prepare for reading, such as 'What do I know about the topic of this book?' and 'What do I know about how the book is organised?'. To initiate and maintain monitoring of meaning construction statements the child is taught to ask such questions as 'Does this make sense?' and the student is encouraged to select and assess appropriate repair statements like 'This doesn't make sense, I'll try the read-on strategy'. Self-monitoring creates planned pauses in action, to allow for structured reflection on strategic reading behaviour. This cognitive approach focuses on the reader's use of reading strategies during the reading of a text. Inhibition is indirectly acted on by self-reinforcement as this component supports the process of self-monitoring.

The action of working memory is directly supported through self-instruction and the visual and kinaesthetic strategy cues of a memory-cue bookmark. The pre-reading self-statements appear on the bookmark and activate the retrieval of relevant background knowledge about text content and structure, allowing the development of a useful anticipatory set. Self-statements such as 'Does this make sense?' during reading help to hold-on line the need to monitor for meaning. The bookmark is likely to prompt action when meaning loss is detected as it reminds the reader of meaning repair actions. Retention of the repertoire of fix-up strategies in working memory is also facilitated through use of the bookmark. Using both visual and kinaesthetic cues on the bookmark provides the multisensory input required by ADHD children (Ostoits, 1999).

Self-regulation of affect/motivation/arousal is directly supported by self-reinforcement and conditional strategy training. Self-reinforcement is designed to increase motivation to engage in the training process and modify reading behaviours. Training in the value of strategy use also increases motivation to act strategically (Paris & Oka, 1986). Self-monitoring also influences affective change as it supports attribution of success to changed reading behaviours by making these changes explicit and assessable. This aims to cause an increase in self-efficacy and the development of a positive attitude to reading (Paris et al., 1986).

Internalisation of speec h is enhanced directly through cognitive training in self-statements, which is supported by strategy training and self-monitoring. The cognitive training process facilitates the development of effective internal speech. It provides self-statements that are able to efficiently and effectively direct and control cognition and provides support for the child as they move to internal use of the statements. Strategy training informs self-statements so that readers are able to incorporate statements of action specific to the reading process. Self-monitoring promotes the use of appropriate self-statements as it provides a means of self-reflection and evaluation of quality and effectiveness of these statements. Use of self-instruction and self-monitoring is further supported by self-reinforcement.

The capacity for reconstitution is enhanced through the action of all intervention components as they influence the reading process and so increase comprehension. This change is likely to improve the reader's ability to use information and understanding from texts to create novel responses. The ability to create multiple plans of action also is likely to improve since strategy training provides an array of strategies from which to choose and self-instruction acts to direct and control the development of plans and strategies.

In summary, the intervention provides a multimodal approach that addresses the academic needs of the ADHD reader as well as the executive function deficits associated with ADHD. It provides the tools to access text (strategies), a means of controlling cognition during reading (self-instruction), and promotes the attribution of success to the actions of the reader. In doing so it establishes affective and cognitive conditions conducive to successful reading. Once initial training is mastered by the student, the intervention should be relatively easy for the classroom teacher to maintain by continuing the self-reinforcement system, managing the resource materials including access to interesting texts appropriate to the reader's ability, and the memory-cue bookmark.

CONCLUSION

ADHD is a disorder that affects a significant proportion of the population, impairing their ability to interact with family, community, work and classroom environments. Associated difficulties with learning are evident by the high co-morbidity rate between ADHD and learning disabilities, with reading disability being the most common co-occurring learning disability. While the association between ADHD and reading disability has not yet been clearly defined, it is likely that executive function deficits resulting from the disorder interfere with the ADHD child's ability to successfully engage in the reading process. The intervention proposed by the author addresses these deficits in an educational intervention that is relatively easy to introduce and maintain within a normal classroom situation.

When attempting to meet the needs of ADHD children in the classroom, teachers need to provide interventions that are able to be maintained and extend the ideas described above to other subject areas since ADHD children often have difficulty generalising learning strategies from one context to another. Identification of ADHD girls also needs to be addressed as an educational priority, particularly if the disorder has already been identified in another member of the family. It is the aim of inclusive education for all children to achieve to the best of their ability. Providing ADHD children with appropriate interventions will facilitate the achievement of this goal.

REFERENCES

Akhutina, T. (1997). The remediation of executive functions in children with cognitive disorders: The Vygotsky-Luria neurpsychological approach. Journal of Intellectual Disability Research, 4 (2), 136-143.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders IV.

Baker, J. (1994). Attention Deficit Hyperactivity Disorder: A creation of the medical profession? Australian Journal of Guidance and Counselling, 4 (1), 65-80.

Barkley, R. (1989). Attention Deficit Hyperactivity Disorder. In E. Mash & R. Barkley (Eds), Treatment of childhood disorders (pp. 39-72). New York: The Guilford Press.

Barkley, R. (1996). The North American perspective on Attention Deficit Hyperactivity Disorder. The Australian Educational and Developmental Psychologist, 13 (1), 2-23.

Cantwell, P., & Baker, L. (1991). Association between Attention Deficit Hyperactivity Disorder and learning disabilities. Journal of Learning Disabilities, 24 (2), 88-95.

Conte, R. (1991). Attention disorders. In B. Wong (Ed.), Learning about learning disabilities (pp. 59-101). San Diego: Academic Press.

Douglas, V.I. (1980). Higher mental processes in hyperactive children. In K.R.M. & D.J. Bakker (Eds), Treatment of hyperactive and learning disordered children: Current research (pp. 65-91). Baltimore: University Park Press.

Epstein, M., Shaywitz, S., Shaywitz, B. & Woolston, J. (1991). The boundaries of Attention Deficit Disorder. Journal of Learning Disabilities, 24 (2), 78-86.

Garner, R. (1994). Metacognition and executive control. In R. Ruddell, M. Ruddell & H. Singer (Eds), Theoretical models and processes of reading (pp. 715-732). Newark, Delaware: International Reading Association.

Goodman, G. & Poillion, M. (1992). ADD: Acronym for Any Dysfunction or Difficulty. The Journal of Special Education, 26 (1), 37-56.

Gordon, C. (1994). Attention Deficit Hyperactivity Disorder: Issues for special educators. Australasian Journal of Special Education, 18 (2), 36-49.

Grainger, J. (1997). Children's behaviour, attention and reading problems. Melbourne: The Australian Council for Educational Research.

Gross, M. (1997). The ADD brain. New York: Nova Science Publishers.

Hay, D. & Levy, F. (1996). The differential diagnosis of ADHD. The Australian Educational and Developmental Psychologist, 13(1), 69-78.

National Health and Medical Research Council. (1997). Attention Deficit Hyperactivity Disorder (ADHD). Canberra: Australian Government Publishing Service.

Ostoits, J. (1999). Reading strategies for students with ADD and ADHD in the inclusive classroom. Preventing School Failure, 43 (3), 129-134.

Paris, S. & Oka, E. (1986). Self-regulated learning among exceptional children. Exceptional Children, 53 (2), 103-108.

Purvis, K. & Tannock, R. (1997). Language abilities in children with attention deficit hyperactivity disorder, reading disabilities, and normal controls. Journal of Abnormal Child Psychology, 25(2), 133-145.

Rosenblatt, L. (1994). The transactional theory of reading and writing. In R. Ruddell, M. Ruddell & H. Singer (Eds), Theoretical models and processes of reading (pp. 1057-1092). Newark, Delaware: International Reading Association.

Ruddell, R. & Unrau, N. (1994). Reading as a meaning-construction process: The reader, the text, and the teacher. In R. Ruddell, M. Ruddell & H. Singer (Eds), Theoretical models and processes of reading (pp. 996-1056). Newark, Delaware: International Reading Association.

Rumelhart, D. (1994). Toward an interactive model of reading. In R. Ruddell, M. Ruddell & H. Singer (Eds), Theoretical models and processes of reading (pp. 864-894). Newark, Delaware: International Reading Association.

Saunders, B. & Chambers, S. (1996). A review of the literature on attention deficit hyperactivity disorder children: Peer interactions and collaborative learning. Psychology in the Schools, 33 (4), 333-340.

Wodrich, D. (1994). Attention deficit hyperactivity disorder: What every parent wants to know. Baltimore: Paul H. Brookes.

Zentall, S., Gohs, D. & Culatta, B. (1983). Language and activity of hyperactive and comparison children during listening tasks. Exceptional Children, 50 (3), 255-266.

Author details: Kathy Baker is working on a PhD thesis at Central Queensland University entitled 'Managing the impact of ADHD on reading achievement'. Before working full-time on her thesis was a classroom teacher. It was through dealing with the real impact of ADHD, on both the individual and the whole classroom, that sparked Kathy's interest in pursuing a research study in this area. (email: k.baker@cqu.edu.au)

Please cite as: Baker, K. B. (2001). Attention deficit hyperactivity disorder and reading achievement. Queensland Journal of Educational Research, 17(1), 68-84. http://education.curtin.edu.au/iier/qjer/qjer17/baker.html


[ Contents Vol 17, 2001 ] [ QJER Home ]
Created 17 Oct 2004. Last revision: 13 Dec 2004.
URL: http://education.curtin.edu.au/iier/qjer/qjer17/baker.html