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Australian Journal of Learning Difficulties

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Language deficits in ADHD preschoolers

Paraskevi Agapitou a; Georgia Andreou a a Department of Special Education, University of Thessaly, Larissa, Greece Online Publication Date: 01 May 2008

To cite this Article Agapitou, Paraskevi and Andreou, Georgia(2008)'Language deficits in ADHD preschoolers',Australian Journal of

Learning Difficulties,13:1,39 49
To link to this Article: DOI: 10.1080/19404150802093711 URL: http://dx.doi.org/10.1080/19404150802093711

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Australian Journal of Learning Diculties Vol. 13, No. 1, May 2008, 3949

Language decits in ADHD preschoolers

Paraskevi Agapitou and Georgia Andreou*
Department of Special Education, University of Thessaly, Larissa, Greece

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The present study examined the impact of preschool ADHD on linguistic and metalinguistic awareness and mental ability. Eight subscales of the Athina Test were administered to ADHD preschoolers and a control group. Results showed that ADHD preschoolers performed signicantly lower than the control group in all tasks. The greatest diculty for ADHD preschoolers was evident in the phoneme synthesis subscale, particularly with metalinguistic awareness. These results support previously reported ndings that ADHD preschoolers have serious language decits, which place them at risk for developing poor reading skills in primary school. Keywords: language skills; preschool ADHD

Introduction The inattention-hyperactivity-impulsivity triptych constitutes the base for the diagnosis of ADHD provided that, according to the American Psychiatric Association (1987, 1994, 2000), some of its basic symptoms are present prior to the age of seven years. Important characteristics of ADHD, which are present at preschool age, are linked to behavioral and academic problems for a signicant percentage of children and adolescents (Pierce, Ewing, & Campbell, 1999), while 50% of ADHD children present symptoms from as young as three years of age (Barkley, 1989). Among preschool children, ADHD has been identied in 2% of children between the ages of two and ve years (Lavigne et al., 1996) with the male-to-female ratio being similar to the school-age population, although somewhat reduced in magnitude, and boys being twice as likely to meet the criteria for ADHD. Despite the early onset of the disorder, however, it has been observed that the peak referral rate is at age seven years (Byrne, Bawden, Dewolfe, & Beattie, 1998), probably because this is the time when children enter primary school and consequently face increased demands of longer periods of inactivity, the need to develop independent work habits, and a high degree of attention (Barkley, 1990). Not surprisingly, then, the majority of research on ADHD has been conducted with school-age children. The paucity of research in the preschool years is due to the fact that frequent irritation on the part of preschoolers hardly determines whether they show abnormal developmental levels of activity, impulsivity, and attention (Barkley et al., 1991; Campbell, 1995). Campbell and her colleagues (1985, 1990) noted that, unlike school-age children, preschoolers inherently

*Corresponding author. Email: andreou@uth.gr

ISSN 1940-4158 print/ISSN 1940-4166 online 2008 Learning Diculties Australia DOI: 10.1080/19404150802093711 http://www.informaworld.com

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exhibit high levels of impulsivity, activity, and inattention, and therefore a deviation from this normal base rate needs to be large to be seen as clinically signicant. Many researchers have shown that children with preschool ADHD are at increased risk for academic and social diculties, including learning disabilities, peer rejection, and decreased teacher expectations (Ladd, Birch, & Buhs, 1999; Vaughn, Hogan, Lancelotta, Shapiro, & Walker, 1992). This is likely due to the fact that during the preschool years, children acquire the social, behavioral, and academic skills that allow them to navigate successfully both through primary school and their later academic and social life. Preschool children learn how to focus their attention on teacher-directed activities, interact appropriately with peers and authority gures, and follow spoken and unspoken rules in the classroom. In addition, they acquire the basic building blocks of later academic success as they learn emergent literacy, mathematics, and language skills. For some children, diculties with impulse control, attentional capacity, and hyperactivity hinder the ability to benet from the valuable lessons of preschool and later academic experiences (Spira & Fischel, 2005). It has been suggested that inattention and hyperactivity during preschool years aect later learning through their negative impact on emergent literacy. Emergent literacy involves the skills, knowledge, and attitudes that are presumed to be developmental precursors to conventional forms of reading and writing (Whitehurst & Lonigan, 1998). Within the set of emergent literacy skills, several skills have been identied as strong predictors of childrens reading performance in primary school. In particular, linguistic awareness, oral language skills, metalinguistic awareness, and print concepts are consistently emphasized as important determinants of childrens later reading ability (Scarborough, 1998). A meta-analysis of 58 studies conducted by Horn and Packard (1985) concluded that the best predictors of reading achievement were attention/ distractibility, internalising behaviour problems, language variables, and general cognitive functioning. Hindshaw (1992) reviewed a number of studies to identify antecedent variables that might explain the association between ADHD and learning problems. Hindshaw highlighted multiple variables of interest, including mild to moderate language decits, poor verbal skills, familial distress or discord, and neurodevelopmental delay. Of the variables reviewed by Hindshaw, language decits received the most attention as a common cause of both learning disabilities and ADHD (Cantwell & Baker, 1991; McGee, Partridge, Williams, & Silva, 1991; Pisecco, Baker, Silva, & Brooke, 2001). Researchers have consistently claimed that preschool ADHD is pervasively linked to learning diculties and that ADHD preschoolers work less, behave more poorly, and present problems in most learning situations (Cunningham & Boyle, 2002). ADHD preschoolers are also characterized by information processing decits (Kal et al., 2005) and suer from language decits, either receptive or expressive, compared to their normal peers (Campbell, 1995; Caueld, Fischel, Debaryshe, & Whitehurst, 1989; Gilliam & Demesquita, 2000; Kaiser, Hancock, Cai, Foster, & Hester, 2000). Moreover, two recent studies found that children who manifest poorer cognitive functioning and poorer linguistic and metalinguistic skills in preschool are at greater risk for continuing behavioural and academic problems. Barkley et al. (2002) examined the utility of adaptive disability (AD), dened as a signicant discrepancy between adaptive functioning and intelligence, as an indicator of continued risk for children with early ADHD. They found that in contrast to children with disruptive behavior alone, children with disruptive behavior and AD in preschool had more symptoms of ADHD and conduct disorder, more severe and pervasive behavior problems at home, more parent-rated

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externalizing and internalizing problems, and more behavioral and academic problems at school in second grade. Rabiner, Coie, and The Conduct Problems Prevention Research Group (2000) conducted a longitudinal study to examine the impact of early inattention and hyperactivity on later reading achievement. Simple correlations indicated that both inattention and hyperactivity were signicantly correlated with reading achievement, with the correlations between inattention and reading achievement being strongest and most consistent. Furthermore, in order to further explore the relationships between these variables, Rabiner et al. (2000) constructed a path model, specically examining the inter-relationships between inattention and reading across the years. One of their most interesting ndings was that preschool inattention was associated with poorer pre-reading achievement, which then had a strong eect on rst grade reading. They also found that inattention in rst grade was predictive of poorer reading achievement, even when pre-reading achievement, IQ, and parental involvement were controlled. Moreover, children whose reading scores were normal at kindergarten exit were at risk for poor reading outcomes if they were classied as inattentive in rst grade, and 34% of the inattentive children in their sample showed poor reading outcomes in fth grade. Based on their ndings, Rabiner et al. (2000) argued for the utility of measuring attention early on. Given the link between preschool language development, emergent literacy skills, and later reading success, and given the paucity of research on ADHD preschool children, the purpose of this study was to assess the overlap between ADHD and emergent literacy skills in preschool children. More specically, this study will examine the impact of preschool ADHD on linguistic and metalinguistic awareness and general mental ability. Methods Participants Our sample consisted of 40 preschool children: 20 ADHD children (18 boys and 2 girls), and a control group of 20 children who were matched for sex and age. The average age of the sample was 5 years 6 months and participants were drawn from state nursery schools of Thessaly. The native language of the sample was Greek. None of the children in the sample were on medication at the time of the study. All of the ADHD children met the Diagnostic and Statistical Manual of Mental Disorders-Fourth edition (DSM-IV: APA, 1994) criteria for an ADHD diagnosis, based on parents and teachers responses to corresponding questionnaires. Materials For the evaluation of the childrens linguistic and metalinguistic awareness and mental ability, we used eight subscales taken from the Athina Test for the Diagnosis of Learning Disabilities, which is standardised for the Greek population by the Faculty of Psychology, School of Philosophy, University of Athens (Paraskevopoulos, KalantziAzizi, & Giannitsas, 1999). Each child was tested individually according to the instructions of the Athina Test manual, particularly with regard to the administration and scoring of each subscale. The subscales administered were: (1) language analogies; (2) pattern copying; (3) vocabulary; (4) sentence completion; (5) word completion; (6) grapheme discrimination; (7) phoneme discrimination; and (8) phoneme synthesis. According to the manual, the rst

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three subscales constitute the factor mental ability, the next two the factor symbol completion, and the last three the factor phonological awareness. Language analogies Language analogies consist of 32 pairs of sentences, where each pair of sentences contains four meanings that were connected with each other (e.g. shape) and form an analogy expressed in words. For each pair of sentences, the rst sentence is complete while the second is incomplete (e.g. the table is square, the sun is . . . ). It is a test of verbal concept formation in which the child must understand what each pair of sentences has in common. This test reects the childs abstract verbal classication abilities. Pattern copying Pattern copying consists of six geometrical patterns that vary in diculty. The childs correct pattern copying requires increasing visuo-conceptual maturity with every pattern. Vocabulary Vocabulary consists of 20 words, mostly verbs and nouns, both concrete and abstract, for which the child needs to give a denition. They vary in diculty from the simplest words (e.g. apple) to more dicult words (e.g. neglect). This test assesses word knowledge, language development and long-term memory. The above-mentioned three subscales are administered in the order verbal scale-practical scale-verbal scale, and they assess both the childs language and visuo-cognitive development. Thus, these subscales enable the examiner to evaluate the childs mental ability. Sentence completion Sentence completion consists of 32 sentences from which a word or phrase is missing (e.g. Smoking seriously harms . . . ; A house with two storeys is called . . . ). This subscale tests verbal skills and assesses general range and fund of knowledge obtained through the childs environment. Word completion Word completion consists of 32 words from which a phoneme is missing, either at the beginning or in the middle of the word (e.g. trapezi [table], podilato [bicycle]). This subscale tests the childs linguistic awareness, which refers to the organization of the phonological structure of language. Together with the previous subscale constitute, the socalled Symbol completion factor, they enable the examiner to evaluate the childs language skills on the basis of either sentence or word symbol completion. Grapheme discrimination Grapheme discrimination consists of 21 pairs of pseudo words. In some pairs the two words are exactly the same, while in other pairs they dier in one or two letters (e.g. talitali, son-con, tarpo-tapro). This subscale tests the childs linguistic awareness through visual perception of graphemes.

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Phoneme discrimination consists of 32 pairs of pseudo words. In some pairs the two words are exactly the same while in others one phoneme is dierent or is missing (e.g. gazamosgazamos, tifali-tifari, kreda-keda). This subscale is also an evaluation of the childs linguistic awareness, which is considered to form the basis for the structure of oral receptive and expressive language. Phoneme synthesis Phoneme synthesis consists of 32 words that have been chosen so as to contain the phonemes of the Greek language in various combinations. The examiner pronounces the phonemes one by one in a natural tone of voice, at a speed of two phonemes per second, and the child is required to nd the word. This subscale tests the childs metalinguistic awareness, which refers to the childs capacity to analyze the elements of the phonological structure of language. Overall, the grapheme discrimination, phoneme discrimination, and phoneme synthesis subscales give the examiner the opportunity to evaluate the childs general phonological awareness, which consists of linguistic and metalinguistic awareness. These two types of phonological awareness are implicated in a reciprocal relationship with the acquisition of reading skill. According to the manual of the Athina Test, the scores obtained for each scale are transformed into a developmental quotient. Following the childrens developmental quotient, which is calculated according to the instructions of the manual, ve diagnostic zones have been dened in the Athina Test: (1) two for the lower-decient development (average-low and decient); (2) one for the average normal development; and (3) two for the superior development (average-superior and exceptional). Statistical analysis Paired sample t-tests were performed to compare the mean dierences between ADHD preschoolers and the control group in their developmental quotients for each subscale of the Athina Test. In addition, paired sample t-tests were performed in the group of subscales that constitute each of the three factors: mental ability, symbol completion, and phonological awareness, in order to compare the developmental quotients of ADHD preschoolers with the control group for each of the factors. The analysis of data was performed using the SPSS statistical programme. Results The mean developmental quotients for each Athina Test subscale of ADHD preschoolers and controls are presented in Table 1. Independent sample t-tests were statistically signicant for language analogies (t 710.85, p .000); pattern copying (t 75.87, p .000); vocabulary (t 77.98, p .000); sentence completion (t 76.52, p .000); word completion (t 76.17, p .000); grapheme discrimination (t 77.42, p .000); phoneme discrimination (t 77.51, p .000); and phoneme synthesis (t 715.28, p .000). The mean developmental quotients for each of the three Athina Test factors of ADHD preschoolers and controls are presented in Table 2. Independent sample t-tests were statistically signicant for mental ability (t 11.95, p .000), symbol completion (t 9.06 p .000), and phonological awareness (t 715.30, p .000).

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Table 1. Mean developmental quotients for Athina Test subscales in preschoolers with the ADHD group and the control group. ADHD group Subscales Language analogies Pattern copying Vocabulary Sentence completion Word completion Grapheme discrimination Phoneme discrimination Phoneme synthesis M 7.55 7.45 7.95 8.00 7.90 7.00 7.20 5.75 SD 1.53 1.95 1.76 1.80 2.26 2.57 2.14 1.65 M 11.60 11.10 12.10 11.70 11.80 11.95 11.15 11.50 Control group SD 1.87 1.91 2.04 1.80 2.01 1.79 1.75 1.73

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Table 2. Mean developmental quotients for Athina Test factors in children with ADHD and the control group. ADHD group Factors Mental ability Symbol completion Phonological awareness M 7.65 7.95 6.65 SD 1.74 2.02 2.14 M 11.26 11.75 11.53 Control group SD 1.88 1.89 1.76

Discussion Our ndings indicate that there is an overlap of ADHD with problems in emergent literacy skills and mental ability in preschool children. ADHD preschoolers in our sample performed signicantly lower than preschoolers in the control group in all the subscales of the Athina Test. Each of the eight subscales will be discussed in turn. ADHD preschoolers obtained lower scores than the control group in the language analogies subscale, suggesting that these children do not experience normal development in abstract verbal classication abilities and language skills. This nding conrms earlier research linking ADHD with poor verbal and language skills in preschoolers (Campbell, 1995; Gilliam & Demesquita, 2000; Kaiser et al., 2000) as well as in older children (Andreou, Agapitou, & Karapetsas, 2005; Grodzinsky & Diamond, 1992; Reader, Harris, Schuerholz, & Dencla, 1994). In the subscale pattern copying, ADHD preschoolers displayed poorer performance than the control group, indicating diculties in applying the skills required for this task. Their level of performance indicates poor visuo-motor-conceptual skills. Previous research (Fowler & Cross, 1986) has also found a specic link between ADHD and poor performance in tasks testing this kind of skills. Vocabulary is also a subscale in which ADHD preschoolers obtained lower scores than the control group, indicating diculties with word knowledge, language development, and long-term memory. The developmental quotient of ADHD preschoolers places them in the lower-decient zone, more specically in the average-low subzone, according to the ve-category diagnostic zone catalogue of the Athina Test. This nding suggests that ADHD preschoolers have lower development in the skills examined by all three subscales.

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The ADHD preschoolers mean developmental quotient of the above three scales (language analogies, pattern copying and vocabulary), which taken together measures the childs mental ability, was also found to be lower than the control group. This nding indicates that ADHD preschoolers have diculty with language, as well as visuo-cognitive development, supporting earlier research (Barkley et al., 2002; Spira & Fischer, 2005). ADHD preschoolers also performed more poorly than the control group in the sentence completion subscale, which indicates that their verbal skills and general knowledge obtained through the environment are developing insuciently. This nding compliments previous research associating ADHD with poor verbal skills (Campbell, 1995; Gilliam & Demesquita, 2000). Diculties with impulse control, attentional capacity, and hyperactivity not only hinder ADHD preschoolers from making the most of the information available in their environment, but also hinder the benet of valuable lessons learned through preschool experiences (Spira & Fischer, 2005). The word completion subscale assesses the childs linguistic awareness, a skill that belongs to the so-called emergent literacy skills that are presumed to be developmental precursors to conventional forms of reading. In this study, ADHD preschoolers displayed lower performance than the control group. This nding indicates that ADHD preschoolers have diculty with linguistic awareness, placing them at risk for developing poor reading skills in primary school. Previous studies have reported similar ndings (Scarborough, 1998; Whitehurst & Lonigan, 1998). ADHD preschoolers poor performance in word completion and sentence completion subscales places them in the lower-decient diagnostic zone of the Athina Test, and more specically in the average-low subzone. Moreover, the mean score of these two subscales, which constitute the factor symbol completion, is also lower among ADHD preschoolers in comparison to the control group. This means that they seriously lack general language skills, which can be either verbal or linguistic awareness skills, needed to recognize written symbols and organize the phonological structure of language (Lundberg, 1999). In the subscales grapheme discrimination and phoneme discrimination, ADHD preschoolers again displayed a poorer performance than the control group, with a developmental quotient in the lowest position in the average-low subzone of the lowerdecient diagnostic zone, suggesting that their linguistic awareness skills are extremely poor and insuciently developing. Poor linguistic awareness skills on the part of ADHD preschoolers may hinder the phonemic representation of words in their short-term memory, a procedure that contributes to the acquisition of proper reading skills (Content, Kolinsky, Morais, & Bertelson, 1986; Tomeus, 1984; Treiman & Zukowski, 1988; Treiman, Fowler, Gross, Berch, & Weatherston, 1995). ADHD preschoolers also performed lower than controls in the subscale phoneme synthesis, and the scores obtained were lower than every other subscale, placing them in the decient subzone of the lower-decient diagnostic zone. This nding indicates that ADHD preschoolers are signicantly decit in metalinguistic awareness, suggesting diculties in their capacity to analyze elements of the phonological structure of their oral language. This diculty is signicant, especially for the Greek language, which is a language with phonemic and syllabic oral structure (Porpodas, 1999), and may hinder children diagnosed with ADHD in acquiring proper reading skills in primary school. The mean score of the above three subscales (grapheme discrimination, phoneme discrimination and phoneme synthesis), which taken together constitute the so-called

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phonological awareness factor, is also lower among ADHD preschoolers in comparison to the control group. This nding compliments previous studies (Barkley et al., 2002; Lonigan et al., 1999), indicating that linguistic and metalinguistic awareness skills are extremely poor or almost decient among ADHD preschoolers. This deciency is of particular concern, since phonological awareness is consistently emphasized as an important determinant of childrens later reading ability (Scarborough, 1998). Overall, the ndings of this study suggest that preschool ADHD has a negative impact on all aspects of language development including verbal skills, word knowledge, linguistic, and metalinguistic awareness. Moreover, it negatively inuences longand short-term memory, general range and fund of knowledge as well as visuo-conceptual maturity. Preschool ADHD seems to particularly aect phonological awareness skills, which belong to the set of emergent literacy skills presumed to be developmental precursors to conventional forms of reading and writing (Lonigan et al., 1999; Mariani & Barkley, 1997; Whitehurst & Lonigan, 1998). The issue of language development is particularly applicable to the preschool population and the comorbidity of ADHD and language decits has often been reported in literature (Campbell, 1995; Gilliam & Demesquita, 2000, Kaiser et al., 2000; McGee et al., 1991). This type of comorbidity is an important concern as it has been demonstrated to have signicant diagnostic and prognostic implications (Baker & Cantwell, 1987; Beitchman, Hood, & Inglis, 1990; Byrne et al., 1998; Cantwell & Baker, 1991; Richman, Stevenson, & Graham, 1982). Limitations and suggestions for further research There are certain limitations to our study since it concerns a small sample and does not make use of a multidimensional protocol. Additional studies of the comorbidity of ADHD and language decits employing larger samples, and using multidimensional protocols within the context of a longitudinal design, would be benecial in terms of accurate early diagnosis and subsequent prognosis for ADHD preschoolers. Despite the limitations of this study, the ndings provide important evidence concerning the implications of co-occurring language decits and ADHD in preschoolers. The overlap of preschool ADHD and low or decient development of language skills stresses the need for early intervention and the development of early assessment protocols, which may lead not only to improved accuracy of early ADHD identication but also to earlier and more appropriate treatment, which may prevent further negative impact of preschool ADHD on later academic achievement. Given that the symptoms of ADHD are related to academic achievement from an early age and the paucity of research on preschool ADHD, it is critical to further pursue the issue in order to understand more completely the nature of that association, and create intervention programmes appropriate for preschool children. More specically, in the language domain, future research could be directed to the identication of dierences between the separate subtypes of preschool ADHD. It has previously been shown that inabilility to control of the ADHD symptoms (hyperactivity, impulsivity, inattention) has a dierent impact on measures of academic achievement (Milich, Balentine, & Lynam, 2001). With a growing body of research, specialists, through consultation with preschool teachers, may implement language development skills intervention programmes which will encourage preschoolers to

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expand their repertoire of receptive and expressive language controlling at the same time their impulsivity, hyperactivity, or inattention in order to make the most of their preschool environment. References
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