Reading DisabilitiesSubtopic: Reading Disabilities and Attentional ProblemsWhat Is Attention Deficit Hyperactivity Disorder (ADHD)? The two major developmental disabilities experienced by school children are Learning Disabilities (LD) and Attention Deficit Hyperactivity Disorder (ADHD). The prevalence rate of LD reportedly varies from 5% to 17.5%, making it a high-incidence disorder. In recent years, ADHD has been investigated extensively, with review studies reporting that nearly 3% to 5% of school-age children experience difficulty in maintaining sustained attention (American Psychiatric Association, 1994). To confound matters further, ADHD reportedly can coexist with reading disability (RD). Estimates of comorbidity (i.e., RD+ADHD) vary widely ranging from 10% to 45%. ADHD is thought to be two inter-related behavioral syndromes; one is hyperactivity/impulsivity and the other is inattention. In a majority of children with ADHD, both syndromes are present even though some children manifest only the inattentive form of ADHD. Because it was not clear whether the inattentive group represented a subtype of ADHD or an entirely different disorder, DSM-IV (Diagnostic and Statistical Manual, published by the American Psychiatric Association) labeled it as ADHD-predominantly inattentive type [ADHD-I]. After reviewing the limited research relevant to this issue, Russell Barkley, a leading investigator of ADHD, notes that ADHD-I children experience problems in the focused and selective component of attention, appear to be sluggish, are inaccurate in information processing, and may also have memory retrieval problems. Attention deficit which predominates ADHD-I is not an "all-or-none" phenomenon where there is a total absence of attention, but is an "on-and-off" phenomenon manifesting as fluctuations in attention. This is evidenced by the fact that DSM IV prefaces most of the symptoms of ADHD with the qualifier "often" or "frequently". Furthermore, individuals with attention deficits do attend to stimuli both external and internal, often in an inconsistent manner, even though such attention is not directed at what the teacher may want. Thus, the nature of the task the child is expected to attend is one of the important variables that causes fluctuations in attention. A great deal of controversy surrounds the nature and origins of ADHD. Some researchers who have studied children with ADHD for many years even question the validity of the label "Disorder"; they prefer to use terms such as "Deficient Attention" or "Inconsistent Attention". Treatment of ADHD is also not agreed upon by everyone. Much less is known about the origins of ADHD. A majority of the investigators believe that the deficit could be caused by an imbalance in the neurotransmitters which normally inhibit or control the excessive activity of the brain. Stimulant medications seem to have a palliative effect by stimulating that part of the brain which sends inhibitory signals to the body as well as other parts of the brain. Thus, the drug helps the brain in inhibiting unwanted activities, both mental and physical. Although somewhat speculative, this might explain why attention problems seem to improve for many children with ADHD. Inconsistent Attention and Reading Deficit The reported incidence of comorbidity (two disorders occurring simultaneously) is more than one would normally expect, possibly due to mistaking one disorder for the other, an error caused by the fact that both Reading Disability and ADHD-I often manifest in poor reading performance even though for entirely different reasons. Such a mistake can happen because children with Reading Disability have weak word recognition skills and, therefore, invest an excessive amount of attention in decoding print. When they are required to read lengthy passages they lose their focus, become frustrated, and indulge in off-task behaviors. As a result, behaviorally they appear to be children who are functionally inattentive. On the other hand, children with ADHD-I are not able to deploy sustained attention and, therefore, indulge in off-task behavior; as a result, they also process information in an inconsistent manner and perform poorly on tests of reading comprehension. Outwardly, they may appear to be children with Reading Disability. How to Tell Whether a Child has Attention Problems or Reading Disabilities ADHD-I related comorbid condition is so challenging to diagnose and treat. In spite of devoting an entire book dealing with the issue of comorbidity, Pliszka, Carson, & Swanson, (1999) had to conclude that there is probably more confusion over the comorbidity of learning disorders than any other topic. The present situation is not likely to change because as Mercugliano, Power, & Blum, (1999) put it. "Despite the extensive amount of research that has been undertaken....ADHD remains controversial in both its diagnosis and its treatment." Currently, diagnosis and assessment of ADHD rely on the use of questionnaires, rating scales, evaluation based on DSM-IV criteria, and continuous performance tests. They all have their own weaknesses. Questionnaires: In his discussion of questionnaires employed to diagnose ADHD, a researcher notes that, "Their reality ultimately depends on the opinions of observers...it will always be a matter of opinion as to how many fidgets constitutes pretty much." A 1996 study showed that there was only a 52% agreement among teachers about which children showed ADHD behaviors. Rating Scales: This type of assessment relies on the ratings given by teachers or parents regarding the behavior of the child suspected of having ADHD. The scores obtained from such rating, however, represent only the informant's qualified opinion about that child's behavior and, thus, potentially are subject to biases. In addition, such ratings are also vulnerable to rater bias and are limited in diagnostic prediction. One study found that there was no agreement among parents, teachers, and staff regarding ADHD in children. In fact, raters were more likely to disagree than agree. DSM-IV: Evaluations based on the Diagnostic and Statistical Manual are equally problematic. Clinicians who use the DSM-IV to guide them in diagnosing ADHD will find a number of limitations of the diagnostic system because the process of establishing objective diagnostic standards for ADHD has itself been quite subjective. As noted earlier, the DSM criteria preface most of the symptoms with the word "often" or "frequently". There is no operational definition regarding how often is "often" and how frequent is "frequent". Continuous Performance Tests (CPT): There are several variations of the CPT, but they all require the child to look at the computer monitor and press a key when a prescribed letter or symbol appears. For instance, a letter of the alphabet appears on the screen at the rate of one per second and remains there for one fourth of a second. The child is asked to press the key only when the letter X appears on the screen and not to respond to other letters. The rate at which the symbol appears varies from one part of the test to the other. At the end of the testing, which usually lasts about 30 minutes, the number of times the child failed to press the key when X appeared as well as the number of times he pressed the key when a letter other than X appeared is noted. The former number represents errors of commission and the latter represents errors of omission. The test is usually administered using a laptop computer which has a built-in program to analyze the data. When the test is administered under standardized conditions, the CPT can provide objective data. But are these data valid measures of ADHD? According to some experts, the interpretation of CPT scores is not always a reliable indicator for ADHD. Others have remarked that although scores on the CPT appear to discriminate between children with ADHD and their normal counterparts at a group level, the utility of these measures in assessing individual children is limited. Our own research shows that the variations seen in the CPT scores (i.e., is the child consistently making commission and omission errors, or is he inconsistent in this respect?) can be used as a measure of inconsistency of attention. Conners CPT provides such a measure of inconsistency of attention. Proposed Differential Diagnostic Procedures In this section we propose a procedure to make differential diagnosis between ADHD-I and reading disability. The procedure is based on two premises.
How Can Children's Attention Be Improved? Two major approaches are used in the treatment of children with ADHD-I: pharmaceutical and behavioral. Frequently a combination of the two are used. Research indicates that a combination of these two produces the best results as far as school achievement is concerned. Drug Treatment Several research studies as well as many teachers report that a significant difference in children's behavior can be seen after children are placed under drug treatment. In spite of the reported positive effect drug therapy has on children with ADHD, many educators and even physicians are not fully supportive of drug therapy. The drug of choice is a member of the stimulant family. Since these drugs do not have a stimulating effect but a calming effect on individuals with ADHD, the outcome is considered paradoxical. However, if we understand the nature of brain functions and how the brain responds to neurotransmitters, this paradoxical effect can be explained. Our brain functions both as an excitatory organ as well as an inhibitory organ. That is, brain impulses can stimulate the muscles to contract and at the same time prevent other muscles from contracting. But for this antagonistic actions, spasticity would result. It is thought that children with ADHD do not have well developed inhibitory brain functions. A segment of the forebrain which is a major inhibitory organ is not mature in children with ADHD and, therefore, these children are not able to inhibit their impulsive behavior. Stimulant drugs stimulate these segments of the brain which in turn inhibit unwanted actions and reduce impulsive behavior. Thus, the paradoxical effect is not really paradoxical. It has to be noted that many people, including physicians, are critical of drug treatment. There are several reasons for this concern. One is the possible long-term side effects of continued use of drugs. The other is the fear that drug treatment could lead to drug abuse. But there are not many published studies that address these fears. Behavioral Approach "Behavior Modification" and effective teaching principles constitute the behavioral approach. First and foremost, the reading task has to be interesting to the child with ADHD. This may mean using simple readable stories and providing appropriate feedbacks. The teacher, along with the child, has to set up a set of goals at every session. That is, the assignments should not only be agreed upon by both parties but the consequences of not accomplishing these tasks should be made clear to the child. Finally, when the child is given a story or text material to read, he should realize that at the end of reading the story he will have to summarize what he has read without looking into the book. "Cognitive Behavior Modification" therapy is a recent educational program which uses behavior modification to train children to stop, think, and then act. Various kinds of rewards may be given for successful control of the impulsive behavior. Studies show that a combination of drug therapy and cognitive behavior modification therapy is quite successful in controlling ADHD behavior.
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