3.3 T HE DEVELOPMENTAL COURSE OF ADHD
3.3.2 Middle childhood
abilities, simple mathematics concepts, and fine motor skills) (Mariani & Barkley, 1997; Shelton, Barkley, Crosswait, Moorehouse, Fletcher, Barrett, Jenkins &
Metevia, 1998).
more varied independent life experiences results in more complex emotional states, as well as greater understanding of others emotions. Moral reasoning progresses from being self-focussed and concrete to other focussed and abstract, fuelled during middle childhood by increasing sociocentrism and advancing cognitive abilities.
During middle childhood, children’s self-concepts become increasingly less behaviourally oriented and more abstract, incorporating psychological traits, beliefs and values. Social comparison helps them establish and develop a working relationship between their real and ideal selves. Self-esteem becomes more realistic as children recognise their shortcomings yet learn to value their strengths.
ADHD children
Studies suggest that formal, compulsory education is the area of greatest impact on the child’s ADHD (Barkley, Fischer et al., 1990; Biederman, 1997) and will create the greatest source of distress for many of them and their parents. Almost all clinic- referred ADHD children are doing poorly at school, typically under-performing relative to their known levels of ability as determined by intelligence and academic achievement tests. According to Barkley (1998) such performance is believed to be the result of their inattentive, impulsive and restless behaviour in the classroom.
Evidence supporting this interpretation comes from numerous studies of stimulant medication with ADHD children that demonstrate significant improvements in academic productivity and sometimes accuracy when the children are on their medication (Barkley, 1977; Pelham, Bender, Caddell, Booth & Moorer, 1985;
Rapport, DuPaul, Stoner & Jones, 1986).
The ability to sit still, attend, listen, obey, inhibit impulsive behaviour, cooperate, organise actions, and follow through on instructions as well as share, play well, and interact pleasantly with other children is essential to negotiating a successful academic career, beyond those cognitive and achievement skills needed to master the curriculum itself (Barkley, 1998). It is not surprising that the vast majority of ADHD children will have been identified as deviant in their behaviour by entry into formal schooling, particularly first grade.
Parents not only have to contend with the ongoing behavioural problems at home noted during the preschool years, but now have the additional burden of helping their children adjust to the academic and social demands of school. These parents must also tolerate the complaints of some teachers who see the child’s problems at school
as stemming entirely from home problems, or poor child-rearing abilities in the parents (Barkley, 1998).
The fact that many schools now assign homework, even to first-graders, adds an additional demand on both the parent and the child to accomplish these tasks together (Barkley, 1998). It is not surprising that homework time at home becomes another area in which conflict arises in the family.
It is presumed that ADHD children are also more likely than normal children to have learning disabilities (Safer & Allen, 1976). A learning disability is typically defined as a significant discrepancy between one’s intelligence, or general mental abilities, and academic achievement, such as reading, mathematics, spelling, handwriting or language. Both intelligence and achievement must be assessed by well-standardised tests.
Barkley, DuPaul and McMurray (1990) investigated the prevalence of ADHD children who had a learning disability using the criterion of a 15-point IQ-achievement discrepancy. They found rates of 40% in reading, nearly 60% in spelling, and nearly 60% in mathematics. However, the rates in the normal control group were 20%, 38%, and 35%, respectively, being defined as learning disabled.
Using a somewhat larger discrepancy (20 points), Frick, Kamphaus, Lahey, Loeber, Christ, Hart and Tannenbaum (1991) estimated that 16% of ADHD children had a reading disability, whereas 21% had a mathematics disability. The corresponding prevalence in their normal control group was 5% and 7% respectively. Likewise, when Semrud-Clikeman, Biederman, Sprich-Buckminster, Lehman, Faraone and Norman (1992) increased the desired discrepancy to 20 points, 23% of the ADHD children could be considered reading disabled and 30% mathematically disabled, versus 2% and 22% of normal children, respectively.
An alternative approach is to define learning disabled as a score falling below 1.5 standard deviations from the normal mean on an achievement test, regardless of the child’s IQ. This approach is far less likely to diagnose normal children as learning disabled. Using this approach, Barkley (1990) found the following prevalence of learning disability in ADHD children: 21% in reading, 26% in spelling, and over 28%
in mathematics. For the normal children, these rates were 0%, 2.9% and 2.9%
respectively.
A more intricate approach to calculating a discrepancy formula involves first converting the standard scores on the IQ and achievement tests to Z scores and then estimating the expected achievement score with a regression equation that takes into consideration both the correlation between the IQ and achievement test and the standard error of estimate for the achievement test. To be learning disabled, the child must have a discrepancy that exceeds a Z score of -1.65 (the p<. 05 confidence level). Using this approach, Frick et al. (1991) reported a prevalence of 13% for reading disability and 14% for mathematics disability. Using this same approach, Faraone, Biederman, Lehman, Keenan, Norman, Seidman, Kolodny, Kraus, Perrin and Chen (1993) found that 18% of their ADHD group had a reading disability and 21% had a mathematics disability.
A different approach being used is to combine several of the previously discussed methods. In this case, learning disabled is defined as both a score below some level on an achievement test, say one standard deviation, and a significant discrepancy between IQ and achievement on that test, say 20 points. August and Garfinkel (1990) defined a learning disability as a 15-point IQ-achievement discrepancy and a standard score below 85 (1 standard deviation) on a reading test and found that 39%
of their ADHD children were reading disabled. Using the same formula, Semrud- Clikeman et al. (1992) found that 15% were reading disabled and 33% were mathematically disabled (compared to none of the control group). Again using this same formula, Casey, Rourke and Del Dotto (1996) found that nearly 31% of children with Attention-Deficit Disorder with Hyperactivity had a reading disorder, 27% had a spelling disorder, and nearly 13% had a mathematics disorder.
In conclusion, if the more rigorous approaches to defining learning disability are employed (i.e. Frick et al.’s regression equation or the combined approach mentioned above) then approximately 8-39% of ADHD children are likely to have a reading disability, 12-30% a mathematics disability, and approximately 12-27% a spelling disorder.
For those ADHD children who have a reading disorder, it will soon be noted as the child tries to master the early reading tasks at school. Among those who will develop mathematics and writing disorders, these problems often go undetected until several years into formal schooling (Barkley, 1998). Even for those without comorbid learning disabilities, almost all ADHD children are haunted by highly erratic educational performance - some days performing at or near normal levels of ability and
accomplishing all assignments, other days failing tests and not completing assigned work. Disorganised desks and notebooks are highly characteristic of these children, forcing others to step in periodically and reorganise their materials to try to facilitate better academic performance.
At home, parents often complain that their ADHD children do not accept household chores and responsibilities as well as do other children their age (Barkley, 1998).
Greater supervision of and assistance with these daily chores and self-help activities (dressing, bathing etc.) are common and lead to the perception that these children are quite immature. Although temper tantrums are likely to decline, as they do in normal children, ADHD children are still more likely to emit such behaviour when frustrated than do normal children (Barkley, 1998). Relations with siblings may be tense, as the sibling grows tired and exasperated at trying to understand and live with so disruptive a force as their ADHD brother or sister. Some siblings develop resentment over the greater burden of work they carry compared to their hyperactive siblings. Certainly, siblings are often jealous of the greater amount of time these ADHD children receive from their parents. At an age when other children are entering extracurricular community and social activities (such as clubs, music lessons, sports and scouts) ADHD children are likely to find themselves barely tolerated in these group activities or outright ejected from them in some cases. Parents frequently find that they must intervene on behalf of their children to explain and apologise for their behaviour and transgressions to others, to try to aid the children in coping better with the social demands, or to defend their children against sanctions that may be applied for their unacceptable conduct (Barkley, 1998).
An emerging pattern of social rejection will have appeared by now, if not earlier, in over half of all ADHD children because of their poor social skills. Even when the ADHD child displays appropriate or pro-social behaviour toward others, it may be at such a high rate of intensity that it elicits rejection and avoidance of the child in subsequent situations, or even punitive responses from his or her peers (Hinshaw, 1992; Ross & Ross, 1982). This rejection can present a confusing picture to the ADHD child attempting to learn appropriate social skills. The high rate of behaviour, vocal noisiness, and tendency to touch and manipulate objects more than is normal for age, combine to make the ADHD child overwhelming, intrusive and even aversive to others. By late childhood many ADHD children commonly develop feelings of depression and a sense of inadequate competence (Diener & Milich, 1997).
By late childhood and preadolescence, these patterns of academic, familial and social conflicts have become well established for many ADHD children. At least 40- 60% have developed Oppositional Defiant Disorder (ODD) and as many as 25-40%
are likely to develop symptoms of Conduct Disorder (CD) and antisocial behaviour between 7 and 10 years of age (Barkley, Fischer et al., 1990; Biederman, Faraone, Taylor, Sienna, Williamson & Fine, 1997). The most common symptoms are lying, petty thievery, and resistance to the authority of others. At least 25% or more may have problems with fighting with other children. It is the minority of ADHD children who have not developed some comorbid psychiatric (ODD/CD), academic (learning disability and underachievement), or social disorder by this time. Those who remain purely ADHD whose attention problems are most prominent are likely to have the best adolescent outcomes, experiencing problems mainly with academic performance and eventual attainment (Fergusson, Lynskey & Horwood, 1997; Weiss
& Hechtman, 1993). For others, an increasing pattern of familial conflict and antisocial behaviour in the community may begin to appear or worsen where it already existed. Such family conflicts often prove particularly recalcitrant to treatment (Barkley, Guevremont, Anastopoulos & Fletcher, 1992).
The majority of ADHD children (60-80%) have by this time been placed on a trial of stimulant medication, and over half have participated in some type of individual and family therapy (Barkley, DuPaul & McMurray, 1990; Barkley, Fischer et al., 1990;
Faraone et al., 1993; Munir, Biederman & Knee, 1987; Semrud-Clikeman et al., 1992). Approximately 30-45% will also be receiving formal special educational assistance for their academic difficulties by the time they enter adolescence. Some gains in scholastic performance have been achieved through cognitive-behavioural programmes that teach ADHD children how to set academic goals that require sustained attention, while allowing these youngsters to reinforce their success with tokens that can be exchanged for prizes (Shaffer, 2002).