Recent study on ADHD

[ADHD RESEARCH UPDATE]

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Greetings:

I hope that you and your family are enjoying the holidays.

Below is an article that appeared in a prior issue of ADHD
RESEARCH UPDATE. The article summarizes an interesting study
on how ADHD may affect young children's understanding of
stories, something that has clear implications for children's
academic performance.

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Sincerely,

David Rabiner, Ph.D.
Duke University

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* HOW ADHD EFFECTS PRESCHOOLERS' UNDERSTANDING OF
STORIES

One of the most profound effects that ADHD can have on children's
development is in the area of academic performance. Numerous
studies - several of which have been reviewed in ADHD RESEARCH
UPDATE - have documented that children with ADHD are at
substantial risk for academic difficulties, and that the
majority fail to achieve at a level that is consistent with
their academic ability. As indicated in the study reviewed above,
children with high levels of attention problems but not high
levels of conduct problems were at specific risk for academic
difficulty over a 6-year period and to require special educational services. In my own work, I have found that attention problems specifically - and not hyperactive/impulsive symptoms - exert
substantial negative effects on the development of children's
reading skills.

A study published recently in the Journal of Clinical Child
Psychology provides an extremely interesting look at how ADHD
can have an adverse impact on skills related to academic performance
even before academic problems are likely to be evident. In this
study (Sanchez, R.P., Lorch, E.P., Milich, R., & Welsh, R. (1999).
Comprehension of televised stories by preschool children with ADHD.
Journal of Clinical Child Psychology, 28, 376-385), the authors
looked at how preschool children with and without ADHD might
differ in their understanding of televised stories.

Televised stories- actually, they used a series of clips from Sesame
Street - were used because the children were young enough so that
most of them would not yet be expected to be reading. In addition,
the benefits of using television to examine young children's
comprehension of stories is that it is a familiar context for
children, it captures children's attention at an early age, and
can provide a less-monotonous context than do many laboratory
tasks that are used to investigate ADHD.

It is certainly a common experience for parents to observe that
their child with ADHD can attend faithfully to his or her favorite
tv shows for an extended period of time, even though the same level
of attending to homework is rarely evident. Children's ability to
understand and comprehend televised stories can thus serve as a
useful medium to learn about their comprehension of story material
more generally. If problems are evident in this context - which
probably captures children with ADHD operating at their best in
terms of attending - then it can inform parents, educators, and
clinicians about the struggles that are even more likely to occur
in a classroom context.

Participants in this study were 27 boys and girls with ADHD between
4 and 6 years old and 52 comparison children without ADHD. About
75% of the children in each group were male and almost 90% were
Caucasian. All the participants with ADHD had been diagnosed
with ADHD, Combined Type. Thus, they had the inattentive and the
hyperactive/impulsive symptoms as opposed to the inattentive symptoms
only. Although many children were being treated with medication at
the time of the study, care was taken to be sure that children were
medication-free when actually tested.

All children viewed a 23 minute videotape that consisted of 13
separate segments of Sesame Street. Four segments that were
embedded in this larger group of segments were the actual target
stimuli for the study. All of the target segments had conventional
story structures and were narrative in nature. In other words,
they were typical of Sesame Street stories.


Children were assigned at random to one of two viewing conditions.
Half of the children in each group viewed the segments with
attractive toys present and available to play with; the other
children viewed the tape without any toys around to serve as
potential distractors.

Each child was videotaped while watching the Sesame Street stories.
This tape was used to identify the amount of time that participants
were actually focusing their attention on the screen where the tape
was playing. Thus, an accurate record of the visual attention of
each participant was available. Each child watched the videotape
individually, so that other children were not present as another
possible source of distraction

Children were told that they would be watching a tv program and
that afterwards, they would be asked some questions about what
they had watched. In the condition where toys were present, it
was simply mentioned that they could play with the toys if they
wanted to. Thus, they were neither specifically encouraged to
play with the toys or discouraged from doing so.

After the tape was over, the experimenter returned to ask each
child questions about the stories they had watched. Questions
were asked about the 4 targeted stories in the order that these
stories had appeared on the tape. Pictures of the characters from
each story were presented to the child, and the names of each
character was provided to try to help cue their recall of what
they had watched.

Two types of questions were asked: factual questions (e.g. What
does the man do with the fish he catches?") and causal relation
questions (e.g. Why does the man kiss the fish?") The former
questions thus test for children's recall of specific events that
occurred in each story. The causal relation questions, in contrast,
required the child to draw upon several different elements in
the story and to recall the relationship between these elements.
Between 12 and 15 questions were asked for each story, and
these were divided equally between the factual and causal
relation type questions.

* RESULTS

The first question the authors examined is how children in the
two groups compared in terms of how attentive they were to
actually watching the videotape and whether this varied
according to whether toys were present. Overall, as might
be expected, children without ADHD were more attentive
(i.e. actually spent more time looking at the screen) than
children without ADHD. In the no-toy condition, the % of
time children in these groups were observed to be "observing
the screen" were 90.4% and 80.3% respectively.

For both groups, the presence of toys substantially reduced
their level of attention. The % of time attending dropped
to 30% on average for children without ADHD, and all
the way to 7% for children with ADHD. In other words,
even though the toys were a substantial distracter for both
groups of children, the adverse impact on attending to what
they needed to was even greater in children with ADHD.
Thus, this is experimental evidence of the far greater
distractibility in children with ADHD, which, after all, is
one of the core symptoms of inattention.

Here is something even more interesting. Even though
children without ADHD reduced their attending behavior
when toys were present from 90% to 30%, the proportion
of questions that they answered correctly DID NOT
CHANGE. This strongly suggests that these children were
"strategic viewers" who could systematically divide their
attention between the tv stories and the toy play such that
their ability to recall and comprehend the stories did not
suffer.

For children with ADHD, however, the findings were
quite different. When toys were not present, children
with ADHD were about as accurate as comparison
children in their responses to factual questions. Thus,
in the absence of distraction, they answered factual
items every bit as well. In the toy-present condition,
however, their performance was adversely affected such
that they now did much worse than comparison children.
In this condition, in fact, they answered correctly to
about 50% fewer questions.

What is important here is that even though the comparison
children also "paid less attention" to the stories when
toys were present, they were still somehow able to
divide their attention between toys and the stories such
that their recall was not hurt. Children with ADHD,
however, apparently could not do that. Thus, not only did
they attend less when distractors were present, but they
were unable to divide their attention in such a way that
their level of performance was preserved.

Results for the causal relation questions were somewhat
different. Here, the children with ADHD did worse
than the comparison children regardless of whether toys
were present as a distracter. Thus, even when their
visual attention to the program was high, children with
ADHD still did not do as well in responding to
questions that required an understanding of how the
different elements in a story fit together.

It would be quite interesting to know whether similar results
would have been obtained for the comprehension items
even if the children with ADHD had been receiving their
medication when testing occurred.

* IMPLICATIONS

The results of this interesting study have potentially
important implications for educating children with ADHD.

First, as has been demonstrated in the past, the presence
of distracting stimuli appear to have a significantly greater
adverse impact on the performance of children with ADHD
than of other children. Not only is a child with ADHD
less likely to pay attention to what he or she is supposed to
when an attractive alternative stimulus is present, but he or
she is also apparently less able to effectively allocate attention
to competing activities in ways that help maintain a good level
of performance.

These data support the benefits of arranging the environment
for many children with ADHD in such a way that potential
distractions are minimized. In a classroom setting, of course,
this is not always easy to do, particularly without isolating a
child in a way that can be stigmatizing. At home, however,
when it comes to getting homework done, this type of
intervention may be easier to accomplish. Please note, however,
that although reducing distractions may be helpful for many
children with ADHD, there will always be exceptions. Thus,
evaluating whether such environmental modifications are
helpful for a particular child always needs to be carefully
evaluated.

The comprehension results seem especially important. These
data indicate that comprehension may be an area of particular
difficulty for children with ADHD, and that such difficulty
may be evident as early as the preschool years. This result
is consistent with another study of reading comprehension in
children with ADHD that was reviewed in an earlier issue
of ADHD RESEARCH UPDATE. (See http://www.helpforadd.com/reading.htm)

Careful assessment of the comprehension abilities of a child with
ADHD, even for a child whose basic reading skills or ability to
recall factual information about stories appears adequate, may
thus be quite useful in identifying necessary targets for
intervention. This, however, is rarely done.

When difficulties in this area is identified, specific training to
help a child with ADHD understand cause-and-effect relations,
both in stories and in real-life social situations, may be quite
helpful. This may be best done by a reading specialist who
is aware of specific techniques and strategies to assist children
in their comprehension skills. Such training may have benefits
not only for academic performance, but for a child's social
relationships as well.



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