Understanding Language

Impairments in Children with ADHD

Carol Westby, PhD (mocha@unm.edu)
Lee Robinson, MS (lee_robinson@byu.edu
Brigham Young University
ASHA 2007
 International Classification
of Functioning

Condition
(disorder/disease)

Body Activities Participation

function&structure (capacity) (performance)
(Impairment) (Limitation) (Restriction)

Environmental Personal
Factors Factors
 DSM-IV Criteria for ADHD

I. Either A or B:
A. Six or more of the following symptoms of inattention have been
present for at least 6 months to a point that is disruptive and
inappropriate for developmental level:
Inattention
• Often does not give close attention to details or makes careless mistakes
in schoolwork, work, or other activities.
• Often has trouble keeping attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow instructions and fails to finish schoolwork, chores, or
duties in the workplace (not due to oppositional behavior or failure to
understand instructions).
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn't want to do things that take a lot of
mental effort for a long period of time (such as schoolwork or homework).
• Often loses things needed for tasks and activities (e.g. toys, school
assignments, pencils, books, or tools).
• Is often easily distracted.
• Is often forgetful in daily activities.
B. Six or more of the following symptoms of hyperactivity-impulsivity
have been present for at least 6 months to a point that is disruptive
and inappropriate for developmental level:
Hyperactivity
• Often fidgets with hands or feet or squirms in seat.
• Often gets up from seat when remaining in seat is expected.
• Often runs about or climbs when and where it is not appropriate
(adolescents or adults may feel very restless).
• Often has trouble playing or enjoying leisure activities quietly.
• Is often "on the go" or often acts as if "driven by a motor".
• Often talks excessively.
• Impulsivity
• Often blurts out answers before questions have been finished.
• Often has trouble waiting one's turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or
games).

C. Some symptoms that cause impairment were present before age 7 years.
D. Some impairment from the symptoms is present in two or more settings
(e.g. at school/work and at home).
E. There must be clear evidence of significant impairment in social, school,
or work functioning.
 Based on these criteria, three
types of ADHD are identified:

ADHD, Predominantly Hyperactive-Impulsive Type: if

Criterion 1B is met but Criterion 1A is not met for the
past six months.
ADHD, Predominantly Inattentive Type: if criterion 1A is
met but criterion 1B is not met for the past six months
ADHD, Combined Type: if both criteria 1A and 1B are
met for the past 6 months
NOTE: Predominantly hyperactivity/impulsivity and combined types have
particularly be associated with deficits in executive functioning and
working memory.

American Psychiatric Association: Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition, Text Revision. Washington, DC,
American Psychiatric Association, 2000.
 Children
Ryan, age 6, on medication
ADHD – predominantly hyperactive-impulsive
?comorbid Asperger’s

Jason, 8, on medication
ADHD – predominantly hyperactive/
Impulsive (may be moving to
combined type)

Zach, age 15
ADHD – predominantly inattentive;
Sluggish cognitive tempo;
Comorbid language/learning disability
 Parent Concerns
for Zach

Talks really loud a lot of time,

I think he is a little obnoxious.
Doesn’t really have hardly any friends at all.
He tries really hard.
Doesn’t understand doesn’t realize that he not
acting the same way as other kids at school.

Talks about Zach is cool.

Zach is always in the story.
It is getting better
It might be that he’s really consumed with
himself still cause that’s a younger child.

E: Is he aware of not having friends

Yeh, Said that he doesn’t have any friends.

 Parent Concerns
for Ryan

Biggest concern we have for him in school is

his social acceptance and his ability to
interact socially.

Anything that would give him skills in being

able to when a friend expresses a different
opionion than his, being able to say, “well,
that’s OK, but this is my opinion.”

When somebody has a toy he wants or isn’t

sharing a turn, being able to approach that
and in a socially acceptable manner, say,
“I’ve waited 5 minutes; can I have a turn
now.”

Give him tools that he can apply in situations

when usually the alternative would be to lash
out, or kinda spit, or take the toy.
 Hyperactivity song by
Mark Lowry

They might tame the wind,

They might calm the sea,
But they’re never harness my energy.
I’m the poster boy for hyperactivity!
It’s not my fault!
The world’s not keeping up with me.
 Sluggish Cognitive Tempo

• Qualitatively different problems

with attention
– Spacey, daydreamy, easily
confused, stares a lot
• Under- rather than over-active
– Lethargic, sluggish, slow moving
• Slow information processing
• Social withdrawal
• Greater risk for anxiety
• Reduced response to stimulants
 Research Evidence on
Effectiveness of ADHD
Treatments
• Medication more effective than psychosocial
treatments in the short-term
• Medication combined with psychosocial
treatments the most effective
• Best supported psychosocial treatments involve:
– Contingency management/reinforcement approaches
– Parent training
– Integration of home and school-based approaches
Multimodal Cooperative Group (2004). National Institute of Mental Health
Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and
growth after the end of treatment. Pediatrics, 113, 762-769.
 Research Evidence on
Effectiveness of ADHD
Treatments
• Limitations of medication treatments
– Problems with compliance to medication regimens
• Limitations of psychosocial treatments
– Failure to maintain post-treatment benefits
– Failure to generalize to broader areas of life functioning
– Failure to achieve long-term gains in academic
achievement
– Persistent deficits in executive functions, motivational
deficits, and impairments in self-regulation

70-80% of adolescents with ADHD have significantly

impairing symptoms
• Need
– Revised diagnostic criteria
– Outcome measures that capture real-
world functioning

Improving long-term efficacy and effectiveness outcomes in ADHD:

A treatment development workshop. March 12-13, 2007, Rockville, MD.
Evidence-Based Practice

Professional
Expertise

Clinical
Client Research
Decision
Evidence Evidence
Making
 Barkley’s Definition of ADHD

ADHD consists of developmental

deficiencies in the regulation and
maintenance of behavior by rules and
consequences. These deficiencies give rise
to problems with inhibiting, initiating, or
sustaining responses to tasks or stimuli and
adhering to rules of instructions, particularly
in situations where consequences for such
behavior are delayed, weak, or nonexistent.

Barkley, R. (1990). Attention-deficit hyperactivity disorder: A Handbook for

diagnosis and treatment. New York: Guilford, p.71.
 Aspects of
Deficits in
Behavioral Inhibition Executive Functioning
Result in deficits in
Deficits in Sense of time
Schema formation
Nonverbal Anticipatory set/hindsight
Working Memory forethought
Complex imitations

Deficits in Verbal Working Memory/ Rule-governed behavior

Internalization of Speech Reading comprehension
Moral reasoning

Deficits in Emotional control

regulation of affect. Perspective taking
arousal, motivation Motivation/ persistence

Analysis and synthesis

Deficits in Creativity
Problem-Solving

Deficits in Goal-Directed Barkley, R.A. (2005). ADHD and the

Behavior nature of self-control. New York:
Guilford.
 Other Disorders
• Associated disorders: disorders that
are a direct result of the ADHD
– A result of the deficits in executive
function; which may include deficits in
theory of mind
• Comorbid disorders: disorders that
exist in addition to the ADHD
 ADHD and Associated Disorders

• Types of communication problems

– Pragmatic deficits
• As evaluated by the DSM-IV
– Difficulty taking turns
– Interrupt
– Don’t listen to what is said
– Excessive talking
• Difficulties in introducing, maintaining, changing
topics; failure to adjust language to listener
• Scores on CCC-2 scales, Inappropriate Initiation and
Social Relationships, differentiated children with
ADHD from controls
– No difference between children with ADHD and
controls on speech, syntax
– Discourse organization

Bruce, Thernlund, & Nettelbladt, 2006;Cameratia & Gibson, 1999; Geurts,

et al, 2004; Nixon, 2001)
 ADHD and Associated Disorders

• Reading problems
– Failure to monitor comprehension
– Failure to understand main ideas
– Difficulty with inferencing
• Failure to use language to regulate
behavior and plan
• Motor development and motor planning

(Barkley, 2005; McInnes, Humphries, Hogg-Johnson, & Tannock, Purvis &

Tannock, 1997)
 Deficits in Identifying
Emotions
• Children with ADHD (7-13 years with no comorbid
disorders)
– less accurate than typical children in identifying the emotions of
happiness, sadness, anger, and fear in pictures and in the tone
of voice of an adult reading a sentence (Cadesky, Mota, &
Schachar, 2000)
– When shown photographs depicting joy, anger, disgust, and
sadness in varying intensities, exhibited particular difficulty in
identifying anger and sadness( Pelc, Kornreich, Foisy, & Dan,
2006).
– Significant correlation between interpersonal problems and
impairment in decoding emotional facial expressions.
• Adults with ADHD had more difficulty identifying
emotions compared to those adults without ADHD
(Rapport, Friedman, Tzelepis, & Van Voorhis, 2002).
 Narrative Comprehension
in Children with ADHD
• Fewer causal connections in stories
• Difficulty establishing a goal (less frequent mention of
initiating event)
• Difficulty using causal, goal-based story structures to
guide ongoing comprehension and later recall
• Use more ambiguous reference
• Include more extraneous information
• Children with ADHD-only answer fewer inferential
questions than children without ADHD
– Children with ADHD +LI answer fewer literal and inferential
questions

(Flory, et al, 2006; Lorch, et al, 2006; McInnes, Humphries, Hogg-

Johnson and Tannock, 2003; Renz, et al, 2003)
 ADHD and Comorbid Disorders

• Externalizing disorders identified more with

predominantly hyperactive-impulsive and
combined types
– Conduct disorder
– Oppositional defiant disorder
• Internalizing disorders identified more with
predominantly inattentive type
– Anxiety/depression
– Speech/language disorders affecting phonology,
syntax, semantics
– Dyslexia (deficits in decoding and syntax)
Assessing Elements of EF
Underlying ADHD
Stroop Task

Black
Blue
Red
Yellow
Green
Orange
Stroop Day-Night Test
Animal Stroop:
Name the body of the animal
Animal Stroop Task
 Types of Cohesion
Category Type Examples
Conjunction Additive The boy saw the present and he read the tag.
Adversative The boy took his dog and baby frog on the raft,
but the big frog wasn’t allowed to come.
Causal The big frog bit the little frog because he didn’t
want another frog in his life.
Temporal When the baby frog saw the big frog on the raft,
he was worried.
Referential Pronominal The boy got a present. He opened it.
Demonstrative The big frog kicked the little frog. He shouldn’t
do that.
Comparative The boy had two frogs. The bigger one was
mean.
Lexical Max got a thistle for a shell. The thistle hurt the
Same word snail’s back.
Max was mad at the bird. He was furious.
Synonym Max tried a thistle, rose, and a mushroom. None
Superordinate of the plants worked.
 Types of Cohesion

Category Type Examples

Impaired Ambiguous The little frog hid there.

cohesion Exophoric Max picked it and gave it to the snail.
Can’t retrieve
from text
Wrong relation Max took the bird home when he liked him.

Inappropriate I like these videos. We see them a lot.

voice (abrupt
shift in role)
Incorrect Use of “the” on first reference or “a” on
determiner second reference, e.g., The boy picked up
the baby frog. He showed a baby frog to
his pets.
 Persuasive Writing
Should Animals be used in a Circus

I think that animals at the circus should be able to do tricks because it is

fun to see it and it looks very dangerous. Other people might not think
that is a good idea, because the people are doing dangerous things. But
they are triand to do that.

It is fun to see it. Becuase people are doing dangerous things like,
makking lions jump through hoops.

It is dangerous and scary to see it, but people are trained to do it. It looks
cool.

People have a lot of fun. People always cheer after ever trick. They are
so happy to come.

In conclusion I think it is cool to have animals do tricks. Because it is fun

to see it, and it has dangerous actors in it. People have a lot of fun there.
 Types of Answers to
QRI Questions

• Failure to link ideas across a passage –

making relational inferences
• Failure to make causal inferences
• Failure to parse syntax
• Excessive elaboration or overreliance on
prior knowledge
• Failure to know a key vocabulary word
• No response – did not answer

Dewitz, P., & Dewitz, P.K. (2003). They can read the words, but they can’t
understand: Refining comprehension assessment. The Reading Teacher,
56:5, 422-435.
 The Octopus – 5th grade
Concept Questions

• What is an octopus?
– A big creature with 8 legs
• Why does an animal attack another animal?
– Wants to eat it
• What are animal defenses?
– Pine needles, claws
• What is animal camouflage?
– So things can’t see it
• Prediction
– Octopus attacking humans
 The Octopus – 5th grade

• Explicit questions
– What is the favorite food of the octopus?
(crabs)
– How does the octopus move forward very
rapidly when it is frightened? Pushes water
from its body
– What does the ink-like fluid do to the water?
Makes it dark (not specific enough)
– What is one color that an octopus can change
to? Pink and blue
 The Octopus – 5th grade

• Implicit
– What is this passage mainly about? An
octopus and what it does when it’s scared or
excited (relational inference across text)
– Why doesn’t an octopus completely change
color when it sees a crab? Don’t know (causal
inference across text)
– What color does an octopus probably become
when it sees an enemy? Dark (relational
inference from text)
– Why might the shy octopus attack another
creature? If hurt (over reliance on prior
knowledge)
 Theory of Mind & Emotion
Understanding

Belief understanding does not guarantee emotion

understanding; emotion understanding does not
guarantee empathy; and empathy does not guarantee
sympathy as manifested by kindness to people who are
sad.

Davis, M., & Stone, T., (2003). Synthesis: Psycholgical understanding and social skills.
In B. Repacholi & V. Slaugher (Eds.), Individual differentes in theory of mind:
Implications for typical and atypical development (pp. 306-352). New York: Psychology
Press.
 Theory of Mind
judges that 2 persons can have different desires
about the same object
recognizes that 2 persons can have different
beliefs about the same object when the child
doesn’t know which is true
judges another person’s false belief about what
is in a distinctive container when the child
knows what is in the container
judges how someone will search given that
person’s false belief
understands words such as know, forget,
remember, guess
Wellman, H.M. & Liu, D. (2004). Scaling of
theory-of-mind tasks. Child Development, 75,
523-541.
Emotion Understanding
identifies emotions from faces and photos
identifies causes of emotions
recognizes that persons’ emotional reactions
depend on their desires
Pons,R. Harris, P., & M. de Rosnay (2004).
Emotion comprehension between 3-11
years : Developmental periods and
hierarchical organization. European Journal
of Developmental, 1, 127-152
recognizes that beliefs determine emotions even
if belief is false
realizes that intensity of emotion decreases with
time
can use strategies to control one’s emotions
can hide a felt emotion from others; knows
social rules for hiding emotions
understands that persons can have more than one
emotion at a time
 Sad

1 2 3 4 5 6
Lonely Disappointed Discouraged Despairing Agonizing Maudlin
Lost tearful Gloomy Devastated Anguished
Sad Heartache Disillusioned Condemned
Tired homesick Dismayed Grave
Upset Hysterical Distraught Overwrought
Troubled Empty Pining
Weak Grieving Subdued
Withdrawn Resigned Tormented
Turmoil

Mind Reading: The Interactive Guide for Emotions

 Perceptual-
language distance
I II III IV
perceptual
Matching Selective Reordering Reasoning
language Perception Analysis of Perception about
distance Perception Perception

Blank, M., Rose, S.A., Berlin, L.J. (1978). The language of learning:
The preschool years. New York: Grune & Stratton.
 Early Childhood
(Alternative Thinking)
• Johnny has been playing with
this truck for a long time, all
morning, and now Jimmy
wants a chance to play with it.
What can Jimmy do or say so
he can have a chance to play
with the truck?
• Peter broke his mom’s favorite
flower pot and his mom might
be mad at him. What could
Peter say or do so that his
mom will not be mad?

Spivack, G., Platt, J.J., & Shure, M.. (1976). The problem-solving approach to
adjustment. San Francisco: Jossey-Bass.
 Middle Childhood
(Means-End Thinking)
Child is told the beginning and end of a story and is
asked to fill in the middle, tell what happens in
between, or tell how the ending got to be that way.
Al (Joyce) moved into the neighborhood. He (she) didn’t
know anyone and felt very lonely. The story ends with Al
(Joyce) having many good friends and feeling at home
in the neighborhood. What happens in between Al’s
(Joyce’s) moving in and feeling lonely, and when he
(she) ends up with many good friends.

Spivack, G., Platt, J.J., & Shure, M.. (1976). The problem-solving
approach to adjustment. San Francisco: Jossey-Bass.
 Adolescence
(Consequential Thinking)
George is in training. The football coach has a rule
that all members of the team get to bed early during
the week. George gets invited to a Tuesday night
social in the next town by a girl he likes a lot. If he
goes, he’ll end up getting to bed rather late. He would
really like to go.
Tell everything that goes on in George’s mind
and then tell what happens.

Spivack, G., Platt, J.J., & Shure, M.. (1976). The problem-solving
approach to adjustment. San Francisco: Jossey-Bass.
 Conflict Resolution
John’s teacher assigned him to work with three other boys on a
project for the science fair. The boy’s decided to build a model
airplane that could actually fly. All of the boys, except one, a boy
named Bob, worked hard on the project. Bob refused to do
anything and just let the others do all the work. This bothered
John very much. Now I’d like you to tell the story back to me.

Now I’d like to ask you some questions about the story.
1. What is the main problem?
2. Why is that a problem?
3. What is a good way for John to deal with Bob?
4. Why is that a good way for John to deal with Bob?
5. What do you think will happen if John does that?
6. How do you think they both will feel if John does that?

Nippold, M.A., Mansfield, T.C., Billow, J.L. (2007). Peer conflict explanations in
children, adolescents, and adults: Examining the development of complex syntax.
American Journal of Speech-Language Pathology, 1, 1798-188.
 Ways social skills
affect academics
• Teacher-student relationships
– Teacher may spend more time addressing child’s
behavioral issues then teaching child academic
concepts
• Peer relationships
– Child not selected for peer work groups
– Child does not fully participate in learning groups
• Ability to make inferences from texts
– If child does not understand emotionality and
temporal-cause/effect relationships in social
situations, cannot use this information to build
mental models for texts
 Specific targets/outcomes
Emotional Understanding

Temporal Problem
Solving Non-verbal
sequence
& cause cues
and effect
 Underlying Principles:
Explicit teaching

• Repeated exposures

• Variety of contexts

• Practice in safety
 Developing episodic memory

• Semantic memory: memory Plan, Do, Review = Episodic Memory

for words and concepts
• Procedural memory: Journal writing
memory for how to do
• Facilitates episodic memory
something
• Take it home and share with the
• Episodic memory: memory
family
for subjective experiences
throughout time; ability to • Culturally appropriate
perceive the present
moment as both a
continuation of the past and
as a prelude to the future.

McGuigan, F., & Salmon, K. (2004). The time to talk: The influence of the timing of
adult-child talk on children’s event memory. Child Development, 75, 669-686.
Tulving, E. (1993). What is episodic memory? Current Directions in Psychological
Science, 2, 67-70.
 Outcomes focus on
participation
• Capacity goal
– Zach will identify when his clinician is
indicating boredom.

• Participation goal
– Zach will make and keep a friend
– Zach will invite a friend to a movie,
arranging time, place and
transportation
 Emotional
understanding

Problem
Solving

Temporal,
cause/effect Noverbal
relationships cues
 Scripts and role-plays

• Teach the script to improve temporal

sequencing
• Cause/effect relationships that exist in
that event (what to do when things
change)
• Must focus on emotionality as well
• Non-verbal
 Thomas profile
• DX: Asperger’s/ High functioning ASD
• High capacity
– Introduces and maintains conversation topics
– Appropriate eye contact
– Appropriate questions
• Can participate appropriately
• Emotional understanding is an issue
– Can choose to be appropriate but …”Mom, I’m done. I
have to go home.”’
– Believes everyone is against him
– Can’t forgive others, ever!
• Parent concerns
– Differentiating between annoying and teasing
– Okay to disagree with a friend but still be friends
 K profile

• Asperger’s
• Normal language scores
• Emotional understanding and script
examples
– “I want a snack and a friend”
– “Ms. Robinson embarrassed me”
• Parent concerns
– Play in peace with her siblings
– Listen and pay attention to others
 Value of Scripts and
Role-plays
• Write out the script beforehand
• Props act as cues and supports
• Practice variations
• Focus on emotions
• Slow down the interaction
• Problem solve solutions when things go wrong
• Confederates both as role models and as
troublemakers
• Explicit teaching, debriefing is critical, more critical in
establishing the episodic memory than the prep
work
 Ryan’s profile

• ADHD, possible Asperger’s

• Low capacity
– Poor narratives, comprehension, inference
– Highly verbal
– Not responsive
– Appropriate social interactions very “scripted”
• Parent concerns
– Social interactions at school
– Sharing
– Accepting others’ ideas
– Stay in own space
 Value of Story Enactment

• Sequence of events, emotions, narrative

• Range of language from immediate/concrete
to remote/abstract
• Story becomes the child’s experience, so
promotes child’s episodic memory
 CD profile

• Classic SLI
• Highly motivated to participate
• Lacks sophisticated emotional understanding
• Takes over the conversation
• Parent concerns
– Let others talk about what they want to talk
about
– Let others talk!
 Value of Videos

• Visual
• Slow things down
• Turn the sound off
• Focus on the non-verbal cues
• Watch it over and over again
• Too subtle=too hard to figure out/start with
the obvious and work towards subtle
• Target what the child is actually doing in a
non-threatening way
• Funny/OTT or more subtle, depending on
the needs of the client
 Conversation game

• Brinton, B., Robinson, L., & Fujiki, M.

(2004). Description of a program for social
language intervention: "If you can have a
conversation, you can have a relationship."
Language, Speech and Hearing Research
in the Schools, 35, 283-290.
 CD, again

• Classic SLI
• Highly motivated to participate
• Lacks sophisticated emotional understanding
• Takes over the conversation
• Parent concerns
– Let others talk about what they want to talk
about
– Let others talk!
 Value of the
Conversation Game
• Practice
• Cause and effect
– Pre-teaching
• Conversational responsiveness
– Checking in with the other person
– Adjusting to the partner, changing
• Balanced turn taking
• Not static but dynamic, changing, flexible
 Measuring progress:

• 1-5 scale
– Emotions
– Content
– Appropriate turn taking/responsiveness
– Non-verbal cues
– Amount of support needed from the clinician
• Parent report
 Zach profile

• Narratives
• Content
• On IEP for LD but no speech services
• Parent concerns
– Doesn’t have friends
– Doesn’t understand that he isn’t acting like
others
– Loud and obnoxious
– Acts like a younger child
 Jason profile

• ADHD only
• Academics
• Social
– Nice kid
– No clue how long he talks
• Parent concerns
– Starting to run into academic
problems
– Behavior!
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