1 CHAPTER-I

1.1. Concept, Meaning and Definition of ADHD

“Let me see if Philip can be a little gentleman;

Let me see if he is able to sit still for once at table.”

Thus spoke, in earnest tone, the father to his son;

And the mother looked very grave

To see Philip so misbehave.

But Philip he did not mind;

His father who was so kind …

See the naughty, restless child,

Growing still more rude and wild,

Till his chair falls over quite.

Philip screams with all his might, catches at the cloth,

But then, that makes matters worse again.

Down upon the ground they fall, glasses, bread, knives forks and all …

Poor Papa and poor Mamma look quite cross,

And wonder how they shall make their dinner now.

- Excerpts from the poem ‘The Story of Fidgety Philip’ by Hoffman

INTRODUCTION

2

The Story of Fidgety Philip’ was an accurate description of a little boy who had

Attention Deficit Hyperactivity Disorder. The condition was first described by

Hoffman (1845).

Many parents experience a ‘Fidgety Philip’ scenario. They find that their child

often fails to finish projects, seems not to listen, is easily distracted, and has difficulty

concentrating even on a chosen task. Other thoughts, sights, or sounds keep getting in

the way, especially when the task is difficult or uninteresting. The child acts before

thinking, switches from activity to activity, needs a lot of supervision, and has difficulty

with organization of time, work, and belongings. The ability to pay attention is an

important prerequisite to success in school. Any difficulty with attending skills can

have an adverse effect on learning. Behavioral problems, poor school work, and

learning difficulties may be the first indicators of a need for evaluation. Attention

Deficit Hyperactivity Disorder (ADHD) is characterized by problems with attention,

impulsivity and over activity.

ADHD is a current diagnostic label for a condition that has been recognized and

studied over a century. It has been known by several other names including behaviour

syndrome (Bradley, 1937); distractibility (Strauss & Werner, 1941), hyperkinetic

impulsive disorder (Laufer, Denhoff., & Solomons, 1957), and minimal brain damage

(Strauss & Kephart, 1955).

During the late 1960s American Psychiatric Association (APA) became

involved in renaming various disorders. They published the Diagnostic Statistical

Manual–II (DSM–II) and called the syndrome, hyperkinetic reaction of childhood. In

1970s, hyperactivity and hyper kinesis were the most popular terms. However, by

1980s, APA published its third Diagnostic Statistical Manual III (DSM-III), and

renamed the disorder as Attention-Deficit Disorder (ADD) and Attention-Deficit

Disorder with Hyperactivity (ADD-H). Within Six years, APA once again brought out

the revised Diagnostic Statistical Manual-IIIR (DSM-IIIR) and renamed the disorder

once again to Attention Deficit Hyperactivity Disorder (ADHD) and this was published

in Diagnostic Statistical Manual-IV (DSM-IV).

Developmentally abnormal levels of sustained attention, impulse control, and

excessive activity (Barkley & Murphy, 1991) characterize ADHD. This disorder arises

3 early in childhood, typically between the ages of 3 and 7. These children

characteristically experience school failure, develop conduct disorders, and antisocial

personalities (Barkley, 2000). As a result of the problem of impulse control, ADHD

children have difficulty in following instructions, make careless errors in school work,

fail to reflect upon the consequences of negative behavior, and engage in frequent,

unnecessary risk-taking acts (Barkley, 1991).

ADHD is the classic inattentive, cant-sit-still behaviour. Rosenthal and Allen

(1978) recorded that ADHD children were reported by teachers, parents and clinicians

to be distractible and to exhibit short attention span, low frustration tolerance and

impulsive behavioural patterns. It is the failure to invent, organize and to maintain

attention and effort, and the inability to modulate arousal levels to meet task demands

that characterize those with ADHD (Douglas, 1980; Keogh & Margolis, 1980).

Barkley (1990) listed the following as behaviours associated with ADHD.

• Poorly sustained attention in almost all situations.

• Diminished persistence on tasks not having immediate consequences.

• Impulsivity, poor delay of gratification.

• Impaired adherence to commands to regulate or inhibit. behavior in

social contexts.

• More active, restless than normal children.

• Difficulty adhering to rules and regulations.

A Lifetime Disorder

ADHD is a common neurobiological condition affecting 5-8% of school age

children (American Academy of Pediatrics, 2000; American Psychiatric Association,

2000; Center for Disease Control and Prevention, 2003; Mayo Clinic, 2001; 2002;

Froehlich et al., 2007; Surgeon General of the United States, 1999).

Although most cases of ADHD are diagnosed in children when they enter

school for the first time, a growing number of children younger than 6 years old are

being diagnosed. Children with ADHD are at risk for potentially serious problems in

adolescence: academic underachievement and school failure, problems in social

4 relations, risk for antisocial behavior patterns, teen pregnancy, and adverse driving

consequences (Barkley, 1998). Symptoms often attenuate during late adolescence

although a minority experiences the full complement of symptoms into mid-adulthood

(DSM-IV).

Studies suggest that between 30% and 70% of children with ADHD continue to

show symptoms of the disease as adults (Faraone, Biederman, & Mick, 2006; Kessler et

al., 2006). Although individuals with this disorder can be very successful in life,

without identification and proper treatment, ADHD may have serious consequences,

including school failure, family stress and disruption, depression, problems with

relationships, substance abuse, delinquency, risk for accidental injuries and job failure.

Early identification and treatment are extremely important.

1.2. Characteristics of Children with ADHD

The three primary characteristics of ADHD are i) Inattention,

ii) Hyperactivity and iii) Impulsivity.

i) Inattention: The term inattentive behaviour encompasses a wide range of

behaviours, including lack of persistence in activities such as play or schoolwork,

orientation to task-irrelevant stimuli, engagement in task irrelevant activity, and

frequent changes of activities (Taylor, 1994).

A child may be exhibiting symptoms of inattention if he or she often ignores

details, makes careless mistakes, has trouble sustaining attention in work or play, does

not seem to listen when directly addressed, does not follow through on instructions, has

difficulty organizing tasks and activities, avoids activities that require a sustained

mental effort, loses things he or she needs, gets distracted by extraneous noise and

activities, and is forgetful in daily activities.

ii) Hyperactivity: Hyperactivity refers to an excess of movement, either in minor,

task-irrelevant movements such as toe-tapping, fidgeting, or in gross body movements

such as restlessness (Taylor, 1994). A research study brought out an interesting finding

that hyperactive children have a preference for immediate reward and are motivated by

a need to keep experience of delay at a minimum (Sonuga-Barke et al., 1996).

5

A child may be exhibiting symptoms of hyperactivity if he or she often fidgets

or squirms, has to get up from seat, runs or climbs when he or she shouldn't, has

difficulty with quiet leisure activities, is on the go as if driven by a motor, and talks

excessively.

iii) Impulsivity: Some children seem to have difficulty holding inappropriate

responses and appear to ‘behave without thinking’. The term impulsiveness is often

applied to such a style of behaviour.

A child may be exhibiting symptoms of impulsivity if he or she often blurts out

answers before questions have been completed, has difficulty waiting his or her turn,

and interrupts or intrudes on others.

Reddy, Ramar and Kusuma (2006) spelled out the behavioural symptoms and

characteristics of children with ADHD as follows:

• Aggression to people and animals.

• Destruction of school property – defacing school desks, graffiti, vandalism etc.

• Little empathy and concern for others; shows no feeling when others are in pain.

• Takes no responsibility for behaviour; lies, cheats and steals easily.

• Disregard for rules and regulations; may be openly defiant.

Associated Characteristics of ADHD

ADHD children also exhibit difficulties in diverse areas of functioning and such

behaviours are known as associated characters. Two thirds of children with ADHD

have at least one other coexisting condition (MTA Cooperative Group, 1999). The most

common disorders to occur with ADHD are disruptive behaviour disorders, mood

disorders, anxiety disorder, and learning disabilities (American Psychiatric Association,

1994; Biederman, Newcorn, & Sprich 1991). Children with ADHD are said to have

intellectual impairment, academic problems and cognitive deficits, social and conduct

problems.

(i) Intellectual Impairment: Children with ADHD perform slightly lower on

general intelligence tests than normal children (Anastopoloces & Barkley, 1992).

Intellectual impairment has been linked to hyperactivity in children as young as three

6 years of age (Sonuga-Bark, Williams, Hall, & Saxton, 1994). ADHD children are

more likely than others to have a specific learning difficulty, to be clumsy and to

experience speech and language difficulties (Barkley 1995; 1998; DuPaul & Stoner,

1994; Tannock, 1998). They have impairments specifically in reading, mathematics,

spelling and other academic areas which are due to lowered general intelligence.

(ii) Academic Problems: Children with ADHD often do not appear to achieve

what they seem capable of. Behaving in an inattentive and impulsive manner may

contribute to poor performance in the classroom. Academic difficulties are also

associated with ADHD (Cantwell & Baker, 1991). Over one-third of clinically-referred

children diagnosed with ADHD have co-morbid reading difficulties (August &

Garfinkel, 1990). Lahey et al. (1998) reported that academic problems may be obvious

in the first few years of schooling.

(iii) Deficits in Cognitive Executive Functioning: Tannock (1998) has

evidence for deficits in executive functioning that involve planning, organizing action

inhibiting responses, mentally representing a task, switching strategies and self-

regulation.

(iv) Social and Conduct Problems: Melnick and Hinshaw (1996) reported that

children with ADHD prefer fun and trouble even at the expense of breaking rules. They

have trouble in making and keeping friends. ADHD children at elementary school level

tend to act without thinking of the consequences of their action. They say and do things

without bothering about others’ responses. They lack self-control and attention-paying

ability, and hence, they are ignored (Hinshaw, Klein, & Abikoff, 1998).

Difficulties in making and / or keeping friends are also generally noted in

children with ADHD. Their peers tend to dislike and reject them. Peer problems may be

particularly evident when ADHD is present in combination with specific learning

disabilities (Flick, 1998) or aggression. Children with ADHD tend to be more

argumentative, dominating, aggressive and disruptive, which can lead to social

rejection and isolation. Their impulsiveness may affect their ability to process socially

relevant cues and information accurately and lead to tendencies to view neural or

ambiguous social interactions in a negative or hostile manner (Milich & Dodge, 1984).

7 Oppositional defiant disorder (ODD) and conduct disorder (CD) are the

common disruptive disorders co-existing with ADHD. About 40 percent of individuals

with ADHD have ODD (Barkley, Anastopoulos, Guevremont, & Fietcher, 1991;

Kuhne, Schachar, & Tanno, 1997; Tannock, 1998). Among individuals with ADHD,

CD is also common, occurring in 25 percent of children, 45-50 percent of adolescents

and 20-25 percent of adults (Biederman, Faraone, Milberger, & Guite, 1996).

Longitudinal research suggests that ADHD is a risk factor for the development of

conduct disorder (Loeber, Farrington, Stouthamer-Loeber, & van Kammen, 1998).

Some children, in addition to being hyperactive, impulsive, and/or inattentive,

may also seem to always be in a bad mood. They may cry daily, out of the blue, for no

reason, and they may frequently be irritable with others for no apparent reason. Both

sad depressive moods and persisting elevated or irritable moods (mania) occur with

ADHD more than would be expected by chance.

1.3 Factors Contributing to ADHD

Several factors are reported to contribute to ADHD. Chief among them are:

Bio-physical, Environmental and Psycho-social.

Biophysical factors

These include genetic, neurological and biochemical conditions. When a child

is diagnosed with ADHD, there is a strong possibility that it will be found in other

blood relatives, too. Numerous studies have shown that higher incidence of parental

psychopathology is present in families of children with ADHD (Barkley, 1998;

Tannock, 1998). Many studies also provide evidence of inheritance and suggest that

inattention and hyperactivity / impulsivity are heritable (Rutter, 1990).

A number of studies made in the U.S. and Europe aimed to find genes that lead

to susceptibility to ADHD (Bakker et al., 2003; Ogdie et al., 2003). Genes, when

mutated, may lead to change in protein structure which naturally reacts on the

individual behaviour. The human genome project has now revealed that ADHD is

genetic- only 10% of the general population acquires this gene. ADHD gene affects the

brain’s relationship with dopamine, norpinephrine and serotonin thus affecting the

biochemistry. This causes one to crave for stimulation just to feel alive.

8

Increasing data support the efficacy of stimulants in preschoolers with ADHD

(Abikoff et al., 2007). Recent British research indicates a possible link between

consumption of certain food additives like artificial colours or preservatives, and an

increase in activity (McCann et al., 2007). For the child without a medical, emotional,

or environmental etiology of ADHD behaviors, a trial of a preservative-free, food

coloring–free diet is a reasonable intervention (Eigenmann & Haenggeliet, 2007).

Aluminium also is one of the most common causes of ADHD. Symptoms

typically include a foggy mind, lack of concentration and poor memory. Iron

deficiency may be suspected with some form of ADHD. 84% of children diagnosed

with ADHD were found to have abnormally low level of ferritin, compared to 18% of

children without ADHD (Konofal, 2004). Low iron levels in the brain are also known

to alter dopamine activity, which is involved in controlling movements. There is a link

between iron deficiency in infants and slower brain development and poorer school

performance in later childhood. Tyrosine and amino-acid necessary for synthesis of

dopamine and nor-epinephrine - the two neurotransmitters - are believed to be involved

in ADHD. Recreational activities such as the types of videos watched, types of music

listened also lead to ADHD.

Environmental factors

Lack of parental discipline is believed to be the most wide spread cause of

ADHD and other behavioural problems. Many environmental factors aggravate the

symptoms of ADHD. Of these, exposure to lead is dangerous to human. High levels of

lead have been associated with serious deficits in biological functioning, cognition and

behaviour. Low levels of exposure over long periods of time have also adverse effects

on children. Exposure to lead can come from lead-based paints, automobile emissions,

leaded crystal, and ceramic dishes. Exposure to bromine- based fire retardants used in

carpets, mattresses, furniture and some electronic equipment is found to be linked with

specific behavioural problems such as ADHD, ODD etc.

Psycho-social factors

Though the psychosocial factors are not considered primary in the etiology of

ADHD, they do play a role. An association of ADHD behaviours with adverse family

9 variables, such as parental malaise, marital discord, coldness to the child and criticism

of the child, was established by Goodman and Stevenson (1989).

Many researchers believe that parents or teachers are a primary cause of

ADHD. In the opinion of Barkley (1996) psychosocial variables particularly family

factors, provide the critical context within which the disorder develops. The

psychosocial variables, no doubt, shape the nature and the severity of the disorders as

well as maintain them over a period of time.

It is also possible that teacher’s behaviours might play a role by influencing a

child’s attentiveness and reflectivity. Classroom organization and the structuring of

activities do have an influence on attentiveness, especially for children predisposed to

ADHD behaviours. Teacher’s perception and tolerance of student behaviour may

influence daily social interactions.

Anxiety disorders affect about 25% of children with ADHD. Symptoms include

excessive worry, fear or panic which can also lead to physical symptoms such as racing

heart, sweating, stomach pains and diarrhoea. Other form of anxiety that can

accompany ADHD is obsessiveness.

1.4 Concept, Meaning, Definition and Types of Specific Learning Difficulties

Difficulties in reading, spelling and associated problems are known as Specific

Learning Difficulties (Reddy, Ramar. & Kusuma, 2006). The phrase also refers to

specific disorder or retardation in one or more of the speech, language perception,

behaviour, reading, spelling and writing. Specific learning difficulties are significant

problems of synthesizing, organizing and memorizing. These problems restrict the

individual’s proficiencies in information processing and produce an intractable learning

problem in some or all the aforesaid skills.

The Federal Register (1977) uses the phrase specific learning disability /

difficulty as a disorder in one or more of the basic psychological processes involved in

understanding or using languages, spoken or written, which may manifest itself in an

imperfect ability to listen, think, speak, read, write, spell or to do mathematical

calculations. The phrase includes perceptual handicaps, brain injury, minimal brain

dysfunction, dyslexia and developmental aphasia. The phrase does not include those

learning problems which are primarily the result of visual, hearing or motor handicaps,

10 of mental retardations, of emotional disturbances or of environmental, cultural or

economic disadvantage (US Office of Education, 1977).

The National Joint Committee for Learning Disabilities (1981) defined learning

disabilities as a generic term that refers to a heterogeneous group of disorders

manifested by significant difficulties in the acquisition and use of listening, speaking,

reading, writing, reasoning or mathematical abilities. Their disorders are intrinsic to the

individual and presumed to be due to central nervous system dysfunction. Even though

a learning disability may occur concomitantly with other handicapping conditions (e.g.

sensory impairment, mental retardation, social and emotional disturbances) or

environmental influences (e.g. cultural differences, insufficient, inappropriate

instruction, psychogenic factors), it is not the direct result of those conditions or

influences (Hammill, Leigh, Mc Nutt and Larsen, 1981).

Common characteristics of LD include (Learning Disabilities Association of

America, 2004):

• Uneven areas of ability.

• Short attention span.

• Poor memory.

• Difficulty following directions.

• Inability to discriminate between/among letters, numerals, or sounds.

• Poor reading and/or writing ability.

• Eye-hand coordination problems; poorly coordinated.

• Difficulties with sequencing.

• Disorganization and other sensory difficulties.

IDEA (2004) defines a specific learning disability as:

A disorder in one or more of the basic psychological processes involved in

understanding or in using language, spoken or written, that may manifest itself in the

imperfect ability to listen, think, speak, read, write, spell, or do mathematical

calculations, including conditions such as perceptual disabilities, brain injury, minimal

brain dysfunction, dyslexia, and developmental aphasia. Specific learning disability

does not include learning problems that are primarily the result of visual, hearing, or

11 motor disabilities, of mental retardation, of emotional disturbance, or of

environmental, cultural, or economic disadvantage.

From the above definitions, it can be concluded that specific learning

difficulties are more concerned with language learning and its usage in reading, writing,

spelling, speaking, calculating and organizational difficulties.

Prevalence of Specific Learning Difficulties

One in every five students has a special educational need; about 1.7 million.

This is a large and very important group of young learners. Specific learning difficulties

are more concerned with language learning and its usage. Generally, these difficulties

are more in learning second language, i.e. English. As English is a foreign language and

it is alienated from native languages, learning difficulties particularly spoken, written,

spelling and organizational difficulties in students are common. Even though there is no

specific scientific survey in India, with common sense one can say that there is ample

number of students with specific learning difficulties not only at school level but also at

collegiate level. In the United Kingdom, where English is the native language, 10% of

children have dyslexia (Crisfield, 1996). The Government of United Kingdom stated

that nationally only 2% of children have special educational needs (Code of Practice,

1994). It is estimated that 10 to 15% of the Indian school population are facing specific

learning difficulties in English (Santhakumari, 2003; Sivakami, 2000).

Types of Specific Learning Difficulties

Specific learning difficulties can be broadly classified into various categories

depending upon the primary problems experienced by the students. Different types of

specific learning difficulties are oral language difficulties, reading difficulties, writing

difficulties and arithmetic difficulties.

i) Oral Language Difficulties: These include dysphasia and aphasia.

Dysphasia is the partial inability to comprehend the spoken word (receptive dysphasia)

and to speak (expressive dysphasia) which is believed to be the result of injury,

disease or maldevelopment of brain. Aphasia is the total loss of ability to comprehend,

manipulate or express word in speech.

12 ii) Reading Difficulties: It comprises dyslexia and alexia. Dyslexia is a disorder

manifested by difficulty in learning to read despite conventional instruction, adequate

intelligence and socio-cultural opportunity. It depends on fundamental cognitive

disabilities, which are frequently constitutional in origin. Another interpretation of

dyslexia is that it is a disorder in children who, despite conventional classroom

experience, fail to attain the language skill of reading, writing and spelling

commensurate with their intellectual abilities. The first definition mentions cognitive

processing as a reason for specific reading deficit and the second speaks of an overall

language processing delay. On the other hand, alexia is the total loss of ability to read,

write languages.

iii) Writing Difficulties: Disorder of writing is referred to as dysgraphia and

agraphia. Dysgraphia denotes extremely poor handwriting or the inability to perform

the motor movements required for handwriting (Lerner, 1981) and agraphia denotes the

loss of previous ability to write resulting from brain injury or brain disease. The

unusual difficulty in learning to write is out of harmony with the other intellectual

accomplishments and normal skills of the individuals.

iv) Arithmetic Difficulties: Dyscalculia and Acalculia are the two arithmetic

difficulties. Dyscalculia is the partial inability to perform calculation and Acalculia is

the total inability to perform calculations.

1.5 Causes of Specific Learning Difficulties

Literature cites many different causes of specific learning difficulties – organic,

biological, genetic and environmental.

a) Neurological Damage: Children with learning difficulties share several

characteristics found in persons with brain damage caused by injury or infection.

Neurological damage can also occur during prenatal, perinatal and postnatal periods.

Factors such as prolonged labour (Colletti, 1979), premature birth, birth complications,

maternal age, use of drugs and alcohol, maternal fetal blood incompatibility, maternal

use of tobacco (Lovitt, 1989), and low birth weight are some of the variables associated

with learning difficulties.

b) Genetic Factors: Evidence suggests that members within a family have a

tendency towards learning difficulty. Several research studies established that genetics

13 is one of the causative factors of learning difficulties (Eldridge, Denckla & Bien et al.,

1989; Reiss & Freund, 1990).

c) Biochemical Factors: Chemical plays an important role in brain activity.

Absence or excessive amount of biochemical substances causes a biological imbalance.

There appears to be some relationship between these chemicals and hyperactivity,

which is associated with learning difficulty. Livingstone, Rosen, & Drislane et al.

(1991) explained physiological and anatomical evidence for a magnocellular defect in

developmental dyslexia.

d) Environmental Factors: There are several factors in the child’s environment

which may lead to learning disability. In economically deprived homes, the child may

not be exposed to adequate sensory, linguistic and cognitive activities. An emotionally

unstable home life may deprive the child of any motivation to learn. Some researchers

(Bruner, 1971; Cole, 1987) believe that poor quality teaching in schools can also cause

a learning disability. A poor teaching style - not giving time to the learner to acquire

basic skills, moving too fast and failure to understand how best a child learn - can result

in learning difficulties. Usage of inappropriate materials and curriculum are other

factors, one must be sensitive to.

1.6 Characteristics of Students with Specific Learning Difficulties

An exact definition of specific language disability is not possible since the

disorder ranges in degree from the very mild to the extremely severe. The key point,

however, is that reading and language skills are definitely out of keeping with overall

intellectual capacities and that this difference persists in spite of competent instruction

over adequate periods of time with pedagogical methods which are successful in the

majority of children. It is in this regard, namely the failure to learn at the usual rates by

the usual pedagogical methods, that the term ‘specific’ is appropriate. A child with a

specific learning difficulty is as able as any other child, except in one or two areas of

their learning.

The U.S. Office of Education (1977) Federal Register provides a framework for

examining characteristics. The list of disability areas (oral expression, reading skills,

reading comprehension, written expression, basic reading skills, listening

14 comprehension, mathematical reasoning) shows that academic and language difficulties

are primary characteristics.

Apart from primary characteristics, there are some specific characteristics as

follows:

1.7 Relationship between ADHD and Learning Difficulties in Children

Up to 80% of children diagnosed with ADHD have been found to exhibit

learning and/or achievement problems (Cantwell & Baker, 1991; Frick et al., 1991).

15 According to Stormom, Stebbins, and McIntosh (1999), around twenty to thirty per

cent of children suffering from ADHD also seem to possess learning disabilities. These

difficulties include problems understanding certain sounds, and expressing oneself in

preschool children. For school going children, they may find difficulty reading,

spelling, writing, or solving arithmetic problems.

Listed below are the characteristics of ADHD children with learning

difficulties:

Characteristics of ADHD Children with Learning Difficulties

• Reading well but not writing well, or vice versa.

• Having short attention span or a tendency to be impulsive or easily distracted.

• Difficulty in following a schedule, being on time, or meeting deadlines.

• Getting lost easily, either driving or finding your way in a large building.

• Misreading or miscopying.

• Confusing similar letters or numbers, reserving them or misreading their order.

• Reserving or writing letters, words or phrases.

• Difficulty in reading the newspaper, distinguishing small print or following columns.

• Difficulty in explaining ideas in writing but not orally.

• Confusing right and left, up and down.

• Inability to restate what has just been said.

One possible connection between learning difficulties and ADHD is that

academic skill deficits eventually lead to display of inattention, impulsivity, and related

behaviour problems. This hypothesis has been articulated by McGee and Share (1988).

They point out that learning disabilities lead to chronic academic failure that over time

causes a child to develop a poor academic self-concept (i.e., low self-esteem). As a

result of lack of confidence in their own academic abilities, these children are less

motivated to attend to instruction and to follow classroom rules. These apparent

behavioural symptoms of DHD then lead to further academic underachievement, thus

completing the vicious circle.

16

Behaviours related to ADHD may interfere with learning in at least two ways.

First, the child’s high activity level could divert his attention from instruction and

thereby minimize the acquisition of academic information. Second, and alternatively,

because children with ADHD are impulsive, they make decisions on academic tasks too

rapid a fashion, thus debilitating their performance on independent tasks.

1.8 Need and Procedure for Identification of ADHD and Specific Learning Difficulties

Learning is a complex process which involves many skills which we often take

for granted such as language production and understanding, visualization of problems,

co-ordination for writing, memory, attention, the ability to see, hear, the ability to sit

still and the ability to sustain repetitive activity for long periods of time. A variety of

emotional, learning, developmental and medical conditions can influence the basic

skills and interfere with a child’s success and self-esteem in school. This often results

in children with less severe disability not being assessed until their difficulties have led

to academic failure. These children often suffer from attention difficulties, memory

difficulties, motor-coordination difficulties and developmental language disorders

which may go undetected. Careful diagnosis of children with ADHD often reveals co-

existing co-ordination or learning difficulties. There is no single identification

procedure for learning difficulties which can cause difficulty in defining which children

have the disorder.

In general, children are classified as children with learning difficulties if they

have a discrepancy of 1.3 to 1.5 standard scale unit between an intelligence test scorer

and a standardized academic achievement test. For example, a child with a measured

IQ score of 115 and a written language standardized test score of 92 could be classified

as a child with learning difficulties in written language. 4% of children with a learning

disability have language disorders.

The appropriate diagnosis of ADHD requires a collaborative effort using

multiple sources of information, regardless of the training involved. It is essential to

obtain multiple perspectives regarding symptoms in order to assess their pervasiveness

and severity. Input from family, teachers and other school personnel who have the

opportunity to observe and interact with the children over time in many different

situations is therefore critical.

17 Educational, mental health and medical personnel with appropriate training can

effectively use systematic methods of assessing inattention, activity level, and factors

that may contribute to attention difficulties. Such methods might include formal

observation in multiple settings, interviews with the students and relevant adults, rating

scale completed by family, teachers and the peers, developmental, school and medical

histories, formal tests to measure attention, persistence and related characteristics, etc.

Most of these measures are not medical procedures. However, it is important

that a physician should know about attention problems. It is always best practice to

obtain evaluation information from multiple sources including both home and school.

Parents usually know the age at which the child initially exhibited symptoms. This

information helps professionals to meet the criteria outlined in the Diagnostic and

Statistical Manual or DSM-IV.

It is always best practice to include the parents, classroom teacher and support

personnel such as school psychologist, school nurse, behaviour support teachers, etc.,

who are trained to understand and identify attention problems. One assessment tool is

the use of behavioural rating scales in the identification of ADHD. The Conners

Teachers Rating Scale (CTRS) (Conners, 1969) uses a 4-point scale. It includes the

following ratings: not at all present, just a little present, pretty much present, and very

much present. There are 28 items in the scale with several questions that collect

demographic information from the respondent. Both the child’s teacher and a parent

complete the scale. The discrepancy score should be determined from the two

completed questionnaires and a determination made as to whether the child is

exhibiting symptoms proportionate with ADHD.

Another rating scale used widely is the Conner’s Abbreviated Symptoms

Questionnaire (ASQ). It is often referred to as the Hyperactivity Index. This 10- item

scale is used for screening purposes to identify hyperactive children (Erford, Peyrot, &

Siska, 1998). The utility of the ASQ has chiefly been in diagnosing children as

hyperactive and in assessing changes in hyperactive and conduct problems behaviours

after interventions particularly “stimulant drug therapy”. The result of analysis of

teaching responses to the Conner’s Abbreviated Symptoms concluded that the ASQ

18 over identifies normal children and disproportionately identifies children who are

hyperactive, and aggressive, and under-identifies distractible children (Erford et al.,

1998).

1.9 Ways and Means to Overcome Specific Learning Difficulties in ADHD Children

Many impulsive and hyperactive children can be supported in a mainstream

class by employing the following ideas and strategies. It will be important to prevent

the child feeling or being rejected by his or her peers as this may exacerbate the

situation. All teaching staff may need information and education about ADHD and

clarity about the reality and myths surrounding it.

Copying from the blackboard: The child will have problem with eye, hand

coordination or other difficulties with writing. It is best for the teachers to have

the information on a hand out.

Getting started: The child with ADHD needs more time to organize his or her

notebooks, pencils and papers. Teachers need to individualize instructional

methods.

Handwriting: One of the specific learning disabilities teachers often complain

about is the child’s handwriting. Handwriting involves the fine motor skills. The

child who has gross motor problems should receive occupational therapy.

Language and speech delay: If a child has delays in language and speech, it

may manifest itself as ADHD because it is very frustrating not to be able to

respond well. Speech therapy should be provided.

Hearing and quality of hearing: Some ADHD children have very

hypersensitive hearing. There are children who are distracted by things like the

noise of a page turning but some children who are not bothered by background

noise of this type also have difficulty in the classroom. If there is a group

discussion going on, the child may try to focus on something else. This child

will be extremely distracted, even if the group is on the other side of the class

room. Teachers should place such children where they could be easily observed

and plan for appropriate activities for such children.

19 1.10 Need for the Development and Use of Cognitive, Metacognitive and

Behavioural Approaches in Overcoming SLD in ADHD Children i) Concept of cognition and its importance in learning

The traditional image of cognition tends to restrict it to the fancier, more

unequivocally ‘intelligent’ process and products of human mind. This image includes

such higher mental processes, types of psychological entities as knowledge,

consciousness, intelligence, thinking, imaging, creating, generating plans and strategies,

reasoning, inferring, symbolizing and perhaps fantasizing and dreaming (Flavell, 1977).

Organized motor movements, perception, imagery, memory, attention and learning

could be added to this list.

Cognitive processes include creating mental representations of physical objects

and events, and other forms of information processing. In cognitive learning, the

individual learns by listening, watching, touching, reading, or experiencing and then

processing and remembering the information. Cognitive learning might seem to be

passive learning, because there is no motor movement. However, the learner is quite

active, in a cognitive way, in processing and remembering newly incoming

information. Cognitive learning enables us to create and transmit a complex culture that

includes symbols, values, beliefs and norms. Cognitive development focuses on

developing functions of the brain such as thinking, learning, awareness, judgment, and

processing information.

In children, cognitive learning occurs by recognizing and remembering various

events as they learn about the world. From the ages of 2-7, children are in the pre-

operational stage. At this point, they are learning to use symbols such as language to

represent objects, and beginning to understand the concept of conservation. It is also

the phase in which memory and imagination is developed. Preschool play leads to real

life cognitive development. Older children also gather information through school,

which requires cognitive learning to recognize concepts that continue to build on

further levels of understanding.

ii) Concept of metacognition and its performance in learning

Metacognition is the ability to understand, to reflect upon and to monitor the

progress of one’s own cognitive process. Metacognition includes such things as an

20 awareness of whether we are paying attention to something or not and an awareness of

whether we understand something or are confused about it. It also includes knowledge

about what factors are likely to increase our attentiveness and whether that factors help

us to understand something. But probably the most important type of metacognitive

skill is the one that involves knowledge and understanding of one’s own learning and

memory processes. Learning how to learn is a metacognitive task.

As the children grow older, they become more skilled in a wide variety of

cognitive tasks, reflecting their growing competence at using their mental machinery in

efficient and effective ways. A major reason for this growth in cognitive competence is

the development of metacognitive skills. Simply put, metacognition is the act of

thinking about thinking. It involves the planning, monitoring and evaluation of one’s

own cognitive tasks such as – memorizing, learning, problem solving, studying,

reading, listening, decision making and comprehending and making judgments about

whether these tasks are proceeding effectively. In other words, metacognition is the

ability to control and regulate one’s own thinking, information handling and learning

processes.

Different researches have given their own theories / meaning for metacognition.

Some of these are as follows:

• Metacognition is the process of planning, assessing and monitoring one’s own thinking; the pinnacle of mental functioning (Cotton, 2001).

• Metacognition means having cognition and having understanding control over and appropriate use of that knowledge (Collins, 1994).

• Metacognition is an awareness of oneself as an actor in his environment that is, a heightened sense of the ego as an active, deliberate stores and retriever of information. It is whatever intelligent weaponry the individual has so far developed, is applied to mnemonic problems (Hacker, 2001).

Metacognitive skills are believed to play an important role in many types of

cognitive activity including oral communication of information, oral persuasion, oral

comprehension, reading comprehension, writing, language acquisition, perception,

attention, memory, problem solving, social cognition and various forms of self-

instruction and self-control. Metacognition or related concepts (e.g., executive

processes) have also recently seen service in the fields of cognitive psychology, like

21 artificial intelligence, human abilities, social learning theory, cognitive behaviour,

modification, personality development, gerontology and education, as well as in the

field of childhood development.

Kronick (1983) suggests a metacognitive approach to the development of social

competence. Some learning disabled students need assistance in generalizing social

skills across areas. Metacognitive approaches include

a) Self-monitoring of selective attention process to ensure attention to the social situation – asking the following questions: “Am I paying attention?” or “What did I miss?”

b) Strategies to facilitate memory – rehearsal and chunking.

c) Awareness of task difficulty based on previous situations and the strategy to the outcome and established goals prediction.

d) Learning the strategy through practice and generalization to real-life situation-implementation.

iii) Cognitive behaviour modification approaches

Cognitive behaviour modification is an executive control strategy that is allied closely to metacognition.

Behavioural Perspective

The behavioural perspective was set into motion by Watson (1913). The control concept of this perspective is that childhood disorders are learned in the same way that other behaviours are learned. Hence the behavioural perspective advocates the study of behaviour and emphasizes objective empirical verification. It also stresses the role of environmental factors influencing behaviour. This amounts essentially to a focus of learning. The key form of learning is conditioning, either classical (Pavlonian or respondent) which formed the basis of Watson’s methodological behaviours, or operant (instrumental) which is at the centre of B.F. Skinners radical behaviourism. Therapies based on classical conditioning concentrate on stimuli that elicit new responses, which are contrary to the old, maladaptive ones. Implosion therapy, flooding and systematic desensitization are the therapeutic approaches based on classical conditioning.

Behaviorists interested in operant conditioning suggest therapies based on extinction, punishment and positive reinforcement. Behaviour approach is based on the behavioural unit, which has three key events called A, B and C. The ABC model is illustrated below

22 A B C

Antecedent Event Target Behaviour Consequent Event

Stimulus Response Reinforcement

A is the antecedent event (or Stimulus), B is the target behaviour (or response),

C is the consequent event (or reinforcement). There are critics of reinforcement theory.

Kohn (1995) describes rewards as bribes that do not lead to long-term changes in

behaviour.

A feature of Individuals with Disabilities Education Improvement Act (IDEA –

2004) is the requirement that the Individualized Education Program (IEP) for a student

with a disability who also has problem behaviours, must include a Functional

Behavioural Assessment and Positive Behavioural Supports. Functional behavioural

assessment is the evaluation of the child’s behaviour, and positive behavioural support

is the intervention to change the behaviour. Because students with learning disabilities

sometimes display behaviour problems in the school setting, this ruling may apply to

some students with learning disabilities (Lewis & Sugai, 1999; Polloway, Patten &

Serna, 2001; U.S. Department of Education, 2000; Yell, Rozalski & Drasgrow, 2001).

Functional Behavioural Assessment

When student displays a challenging behaviour, it is serving purpose or function

for the student. Through the Functional Behavioural Assessment, the child’s antecedent

behaviour is described and analyzed to discover what needs this challenging behaviour

in fulfilling for the student.

Positive Behavioural Support

Once the teacher understands the reason for the students antecedent behaviour,

the teacher looks for a substitute activity for reading aloud – a positive behavioural

support. Clinical teaching illustrates the principles of explicit instruction. Direct

instruction is similar to explicit teaching. It is also based on a behavioural orientation,

focussing on the academic skills that the students need to learn and structuring the

environment to ensure that the student learns these skills (Algozzine, 1991).

Direct instruction helps to teach academic skills directly, is teacher directed and

controlled, uses carefully sequenced and structured materials, facilitates students

mastery of basic skills, sets goals that are clear to students, allocates sufficient time for

23 instruction, uses continuous monitoring of student performance, provides immediate

feedback to students, and teaches a skill until mastery of that skill is achieved

(Rosenshine (1986); Rosenshine & Stevens, 1986).

Implications of Behavioural Approaches for Learning Difficulties

Behavioural theories have important implications for teaching a student with

learning difficulties.

i) Explicit teaching and direct instruction are effective: It is important for the

students with learning difficulties to receive direct instruction in academic tasks.

Teachers should understand how to analyze the components of a curriculum and

how to structure sequential behaviours.

ii) Explicit teaching and direct instruction can be combined with many other

approaches to teaching: When the teacher is sensitive to a student’s unique

style of learning and particular learning difficulties, direct instruction can be

even more effective. For the student who lacks phonological awareness, for

example, the sensitive teacher can anticipate difficulties in learning phonics

during a direct instruction lesson. To learn the skill, this student will need more

time, practice, review, and alternative presentation of the concepts. The

sensitive teacher will use knowledge of the curriculum and of the individual

student in planning instruction.

iii) Functional behavioural assessment and positive behavioural support can help

a student with behavioural problems: These methods provide a valuable means

to understand undesirable behaviour and to overcome specific learning

difficulties in ADHD children.

The above discussion clearly indicates the importance of cognitive,

metacognitive and behavioural modification approaches in overcoming problem

behaviours and learning disabilities in students. The studies already available in

western context show the importance of these approaches in learning. In Indian

scenario, studies are limited in this direction and attempts are needed to develop and

use of such approaches to overcome learning difficulties in ADHD children. The

present study is an earnest attempt in this regard.

The review of literature related to the present study is given in the next chapter.