Agenda. A quick primer on ADHD Expository Language Skills in school-age children with ADHD

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1 Expository Language Skills in school-age children with ADHD Alison McInnes, Ph.D., S-LP(C) Department of Educational Psychology Faulty of Education University of Alberta SAC Annual Conference Edmonton, AB May 3, 2018 Quick primer on ADHD Agenda Research context Research questions and methods Findings Implications A quick primer on ADHD What is ADHD? - a common neurodevelopmental disorder characterised by behavioural symptoms of inattention and/or hyperactivity/impulsivity - DSM-V (2013) - reclassification age of onset symptoms prior to age 12 - approx. 5-7% of children (1-2 kids in every classroom) - 2.5% of adults - high heritability - prevalence similar across continents/cultures - associated with lifelong functional impairments in social, school, and occupational contexts A. McInnes, Ph.D., U of Alberta 1

2 A quick primer on ADHD - involvement of pre-frontal, dorsolateral networks involved with executive functions - dysregulation of neurotransmitters - frequent co-morbidity with learning disabilities, disruptive behaviour disorders (ODD, CD), mental health conditions (Anxiety, Depression) - highly heterogeneous A. McInnes, Ph.D., U of Alberta (Faraone, Asherson et al, Nature Reviews, (vol. 1) 2015) Cognitive Deficits in ADHD Executive functions Processing Speed Working Memory Verbal Visual Spatial ORAL LANGUAGE DEFICITS IN ADHD Basic language skills Higher level/advanced language skills Pragmatic language skills A. McInnes, Ph.D., U of Alberta Research Context Chronic academic underachievement is one of the most pervasive and impairing functional outcomes of ADHD in school age children (Barbaresi et al., 2007; Currie & Stabile, 2006) ADHD frequently co-occurs with various neurodevelopmental and mental health conditions (e.g., Reading/Writing/Math Disabilities, Depression, Anxiety) (Willcutt & Pennington, 2000; Mueller & Tomblin, 2012) Oral Language Impairments co-ccur with ADHD and ADHD+RD in % of cases, depending on age, sample, and assessments used (see Martinussen, 2015; Mueller & Tomblin, 2012; Helland et al., 2012). BUT research samples typically do not distinguish ADHD (noli) from ADHD+LI 2

3 Research Context Picture is unclear to date regarding profiles of language impairment in ADHD Some attempts to find phenotypic boundaries for ADHD and LI in young children 5-9 yr (Redmond et al., 2005, Redmond et al., 2014) No clear differences between ADHD+LI and LI No clear evidence that language impairments that co-occur with ADHD are similar to what we refer to as SLI, or more recently, Developmental Language Disorder Research/Practices re: ADHD, Language, and Academic Performance Co-occurrence of structural language not commonly addressed in research (i.e., ADHD (noli) from ADHD+LI) or school-based interventions / programming Language deficits have different manifestations and functional impact at different developmental levels Preschool, primary grades vs. later elementary Intervention focus may be on behaviour not language & literacy concerns Lack of consistent approaches and tools for identifying oral language deficits in ADHD CCC-3 (parent ratings) standardised tests -CELF-4, CELF-5 etc. A. McInnes,/ Ph.D., U of Alberta Working Memory and Language Baddeley s model of WM, (1986, 2000) INFORMATION STORAGE verbal storage Phonological loop verbal + visual storage of event sequences visual-spatial storage Visualspatial sketchpad INFORMATION PROCESSING Central executive 9 3

4 Advanced language development and expectations in the 21 st century classroom: comprehend, interpret, and express information and ideas clearly and purposefully. for acquisition and exchange of information and ideas (Alberta Education, Gr. 4 Social Studies) deliberative enquiry - initiating and planning, analysing interpreting, and communicating scientific ideas and results, working collaboratively (Alberta Education, Gr. 7-9 Science) Advanced Discourse Level Oral Language & Content Area Learning Increasing reliance on EXPOSITORY GENRE in higher grades language of explanation, logic, instruction, transmission of information, persuasion, assertion, language of textbooks defining, explaining, describing, summarising, comparing/contrasting giving opinions and reasons language of assessment answering questions explaining and presenting information in project work telling what you know and what you learned Expository vs. narrative Language Higher vocabulary density (+ new disciplinary vocabulary) More complex syntax (e.g., describing cause-effect and contingent relationships) Variable and unpredictable text structure Compare-contrast Cause-effect Enumerative Higher processing demands (Snyder & Caccamise, 2010) Sequence Opinion / persuasion Or: combination of text structures within the text Narratives familiar and predictable text structure, more familiar vocabulary, more personal relevance 4

5 Research Focus: ADHD & Expository Language past research in ADHD and discourse has focused on narratives limited research in how children with ADHD process and express expository language (Mathers, 2007; McInnes et al., 2003; ) competency with discourse level language is relevant to both academic performance and peer relations (Green et al., 2014) - information re-telling - self-generated explanations INFORMATIVENESS Research questions How proficient are children with ADHD (but without LI) in expository re-tells compared with typically developing peers? How informative are their explanations? re-tells (via external information) self-generated explanations (via background knowledge) Are aspects of language productivity and informativeness related to EFs such as working memory? Methodology - Samples ADHD group (9-12 yr) no LI Clinic and parent-referred samples *ADHD participants off medication for research assessment Criteria: previous Dx by Pediatrician or Clinical Psychologist DSM-IV symptoms confirmed with parent ratings (SWAN, SDQ, Conners Rating Scales (CRS-3 rd ed)) Rec/Exp Language Scores > 85 on CELF-4 Typically Achieving Peers (9-12 yr) Teacher nominated students achieving at grade level in L.A. and Math (gifted students excluded) public school board K-8 schools 5

6 Measures Core Language Tests (CELF-4) Non-verbal cognitive skills (Matrix Reasoning, WASI) Expository passage tasks comprehension / expression Working memory tasks Verbal Digit Span (Forward/backward) (CELF-4) - Sentence Span task Visual-spatial Finger Windows subtest (WRAML) - Self-Ordered Pointing Task Expository Language Tasks 1. Expository listening comprehension/retell task procedural explanations (McInnes, 2003) how cranberries are grown how hot air balloons how wasps build their nests 2. Elicited expository language task Favourite Game or Sport task (Nippold, 2007) Expository passage task - children listen to recorded expository passage - sequential text structure - 14 sentences - Dale-Chall vocabulary level Grade 5 - answer 5 factual and 10 inferential questions - total comprehension score - re-tell the information as if they were explaining it to a friend A. McInnes, Ph.D., U of Alberta Productivity measures Information content 6

7 1. Expository Passage Task (McInnes et al., 2003) Dynamic Assessment process (based on Campione & Brown, 1987) - listen - comprehension questions with graduated prompts - re-tell goal is to create optimal conditions for recounting and explaining main ideas and information details Language Sample Analysis Oral language samples transcribed, coded, and analysed using Systematic Analysis of Language Transcripts (SALT) (Miller, Andriacchi, & Nockerts, 2011) Language productivity indicators - length - # communication units (C-units), # words - vocabulary diversity - Number of Different Words (NDW) - syntactic complexity - Mean Length of Utterance (MLU) - Subordination Index (SI) - fluency % of utterances with mazes and pauses Study 1 Pilot Study ADHD-no LI (n=11) ; Typically Achieving Peers (n=11) Matched on age; non-verbal IQ >85 No difference in comprehension scores, length of samples, vocabulary diversity: # words, # C-units, NDW Group Differences: Working Memory (TA peers > ADHD-noLI) Digits Forward** Digits Backward** Finger Windows Backward** **p<.01 7

8 Study 1 - T.A. > ADHD(-LI) Group Differences: Language productivity (via SALT) MLU (words, morphemes)** Type Token Ratio** Subordination Index* Group Differences: Content Informativeness (counts) Information details* Group Differences Overall quality (rubric) Gist* Fluency* Content a Overall rating* *p<.05 **p<.01 Study 2 ADHD group (no LI): n = 31 (age: 9-12) selected from a larger sample (n=50) recruitment from local ADHD and LD associations and university psycho-educational assessment clinic waitlist Typically achieving group: n = 26 (age: 9-12) Expository passage task, Favourite Game or Sport task Working memory measures Digit span (Forward and Backward) Sentence Span Finger Windows (Forward and Backward) Self-Ordered Pointing Task (SOPT) Verbal WM Visual-Spatial WM Group comparisons No group differences: ADHD and TA group Age Non-verbal cognitive ability - Matrix Reasoning (WASI) Total Passage Comprehension scores ADHD group Expressive Language scores Mean SD Formulated Sentences 11.7 (2.1) Explaining Word Associations 10.3 (1.9) (CELF-4) 8

9 Group comparisons - Productivity ADHD (n=31) TA (n=26) C-units 13.0 (4.8) 11.1 (2.9) Word count (56.6) (45.2) #Diff Words 61.1 (19.3) 66.5 (17.7) MeanLengthUtt (MLU) 10.3 (2.2)** 13.0 (2.1) Subord Index (SI) 1.1 (.4)** 1.5 (.5) %Mazes 44.9 (16.6) 40.6 (17.7) %Pauses 46.2 (15.3)*** 12.4 (12.1) Poor expressive control over complex syntax needed to get the information across to the listener Group Comparisons - Content Proportion scores main ideas and information details mentioned in re-tells ADHD (n=31) TA (n=26) Main ideas.41 (.19)**.56(.17) Information units.27 (.10)***.40 (.12) Group comparisons - Working memory ADHD (n=31) TA (n=26) Digits Forward 7.3 (2.2)** 10.3 (3.2) Digits Backward 7.8 (1.9)** 10.7 (2.4) Sentence Span (#correct) 15.3 (2.7)** 19.1 (3.0) Finger Windows Forward 9.4 (2.8)** 11.9 (2.5) Finger Windows Backward 9.2 (4.2)** 15.2 (3.0) Self-Ordered Pointing Task 30.3 (2.4)** 32.9 (1.9) 9

10 Errors / production difficulties in ADHD samples Incomplete words and phrases Abandoned utterances Odd / awkward wording grammatical errors Unintended wording - revisions Poor anaphoric referencing Events / steps out of order Erroneous details Extraneous information (not from passage) Over-referencing from background knowledge rather than from the passage Difficulty being informative challenging for both groups to reformulate the information TA group still managed to get more information across and use more complex sentences, clear orderly sequence, and adequate referencing children with ADHD (no LI) struggled to coordinate linguistic (grammar, syntax) and informational aspects of the task (main ideas, details) to provide a complete account 2. Self-generated explanation: Favourite game or sport task (Nippold, 2007) Expository Scoring Scheme Rubric (Heilman & Malone, 2014) Content categories ratings: 0 5 Object of Game Preparations Start Course of Play Rules Duration Strategy Terminology Cohesion 10

11 ADHD group ratings Miminal / Immature - Emerging - Proficient No samples rated above 3 (emergent level) ADHD (no LI) n=20 ADHD+LI n=7 - All participants needed prompting to add details - Many categories omitted / incomplete / vague - Poor organization of information for the listener - Poor referencing - Vague descriptions, poor specificity, need for clarification - Tangential off-task - Poor coherence points don t hang together sequentially, much jumping between topics / abrupt transitions Implications for understanding oral communication breakdowns in ADHD In higher challenge expository discourse, more likely to see - poverty of content (incomplete, inadequate information) - awkward and poorly formulated explanations - reliance on simple basic sentences (trade-off?) Expository discourse demands greater executive control for coordinating linguistic and informational aspects of the message - working memory issues more likely to affect this level of functioning Could this extend to and underlie written formulation difficulties in ADHD? Implications SLPs Standardised language tests do not address higher level language issues that are relevant to language functions needed in the classroom in mid elementary grades and beyond Oral language issues in ADHD are under-addressed clinically and educationally All children with ADHD should have their language skills assessed, especially those who are struggling academically even if they receive a language assessment, does not tell the whole story Ideal context is in situ working with complex tasks in the classroom Limited proficiency with expression of higher level academic language may account in part for chronic underachievement 11

12 Implications teachers and classroom assessment - Getting the message across Improving verbal expository discourse is not a typical target for instructional support or intervention, yet it supports so many academic skills Poorly formulated immediate responses may be poor and inaccurate reflection of child s knowledge need to probe higher level communication difficulties should be on the radar for children with ADHD as a potential source of poor academic performance Potentially Useful Models/ Resources to Support Intervention Self-Regulated Strategy Development (SRSD) writing Graham & Harris (2007) Think-alouds EMPOWER Writing Academic Discussions CH Assessment and Intervention for Advanced Language: Language Disorders: From Infancy through Adolescence (4 th ed) (2012). Rhea Paul & Courtenay Norbury Selected References Green, B., Johnson, K., & Bretherton, L. (2014). Pragmatic language difficulties in children with hyperactivity and attention problems: an integrated review. International J of Language and Communication Disorders, 49(1), Heilman, J., & Malone, T. (2014). The rules of the game: Properties of a database of expository language samples. Language Speech Hearing Services in Schools, 45, Koonce, N.M. (2015). When it comes to explaining. A preliminary investigation of the expository language skills of African American school-age children. Topics in Language Disorders, 35(1), Martinussen, R. (2015) The overlap of of ADHD, reading disorders, and language impairment. Perspectives on Language and Literacy, 41(1),

13 Selected References Mathers, M. (2006). Aspects of language in children with ADHD: Applying functional analysis to explore language use. J of Attention Disorders, 9(3), Miller, J., Andriacchi, K., & Nockerts, A. (2011). Assessing Language Production Using SALT Software: A Clinician s Guide to Language Sample Analysis. Middleton, WI: SALT Software, LLC Nippold, M., & Scott, C. (2010). Overview of expository discourse: Development and disorders. In Marilyn A. Nippold and Cheryl M. Scott (Eds.), Expository Discourse in Children, Adolescents, and Adults. New York, NY: Psychology Press. Selected References Sciberras, E., Mueller, K., Efron, D., Bisset, M., & Anderson, V. (2014). Language problems in children with ADHD: A community-based study. Pediatrics, 133(5), Westerveld, M., & Moran, C. (2013). Spoken expository discourse of children and adolescents: Retelling versus generation. Clinical Linguistics and Phonetics, 27(9),