Running Head: Reading and writing deficits associated with adhd, rd & adhd+RD

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ADHD, RD & ADHD+RD, Reading and Writing skills

Running Head: Reading and writing deficits associated with ADHD, RD & ADHD+RD

Qualitatively distinct and common patterns of reading and writing deficits associated with reading disability (RD), attention deficit disorder (ADHD( and the comorbidity of both: Evidence from Hebrew Speakers.

Michal Shany

School of Education, Haifa University

Ilana Ben-Dror

School of Education, Hebrew University


Hebrew speakers adolescents with reading disability only (RD), attention deficit disorder only (ADHD), RD+ADHD and normally developed were compared on tasks assessing reading speed, spelling accuracy and associated underlying phonological processing: phonological awareness, rapid automatized naming and non-word reading. In addition, their expository writing samples were analyzed. Findings reveal similarities between RD and RD+ADHD groups on tasks assessing reading speed, spelling accuracy and phonological processing. ADHD (only) group did not differ in these aspects from normally achieving control subjects. In comparison, analysis of written samples reveals similar low performance level for ADHD and RD groups, and much more profound performance in the case of RD+ADHD. These data were taken as providing further support for the notion that RD and ADHD are the products of different etiologies, and highlight the separate paths of each disorder from different cognitive deficit to common failure in written expression, the most used vehicles to assess academic achievements in school settings.

Qualitatively distinct and common patterns of reading and writing deficits associated with reading disability (RD), attention deficit disorder (ADHD( and the comorbidity of both: Evidence from Hebrew Speakers.


Specific learning disorder (LD), such as developmental reading and writing disabilities and attention deficit hyperactivity disorder (ADHD) are separate but often overlapping syndromes. The overlap between LD and ADHD has been consistently reported in the literature. The reported degree of overlap ranges from 10% to 92%, with 20% being the most commonly accepted rate (Dykman & Ackerman, 1991). Furthermore, studies have suggested that children suffering from either condition tend to perform worse in school compared to normally developed children (Biederman, Newcorn & Sprich, 1991; DuPaul & Stoner, 1994; Dupaul & Eckert, 1998; Marshall, Hynd & Hall, 1997). In addition, follow-up studies have found that academic and learning problems of children with RD or with ADHD persist into adolescence and are associated with chronic under-achievement and school failure (Gittelman, Mannuzza & Shenker, 1985; Reid & Maag, 1998; Weiss, Hechtman & Milroy, 1985).

It has been argued that the significant rate of co-occurrence of these disorders and the large variability reported in the literature is due most likely to differences in the selection criteria, sampling, measurements and criteria used to diagnose RD and ADHD (Biederman, Newcorn & Sprich, 1991; Dykman & Ackerman, 1991).

The overlap between the disorders on one hand and the data that indicate distinct patterns of behavioral manifestation of these disorders on the other hand pose theoretical and educational challenges that have led researchers to focus on the question of whether there is a qualitatively distinct pattern of cognitive deficits associated with each disorder (Javorsky, 1996).

Initial attempts to clarify the nature of the association between the disorders led to pair clinical groups (ADHD, RD) and to compare their performance on cognitive processes that are differentially associated with each disorder: Phonological processing, assessed by phonological awareness, naming tasks, and non-word reading, are typically associated with poor reading abilities (Bentin, 1992; Stanovich & Siegel, 1994; Vellutino & Scanlon, 1982; Torgesen Wagner & Rashotte, 1997), while symptoms of inattention, hyperactivity and impulsivity are conceptualized as clinical markers of ADHD and reflect deficits in executive functions (EF) (Barkley, 1997; Conte, 1998; Pennington, Groisser & Welsh, 1993). Thus, comparisons between clinical groups were typically conducted on the basis of subjects performance on tasks assessing phonological and EF processing (Ackerman & Dykman, 1993). Findings that are based on this type of analysis indicate that subjects with ADHD only out-performed subjects with RD only on tasks assessing reading, spelling and phonological processing. Their performance on those tasks resembles the performance of normally developed readers. On the other hand, children with RD only out-performed children with ADHD only on tasks assessing EF functions. Deficits of children with ADHD only were consistent with deficits in higher-order executive functions, which differentiated them from skilled readers; children with RD only did not exhibit difficulties with higher-order executive functions, and their cognitive profiles more closely resembled those of normally developed participants (Ackerman & Dykman, 1993; Hyand, Morgan, Edmonds & Black, 1995; Javorsky 1996, Nigg, Hinshaw, Carte & Treuting 1998). Thus, research evidence rather clearly indicates that ADHD does not cause developmental dyslexia. The data further demonstrate that severity of ADHD symptomatology is not correlated to severity of reading retardation (Shaywitz, et al, 1995 ;Wood, Felton, Flowers & Naylor, 1991).

The relationship between both disorders was further explored by recent studies that focused on groups that exhibited comorbid pattern of difficulties, namely: reading disability and ADHD (e.g. Felton & Wood, 1989; Pennington, Groisser, & Welsh, 1993; Robins, 1992; Semrud, Biederman, Sprich, Lehman, Faraone & Norman, 1992). Findings of clinical samples support the previous notion that ADHD and RD are separate disorders and indicate that they can be differentiated with a double dissociation, indicating that EF measures characterize ADHD and phonological processing measures pinpoint RD (Nigg et al ,1998, Pennington et al, 1993) with or without ADHD.

Recently, several studies have extended the focus of research to include other language functions, such as semantic, syntactic, oral and written organizational language skills (Elbert, 1993; Purvis & Tannock, 1997, Tannock & Schachar, 1996). It has been reported that children with both ADHD and LLD (language learning disabilities) have significantly more trouble formulating grammatically correct sentences than their peers do. Syntactical deficits are seen in the area of planning and organization in both oral and written language (Cohen, Davine & Meloche, 1989). Similar results are reported by Javorsky (1996) who found that subjects with ADHD + LLD performed significantly more poorly than did those with ADHD and normal groups on measures of phonology and syntax. Further difficulties in organizing language products were reported recently by Purvis & Tannock (1997). They reported that children with ADHD and ADHD+RD exhibited difficulties in organizing and monitoring their story retelling. In addition, children with ADHD, regardless of RD-status exhibited difficulties in organizing and monitoring their verbal productions. The researchers argued that the comorbid group had deficits of both ADHD and RD suggesting that the deficiencies of children with ADHD are consistent with higher-order executive function deficits, while the deficiencies of children with RD are consistent with deficits in the basic processing of language. In sum, research findings suggest that although those two clinical conditions reflect different etiologies, when learning deficits that are intrinsic to RD (phonological processing) and ADHD (executive functions) interact; additional information processing deficits tend to appear. Thus, the additive influence of these conditions may explain the large reported overlap between the disorders (Javorsky, 1996; Webster, Hall, Brown, & Bolen, 1996).

Expect few recent studies that analyzed ecological language products such as story retelling, most studies focused specifically on underlying processing that are associated with each disorder in order to specify and differentially diagnose each cognitive profile. Most of those studies were conducted in English, thus providing symptoms that are evident in this orthography.

In light of the above, the purpose of the present study was to examine specific manifestation of each disorder as a function of the unique characteristic of the Hebrew orthography. In addition we intended to further explore the impact of underlying phonological processing deficits (core deficit in reading disabilities) and EF deficits (core deficit in ADHD) on ecological manifestation of reading and writing characteristics of subjects presenting RD profile, ADHD profile or both conditions.

Our first aim was to look at basic reading and writing characteristics, operationally defined in this study as reading speed and spelling accuracy, as well as at associated underlying phonological processing: phonological awareness, rapid automatized naming and non-word reading. Next, we intended to explore the impact of each disorder on higher-level expository writing skill, a skill that requires planning and monitoring abilities.

We focused on adolescents as subjects for the present study from two reasons: previous studies based on skilled Hebrew readers suggested that in this age group basic reading skills as well as spelling efficiency are developed to the level of mastery (Ravid, 1996; Shany, Zeiger & Ben-Dror, 2000; Share & Levin 2000), in addition higher language skills such as expository written language strategies are directly taught and practiced. Thus specific reading and writing difficulties that are associated with each clinical group at this age can reflect upon intrinsic continues cognitive deficits, rather than developmental lag, or incidental influence of a teaching method.

With regard to the first issue, basic reading and writing characteristics: We questioned whether the three clinical Hebrew reader groups: RD, ADHD and ADHD+RD, will present reading speed and level of spelling accuracy similar to each other but from different reasons, or their reading performance would be differentiated in terms of reading speed and spelling accuracy.

We raised these questions due to the specific characteristics of the Hebrew orthography (for further details the reader is referred to Ben-Dror, Frost & Bentin, 1995; Frost, Katz, & Bentin, 1987; Share & Levin, 2000; Shimron 1993, 1999). There are two modes of writing Hebrew: pointed and unpointed. The pointed writing system provides all the phonological information that is required to decode written words (Frost, Katz & Bentin, 1987), while in reading the unpointed print, word identification often has to be supported by context (Shimron, 1993). Children reading pointed texts encounter near-perfect one-to-one grapheme- to-phoneme correspondence (Shimron, 1993). However, phoneme to grapheme relationships in both pointed and unpointed scripts frequently vary, with a number of pairs of consonants letters (once phonemically distinct) now representing the same phoneme. The vast majority of Hebrew words therefore contain phonemes that could be spelled with alternate letters. Taking into account that the Hebrew writer, when spelling, uses only letters (representative of either consonants or vowels) and omits the diacritic marks, the spelling errors most characteristic of Hebrew writers are instances of alternate letters.

Since we used only pointed texts that present full phonological information, it is possible that although the texts we used represents surface orthography which requires direct translation from grapheme to phoneme, subjects with RD who experience phonological deficit will not be able to use this information efficiently, thus present slow reading rate. It is possible that subjects with ADHD will also present slow reading rate due to the interaction between the heavily visual load caused by the vowel marks that characterized the Hebrew orthography and the cognitive characteristics of ADHD subjects such as low ability to monitor and maintain stable reading rates (manifestation of EF deficits). In addition spelling inaccuracies might reflect underlying phonological and orthographic processing deficit in the case of subjects with RD, or else misspelling might reflect inadequate work habits, inattentive work that might result in similar pattern.

The specific manifestation of phonological deficit should also be infected by orthographic characteristics. While it is reasonable to expect to find similar results in Hebrew to results reported in English on tasks assessing phonological awareness and naming of alphanumeric symbols of RD and ADHD subject (namely: difficulties on these tasks were expected to represent the performance of RD subjects but not that of ADHD subjects (Denckla & Rudel, 1974; Manis, Siedenberg & Doi, 1999; Naerha & Ahonen, 1995; Semrud, Guy, Griffin & Hynd, 2000), a different pattern may be observe in a non-word reading task, a task that is reflecting a phonological decoding and is highly dependent on the unique features of each orthography. We questioned whether the interaction between the specific characteristics of Hebrew orthography, which requires attention to small, detailed, graphic visual features (vowels), and the cognitive characteristics of ADHD (impulsivity, inattention) will result in a reading performance pattern of non-words that is different from the pattern reported for English. Namely, studies that are based on English orthography consistently report difficulties in non-word reading as a clinical marker of RD but not of ADHD. In contrast to this pattern we were interested to explore whether ADHD Hebrew readers might display levels of inaccuracy in reading of non-words similar to those of RD readers but for different reasons. In the case of ADHD, errors in non-word reading might occur as a result of failure to pay close attention to details and a tendency to make careless mistakes (traditional clinical diagnostic criteria for ADHD) rather than to weak phonological processing, as is the case with RD. In line with previous research, we questioned whether children displaying both conditions would achieve the lowest level of non-word reading performance as a result of the additive influence of both conditions.

Thus, analysis of reading speed and spelling accuracy of the three clinical groups as evident in Hebrew will add information regarding the interaction between the manifestation of each disorder and the characteristics of the orthography. These data will further enrich our understanding of core deficits that hold cross languages and specific manifestation due to specific characteristic of different orthographies.

Our next purpose was to explore the impact of each disorder on expository writing abilities. The literature suggests that skilled writers employ a variety of strategies to help them achieve writing goals and to overcome difficulties they encounter while writing. These strategies are employed for planning, generating information, evaluating, revising, and so forth. (Graham, Schwartz & MacArthur, 1993; Graham &, Harris, 1994; Graham, Harris, & Schwartz, 1998; Scardamalia & Bereiter, 1986). In contrast to skilled writers, it has been argued, that children with learning disabilities employ an approach to composition that minimizes planning, revising and other self-regulating strategies. In addition, in contrast to skilled writers, many students with LD struggle with the basic mechanics of writing, producing papers full of spelling, punctuation and handwriting miscues. These traits have been suggested as characteristic of children with learning disabilities in general, irrespective of any of learning disability sub-type, or the etiology that might explain the difficulties associated with each sub-type. In this study, we tried to look more carefully at the impact of the underlying cognitive mechanism in each disorder on the expository writing products.

The findings of this study, will highlight the impact of the underlying cognitive deficit that is associated with each disorder on various components of reading and writing abilities and will help illuminate the overall pattern of similarities and differences between the three clinical groups.

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