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Language deficits in ADHD preschoolersParaskevi Agapitou a; Georgia Andreou a

a Department of Special Education, University of Thessaly, Larissa, Greece

Online Publication Date: 01 May 2008

To cite this Article Agapitou, Paraskevi and Andreou, Georgia(2008)'Language deficits in ADHD preschoolers',Australian Journal ofLearning Difficulties,13:1,39 — 49

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Language deficits in ADHD preschoolers

Paraskevi Agapitou and Georgia Andreou*

Department of Special Education, University of Thessaly, Larissa, Greece

The present study examined the impact of preschool ADHD on linguistic andmetalinguistic awareness and mental ability. Eight subscales of the Athina Test wereadministered to ADHD preschoolers and a control group. Results showed that ADHDpreschoolers performed significantly lower than the control group in all tasks. Thegreatest difficulty for ADHD preschoolers was evident in the ‘‘phoneme synthesis’’subscale, particularly with metalinguistic awareness. These results support previouslyreported findings that ADHD preschoolers have serious language deficits, which placethem at risk for developing poor reading skills in primary school.

Keywords: language skills; preschool ADHD

Introduction

The ‘‘inattention-hyperactivity-impulsivity’’ triptych constitutes the base for thediagnosis of ADHD provided that, according to the American Psychiatric Association(1987, 1994, 2000), some of its basic symptoms are present prior to the age of seven years.Important characteristics of ADHD, which are present at preschool age, are linked tobehavioral and academic problems for a significant percentage of children and adolescents(Pierce, Ewing, & Campbell, 1999), while 50% of ADHD children present symptoms fromas young as three years of age (Barkley, 1989). Among preschool children, ADHD hasbeen identified in 2% of children between the ages of two and five years (Lavigne et al.,1996) with the male-to-female ratio being similar to the school-age population, althoughsomewhat reduced in magnitude, and boys being twice as likely to meet the criteria forADHD.

Despite the early onset of the disorder, however, it has been observed that the peakreferral rate is at age seven years (Byrne, Bawden, Dewolfe, & Beattie, 1998), probablybecause this is the time when children enter primary school and consequently faceincreased demands of longer periods of inactivity, the need to develop independent workhabits, and a high degree of attention (Barkley, 1990). Not surprisingly, then, the majorityof research on ADHD has been conducted with school-age children. The paucityof research in the preschool years is due to the fact that frequent irritation on the part ofpreschoolers hardly determines whether they show abnormal developmental levels ofactivity, impulsivity, and attention (Barkley et al., 1991; Campbell, 1995). Campbell andher colleagues (1985, 1990) noted that, unlike school-age children, preschoolers inherently

*Corresponding author. Email: [email protected]

Australian Journal of Learning Difficulties

Vol. 13, No. 1, May 2008, 39–49

ISSN 1940-4158 print/ISSN 1940-4166 online

� 2008 Learning Difficulties Australia

DOI: 10.1080/19404150802093711

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exhibit high levels of impulsivity, activity, and inattention, and therefore a deviation fromthis normal base rate needs to be large to be seen as clinically significant.

Many researchers have shown that children with preschool ADHD are at increasedrisk for academic and social difficulties, including learning disabilities, peer rejection, anddecreased teacher expectations (Ladd, Birch, & Buhs, 1999; Vaughn, Hogan, Lancelotta,Shapiro, & Walker, 1992). This is likely due to the fact that during the preschool years,children acquire the social, behavioral, and academic skills that allow them to navigatesuccessfully both through primary school and their later academic and social life.Preschool children learn how to focus their attention on teacher-directed activities,interact appropriately with peers and authority figures, and follow spoken and unspokenrules in the classroom. In addition, they acquire the basic building blocks of later academicsuccess as they learn emergent literacy, mathematics, and language skills. For somechildren, difficulties with impulse control, attentional capacity, and hyperactivity hinderthe ability to benefit from the valuable lessons of preschool and later academic experiences(Spira & Fischel, 2005).

It has been suggested that inattention and hyperactivity during preschool years affectlater learning through their negative impact on emergent literacy. Emergent literacyinvolves the skills, knowledge, and attitudes that are presumed to be developmentalprecursors to conventional forms of reading and writing (Whitehurst & Lonigan, 1998).Within the set of emergent literacy skills, several skills have been identified as strongpredictors of children’s reading performance in primary school. In particular, linguisticawareness, oral language skills, metalinguistic awareness, and print concepts areconsistently emphasized as important determinants of children’s later reading ability(Scarborough, 1998). A meta-analysis of 58 studies conducted by Horn and Packard(1985) concluded that the best predictors of reading achievement were attention/distractibility, internalising behaviour problems, language variables, and generalcognitive functioning. Hindshaw (1992) reviewed a number of studies to identifyantecedent variables that might explain the association between ADHD and learningproblems. Hindshaw highlighted multiple variables of interest, including mild tomoderate language deficits, poor verbal skills, familial distress or discord, andneurodevelopmental delay. Of the variables reviewed by Hindshaw, language deficitsreceived the most attention as a common cause of both learning disabilities and ADHD(Cantwell & Baker, 1991; McGee, Partridge, Williams, & Silva, 1991; Pisecco, Baker,Silva, & Brooke, 2001).

Researchers have consistently claimed that preschool ADHD is pervasively linked tolearning difficulties and that ADHD preschoolers work less, behave more poorly, andpresent problems in most learning situations (Cunningham & Boyle, 2002). ADHDpreschoolers are also characterized by information processing deficits (Kalff et al., 2005)and suffer from language deficits, either receptive or expressive, compared to their normalpeers (Campbell, 1995; Caufield, Fischel, Debaryshe, & Whitehurst, 1989; Gilliam &Demesquita, 2000; Kaiser, Hancock, Cai, Foster, & Hester, 2000).

Moreover, two recent studies found that children who manifest poorer cognitivefunctioning and poorer linguistic and metalinguistic skills in preschool are at greater riskfor continuing behavioural and academic problems. Barkley et al. (2002) examined theutility of adaptive disability (AD), defined as a significant discrepancy between adaptivefunctioning and intelligence, as an indicator of continued risk for children with earlyADHD. They found that in contrast to children with disruptive behavior alone, childrenwith disruptive behavior and AD in preschool had more symptoms of ADHD and conductdisorder, more severe and pervasive behavior problems at home, more parent-rated

40 P. Agapitou and G. Andreou


externalizing and internalizing problems, and more behavioral and academic problemsat school in second grade. Rabiner, Coie, and The Conduct Problems PreventionResearch Group (2000) conducted a longitudinal study to examine the impact of earlyinattention and hyperactivity on later reading achievement. Simple correlations indicatedthat both inattention and hyperactivity were significantly correlated with readingachievement, with the correlations between inattention and reading achievement beingstrongest and most consistent. Furthermore, in order to further explore the relationshipsbetween these variables, Rabiner et al. (2000) constructed a path model, specificallyexamining the inter-relationships between inattention and reading across the years. Oneof their most interesting findings was that preschool inattention was associated withpoorer pre-reading achievement, which then had a strong effect on first grade reading.They also found that inattention in first grade was predictive of poorer readingachievement, even when pre-reading achievement, IQ, and parental involvement werecontrolled. Moreover, children whose reading scores were normal at kindergarten exitwere at risk for poor reading outcomes if they were classified as inattentive in first grade,and 34% of the inattentive children in their sample showed poor reading outcomes in fifthgrade. Based on their findings, Rabiner et al. (2000) argued for the utility of measuringattention early on.

Given the link between preschool language development, emergent literacy skills,and later reading success, and given the paucity of research on ADHD preschoolchildren, the purpose of this study was to assess the overlap between ADHD andemergent literacy skills in preschool children. More specifically, this study will examinethe impact of preschool ADHD on linguistic and metalinguistic awareness and generalmental ability.

Methods

Participants

Our sample consisted of 40 preschool children: 20 ADHD children (18 boys and 2 girls),and a control group of 20 children who were matched for sex and age. The average age ofthe sample was 5 years 6 months and participants were drawn from state nursery schoolsof Thessaly. The native language of the sample was Greek. None of the children in thesample were on medication at the time of the study. All of the ADHD children met theDiagnostic and Statistical Manual of Mental Disorders-Fourth edition (DSM-IV: APA,1994) criteria for an ADHD diagnosis, based on parents’ and teachers’ responses tocorresponding questionnaires.

Materials

For the evaluation of the childrens’ linguistic and metalinguistic awareness andmental ability, we used eight subscales taken from the Athina Test for the Diagnosis ofLearning Disabilities, which is standardised for the Greek population by the Faculty ofPsychology, School of Philosophy, University of Athens (Paraskevopoulos, Kalantzi-Azizi, & Giannitsas, 1999). Each child was tested individually according to the instructionsof the Athina Test manual, particularly with regard to the administration and scoring ofeach subscale.

The subscales administered were: (1) language analogies; (2) pattern copying; (3)vocabulary; (4) sentence completion; (5) word completion; (6) grapheme discrimination;(7) phoneme discrimination; and (8) phoneme synthesis. According to the manual, the first

Australian Journal of Learning Difficulties 41


three subscales constitute the factor ‘‘mental ability’’, the next two the factor ‘‘symbolcompletion’’, and the last three the factor ‘‘phonological awareness’’.

Language analogies

Language analogies consist of 32 pairs of sentences, where each pair of sentences containsfour meanings that were connected with each other (e.g. shape) and form an analogyexpressed in words. For each pair of sentences, the first sentence is complete while thesecond is incomplete (e.g. the table is square, the sun is . . . ). It is a test of verbal conceptformation in which the child must understand what each pair of sentences has in common.This test reflects the child’s abstract verbal classification abilities.

Pattern copying

Pattern copying consists of six geometrical patterns that vary in difficulty. The child’scorrect pattern copying requires increasing visuo-conceptual maturity with every pattern.

Vocabulary

Vocabulary consists of 20 words, mostly verbs and nouns, both concrete and abstract, forwhich the child needs to give a definition. They vary in difficulty from the simplest words(e.g. apple) to more difficult words (e.g. neglect). This test assesses word knowledge,language development and long-term memory. The above-mentioned three subscales areadministered in the order verbal scale-practical scale-verbal scale, and they assess both thechild’s language and visuo-cognitive development. Thus, these subscales enable theexaminer to evaluate the child’s mental ability.

Sentence completion

Sentence completion consists of 32 sentences from which a word or phrase is missing (e.g.Smoking seriously harms . . . ; A house with two storeys is called . . . ). This subscale testsverbal skills and assesses general range and fund of knowledge obtained through thechild’s environment.

Word completion

Word completion consists of 32 words from which a phoneme is missing, either at thebeginning or in the middle of the word (e.g. trapezi ¼ [table], podilato ¼ [bicycle]). Thissubscale tests the child’s linguistic awareness, which refers to the organization of thephonological structure of language. Together with the previous subscale constitute, the so-called Symbol completion factor, they enable the examiner to evaluate the child’s languageskills on the basis of either sentence or word symbol completion.

Grapheme discrimination

Grapheme discrimination consists of 21 pairs of pseudo words. In some pairs the twowords are exactly the same, while in other pairs they differ in one or two letters (e.g. tali-tali, son-con, tarpo-tapro). This subscale tests the child’s linguistic awareness throughvisual perception of graphemes.



Phoneme discrimination

Phoneme discrimination consists of 32 pairs of pseudo words. In some pairs the two wordsare exactly the same while in others one phoneme is different or is missing (e.g. gazamos-gazamos, tifali-tifari, kreda-keda). This subscale is also an evaluation of the child’slinguistic awareness, which is considered to form the basis for the structure of oralreceptive and expressive language.

Phoneme synthesis

Phoneme synthesis consists of 32 words that have been chosen so as to contain thephonemes of the Greek language in various combinations. The examiner pronounces thephonemes one by one in a natural tone of voice, at a speed of two phonemes per second,and the child is required to find the word. This subscale tests the child’s metalinguisticawareness, which refers to the child’s capacity to analyze the elements of the phonologicalstructure of language. Overall, the ‘‘grapheme discrimination’’, ‘‘phoneme discrimina-tion’’, and ‘‘phoneme synthesis’’ subscales give the examiner the opportunity to evaluatethe child’s general phonological awareness, which consists of linguistic and metalinguisticawareness. These two types of phonological awareness are implicated in a reciprocalrelationship with the acquisition of reading skill.

According to the manual of the Athina Test, the scores obtained for each scale aretransformed into a ‘‘developmental quotient’’. Following the children’s developmentalquotient, which is calculated according to the instructions of the manual, five diagnosticzones have been defined in the Athina Test: (1) two for the ‘‘lower-deficient’’ development(average-low and deficient); (2) one for the ‘‘average normal’’ development; and (3) twofor the ‘‘superior’’ development (average-superior and exceptional).

Statistical analysis

Paired sample t-tests were performed to compare the mean differences between ADHDpreschoolers and the control group in their developmental quotients for each subscale ofthe Athina Test. In addition, paired sample t-tests were performed in the group ofsubscales that constitute each of the three factors: mental ability, symbol completion, andphonological awareness, in order to compare the developmental quotients of ADHDpreschoolers with the control group for each of the factors. The analysis of data wasperformed using the SPSS statistical programme.

Results

The mean developmental quotients for each Athina Test subscale of ADHD preschoolers andcontrols are presented in Table 1. Independent sample t-tests were statistically significantfor language analogies (t ¼ 710.85, p ¼ .000); pattern copying (t ¼ 75.87, p ¼ .000);vocabulary (t ¼ 77.98, p ¼ .000); sentence completion (t ¼ 76.52, p ¼ .000); wordcompletion (t ¼ 76.17, p ¼ .000); grapheme discrimination (t ¼ 77.42, p ¼ .000); phonemediscrimination (t ¼ 77.51, p ¼ .000); and phoneme synthesis (t ¼ 715.28, p ¼ .000).

The mean developmental quotients for each of the three Athina Test factors of ADHDpreschoolers and controls are presented in Table 2. Independent sample t-tests werestatistically significant for mental ability (t ¼ 11.95, p ¼ .000), symbol completion(t ¼ 9.06 p ¼ .000), and phonological awareness (t ¼ 715.30, p ¼ .000).



Discussion

Our findings indicate that there is an overlap of ADHD with problems in emergent literacyskills and mental ability in preschool children. ADHD preschoolers in our sampleperformed significantly lower than preschoolers in the control group in all the subscales ofthe Athina Test. Each of the eight subscales will be discussed in turn.

ADHD preschoolers obtained lower scores than the control group in the languageanalogies subscale, suggesting that these children do not experience normal developmentin abstract verbal classification abilities and language skills. This finding confirms earlierresearch linking ADHD with poor verbal and language skills in preschoolers (Campbell,1995; Gilliam & Demesquita, 2000; Kaiser et al., 2000) as well as in older children(Andreou, Agapitou, & Karapetsas, 2005; Grodzinsky & Diamond, 1992; Reader, Harris,Schuerholz, & Dencla, 1994).

In the subscale pattern copying, ADHD preschoolers displayed poorer performancethan the control group, indicating difficulties in applying the skills required for this task.Their level of performance indicates poor visuo-motor-conceptual skills. Previous research(Fowler & Cross, 1986) has also found a specific link between ADHD and poorperformance in tasks testing this kind of skills.

Vocabulary is also a subscale in which ADHD preschoolers obtained lower scoresthan the control group, indicating difficulties with word knowledge, language develop-ment, and long-term memory. The developmental quotient of ADHD preschoolers placesthem in the lower-deficient zone, more specifically in the average-low subzone, accordingto the five-category diagnostic zone catalogue of the Athina Test. This finding suggeststhat ADHD preschoolers have lower development in the skills examined by all threesubscales.

Table 1. Mean developmental quotients for Athina Test subscales in preschoolers with the ADHDgroup and the control group.

ADHD group Control group

Subscales M SD M SD

Language analogies 7.55 1.53 11.60 1.87Pattern copying 7.45 1.95 11.10 1.91Vocabulary 7.95 1.76 12.10 2.04Sentence completion 8.00 1.80 11.70 1.80Word completion 7.90 2.26 11.80 2.01Grapheme discrimination 7.00 2.57 11.95 1.79Phoneme discrimination 7.20 2.14 11.15 1.75Phoneme synthesis 5.75 1.65 11.50 1.73

Table 2. Mean developmental quotients for Athina Test factors in children with ADHD and thecontrol group.

ADHD group Control group

Factors M SD M SD

Mental ability 7.65 1.74 11.26 1.88Symbol completion 7.95 2.02 11.75 1.89Phonological awareness 6.65 2.14 11.53 1.76



The ADHD preschoolers’ mean developmental quotient of the above threescales (language analogies, pattern copying and vocabulary), which taken togethermeasures the child’s mental ability, was also found to be lower than the control group.This finding indicates that ADHD preschoolers have difficulty with language, as well asvisuo-cognitive development, supporting earlier research (Barkley et al., 2002; Spira &Fischer, 2005).

ADHD preschoolers also performed more poorly than the control group in thesentence completion subscale, which indicates that their verbal skills and generalknowledge obtained through the environment are developing insufficiently. This findingcompliments previous research associating ADHD with poor verbal skills (Campbell,1995; Gilliam & Demesquita, 2000). Difficulties with impulse control, attentional capacity,and hyperactivity not only hinder ADHD preschoolers from making the most of theinformation available in their environment, but also hinder the benefit of valuable lessonslearned through preschool experiences (Spira & Fischer, 2005).

The word completion subscale assesses the child’s linguistic awareness, a skill thatbelongs to the so-called emergent literacy skills that are presumed to be developmentalprecursors to conventional forms of reading. In this study, ADHD preschoolers displayedlower performance than the control group. This finding indicates that ADHDpreschoolers have difficulty with linguistic awareness, placing them at risk for developingpoor reading skills in primary school. Previous studies have reported similar findings(Scarborough, 1998; Whitehurst & Lonigan, 1998).

ADHD preschoolers’ poor performance in word completion and sentencecompletion subscales places them in the lower-deficient diagnostic zone of the AthinaTest, and more specifically in the average-low subzone. Moreover, the mean score of thesetwo subscales, which constitute the factor symbol completion, is also lower among ADHDpreschoolers in comparison to the control group. This means that they seriously lackgeneral language skills, which can be either verbal or linguistic awareness skills, neededto recognize written symbols and organize the phonological structure of language(Lundberg, 1999).

In the subscales grapheme discrimination and phoneme discrimination, ADHDpreschoolers again displayed a poorer performance than the control group, with adevelopmental quotient in the lowest position in the average-low subzone of the lower-deficient diagnostic zone, suggesting that their linguistic awareness skills are extremelypoor and insufficiently developing. Poor linguistic awareness skills on the part of ADHDpreschoolers may hinder the phonemic representation of words in their short-termmemory, a procedure that contributes to the acquisition of proper reading skills (Content,Kolinsky, Morais, & Bertelson, 1986; Tomeus, 1984; Treiman & Zukowski, 1988;Treiman, Fowler, Gross, Berch, & Weatherston, 1995).

ADHD preschoolers also performed lower than controls in the subscalephoneme synthesis, and the scores obtained were lower than every other subscale, placingthem in the deficient subzone of the lower-deficient diagnostic zone. This findingindicates that ADHD preschoolers are significantly deficit in metalinguisticawareness, suggesting difficulties in their capacity to analyze elements of the phonologicalstructure of their oral language. This difficulty is significant, especially for the Greeklanguage, which is a language with phonemic and syllabic oral structure (Porpodas, 1999),and may hinder children diagnosed with ADHD in acquiring proper reading skills inprimary school.

The mean score of the above three subscales (grapheme discrimination, phonemediscrimination and phoneme synthesis), which taken together constitute the so-called



‘‘phonological awareness’’ factor, is also lower among ADHD preschoolers incomparison to the control group. This finding compliments previous studies(Barkley et al., 2002; Lonigan et al., 1999), indicating that linguistic and metalinguisticawareness skills are extremely poor or almost deficient among ADHD preschoolers.This deficiency is of particular concern, since phonological awareness is consistentlyemphasized as an important determinant of children’s later reading ability(Scarborough, 1998).

Overall, the findings of this study suggest that preschool ADHD has a negativeimpact on all aspects of language development including verbal skills, word knowledge,linguistic, and metalinguistic awareness. Moreover, it negatively influences long-and short-term memory, general range and fund of knowledge as well as visuo-conceptualmaturity. Preschool ADHD seems to particularly affect phonological awarenessskills, which belong to the set of emergent literacy skills presumed to be develop-mental precursors to conventional forms of reading and writing (Lonigan et al., 1999;Mariani & Barkley, 1997; Whitehurst & Lonigan, 1998). The issue of languagedevelopment is particularly applicable to the preschool population and the comorbidityof ADHD and language deficits has often been reported in literature (Campbell, 1995;Gilliam & Demesquita, 2000, Kaiser et al., 2000; McGee et al., 1991). This type ofcomorbidity is an important concern as it has been demonstrated to have significantdiagnostic and prognostic implications (Baker & Cantwell, 1987; Beitchman, Hood, &Inglis, 1990; Byrne et al., 1998; Cantwell & Baker, 1991; Richman, Stevenson, & Graham,1982).

Limitations and suggestions for further research

There are certain limitations to our study since it concerns a small sample and does notmake use of a multidimensional protocol. Additional studies of the comorbidity of ADHDand language deficits employing larger samples, and using multidimensional protocolswithin the context of a longitudinal design, would be beneficial in terms of accurate earlydiagnosis and subsequent prognosis for ADHD preschoolers.

Despite the limitations of this study, the findings provide important evidenceconcerning the implications of co-occurring language deficits and ADHD in preschoolers.The overlap of preschool ADHD and low or deficient development of language skillsstresses the need for early intervention and the development of early assessment protocols,which may lead not only to improved accuracy of early ADHD identification but also toearlier and more appropriate treatment, which may prevent further negative impact ofpreschool ADHD on later academic achievement.

Given that the symptoms of ADHD are related to academic achievement from anearly age and the paucity of research on preschool ADHD, it is critical to furtherpursue the issue in order to understand more completely the nature of that association,and create intervention programmes appropriate for preschool children. Morespecifically, in the language domain, future research could be directed to theidentification of differences between the separate subtypes of preschool ADHD. Ithas previously been shown that inabilility to control of the ADHD symptoms(hyperactivity, impulsivity, inattention) has a different impact on measures of academicachievement (Milich, Balentine, & Lynam, 2001). With a growing body of research,specialists, through consultation with preschool teachers, may implement languagedevelopment skills intervention programmes which will encourage preschoolers to



expand their repertoire of receptive and expressive language controlling at the sametime their impulsivity, hyperactivity, or inattention in order to make the most of theirpreschool environment.

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