Dr. David Rabiner: New Research
* HOW ADHD AFFECTS PRESCHOOLERS' UNDERSTANDING OF STORIES
One of the most profound effects that ADHD can have on children's development is in the area of academic performance. Numerous studies - several of which have been reviewed in ADHD RESEARCH UPDATE - have documented that children with ADHD are at substantial risk for academic difficulties, and that the majority fail to achieve at a level that is consistent with their academic ability. As indicated in the study reviewed above, children with high levels of attention problems but not high levels of conduct problems were at specific risk for academic difficulty over a 6-year period and to require special educational services. In my own work, I have found that attention problems specifically - and not hyperactive/impulsive symptoms - exert substantial negative effects on the development of children's reading skills.
A study published recently in the Journal of Clinical Child Psychology provides an extremely interesting look at how ADHD can have an adverse impact on skills related to academic performance even before academic problems are likely to be evident. In this study (Sanchez, R.P., Lorch, E.P., Milich, R., & Welsh, R. (1999). Comprehension of televised stories by preschool children with ADHD. Journal of Clinical Child Psychology, 28, 376-385), the authors looked at how preschool children with and without ADHD might differ in their understanding of televised stories.
Televised stories- actually, they used a series of clips from Sesame Street - were used because the children were young enough so that most of them would not yet be expected to be reading. In addition, the benefits of using television to examine young children's comprehension of stories is that it is a familiar context for children, it captures children's attention at an early age, and can provide a less-monotonous context than do many laboratory tasks that are used to investigate ADHD.
It is certainly a common experience for parents to observe that their child with ADHD can attend faithfully to his or her favorite tv shows for an extended period of time, even though the same level of attending to homework is rarely evident. Children's ability to understand and comprehend televised stories can thus serve as a useful medium to learn about their comprehension of story material more generally. If problems are evident in this context - which probably captures children with ADHD operating at their best in terms of attending - then it can inform parents, educators, and clinicians about the struggles that are even more likely to occur in a classroom context.
Participants in this study were 27 boys and girls with ADHD between 4 and 6 years old and 52 comparison children without ADHD. About 75% of the children in each group were male and almost 90% were Caucasian. All the participants with ADHD had been diagnosed with ADHD, Combined Type. Thus, they had the inattentive and the hyperactive/impulsive symptoms as opposed to the inattentive symptoms only. Although many children were being treated with medication at the time of the study, care was taken to be sure that children were medication-free when actually tested.
All children viewed a 23 minute videotape that consisted of 13 separate segments of Sesame Street. Four segments that were embedded in this larger group of segments were the actual target stimuli for the study. All of the target segments had conventional story structures and were narrative in nature. In other words, they were typical of Sesame Street stories.
Children were assigned at random to one of two viewing conditions. Half of the children in each group viewed the segments with attractive toys present and available to play with; the other children viewed the tape without any toys around to serve as potential distractors.
Each child was videotaped while watching the Sesame Street stories. This tape was used to identify the amount of time that participants were actually focusing their attention on the screen where the tape was playing. Thus, an accurate record of the visual attention of each participant was available. Each child watched the videotape individually, so that other children were not present as another possible source of distraction
Children were told that they would be watching a tv program and that afterwards, they would be asked some questions about what they had watched. In the condition where toys were present, it was simply mentioned that they could play with the toys if they wanted to. Thus, they were neither specifically encouraged to play with the toys or discouraged from doing so.
After the tape was over, the experimenter returned to ask each child questions about the stories they had watched. Questions were asked about the 4 targeted stories in the order that these stories had appeared on the tape. Pictures of the characters from each story were presented to the child, and the names of each character was provided to try to help cue their recall of what they had watched.
Two types of questions were asked: factual questions (e.g. What does the man do with the fish he catches?") and causal relation questions (e.g. Why does the man kiss the fish?") The former questions thus test for children's recall of specific events that occurred in each story. The causal relation questions, in contrast, required the child to draw upon several different elements in the story and to recall the relationship between these elements. Between 12 and 15 questions were asked for each story, and these were divided equally between the factual and causal relation type questions.
The first question the authors examined is how children in the two groups compared in terms of how attentive they were to actually watching the videotape and whether this varied according to whether toys were present. Overall, as might be expected, children without ADHD were more attentive (i.e. actually spent more time looking at the screen) than children without ADHD. In the no-toy condition, the % of time children in these groups were observed to be "observing the screen" were 90.4% and 80.3% respectively.
For both groups, the presence of toys substantially reduced their level of attention. The % of time attending dropped to 30% on average for children without ADHD, and all the way to 7% for children with ADHD. In other words, even though the toys were a substantial distracter for both groups of children, the adverse impact on attending to what they needed to was even greater in children with ADHD. Thus, this is experimental evidence of the far greater distractibility in children with ADHD, which, after all, is one of the core symptoms of inattention.
Here is something even more interesting. Even though children without ADHD reduced their attending behavior when toys were present from 90% to 30%, the proportion of questions that they answered correctly DID NOT CHANGE. This strongly suggests that these children were "strategic viewers" who could systematically divide their attention between the tv stories and the toy play such that their ability to recall and comprehend the stories did not suffer.
For children with ADHD, however, the findings were quite different. When toys were not present, children with ADHD were about as accurate as comparison children in their responses to factual questions. Thus, in the absence of distraction, they answered factual items every bit as well. In the toy-present condition, however, their performance was adversely affected such that they now did much worse than comparison children. In this condition, in fact, they answered correctly to about 50% fewer questions.
What is important here is that even though the comparison children also "paid less attention" to the stories when toys were present, they were still somehow able to divide their attention between toys and the stories such that their recall was not hurt. Children with ADHD, however, apparently could not do that. Thus, not only did they attend less when distractors were present, but they were unable to divide their attention in such a way that their level of performance was preserved.
Results for the causal relation questions were somewhat different. Here, the children with ADHD did worse than the comparison children regardless of whether toys were present as a distracter. Thus, even when their visual attention to the program was high, children with ADHD still did not do as well in responding to questions that required an understanding of how the different elements in a story fit together.
It would be quite interesting to know whether similar results would have been obtained for the comprehension items even if the children with ADHD had been receiving their medication when testing occurred.
The results of this interesting study have potentially important implications for educating children with ADHD.
First, as has been demonstrated in the past, the presence of distracting stimuli appear to have a significantly greater adverse impact on the performance of children with ADHD than of other children. Not only is a child with ADHD less likely to pay attention to what he or she is supposed to when an attractive alternative stimulus is present, but he or she is also apparently less able to effectively allocate attention to competing activities in ways that help maintain a good level of performance.
These data support the benefits of arranging the environment for many children with ADHD in such a way that potential distractions are minimized. In a classroom setting, of course, this is not always easy to do, particularly without isolating a child in a way that can be stigmatizing. At home, however, when it comes to getting homework done, this type of intervention may be easier to accomplish. Please note, however, that although reducing distractions may be helpful for many children with ADHD, there will always be exceptions. Thus, evaluating whether such environmental modifications are helpful for a particular child always needs to be carefully evaluated.
The comprehension results seem especially important. These data indicate that comprehension may be an area of particular difficulty for children with ADHD, and that such difficulty may be evident as early as the preschool years. This result is consistent with another study of reading comprehension in children with ADHD that was reviewed in an earlier issue of ADHD RESEARCH UPDATE. (See http://www.helpforadd.com/reading.htm)
Careful assessment of the comprehension abilities of a child with ADHD, even for a child whose basic reading skills or ability to recall factual information about stories appears adequate, may thus be quite useful in identifying necessary targets for intervention. This, however, is rarely done.
When difficulties in this area is identified, specific training to help a child with ADHD understand cause-and-effect relations, both in stories and in real-life social situations, may be quite helpful. This may be best done by a reading specialist who is aware of specific techniques and strategies to assist children in their comprehension skills. Such training may have benefits not only for academic performance, but for a child's social relationships as well.
A note from Dr. Rabiner:
I hope the above information was of interest to you and potentially helpful. Staying informed about the latest research findings on ADD/ADHD will enable you to make better informed decisions about the best ways to promote your child's healthy development. That is my objective in publishing a monthly newsletter, ADHD RESEARCH UPDATE, and I invite you to become a regular subscriber. If you work with children who have ADHD in a professional capacity, I also think you will find that ADHD RESEARCH UPDATE is a convenient way to stay on top of important new research information.
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David Rabiner, PhD
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"Thank you for understanding me."
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