Introduction

The following exercise is a case study of two boys (‘Adam’ and ‘Abraham’) with attention deficit hyperactivity disorder who were studied by Peets (Reference Peets2009). The boys attended primary school special education classes in a large, urban, publicly funded school system in Toronto. These classes were designed to support children with language impairment. The case study is presented in five sections: primer on attention deficit hyperactivity disorder; language in attention deficit hyperactivity disorder; client language status; focus on narrative production – Adam; and focus on narrative production – Abraham.

Primer on attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that has its onset in childhood and can persist into adulthood. The disorder is diagnosed on the basis of symptoms of inattention and hyperactivity and impulsivity which are described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). Among the behaviours which are used to identify these symptoms are a failure to pay close attention to details, an inability to remain seated in appropriate situations, and difficulty organising tasks and activities. To receive a diagnosis of ADHD, children must have at least six symptoms from either (or both) the inattention criteria or the hyperactivity and impulsivity criteria in DSM-5. Older adolescents and adults must present with at least five symptoms for a diagnosis to be made. ADHD symptoms must not occur exclusively during the course of schizophrenia or another psychotic disorder, and must not be better explained by another mental disorder or by substance intoxication or withdrawal. Unlike earlier editions of DSM, DSM-5 does not contain exclusion criteria for individuals with autism spectrum disorder.

The prevalence of ADHD has been examined in several epidemiological studies. A recent study by Pastor et al. (Reference Pastor, Reuben, Duran and Hawkins2015) in the US estimated that in 2011 to 2013, 9.5% of children aged 4–17 years were diagnosed with ADHD. Within this figure, the prevalence of ADHD in children aged 4–5 years, 6–11 years and 12–17 years was 2.7%. 9.5% and 11.8%, respectively. Among all age groups, the prevalence of diagnosed ADHD was more than twice as high in boys as in girls. There is a complex interplay of genetic and non-genetic factors in the aetiology of ADHD. That there is a genetic susceptibility for ADHD is supported by findings of higher rates of ADHD in parents and siblings of affected probands compared to relatives of unaffected controls, and by higher concordance rates for ADHD in monozygotic than in dizygotic twin pairs (Thapar et al., Reference Thapar, Cooper, Jefferies and Stergiakouli2012). Lichtenstein et al. (Reference Lichtenstein, Carlström, Råstam, Gillberg and Anckarsäter2010) reported concordance rates for ADHD in monozygotic and dizygotic twin boys of 44% and 10%, respectively. Among environmental factors that have been associated with ADHD are maternally related prenatal risks (e.g. alcohol consumption, smoking and drug use in pregnancy), pregnancy and birth complications (e.g. prematurity and low birth weight) and external agents (e.g. infections, exposure to lead and other toxins) (Thapar et al., Reference Thapar, Cooper, Jefferies and Stergiakouli2012).

Comorbid conditions are commonly found in ADHD. These conditions can affect the assessment and treatment of ADHD. In the United States, Larson et al. (Reference Larson, Russ, Kahn and Halfon2011) examined the comorbidities of 5,028 children with ADHD aged 6–17 years. Learning disability was reported in 46% of these children. Other significant comorbidities were conduct disorder (27%), anxiety (18%), depression (14%) and speech problems (12%). Among these children, 33% had one comorbid disorder, while 16% had two comorbid disorders and 18% had three or more comorbid disorders. Giacobini et al. (Reference Giacobini, Medin, Ahnemark, Russo and Carlqvist2016) reported significant psychiatric comorbidity in Swedish children, adolescents and adults with ADHD. Autism spectrum disorders were the most common comorbidities for younger patients, while substance abuse, anxiety and personality disorder were the most common comorbidities in older patients. There are poor academic, vocational and psychosocial outcomes in children with ADHD. Sayal et al. (Reference Sayal, Washbrook and Propper2015) reported a 27- to 32-point reduction in GCSE scores in children with ADHD, while in boys with the disorder there was more than a twofold increased likelihood of not achieving five good GCSEs. Tervo et al. (Reference Tervo, Michelsson, Launes and Hokkanen2016) reported less education, more involuntary job dismissals and more alcohol abuse at 30 years of age in a group of 122 subjects with ADHD.

Language in attention deficit hyperactivity disorder

Children with ADHD often have receptive and expressive language impairments. DaParma et al. (Reference DaParma, Geffner and Martin2011) examined the scores of 100 children with ADHD aged 6–16 years on the Clinical Evaluation of Language Fundamentals – 4th edn (CELF-4; Semel et al., Reference Semel, Wiig and Secord2003). Compared to the typical population on whom the CELF-4 is standardised, a greater proportion of children with ADHD obtained scaled scores ≤ 4 (−2 SDs) on a number of receptive and expressive language measures. These children had problems understanding spoken language, following directions and understanding concepts, and understanding grammatical relationships. Children with ADHD also had trouble formulating sentences, recalling words rapidly and performing word association tasks. Reading and written expression are also impaired in ADHD. In a study of 179 children with ADHD aged 6 to 8 years, Sciberras et al. (Reference Sciberras, Mueller, Efron, Bisset, Anderson, Schilpzand, Jongeling and Nicholson2014) reported a higher prevalence of language problems than in controls after adjustment for sociodemographic factors and comorbidities. ADHD children with language problems had poorer word reading than children who had ADHD alone. Martinussen and Mackenzie (Reference Martinussen and Mackenzie2015) reported that young people with ADHD scored significantly lower than a comparison group on a standardised measure of reading comprehension. Poor comprehenders with ADHD exhibited weakness in expressive vocabulary and written expression relative to good comprehenders with ADHD.

Pragmatic and discourse skills are also impaired in children with ADHD. Bruce et al. (Reference Bruce, Thernlund and Nettelbladt2006) used a parental questionnaire to examine language and communication skills in 76 children with ADHD. The majority of these children had pragmatic problems. These problems were associated with some of the core aspects of ADHD symptoms, particularly inattention and impulsiveness. Redmond (Reference Redmond2004) examined the conversational profiles of children with ADHD and SLI. Children with ADHD were found to produce significantly more mazes and longer mazes than children with SLI or typically developing children. Mazes included false starts, fillers, revisions and repetitions. Discourse production and comprehension problems are also found in children with ADHD. Rumpf et al. (Reference Rumpf, Kamp-Becker, Becker and Kauschke2012) examined the organisation of narratives in children with ADHD. Only one of 9 children with ADHD (11%) was able to verbalise the core aspects of the story adequately. This contrasted with 27% of children with Asperger's syndrome and 82% of healthy controls. This difference in frequencies was significant and pointed to limited coherence in the narratives of children with ADHD (and Asperger's syndrome also). Berthiaume et al. (Reference Berthiaume, Lorch and Milich2010) found that boys with ADHD were less able than comparison peers to draw inferences, particularly explanatory inferences, which link events in a story. They were also less able than peers to monitor their ongoing comprehension of texts.

Client language status

The two children with ADHD in this study – Adam and Abraham – are both monolingual English speakers who live in English-speaking families. Both children met criteria for language impairment which were set by the school board. The parents of these children reported that they were late talkers. The listening comprehension and oral expression subtests of the Oral and Written Language Scale (OWLS; Carrow-Woolfolk, Reference Carrow-Woolfolk1995) were used to assess expressive and receptive language. Adam and Abraham scored more than 1.5 standard deviations below the mean on the composite language score of the OWLS and had percentile scores of 4 and 3, respectively. The expressive and receptive scores of these children did not differ significantly.

Focus on narrative production – Adam

Adam and Abraham were identified as having pragmatic difficulties. To examine these difficulties, Peets (Reference Peets2009) also analysed the narrative discourse skills of both children. In the extract below, Adam (A) is talking to his teacher (T) about snow tubing. This extract is part of a longer exchange in which Adam successfully engages the other children present, some of whom ask him questions. Adam is very popular among both teachers and his peer group on account of his vivacious and enthusiastic personality.

Focus on narrative production – Abraham

Abraham is an equally engaging story teller. In the extract below, he relates to his teacher in the presence of other students (S) an interaction he had with his baby brother.