Conditions Associated With Risk: Within Child

Attention Deficit Hyperactivity Disorder

The most prevalent disorder in children is attention deficit/hyperactivity disorder (ADHD) (Barkley, 1998; Zentall, 2006). Children with ADHD are most commonly identified in early elementary grades and are most often educated in the general education classroom (McKinley, 2003; Zentall, 2005, 2006). Although children can be identified as having a disability under specific learning disability, emotional disturbance, or other health impairments, at least half of children with ADHD are not identified as having a disability and do not receive any special services (McKinley, 2003; Zentall, 2006).

To be identified by a licensed psychologist or medical doctor as having one of three main types of attention deficit/hyperactivity disorder, children must manifest specific characteristics according to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychological Association, 2000). According to the DSM-IV-TR, children can be diagnosed with Inattentive Type (ADHD-I) if they manifest at least six of the nine inattention characteristics, Hyperactive-Impulsive Type (ADHD-H) if they have at least six of the nine hyperactive and impulsive characteristics, or Combined Type (ADHD-C) if they meet the criteria for both Inattention and Hyperactivity-Impulsivity. Most school-age children have Combined Type ADHD (ADHD-C; Barkley, 1998; Zentall, 2006). Boys are at least two to three times more likely than girls to have ADHD (Raymond, 2004; Zentall, 2006). Children with ADHD typically have significant problems in school academically and socially.

Educational Characteristics

Children with ADHD are much more likely than peers with similar intelligence to experience failure in school (Barkley, 1998; Zentall, 1993). By the time these children reach the late elementary grades, many are years behind in several areas, and as many as one in three will have repeated a grade. Without early understanding and support, children with ADHD may continue on a course of failure in school upto 30% of children with ADHD will repeat a grade and 35% will drop out of high school (Barkley, 1998).

Children with ADHD typically have problems in attention, impulsivity, and hyperactivity that greatly affect their educational performance (American Psychological Association, 2000; Barkley, 1995, 1998; Lerner, Lowenthal, & Lerner, 1995; Zentall, 1993, 2005, 2006). Each of these characteristics interacts to make success in school very challenging for most children with ADHD. The following list describes the most common educational characteristics of children with ADHD (American Psychological Association, 2000; Barkley, 1995; 1998; Lerner et al., 1995; Zentall, 1993, 2005, 2006).

Attention difficulties, including

• Problems attending to what they should be attending to, according to the teacher, at any given time (selective attention).
• Being easily pulled off-task to other more rewarding, fun, novel, or interesting activities.
• Difficulty getting started on tasks.
• Difficulty figuring out the important parts of tasks, activities, or assignments.
• Problems seeing the “big picture” or main idea when it is accompanied by extensive detail.
• Difficulty attending to tasks across a school day (problems more likely toward end of school day).
• Difficulty with tasks that are long, or involve repetitious or rote responding, attention to detail, or handwriting.
• Problems sustaining attention for very long to something that is not interesting. Children can be seen as having sustained interest problems rather than sustained attention problems.

Activity needs, including

• Problems refraining from activity for period of time (length of time depends on age).
• A need to move more than peers when given a choice to do so (learning center, free play).
• A need to talk more.

Behavioral inhibition and internal organizational problems, including

• Problems organizing actions according to rules.
• Problems using past consequences to direct behavior.
• Frequent impulsive and intense responses.
• Tendency to do inconsistent work.
• Tendency to do sloppy work (often due to a desire to do something else).
• Problems delaying reinforcement. Need immediate reinforcement.

Finally, young children with ADHD need extensive adult assistance to complete activities (Barkley, 1995). By understanding the unique ways that children with ADHD perceive and interact with their environments, professionals can be better prepared to meet their needs in educational settings. Their unique characteristics also impact their social behavior.

Social Characteristics

Children with ADHD are more likely to have social problems, including negative social behavior, inadequate social knowledge, and negative interactions with peers (Stormont, 2001a). They are more likely than their peers to have more behavior problems, including aggression, disruptive behavior, off-task behavior, and oppositional behavior. Research has found that 62% of kindergarten children with ADHD characteristics had social problems according to their teachers as compared to only 12% of their kindergarten peers (Merrell & Wolfe, 1998). Children with hyperactive and aggressive types of behavior are at risk for being rejected by their peers as early as kindergarten, and this negative peer status lasts into the second grade (Vitaro, Tremblay, Gagnon, & Biovin, 1992; Vitaro, Tremblay, Gagnon, & Pelletier, 1994). The following list includes specific social characteristics of children with ADHD that influence their relationships with peers and adults (Bloomquist, August, Cohen, Doyle, & Everhart, 1997; Cunningham & Siegel, 1987; Diener & Milich, 1997; Grenell, Glass, & Katz, 1987; Hubbard & Newcomb, 1991; Landau & Milich, 1988; Landau & Moore, 1991):

• Limited social knowledge related to selecting good choices for specific social settings and connecting actions with consequences.
• Problems explaining why they selected certain behaviors.
• Tendency to propose aggressive solutions to problems.
• Difficulty adjusting social behavior to fit role-play situations.
• More negative interactions with peers (and negative ratings from peers), especially when the task is structured.
• Problems generating rules or an organizational structure to guide work or play activities.

Causal Myths and Factors

Many teachers have received inaccurate information regarding the causes of ADHD (Stormont & Stebbins, 2005). Perhaps the greatest myth regarding the cause of ADHD is that it is due to diet. In a summary of the myths related to ADHD, Barkley (1995) succinctly described how diet has been widely disseminated as a cause of ADHD. First, food additives were reported to be a primary cause of ADHD, and diets free of additives, such as the Feingold diet, were recommended for treatment. Despite the fact that no scientific research has supported the use of such a diet for treatment of ADHD, as late as the 1980s, well-known individuals, such as advice columnist Ann Landers, directed parents of children with ADHD to the Feingold Association. After much study, the validity and interest in food additives waned. However, sugar began to be linked to ADHD and continues to be a widespread dietary myth as a cause of ADHD. According to Barkley (1995),

So widely accepted had this idea become that in January 1987 it was paired as the correct response to the statement “The major cause of ADHD in North America” on the popular game show Jeopardy. Not a single scientific study has been provided by proponents to support these claims. (p. 66)

Why is it important to dispel myths and clarify likely causes? For greater understanding of the disorder and the impact that its characteristics have on educational and social behavior, it is important to know causal factors. In addition, for treatment directions, professionals cannot fall into the trap of believing widely disseminated but not scientifically validated causes. For interventions to be successful, they need to be directed at the educational manifestations of the disorder, with an understanding of brain-based differences in learning. Simply assuming that a child had a doughnut for breakfast or candy at lunch and waiting for the behavior to subside is not an effective treatment for ADHD.

So what is the real cause of ADHD? ADHD can be seen as a brain-based difference that is usually the result of inherited traits. Most of these children have someone in their immediate family with similar characteristics. In cases where ADHD tendencies cannot be found in family members, and as a result a genetic link is not likely, the cause has been linked to injury to the brain before, during, and/or after birth (Barkley, 1995, 1998; Raymond, 2004).

Challenging Behavior

In this text, the within-child characteristic of challenging behavior includes children with significant behavior concerns who do not meet the criteria for an emotional disturbance under the Individuals with Disabilities Education Act, a federal law (Raymond, 2004). Thus, this within-child characteristic includes children with early challenging behavior who are at risk for developing stable behavior and academic problems. These problems may eventually lead to a referral for evaluation for special education and related services. However, with understanding and supports-many children can be diverted from this path (Horner et al., 2005).

Children with early behavior problems are vulnerable for social and academic problems. The most common types of challenging behavior patterns are externalizing behavior problems, including aggression, acting out, noncompliance, and oppositional behavior (Arnold, 1997; Walker et al., 2004). The majority of children with externalizing antisocial behavior patterns are boys (Kauffman, 2005). In the classroom, teachers may see such children having difficulty following directions, showing limited self-control, and requiring extensive need for teacher attention and direction. Children may also have attention problems, impulsivity, immaturity, and low self-confidence. They often have limited knowledge of how to get their needs met in socially appropriate ways and may use aggression to secure objects, to resolve conflicts, to escape certain settings, or to get attention from peers. Children with aggressive tendencies often have a difficult time generating alternative prosocial solutions to resolving conflicts (Bloomquist et al., 1997; Coie & Dodge, 1988; Stormont, 2001a; Walker et al., 2004). They are also at risk for significant academic problems (Arnold, 1997; Horner et al., 2005; Kauffman, 2005; Walker et al., 2004). When children have both challenging behavior and low achievement, their risk for continued and more serious problems is much greater (Arnold, 1997; Kauffman, 2005).

Sadly, children’s risk for failure increases dramatically each year that their needs are not addressed. Children with challenging behavior patterns can be identified as early as age 4 (Stormont, 2001b; Walker et al., 2004). However, as a group, these children are not typically identified and, as a result, prevention efforts with young children with challenging behaviors are rare (Kaiser & Hester, 1997; Kauffman, 2005; Walker et al., 2004; Webster-Stratton, 1997). As previously noted, children who do not receive remediation and support for challenging behavior in the primary grades are vulnerable for developing very serious antisocial behavior problems. By the end of the fifth grade, researchers can accurately identify children who are at greatest risk for being arrested 5 years later (Walker, Colvin, & Ramsey, 1995).

Contributing Factors to Early Behavior Problems

Multiple factors contribute to the development and sustainment of challenging behavior in young children. It is critical that educational professionals increase their understanding of such characteristics as early as possible, and then use this understanding to inform intervention efforts.

In preschool, many children have behavior problems that they outgrow. However, if early behavior problems are severe, include multiple externalizing behaviors (hyperactivity and aggression), and are present across different environments, then children are more likely to continue to have problems (Campbell, 1998; Campbell & Ewing, 1990; Stormont, 2001b; Webster-Stratton, 1997). Each of the family characteristics presented in the next section has been documented to be associated with behavior problems in young children.

In early elementary school, young children with behavior problems are often met with inappropriate teacher expectations for social behavior and limited individualized help for their needs (Arnold, 1997; Espinosa & Laffey, 2003; Gunter & Coutinho, 1997; Van Acker et al., 1996). As discussed in the section about schools, teachers have rated social skills as more important than academic skills for kindergarten success (Graue & DiPerna, 2000; Piotrkowski, Botsko, & Matthews, 2000). When teacher expectations and children’s inappropriate behavior collide, children often receive frequent negative attention from their teachers (Herring & Wahler, 2003). Children with challenging behavior may also experience negative attention from their peers and may be rejected as early as kindergarten (Olson, 2001; Stormont, 2002). Early peer rejection is a critical characteristic to consider for Page Number:16
children’s futures. Experts in this area note that after children are rejected by their same-age “normal” peers they gravitate toward each other. Once children with significant antisocial behavior find each other, often in later elementary grades, their risk for engaging in more serious antisocial behavior increases substantially (Walker et al., 1995). Overall, by the end of the elementary grades, many children with early behavior problems appear to be headed for the worst possible outcomes. Many societal conditions further compound children’s risk for behavior problems.

Community and Societal Factors

Children today are faced with multiple additional risk factors that create environments where problem behavior is glorified and sometimes celebrated. Contributing community factors include living in an area with a high crime rate, gang influences, and limited opportunities to access prosocial recreation activities (Walker et al., 1995). Compounding these community factors, children today are exposed to excessive violence in the media (Kauffman, 2005; Walker et al., 2004). According to Lieberman, media violence is available for children 24 hours a day and should be viewed as a serious contributing factor for endorsing violent behavior:

Hundreds of empirical studies have documented that exposure to media violence (video games, TV news, cartoons, children’s programs, films, and daily television programs) desensitizes children to violent acts, makes them more likely to behave in an aggressive fashion, and increases the likelihood that they will commit violent acts themselves. (as cited in Walker et al., 2004, p. 46)

Violence is also readily available for children on the Internet.

Thus, children and youth are often sent a mixed message. The media floods children’s lives with aggressive and irresponsible behavior and uses high-status models to do so. However, youth who engage in such behavior are often punished by the same society that supported its development (Kauffman, 2005; Walker et al., 2004). The children most likely to model the aggression they see in the media are children who are already vulnerable due to within-child and environmental risk factors (Kauffman, 2005; Stormont, 2002).

In summary, many factors contribute to the development of early problem behavior patterns. The combination of multiple within-child and environmental risk factors dramatically increases children’s risk for continued problems. Essentially, young children who are the most vulnerable for continued behavior problems are those who “do not have either the internal resources or the external supports to help them overcome early difficulties with self-regulation and behavior control” (Campbell, Pierce, March, Ewing, & Szumowski, 1994, p. 837).

Limited English Proficiency

According to Espinosa (2005), “Children from different cultures and low-income households who enter school programs speaking little or no English are highly vulnerable to chronic academic underachievement and eventual school failure” (p. 837). As many as 20% of children in the United States are limited in their English proficiency (Slavin & Cheung, 2003). Hispanic children represent the largest group of children in the United States (14%) who enter school with limited English (Espinosa, 2005; Freund & Rich, 2005). In the year 2000, 36% of children entering kindergarten in California were limited in their English proficiency, and the vast majority of these children spoke Spanish (Espinosa, 2005). According to recent demographic data, 85% of students who were English language learners in California in 2003–2004 spoke Spanish (California Department of Education, 2005).

The impact of entering school as an English language learner is influenced by the preparedness of schools and teachers to accommodate learner differences and to create an environment where children can be successful. The needs of children with limited English can be extensive as they may enter school already vulnerable for failure due to discrepancies between their skills and those of their peers. Further contributing to and in many cases mediating their risk for failure in school, children from Hispanic backgrounds are at higher risk than children from White or Asian backgrounds for living in poverty (Espinosa, 2005; Hodgkinson, 2003).

Children with a strong command of their primary language are more successful in school and have an easier time developing fluency in a second language (Freund & Rich, 2005). However, many students enter elementary school with borderline mastery of underlying concepts in their primary language and are then required to develop English language proficiency with this shaky foundation. Children who have limited English proficiency are at greatest risk for achievement problems when educational tasks rely heavily on language (English). When students with limited English proficiency were assessed in less language-based areas, such as mathematics, their scores were more comparable to their peers (Abedi, 2003).

The outcomes for children with limited English in the area of reading are of great concern. In a synthesis of the literature in the area of reading and English language learners, Slavin and Cheung (2003) noted that less than half of Latino children in the fourth grade (44%) met or exceeded a “basic” reading level on the National Assessment of Educational Progress exam. Children from “Anglo” backgrounds performed much better, with 75% meeting or exceeding a basic level of proficiency. As a result of their vulnerability for underachievement in reading, Slavin and Cheung (2003) stated that “The reading education of English language learners (ELLS) has become one of the most important issues in all of educational policy and practice” (p. 1).

Low Achievement

Children with ADHD, challenging behavior, and limited English are all at risk for being low achievers. However, children may underachieve without these other characteristics. Low achievement does exacerbate children’s risk for failure even if they do have other risk characteristics. It is important to discuss early underachievement as a risk factor for school failure in order to stress the need to initiate early systematic assessment and instruction. Early intervention for children with limited  knowledge in specific areas is important. First, many students will respond to early intervention and be placed on a more even level with their peers in the primary grades. This initial success can foster future success, and such children will not be subject to failure, grade retention, and self-esteem issues related to academic failure.

Second, in order to determine if underachievement is due to limited prior knowledge and other risk characteristics that can be remediated or supported in the general education classroom or due to an underlying disability, it is critical to first use systematic assessments and supports for individualized instruction. Only after these assessments and supports have been tried should children be referred for an evaluation. Thus, contributing child and environmental factors for underachievement should be identified to individualize curriculum and instruction before more intrusive strategies are recommended.