Running Head: EDPS 651 Final Exam

Is Oppositional Defiant Disorder a Real Disorder?

Lindsay A. Birchall
University of Calgary

Disorders of Learning and Behaviour EDPS 651 Final Exam Section 1

Dr. Brent Macdonald
December 4, 2013

Running Head: EDPS 651 Final Exam

Critical Issues
The conceptualization of Oppositional Defiant Disorder (ODD) is controversial. The
general public and parents have access to information that questions the diagnostic validity of
ODD, mainly through the internet. From personal experience clinicians question the validity of
ODD as a disorder. We have all heard, Its not O-D-D, its B-A-D. So, is ODD just a product
of bad parenting? Or, is it a reliable and valid disorder of child psychopathology? The second
critical issue I would like to address is the catch 22 that presents when children are too young
to be diagnosed with ODD, but require early interventions to improve prognosis. In Alberta, a
diagnosis is required for funding within Alberta Education and Family Services for Children with
Disabilities (FSCD).
My Current Understanding Research/Theory
As a psychologist, it is unethical to pick and choose which disorders you support in the
Diagnostic and Statistical Manual of Mental Disorders (Macdonald, 2013, October). Your
understanding of a disorder should be based on evidence, not opinion. As such, it is easy to say
that ODD is a real disorder. However, it is not that simple. There are aspects of the diagnosis that
contribute to the on-going examination of the credibility of ODD.
Firstly, the diagnostic criteria are highly subjective, including wording such as
vindictiveness, argumentative and having an angry/irritable mood (APA, 2013 p. 462).
Second, the measurability within each criteria is subjective, including often as the key
measurable term (e.g. often loses temper, is often angry and resentful (APA, 2013, p.462).
Subjectivity makes for less reliable diagnosis. Third, because the normal developmental
trajectory for typical children under 5 includes periods of defiance and opposition it can be

Running Head: EDPS 651 Final Exam

difficult to determine differences between normal behaviour patterns and ODD symptomology.
Toddlers and teenagers are the most noted developmental phases where oppositional
behaviours may be heightened. Lastly, having an oppositional child makes parenting difficult and
often creates a negative relationship between the parent and the child. This poses the question of
which came first, the childs oppositional behaviour, or the parents difficulties. These reasons,
and more, contribute to diagnostic controversy. As Masch & Barkley, 2003 (p. 154) say the
validity of ODD as a diagnostic entity in an unresolved issue.
However, one can implement the use of frequency, severity and duration (Macdonald,
2013, October). As Masch & Barkley, 2003 (p. 152) identify it would take an extremely high
level and severity of such patterns, in comparison with age and sex norms to warrant diagnosis,
(e.g. a young child who was highly aggressive, risking their safety and others). Behaviours must
persist for more than 6 months and must be present with someone who is not a sibling, which is
sensible criterion. These behaviour criteria create a significant different in patterns compared to
developmental norms, supporting diagnostic validity.
There is well documented evidence for the development of ODD as a disorder. A childs
temperament (e.g. high levels of emotional reactivity) and demonstration of early and extreme
aggressive behaviours are risk factors for severe ODD (APA, 2013, p.464; Masch & Barkley,
2003 p. 165). Approximately 90% of youths diagnosed with Conduct Disorder (CD) had a
previous diagnosis of ODD, but the majority of youngsters with ODD do not appear to progress
to the more severe CD; under approximately 50% (Masch & Barkley, 2003, p.162). CD often
precedes Anti-Social Personality Disorder (ASPD) (Macdonald, 2013, October). It is important
that we differentiate diagnoses as three distinct disorders. Although ODD, CD and ASPD do
have potential relations in developmental trajectory, there is no predictive or causal linear

Running Head: EDPS 651 Final Exam

relationship (Donovan, et. al., 2013, October). With appropriate intervention provided, 67% of
children show a resolution of symptoms by 18 years old (Donovan, Medland, Juchnowski, 2013,
October). Stability in prognosis and a developmental trajectory validates ODD as a disorder.
The question still arises if ODD is a result of poor parenting? Masch & Barkley, 2003, (p.
173) identify familial risk factors such as: maternal psychopathology, parental substance abuse,
family dissolution/single-parent status, lack of sufficient child-infant attachment, young age of
mothers, maternal depression, multiple caregivers, the use of harsh or inconsistent punishments,
lack of parental supervision, abuse, neglect and low SES (Masch & Barkley, 2003, p. 170-182;
Donovan et. al., 2013, October; APA, 2013, p. 464). It is important to note that some of these
factors appear to be indirect (e.g. single-parentincreased stress, large family sizeincreased
poverty) (Masch & Barkley, 2003 p. 174-175). Further indirect factors associated with early
onset of anti-social behaviours include: anti-social peer influences, multiple family transitions
and parental unemployment (Masch & Barkley, 2003, p.180). In addition, there may be
neurological differences in children with ODD. Systems involved in poor reasoning, judgement
and impulse control have all been identified in children with ODD (Donovan et. al., 2013,
October). Although the list of risk factors is extensive, empirical evidence does not support the
notion that poor parenting is a single causal factor in ODD.
That being said, parent-child interactions do play a critical role in the severity of ODD
symptomology (APA, 2013, p.464). Masch & Barkley, 2003 (p. 175) explain a cyclical pattern
where parents experience reward in the form of negative reinforcement. This happens in two
ways: backing down from requests when the childs behaviour escalates and harsh and abusive
discipline practices which immediately reduce the childs severe misbehaviour. This mutual
training in aversive responding fuels both aggressive child behaviour and greater levels of

Running Head: EDPS 651 Final Exam

harsh, nonresponsive parenting (Masch & Barkley, 2003, p.175). An unstable home
environment including negative sibling relationships become the norm. Although most
children diagnosed with ODD experience dysfunctional family dynamics, not all do (Macdonald,
2013, October). Despite that parenting style and family interactions may impact the progression
of ODD, there is no evidential support that this is the cause of ODD.
Specific empirically based interventions such as Cognitive Behaviour Therapy, Social
Skills Training and Problem Solving Therapy, through a multidisciplinary team are
recommended (Donovan et. al., 2013, October). Teaching parents to reframe their view of their
childs behavior can support a proactive parenting approach (i.e. behaviours are not
purposefully disruptive, but the child is lacking specific skills). Direct parent training,
developing short and long term behavioural solutions and developing awareness of each family
members needs should also be addressed (Donovan et. al., 2013, October). Medications are not
typically recommended for children with ODD. If there is co-morbid ADHD, the child is
demonstrating extreme aggression and other treatment modalities have been exhausted, the use
of medications may be warranted (Donovan et. al., 2013, October). Within treatment Functional
Behaviour Analysis is highly recommended as a critical and valuable tool for parents and
educators (Macdonald, 2013, October). Specific Evidence based interventions does support the
conceptualization of ODD as a disorder.
The first symptoms of ODD usually appear in the preschool years and rarely during
adolescence (APA, 2013, p. 464). Although most clinicians would evaluate behaviours compared
to normative levels, making a reliable diagnosis of ODD in children under the age of 5 is
questionable. This presents a second dilemma, knowing that early intervention is a key
mitigating factor in the positive prognosis of ODD. Moreover, the later intervention occurs, the

Running Head: EDPS 651 Final Exam

more resistant children can become. To add to this issue, misdiagnosis is also common in
children under 5 years (Donovan et. al., 2013, October). This presents a problematic situation;
diagnose early and the family will access treatment, risk misdiagnosis?, or worse Wait to fail?.
Analysis of My Understanding Bias/Rationales for interest in ODD
I have had the opportunity to work with a multitude of children under 6 over the past 11
years. However, I have not worked with a child diagnosed with ODD. Within my career, I have
observed a multitude of unskilled parenting practices. Many professionals that I have worked
with believe that ODD is not a real disorder, just a product of bad parenting. I have been of this
opinion.
However, I have also learned that successful parenting happens within any culture, SES,
race, background and family structure. Additionally, when parents struggle to implement
consistent behavioural rules and boundaries, this can be for many different reasons (e.g. maternal
depression, parental SLDs). Families can be in crisis (Donovan et. a., 2013, October). Parents do
not feel like they can take on more work, but it is often these families that need interventions
the most. In addition, it is important to understand the stigmatizing environment that parents of
children with ODD experience. Often there is heavy sense of guilt and blame about their childs
disorder (Donovan et. al., 2013, October). For these reasons, parents may be resistant to family
treatment. Parents may also resist participation in their childs education or may avoid
community social settings due to their child behaviours. As a clinician, this is a highly
challenging situation to work in. I have had experiences working diligently with families with
little return. I feel that I have been conditioned to expect less, although I know this is a biased,

Running Head: EDPS 651 Final Exam

inaccurate view. It is likely that additional supports, such as parent groups, personal counselling
and respite, may assist in the reduction of family stress and increase participation.
How the Course has Shaped My Understanding
I am very grateful that ODD was a topic covered within this class because my
understanding was very limited. I feel that my bias has been challenged and refuted. I do believe
that ODD is a real diagnosis that is multifaceted in nature with multiple contributing factors. I
have a better understanding of family dynamics and how difficult it must be to parent a child
with ODD. Specific intervention strategies helped reframe my understanding of how to best
work with the family and the child. There were several key points that were addressed that I felt I
can directly use in my practice.
Specifically, I have a better understanding of the use of negative consequences, which is a
common response to disruptive behaviours. From experience, parents and educators often feel
they need to let the child know their behaviour was wrong by giving the child a consequence.
However, with children diagnosed with ODD, research states this is not the best course of action.
When teaching replacement behaviours it is recommended that reinforcement is used and
punishment is avoided. From professional experience, cost/response systems are often
implemented to assist the child in identifying appropriate vs. inappropriate behaviours and to
motivate children with the gain and potential loss of reinforcement. I have implemented many
cost/response systems in my practice. For children diagnosed with ODD, this may not be the best
strategy if they struggle to learn from negative consequences (Donovan et. al., 2013, October).
As such, positive practice is recommended. Ideally, if an adult can proactively plan or guide

Running Head: EDPS 651 Final Exam

the childs behaviours, the child will feel more successful. In turn, the parent will also feel more
successful, preventing aversive interactions (Masch & Barkely, 2003 p. 17).
In my practice I often tell parents that when a child is strong willed their behaviours
can be very challenging to work with, however, these characteristics are actually positive
personality traits that will serve the child well as they grow. Parents often appreciate this
perspective. In the presentation several strengths were pointed out for children diagnosed with
ODD (i.e. determined, strong willed, have the courage to be different), which confirms
emphasizing childrens strengths within interventions.
I really appreciated the final statement in the presentation which was, Discipline without
a relationship leads to rebellion (Donovan et. al., 2013, October). Considering complex family
dynamics, it is imperative that family based therapy focuses on positive relationship building
between the child and all family members. The presentation brought forth an excellent list of
ways to train yourself as a parent or clinician. Primarily, proactively planning your actions and
not reacting to the childs behaviour was emphasized (Donovan et. al., 2013, October).
Specifically, adults should stay calm, use proactive problem solving, view the behaviour as
challenging not the student, avoid power struggles, tell the child what to do (not what not to do),
use I statements (e.g. I like the way that you___) and know when to take a break yourself.
This is a great resource for clinicians and parents. In addition, if clinicians can get parents to
reframe their thinking about their childs behaviours and skill deficits, not purposeful bad
behaviour, parents are more likely to be able to successfully participate in family therapy.
Empirical evidence for specific treatments support a cluster of symptomology, which supports
the essence of ODD as a disorder.

Running Head: EDPS 651 Final Exam

My Professional Plan/Course of Action

ODD is a complex disorder involving a multitude of risk factors and often challenging
family dynamics. Although I am highly experienced in FBA and ABA, I have little experience in
family therapy. As such, it would be helpful for me to gain more experience in this area, such as
course work, reading and workshops.
Service providers (e.g. FSCD) often recommend parenting classes. In the Calgary area
there are several agencies such as Wildrose, and Triple P Parenting that are endorsed by Alberta
Health. I have attended the Triple P Parenting workshops and do feel their information is useful
as general information. I do not have experience with Wildrose. I should explore what their
service provision includes.
As a clinician, I am solution based. The use of a Provisional diagnosis is new to the
DSM-V (APA, 2013, p. 462-466) and is recommended for use when there is insufficient
information available and/or the full criteria of a disorder is not met, but, there is evidence of
clinical impairment and the diagnostic criteria will likely be met in the future (e.g. too young to
be diagnosed with ODD) (Macdonald, 2013, October). Is it possible to provide young children
with a provisional diagnosis of ODD when they are less than five years of age? And, would this
be enough to access family services?
How my Experiences have Enhanced and Changed My Collaboration
I feel that I am better equipped to provide information to parents and professionals about
ODD as a diagnosis. Although it is unlikely I will have the opportunity to work with a child
diagnosed with ODD, I will continue to encounter challenging families and children with similar

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behavioural symptomology. I am better equipped to implement empirically based interventions
for families and educators.
I am lucky to work within early intervention, so I have the opportunity to identify ODD
symptoms early and work with children and families to improve functioning. Additionally, the
presentation identified that 95% of success is relationship based. I will ensure a consistent focus
is placed on the development of a close trusting relationship before implementing behaviour
management techniques.
I feel I am in a privileged place when working with Pre-K children. Specifically, I have
built relationships with several social workers at FSCD, and the agency I work for has a long
standing positive relationship with Alberta Education. I have the opportunity to address the
loophole that occurs within these funding models for pre-K children that are demonstrating
challenging behaviours. I am familiar with the long term negative outcomes for children
diagnosed with ODD that do not receive early intervention supports and I have evidence based
information to support prognosis. A couple of weeks ago I had the opportunity to speak with a
social worker at FSCD about this problem in service provision. And, although the social worker
was not able to provide me with a firm direction, I believe that he did understand the big
picture issue within FSCDs services.
Lastly, although there is questionable support for the Response to Intervention model in
the USA, this system of supports may be helpful in this particular situation. Children can access
assistance without a diagnosis, which is what is needed for pre-K children in Alberta who fall
through the cracks in the current funding models.

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References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition. 5th. Arlington, VA: American Psychiatric Association; 2013:265-70.

Donovan, S., Juchnowski, S. A., Medland, A., (2013, October). Oppositional Defiant
Disorder, Disorders of Learning and Behaviour EDPS:651, Lecture Conducted from
University of Calgary, Calgary, AB.

Macdonald, B. (2013, October). Oppositional Defiant Disorder, Disorders of Learning and

Behaviour EDPS:651, Lecture Conducted from University of Calgary, Calgary, AB.

Mash, E., & Barkley, R. (2003). Child Psychopathology (2nd ed.). The Guildord Press. New
York, NY.

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12

Attention Deficit/Hyperactivity Disorder and Specific Learning Disorder

Lindsay A. Birchall
University of Calgary

Running Head: EDPS 651 Final Exam

13

Disorders of Learning and Behaviour EDPS 651 Final Exam Section 2

Dr. Brent Macdonald
December 4, 2013

Introduction
The writer works with Pre-K children with disabilities. As such, the writer has had
limited opportunities to work with children diagnosed with Attention Deficit/Hyperactivity
Disorder (ADHD) or Specific Learning Disorder (SLD). Rates of SLD and ADHD are high
within funding and coding models in Alberta (Chase, 2013, May). The diagnostic criteria of SLD
and ADHD have significantly changed over the years, impacting empirically based interventions
(Macdonald, 2013, October; November). Additionally, ADHD and SLD are often co-morbid. As
Semrud-Clikeman, 2005 explains, we are just beginning to understand the contribution of these
related but separate diagnoses to learning.
Diagnostic Features
ADHD. In the DSM V, ADHD is characterized by a persistent pattern of inattention
and/or hyperactivity-impulsivity that interferes with functioning or development (APA, 2013, p.
57-58). Six or more behaviours from the category of inattention and/or hyperactivity/impulsivity
must be present for a diagnosis of ADHD. Symptoms of inattention include: overlooking details,
avoidant within difficult tasks or when persistence is required, limited accurate follow through
with instructions, disorganization, forgetful in daily activities, often losing belongings and easily
distracted by external stimuli or intrusive thoughts (APA, 2013, p. 59; Chase, 2013, May).
Symptoms of hyperactivity-impulsivity include: highly levels of movement (e.g. fidgeting,

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getting out of their chair, climbing on things, uncomfortable having to be still for periods of
time), unable to engage in activities quietly, excessive talking and interrupting and having
difficulty waiting their turn (e.g. in a conversation, waiting in line) (APA, 2013, p.60). The
clinician is responsible to report one of three presentations: 1. Combined meets criteria for both
inattention and hyperactivity-impulsivity, 2. Predominantly Inattentive or 3., Predominantly
Hyperactive-Impulsive (APA, 2013, p.60).
Specific LD. Each diagnostic criterion for SLD is based on the type of academic
challenge (e.g. reading, math, written expression). Specifically, childrens skills must be
substantially and quantifiably below those expected for the individuals chronological age
(APA, 2013, p. 67). This deficit must cause significant interference with academic or
occupational performance or within activities of daily living (APA, 2013, p.67). SLD occurs in
children and adolescence who otherwise demonstrate normal levels of intellectual functioning
(i.e. IQ score greater than 70 +/-5) (APA, 2013, p.69) and often co-occurs with behavioural and
emotional issues (Griffiths, 2013, November). The clinician must specify all academic domains
and sub skills that are impaired as well as severity (e.g. Reading accuracy moderate, Reading
- comprehension severe) (APA, 2013, p.67). If there is an intellectual disability or global
developmental delay, SLD cannot be diagnosed. Specific assessment measures are often used to
assess the childs academic performance and cognitive abilities (e.g. WISC/WIAT). Individual
scores should show a statistically significant discrepancy between academic achievement and
cognitive abilities (APA, 2013, p. 69) commonly known as the IQ/Achievement discrepancy
model.
Critical Issues ADHD

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Diagnosis. The diagnostic criteria for ADHD require a clinician to compare and contrast
the childs behaviours to that of the normative group. Children with ADHD often display low
frustration tolerance, irritability and mood liability (APA, 2013, p. 61). They also often exhibit
deficits in underlying cognitive functions such as attention, executive functions or memory
(APA, 2013, p. 61). It is imperative that the clinician observes impairment in the childs social
and academic functioning, within the home, school and other environments, before 12 years of
age, in order for a valid and reliable diagnosis to be made. The severity of behaviours must be
specified (i.e. mild-moderate-severe) and the clinician is required to report when symptoms are
in remission (APA, 2013, p. 59-61).
This presents with two significant challenges for the clinician. First, making a reliable
and valid diagnosis in young children, where developmental norms include impulsivehyperactive and inattentive behaviours. Second, making a reliable and valid diagnosis using
highly subjective criteria for behaviours that occur in people of all ages (Macdonald, 2013,
October). Ultimately, the clinician is responsible for considering frequency, duration and severity
when observing and assessing behaviours relative to diagnostic criteria. Individual differences,
when ADHD is co-morbid and when it is not, should also be considered. To ensure
comprehensive assessment, observation of the child within multiple environments and
collaboration between the clinician, parents and the school is ideal.
Co-Morbidity. In addition to diagnostic subjectivity, ADHD is often co-morbid with
many other disorders. In the general population Oppositional Defiant Disorder occurs within
approximately half of children with the combined presentation of ADHD and about a quarter
with predominantly inattentive presentation (APA, 2013, p. 65). Conduct Disorder, Disruptive
Mood Dysregulation Disorder and SLD are also commonly co-morbid (APA, 2013, p.65). Masch

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& Barkley, 2003 (p. 81) hypothesize that the commonality among most or all of these disparate
abilities is that all have been considered to fall within the domain of executive functions.
Critical Issues LD
Diagnosis. One major challenge within LD is the diagnosis itself. The DSM-V provides
the clinician with specific ranges of assessment scores to either diagnose or to specific severity
within academic domains. However, it states that academic skills are distributed along a
continuum, so there is no natural cut point that can be used to differentiate individuals with and
without specific learning disabilities (APA, 2013, p. 69). The DSM-V (APA, 2013, p.69) goes
on to say low achievement scores on one or more standardized tests or subtests within academic
domains (i.e. at least 1.5 standard deviations below the population mean for agea score of 78
or lessbelow the 7th percentile) are needed for the greatest diagnostic certainty. The DSM also
states that on the basis of clinical judgement, a more lenient threshold may be used (APA,
2013, p.69), which provides the clinician an opportunity to diagnose a child whos scores may
not be low enough, but their disability significantly impairs functioning. All together, the criteria
are quite convoluted. For a less experienced clinician the arbitrary measurements would be
daunting. However, for a more experienced clinician, the flexibility in the use of clinical
judgment may be of benefit.
IQ/Achievement discrepancy model. The second major challenge with diagnosing a
child with an SLD is the IQ/Achievement Discrepancy model (IQ/ACH model), or what the
DSM-V identifies as, unexpected academic underachievement (APA, 2013, p. 69). Evidence
for this model is questionable at best as the IQ/ACH model does not reliably distinguish
between disabled and non-disabled learners (Masch & Barkley, 2003, p. 531). Masch &

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Barkley, 2003, (p. 531) also identify little difference in symptomology between those children
with average IQ and low achievement and those children with low achievement and low IQ. In
addition, medical or neurological conditions (e.g. head injury, epilepsy) are considered
exclusionary although similar symptoms may present (Griffiths, 2013, November). Cultural
factors also impact valid measurements of IQ and achievement between individuals, which effect
rates of diagnosis within different cultures (Chase, 2013, May).
Restori, Katz & Lee, 2009 identify several problems within the IQ/ACH model. The first
is that young children experiencing academic problems in the early elementary grades do not
demonstrate the IQ/ACH discrepancy necessary to meet eligibilitywhich has made early
identification and intervention of children with suspected SLDs difficult. Because of this, it is
not uncommon for these students to continue to fail for years before a diagnosis can be made
(Restori et. al., 2009). A second major criticismis the inconsistent manner in which
practitioners apply the diagnostic approach (Restori et. al., 2009). Third is that many students
that experience long-term academic achievement problems never receive special education
services because of below average intellectual ability (i.e. slow learners) (Restori et. al., 2009).
Fourth questions the use of intelligence tests as part of the SLD definition, which assumes that
IQ and achievement is perfectly correlated (Restori et. al., 2009). As Sattler, 2001 identified the
correlation between IQ and achievement rarely exceeds .60 thereby accounting for only 36% of
the shared variance. Restori et. al, 2009 identify a fifth issue with the IQ/Ach model, which is
startling. There is little to no empirical evidence demonstrating the reliability and validity of the
IQ/ACH model for identifying SLDs (Francis, Fletcher, & Stuebing, 2005; Stuebing, Fletcher,
LeDoux, Lyon, Shaywitz, & Shaywitz, 2002; Vellutino, Scanlon, & Lyon, 2000). Lastly with
regard to validity, a substantial body of research has concluded that using an IQ/ACH

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discrepancy approach does not accurately identify discrepant low achievers from non-discrepant
low achievers (Fletcher et al., 2002; Francis, Shaywitz, Stuebing, Shaywitz, & Fletcher, 1996;
Hoskyn & Swanson, 2000; Vellutino et al., 2000). This indicates that the discrepancy model is
not valid for the purposes of identifying SLD (Restori et. al., 2009).
Compare/Contrast SLD and ADHD
Individual Differences. We must consider that all SLDs are unique and complex within
the individual. Children present with individual differences in symptoms, academic achievement
difficulties, social, emotional and behavioural challenges (Griffiths, 2013, November). Many
factors may are involved that may affect how well or poorly a child performs in a specific
academic domain. For example, in a reading disability, factors effecting performance may be:
phonological processing problems, basic visual processing skills, recursive relationship between
phonological processing and early reading skills, motivation, working memory, executive
functioning skills (Griffiths, 2013, November). Process oriented assessment for SLDs is
recommended in order to identify individual differences and consider them within remediation
(Griffiths, 2013, November). Additionally, individual differences should be considered within
ADHD for similar reasons. Individual symptoms within criteria and co-morbidity of other
disorders can vastly impact an individuals presentation of ADHD. As such, interventions should
focus on these differences, working on childrens weaknesses and emphasizing their strengths.
Diagnosis. Within each disorder behaviours must be present for 6 months before a
diagnosis can be made. However, it is important to note that symptoms are life long and
therefore have ongoing implications for the individual. As such, this 6 month measure may not
be the most appropriate for symptom presentation in ADHD or SLD. (Macdonald, 2013,

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October). It is also important to note that both ADHD and SLD can occur within intellectually
gifted children. ADHD in gifted children is likely to present itself in similar ways to typically
developing children with ADHD. When gifted children are presenting with academic abilities in
the average range, this may signify an SLD, as they are not performing within their intellectual
potential (Macdonald, 2013, October).
Prevalence. Multiple co-morbidities exist in each disorder (Masch & Barkley, 2003, p.
539; APA, 2013 p. 74, 65). Approximately 20-50% of ADHD students have a co-morbid SLD
(Chase, 2013, May; Semrud-Clikeman, 2005). ADHD occurs in approximately 5% of youth and
2.5 % of adults (APA, 2013, p.61). LD occurs in 5-15% of school-aged children across the
academic domains of reading, writing and mathematics (APA, 2013, p.70). Prevalence of SLD in
adults is unknown, but appears to be approximately 4% (APA, 2013, p. 70). It appears that both
ADHD and SLD have reduced prevalence rates in adulthood. This is commonly explained as
underdiagnosed adults (Macdonald, 2013, October; November). As such, prevalence rates should
slowly even out over the next 20 years.
Gender and Age. Boys are more likely to be diagnosed with ADHD and SLD (ratios
range from about 2:1 to 3:1) (APA, 2013, p. 73, 63). When girls are diagnosed with either ADHD
or SLD the mean age is typically older than boys, likely due to less externalizing behaviours,
which are a common by-product of poor academic achievement (Chase, 2013, May; Macdonald,
2013, October; November). Educators should be aware of this higher threshold which potentially
creates wait to fail approach for girls with ADHD (Macdonald, 2013, October; November).
Changes in manifestation of SLD symptoms often occurs with age, so the individual may
have a persistent or shifting array of learning difficulties across the lifespan (APA, 2013, p.71).

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Individuals with ADHD show a relatively stable course, with early hyperactivity reducing with
age, inattention becoming more prominent and impulsivity remaining problematic (APA, 2013,
p. 62). Individuals with ADHD that develop anti-social behaviour may have a worsened course
(APA, 2013, p.62).
SLD can only be diagnosed after formal education starts (APA, 2013, p.70). Similarly,
children with ADHD are often diagnosed after they enter the formal school system, but for
different reasons. SLD requires formal assessment and synthesis of educational information (e.g.
portfolios, curriculum based assessment, school reports) (APA, 2013, p. 70), which are only
available after a child enters the formal education system. When diagnosing ADHD, clinicians
often refrain from making a diagnosis in children under six due to comparative norms of
hyperactive, inattentive and impulsive behaviours in typical children that age. Although both
disorders may show early signs of presentation, a reliable and valid diagnosis can only be made
after kindergarten at the earliest.
Culture. Differences in prevalence rates for ADHD occur across regions (APA, 2013,
p.62). This is assumed to be due to cultural variations in attitudes toward or interpretations of
childrens behaviours (APA, 2013, p. 62). This suggests that culturally appropriate practices
are relevant in assessing ADHD (APA, 2013, p.62). It is likely that because different cultures
have different normative social behaviours (e.g. is often late), their views of individual
symptoms of ADHD would be effected (e.g. Native American culture - being on time is not a
necessary boundary) (Macdonald, 2013, November). Similarly, SLD as diagnosis is impacted by
culture and may vary in its manifestation according to the nature of the spoken and written
symbol systems and cultural educational practices (APA, 2013, p. 72). For example, in the
English language slow inaccurate reading is a hallmark symptom of a SLD, however, in non-

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alphabetic languages the hallmark feature may be slow but accurate reading (APA, 2013, p. 7273). Even the label of learning disability may carry a different meaning. In Brittan learning
disability is equivalent to the North American diagnosis of intellectual disability (Macdonald,
2013, October). Similarly, in France, ADHD is not considered a disorder (Griffiths, 2013,
November).
Genetic Links. ADHD is elevated within the first degree of biological relatives of
individuals with ADHD (APA, 2013, p. 62). Similarly, SLDs are four to 10 times more likely to
manifest within first order relations (Macdonald, 2013, November). This shows substantial
heritability for both disorders, which is especially important for parents that may be undiagnosed
with ADHD or an SLD. Environmental factors that result from being undiagnosed (e.g. less
books in the home, less reading in the home) may impact the severity of and SLD (Chase, 2013,
May).
ADHD and Co-morbid SLD. One could hypothesize one causal model for academic
difficulties when a child is diagnosed with both ADHD and an SLD. Factors that may impact
success in a child may be a childs neurobiology (e.g. neural pathways lack organization),
behaviour psychosocial factors (e.g. motivation and affect), cognitive core processes (i.e. overall
intellectual ability) and their environment (e.g. SES, school, intervention) (Chase, 2013, May).
All of these factors have the potential to enable or further disable the childs performance in
academic, occupational and daily living domains in children with ADHD and SLDs (Chase,
2013, May).
For example, poor executive functions, as often present in ADHD and SLD, may impede
the childs ability to plan and organize school assignments. The childs environment may provide

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reduced opportunities for appropriate interventions (e.g. educator that does not believe ADHD is
a real disorder). If the child has experienced repetitive failure, the child has not been exposed to
the skill or knowledge required for the task or avoidance behaviours have been reinforced by
adults, the child will be more resistant to interventions (Chase, 2013, May). It is imperative,
during academic and cognitive assessment, that the clinician observes the child putting forth their
best efforts, to assist in deciphering between the impacts of cognition, behaviour and academic
ability when a child has co-morbid SLD and ADHD.
Executive Functioning. One overarching concept is the common belief that executive
functions may be underdeveloped in children with co-morbid ADHD and SLD. Specifically,
attentional control, planning and anticipation, organization, self-monitoring, self-correction,
mental flexibility/set shifting, metacognition, initiation, perseverance and impulse and emotional
control deficits all have the potential to highly impact a childs success and significantly impair
functioning in all environments (Griffiths, 2013, November). Barkleys model of behavioural
inhibition further describes how executive functions impact children diagnosed with ADHD who
struggle with inhibiting responses, stopping an ongoing response and to control interfering
stimuli (Barkley, 1997). Social and communication deficits can also occur in children diagnosed
with ADHD and SLD, which further impact functioning (Griffiths, 2013, November). Although
there are no biological markers for ADHD or SLD, neurological soft signs and neurological
associates in both ADHD and SLD are mainly attributed to deficits in the pre-frontal cortex
(Masch & Barkley, 2003, p. 111-115, 549-558, 569, 573).
Summary/Conclusion

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Both ADHD and SLD can have negative functional consequences across the lifespan,
including lower academic achievement, higher rates of high school drop-out, less post-secondary
schooling, poorer vocational achievement, poorer overall mental health and suicidality (APA,
2013, p. 63, 73). In addition, children with ADHD are at risk for developing co-morbid mood
disorders, conduct disorder or substance abuse disorder (APA, 2013, p.61). Children with SLD
are at risk for depressive disorder (APA, 2013, p.73). High levels of social and emotional support
predict better outcomes in children with SLD and ADHD (APA, 2013, p. 73; Macdonald, 2013,
October; November). The prognosis of both ADHD and SLD is dependent on early identification
and early intervention (Macdonald, 2013, November).
A combination of CBT, family systems therapy, accommodations and learning supports
should be put in place as a means to improve the individual childs functioning in multiple
environments. Providing older children with rationale for behaviour change may also be
important (e.g. to write your drivers test, you will have to read the test and complete it within a
minimal amount of time). Although medications can provide improve functioning in children
with ADHD and children with co-morbid ADHD and SLD, medications are not effective in
children with SLD alone. Token economies, particularly cost/response systems can also be
effective with young children (Macdonald, 2013, October, 2013).
When we have co-morbid ADHD and SLD, or individual diagnosis, it is imperative that
the intervention is specific to the individual. Especially in later grades, assessment should refrain
from evaluating only what the child produces, and more on the processes children use to
complete more inferential or abstract tasks (Semrud-Clikeman, 2005). Executive functions
deficits are often present in both ADHD and SLD, which can impact success and impair
functioning across domains. For example, children with an SLD may also have attention

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difficulties (i.e. not ADHD) and emotional challenges (e.g. anxiety) that impact their ability to
read fluently. Identifying all impacting variables will assist in the development of individualized
interventions, likely to have a greater positive effect on the individual child.

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