**2. ADHD and writing**

The problems of the ADHD are very common; between 3 and 6 per cent of all children in school age suffer from it (American Psychiatric Association [APA], 2002) and the problems continue for these children as they grow up in about 40 per cent of the cases, as the revision of Nolan, Volpe, Gadow, & Sprafkin (1999) points out. Other researches even increase this number stating the percentage of children suffering from ADHD in school age to up to 5 to 10 per cent (Scahill & Schwab-Stone, 2000). With these facts and facing the education procedure, we have to keep in mind that in our classrooms there is at least one child that suffers from ADHD (DeShazo, Lyman, & Grofer, 2002). These research studies show us the need of considering this kind of problems, approaching diagnosis and intervention about

Attention Deficit Hyperactivity Disorder (ADHD) and Writing Learning Disabilities 51

al., 2002). The research about the overlap seems very relevant if we look at it from the developing and intervention point of view. Concentrating on the context and the various components and considering the main problem the lack of ability of self-regulation and control of impulses (Barkley 1997a, 1997b, 1998, 2001; Miranda & Presentación, 2000) and do that in relation with writing. For example, according to the theory of Barkley (1997a; 1997b), the problem that people suffering from ADHD presents is a lack of behavioural inhibition which affects four important executive functions (working memory; self-regulation of affection/motivation/activation; language internalization; and reconstitution); all of which affect the force/fluency/syntax control of the behaviour. It is predictable that we can achieve some understanding about the problem that these people suffer from by doing a research on written composition, but we also need more specific and in-depth research. Furthermore, there is a lack of research which considers the educational point of view of the overlap between ADHD and the written composition, and here is where this research line is

It is to be stressed, - and it might seem shocking - that with these premises the research about the ADHD and writing have not been done with nearly the depth that these facts imply. In the same way, it is one of the important limitations we have found in the making of this work; the very few previous researches to study, and the lack of previous theory. This fact composes the biggest difficulty in the research that we are going to present on the coming pages, but we have also faced the complexity of carrying out a study which covers a

Finally, and briefly previously mentioned, it seems necessary to know in depth how the problems of ADHD affect written composition. It also seems necessary to answer the question or assumption of a link or/and an overlap, of the learning difficulties in written composition and how ADHD is affecting other LD such as in mathematics or in reading (Miranda, Meliá-de Alba, Marco-Taverner, Roselló, & Mulas, 2006), specifically when it comes to learning disabilities in mathematics LDM. Fletcher (2005) considers that the combination of LDM and ADHD seems to be linked; a child with these problems is affected by the typical learning difficulties in both diagnoses. The outline of the cognitive test results of children suffering from control group and ADHD were similar, but with a different

Presently, are necessary analyzing theoretical models of writing with a view to considering possible connections between writing and ADHD. This connection is not proposed directly by the theoretical models, but given the types of components they include we can make some inferences that will help us to better understand the relationship of overlap or comorbidity between ADHD and LD in writing, for example (Rodríguez et al., 2010). We have seen that the main theories on writing and the main theories on ADHD include aspects that are related to each other. And throughout these theories we can support a common base to explain the relation between the two problems. With this theoretical approaching we have answered another of the theoretical problems, which was to analyse the link between different theories on written composition and theories on ADHD, and also with recent

variety of complex structures, such as ADHD and writing.

**2.1 Prevalence data and epidemiology** 

trends of diagnosis and intervention in this disorder.

outline both within group of LDM as well as between ADHD and LDM.

important and relevant.

ADHD. We also need to provide them strategies that can help in their day-to-day life since there is still no total solution to the problem.

On the other hand, another reason for this chapter is the link this diagnosis presents with other problems or difficulties, as supported by a number of studies (comorbidity with anxiety disorders, bipolar disorder, ODD, etc.). In these studies it is stated that the overlap of the ADHD might be up to 80 per cent with two or three or even more developmental disorders (Kaplan, Dewey, Crawford, & Wilson, 2001). Considering the high prevalence and the large overlap, and that the people suffering from ADHD shows a lack of control of their impulses, it is probable that this will be shown in the written composition.

It is known that writing requires thinking about the aim, the readers, the rhetorical elements, outline, details, complexity, result, coherence, etc. (Alamargot & Chanquoy, 2001; García & de Caso, 2002; Kellogg, 1994; Munro & Howes, 1998; Torrance & Galbraith, 2006; Wong, 2000). Furthermore, the written composition is a complex process that includes having a lot of information in the long term memory and keeps that in mind during the whole process of work, at the same time as one plan, create and revise the ideas. All these activities require a high standard on the attention system and on the working memory, which gives as a result that children suffering from ADHD commit syntactic errors, coherence errors, and that they use a simple structure and a very basic vocabulary (Gregg, Coleman, Stennett, & Davis, 2002).

On the other hand, the short time of planning and supervision of the work produced by students with ADHD, using processes of writing that are very fixed and basic, also influences the final result in a negative way with the creation of short stories in which some of the most fundamental components are omitted and with low coherence. In this point double theory comes, the first one is if the difficulties in writing are secondary problems of the ADHD or are problems related with, and the second one is about the way oneself could interfere and contribute to solve these difficulties.

Considering it in this way, the effective writer chooses, adopts or invents strategies that will improve his aims (Buttler, Elaschuk & Poole, 2000; de la Paz, 1999, 2001), that is, in an autosettled way (Graham & Harris, 2000), which implies an efficient use of the cognitive ways, such as the reflexive. The intervention focused on improving the strategy of the reflexive process is important and interesting, as well as the cases of overlapping between the ADHD and problems with written composition.

We have to consider the fact that the mental effort and the attention resourses are limited when written assignments are being carried out (Alamargot & Chanquoy, 2001). This implies that several processes have to be considered at the same time (the search for a letter, the theme, the ideas, the readers, or the general plan of the written composition) and in a auto-settled and developing way (García & Fidalgo, 2003); which gives the result that if someone has attention difficulties this would be reflected in the written composition, and also in the complex process of writing (Gregg et al., 2002).

These research studies show us the need and relevancy of going deeper into the research about the overlap between the ADHD and the learning difficulties, since very few researchers have tried to identify the relationship between different frequent subtypes amongst students suffering from ADHD and LD, that is, extending current studies (Gregg et

ADHD. We also need to provide them strategies that can help in their day-to-day life since

On the other hand, another reason for this chapter is the link this diagnosis presents with other problems or difficulties, as supported by a number of studies (comorbidity with anxiety disorders, bipolar disorder, ODD, etc.). In these studies it is stated that the overlap of the ADHD might be up to 80 per cent with two or three or even more developmental disorders (Kaplan, Dewey, Crawford, & Wilson, 2001). Considering the high prevalence and the large overlap, and that the people suffering from ADHD shows a lack of control of their

It is known that writing requires thinking about the aim, the readers, the rhetorical elements, outline, details, complexity, result, coherence, etc. (Alamargot & Chanquoy, 2001; García & de Caso, 2002; Kellogg, 1994; Munro & Howes, 1998; Torrance & Galbraith, 2006; Wong, 2000). Furthermore, the written composition is a complex process that includes having a lot of information in the long term memory and keeps that in mind during the whole process of work, at the same time as one plan, create and revise the ideas. All these activities require a high standard on the attention system and on the working memory, which gives as a result that children suffering from ADHD commit syntactic errors, coherence errors, and that they use a simple structure and a very basic vocabulary (Gregg,

On the other hand, the short time of planning and supervision of the work produced by students with ADHD, using processes of writing that are very fixed and basic, also influences the final result in a negative way with the creation of short stories in which some of the most fundamental components are omitted and with low coherence. In this point double theory comes, the first one is if the difficulties in writing are secondary problems of the ADHD or are problems related with, and the second one is about the way oneself could

Considering it in this way, the effective writer chooses, adopts or invents strategies that will improve his aims (Buttler, Elaschuk & Poole, 2000; de la Paz, 1999, 2001), that is, in an autosettled way (Graham & Harris, 2000), which implies an efficient use of the cognitive ways, such as the reflexive. The intervention focused on improving the strategy of the reflexive process is important and interesting, as well as the cases of overlapping between the ADHD

We have to consider the fact that the mental effort and the attention resourses are limited when written assignments are being carried out (Alamargot & Chanquoy, 2001). This implies that several processes have to be considered at the same time (the search for a letter, the theme, the ideas, the readers, or the general plan of the written composition) and in a auto-settled and developing way (García & Fidalgo, 2003); which gives the result that if someone has attention difficulties this would be reflected in the written composition, and

These research studies show us the need and relevancy of going deeper into the research about the overlap between the ADHD and the learning difficulties, since very few researchers have tried to identify the relationship between different frequent subtypes amongst students suffering from ADHD and LD, that is, extending current studies (Gregg et

impulses, it is probable that this will be shown in the written composition.

there is still no total solution to the problem.

Coleman, Stennett, & Davis, 2002).

interfere and contribute to solve these difficulties.

also in the complex process of writing (Gregg et al., 2002).

and problems with written composition.

al., 2002). The research about the overlap seems very relevant if we look at it from the developing and intervention point of view. Concentrating on the context and the various components and considering the main problem the lack of ability of self-regulation and control of impulses (Barkley 1997a, 1997b, 1998, 2001; Miranda & Presentación, 2000) and do that in relation with writing. For example, according to the theory of Barkley (1997a; 1997b), the problem that people suffering from ADHD presents is a lack of behavioural inhibition which affects four important executive functions (working memory; self-regulation of affection/motivation/activation; language internalization; and reconstitution); all of which affect the force/fluency/syntax control of the behaviour. It is predictable that we can achieve some understanding about the problem that these people suffer from by doing a research on written composition, but we also need more specific and in-depth research. Furthermore, there is a lack of research which considers the educational point of view of the overlap between ADHD and the written composition, and here is where this research line is important and relevant.

It is to be stressed, - and it might seem shocking - that with these premises the research about the ADHD and writing have not been done with nearly the depth that these facts imply. In the same way, it is one of the important limitations we have found in the making of this work; the very few previous researches to study, and the lack of previous theory. This fact composes the biggest difficulty in the research that we are going to present on the coming pages, but we have also faced the complexity of carrying out a study which covers a variety of complex structures, such as ADHD and writing.

Finally, and briefly previously mentioned, it seems necessary to know in depth how the problems of ADHD affect written composition. It also seems necessary to answer the question or assumption of a link or/and an overlap, of the learning difficulties in written composition and how ADHD is affecting other LD such as in mathematics or in reading (Miranda, Meliá-de Alba, Marco-Taverner, Roselló, & Mulas, 2006), specifically when it comes to learning disabilities in mathematics LDM. Fletcher (2005) considers that the combination of LDM and ADHD seems to be linked; a child with these problems is affected by the typical learning difficulties in both diagnoses. The outline of the cognitive test results of children suffering from control group and ADHD were similar, but with a different outline both within group of LDM as well as between ADHD and LDM.

## **2.1 Prevalence data and epidemiology**

Presently, are necessary analyzing theoretical models of writing with a view to considering possible connections between writing and ADHD. This connection is not proposed directly by the theoretical models, but given the types of components they include we can make some inferences that will help us to better understand the relationship of overlap or comorbidity between ADHD and LD in writing, for example (Rodríguez et al., 2010). We have seen that the main theories on writing and the main theories on ADHD include aspects that are related to each other. And throughout these theories we can support a common base to explain the relation between the two problems. With this theoretical approaching we have answered another of the theoretical problems, which was to analyse the link between different theories on written composition and theories on ADHD, and also with recent trends of diagnosis and intervention in this disorder.

Attention Deficit Hyperactivity Disorder (ADHD) and Writing Learning Disabilities 53

evaluation, it would not be entirely enough to do a diagnosis of ADHD. Some of the aspects, such as the sustained attention, would need other tests to be able to state a diagnosis, and

Even so, our purpose was not to state a diagnosis but to simulate situations from school as much as possible. The evaluation and diagnosis have been put together by a professional that knows about the methods of investigation and testing to make a diagnosis, this is of

Finally, another purpose of this chapter is to know epidemiological data of our sample, since it is broad and has an important clinical support. In first place we wanted to know if the ratio male-female correspond to other international studies (Egger, Kondo, & Angold, 2006). The results correspond almost exactly, having a percentage of an 80.8 per cent male and 19.2 per cent female in the sample, which correspond to the ratio of four to one explained in

Other interesting aspect (Willcutt & Pennington, 2000) has to do with the percentage of children suffering from ADHD who present LD in writing. Generally, a 59.59 per cent of the children suffering from ADHD suffer also from LD in writing in function of the criteria used, and the remaining 40.4 per cent have not LD in writing. Table 1 shows a summary of

**ADHD** 

**Total** 59/ 59,59% 40/ 40,4% Ratio male/female

Finally, all the theoretical revision and the empiric studies on ADHD do not answer the question if the relation between ADHD and learning disabilities in writing is possibly an overlap or link. It is a question that is yet not answered, and therefore, with this research, we hope to make progress in answering it, although not completely. We will later extend and reflect on the conclusions we have made on this topic but it is essential to stress that we can partly be satisfied with the results we have made regarding this, and with the partial

In short, the theoretical perspective of this chapter has served to let us know about the concept of ADHD, a concept that is under change and that is in need of empirical studies to narrow its current gap. Even so, we have gotten to know a theoretical model which has been of great use, and which we have also been able to apply to our study field. We have also given the disorder a psycho-educational approach, both in terms of diagnosis as well as

ADHD: attention deficit and hyperactivity disorder (ADHD), WLD: writing Learning Disabilities

**Male** 50/ 50,5% 30/ 30,30% 80/ 80,8 **Female** 9/ 9,09% 10/ 10,10% 19/ 19.19%

**without LD WLD** 

4 a 1

for that purpose an individual evaluation would then have been more adequate.

great interest and applicability (Álvarez et al., 2007).

**ADHD with WLD** 

Table 1. Epidemiological data of the sample, total and percentage

other epidemiological studies.

these epidemiological data.

achievement of our aim.

intervention, agreeing with our aims.

Secondly, this research line has also opened a way for a future link between the theories on ADHD and the theories on written composition, since we have seen that both models fit with each other in several ways, above all when it comes to the working memory and the executive function (Rodríguez et al., 2010). We can also see that the expected growing importance of the working memory and the attention, within what is called s*luggish cognitive tempo* as a difference to the inattentive subtype in ADHD, make these relations increase since basically all theories support on the working memory, such as the ones of Kellogg or Hayes. They consider this subtype to be the most probable of all three subtypes to have learning disabilities in writing (Rodríguez et al., 2011a; Seidman, Biederman, Monuteaux, Valera, & Doyle, 2005).

As we have known throughout the theoretical support of this line, the whole scientific world agrees on that the problems of ADHD and LD on writing are frequently related. We have also seen this in the analysis of the theories on this type, which are also backed up by empiric studies (Holowenko, & Pashute, 2000; Kadesjö & Gillbert, 2001; Mayes, Calhoun, & Crowell, 2000).

On the one hand the link between ADHD and writing on a theoretical level and on the other on a field research level, contrast the influence of ADHD in school, being one of the most important disorders causing LD in writing. We can also see that these theories are not backed up by scientific empiric studies in this aspect (Rodríguez et al., 2011b).

In this sense we had the aim to find out about the current state of investigation and empiric studies on writing and ADHD. When investigating this it has been found that the scientific research in this aspect – the link between ADHD and writing – was generally limited to mechanical aspects of this ability, simple aspects such as the graph. The few times it is done on a deeper level the samples are not broad enough, or they are based on studies epidemiological or a questionnaire to define the child suffering from ADHD. One could say that generally, the underlying processes to ADHD are neither analysed nor profoundly studied, but studied in a wide, general way and not deeply (Ambalavanan & Loteen, 2005).

An important aspect to consider, and an implication in this chapter, has to do with something very important when this research began, and is based on the aim of analysing new tendencies in the diagnosis and intervention on ADHD, and to put this in relation to problems added to this disorder, specifically LD in writing.

In first place, the sample that we have used in the greater part of our empiric study, consists of a group of children who are clinically diagnosed with ADHD. That can show us, by analysing the results of these children, whether these diagnoses are generally correct. We can also see, if there within the group of children with LD are cases without diagnosis, how the problems of diagnosis are reflected in the comparing analysis of the results of attention, working memory, etc. If we look at the two groups comparing the results, they are quite similar, which is why we consider the diagnosis to be correct. Even so, in the future it would be possible to adjust the group of children with LD a little, trying to find possible cases of ADHD, and then the differences might be bigger.

We also have to mention that even though the tests used to measure the aspects related to ADHD, such as attention and working memory, are many - with the results of a large

Secondly, this research line has also opened a way for a future link between the theories on ADHD and the theories on written composition, since we have seen that both models fit with each other in several ways, above all when it comes to the working memory and the executive function (Rodríguez et al., 2010). We can also see that the expected growing importance of the working memory and the attention, within what is called s*luggish cognitive tempo* as a difference to the inattentive subtype in ADHD, make these relations increase since basically all theories support on the working memory, such as the ones of Kellogg or Hayes. They consider this subtype to be the most probable of all three subtypes to have learning disabilities in writing (Rodríguez et al., 2011a; Seidman, Biederman, Monuteaux,

As we have known throughout the theoretical support of this line, the whole scientific world agrees on that the problems of ADHD and LD on writing are frequently related. We have also seen this in the analysis of the theories on this type, which are also backed up by empiric studies (Holowenko, & Pashute, 2000; Kadesjö & Gillbert, 2001; Mayes, Calhoun, &

On the one hand the link between ADHD and writing on a theoretical level and on the other on a field research level, contrast the influence of ADHD in school, being one of the most important disorders causing LD in writing. We can also see that these theories are not

In this sense we had the aim to find out about the current state of investigation and empiric studies on writing and ADHD. When investigating this it has been found that the scientific research in this aspect – the link between ADHD and writing – was generally limited to mechanical aspects of this ability, simple aspects such as the graph. The few times it is done on a deeper level the samples are not broad enough, or they are based on studies epidemiological or a questionnaire to define the child suffering from ADHD. One could say that generally, the underlying processes to ADHD are neither analysed nor profoundly studied, but studied in a wide, general way and not deeply (Ambalavanan &

An important aspect to consider, and an implication in this chapter, has to do with something very important when this research began, and is based on the aim of analysing new tendencies in the diagnosis and intervention on ADHD, and to put this in relation to

In first place, the sample that we have used in the greater part of our empiric study, consists of a group of children who are clinically diagnosed with ADHD. That can show us, by analysing the results of these children, whether these diagnoses are generally correct. We can also see, if there within the group of children with LD are cases without diagnosis, how the problems of diagnosis are reflected in the comparing analysis of the results of attention, working memory, etc. If we look at the two groups comparing the results, they are quite similar, which is why we consider the diagnosis to be correct. Even so, in the future it would be possible to adjust the group of children with LD a little, trying to find possible cases of

We also have to mention that even though the tests used to measure the aspects related to ADHD, such as attention and working memory, are many - with the results of a large

backed up by scientific empiric studies in this aspect (Rodríguez et al., 2011b).

problems added to this disorder, specifically LD in writing.

ADHD, and then the differences might be bigger.

Valera, & Doyle, 2005).

Crowell, 2000).

Loteen, 2005).

evaluation, it would not be entirely enough to do a diagnosis of ADHD. Some of the aspects, such as the sustained attention, would need other tests to be able to state a diagnosis, and for that purpose an individual evaluation would then have been more adequate.

Even so, our purpose was not to state a diagnosis but to simulate situations from school as much as possible. The evaluation and diagnosis have been put together by a professional that knows about the methods of investigation and testing to make a diagnosis, this is of great interest and applicability (Álvarez et al., 2007).

Finally, another purpose of this chapter is to know epidemiological data of our sample, since it is broad and has an important clinical support. In first place we wanted to know if the ratio male-female correspond to other international studies (Egger, Kondo, & Angold, 2006). The results correspond almost exactly, having a percentage of an 80.8 per cent male and 19.2 per cent female in the sample, which correspond to the ratio of four to one explained in other epidemiological studies.

Other interesting aspect (Willcutt & Pennington, 2000) has to do with the percentage of children suffering from ADHD who present LD in writing. Generally, a 59.59 per cent of the children suffering from ADHD suffer also from LD in writing in function of the criteria used, and the remaining 40.4 per cent have not LD in writing. Table 1 shows a summary of these epidemiological data.


ADHD: attention deficit and hyperactivity disorder (ADHD), WLD: writing Learning Disabilities

Table 1. Epidemiological data of the sample, total and percentage

Finally, all the theoretical revision and the empiric studies on ADHD do not answer the question if the relation between ADHD and learning disabilities in writing is possibly an overlap or link. It is a question that is yet not answered, and therefore, with this research, we hope to make progress in answering it, although not completely. We will later extend and reflect on the conclusions we have made on this topic but it is essential to stress that we can partly be satisfied with the results we have made regarding this, and with the partial achievement of our aim.

In short, the theoretical perspective of this chapter has served to let us know about the concept of ADHD, a concept that is under change and that is in need of empirical studies to narrow its current gap. Even so, we have gotten to know a theoretical model which has been of great use, and which we have also been able to apply to our study field. We have also given the disorder a psycho-educational approach, both in terms of diagnosis as well as intervention, agreeing with our aims.

Attention Deficit Hyperactivity Disorder (ADHD) and Writing Learning Disabilities 55

this could lead to the creation of a specific model which accounts for both aspects, as a first

This research line exampled in this chapter would be both important and relevant, as it is a study into ADHD and writing LD covering the various aspects which link these disorders using various research designs. In the first place, children with normal development (cuasiexperimental study in attention and writing) are the subject. Secondly, ADHD children both with and without writing LD and without both problems, in attention, writing revision and working memory measurements (first comparative study) are the aim of investigation, and finally the attention is given to the writing product, processes and its orchestration (second

First study aims to describe the role that attention plays in the writing process. The independent variables are subjected to different kinds of manipulation in the evaluation of written compositions. We investigated the effect of different psychological aspects related to ADHD in the main processes involved in composition writing. We also introduced aids, such as graphic organizers, in an attempt to understand its adaptability in the changing tasks of writing, and to show its merit when it comes to facilitating the textual planning and

This study comprised a sample of 326 pupils, aged between 10 and 16 years old, in the 5th and 6th years of Primary School and in the 1st and 2nd years of Secondary School. We used a nest experimental design; we compared the two groups, one of which made use of the graphic organizer during the writing process Each of these groups is divided in two, and evaluated using a register of time intervals, with an average interval of 45 seconds for one group and 90 seconds for the other one, marked by a beep sounded during the realization of the writing task. The pupils must register their activity in the process categories when the

All the participants completed two different writing tasks (argumentative and cause-effect) in order to assess the productivity, quality and structure, as well as the writing processes. A *writing log* which is a time-sampled self-report on-line technique was employed (modified double and triple task) (Olive, Kellogg, & Piolat, 2002; Torrance & Galbraith, 2006). Finally, we tested in the class groups the influence of variables related to ADHD (sustained and

The results illustrate the negative effect of the interval register used during the use of writing log. It was found that a lower average provides greater information but, at the same time it distorts the task and the obtained results. This may be a result of the greater cognitive effort that the double task requires. We also studied the extent of the practical use of the graphic organizer during the writing tasks, and the consequent improvement in the compositions of the students using it. The results we had confirmed the achievement of the aim, but the most important results are that they indicate very interesting applications and

Finally, it is important to highlight that the positive influence of the planning and organization of the graphic organizer is superior to the distortion provoked by a lower

selective attention, ADHD symptoms, DSM-IV and working memory).

future prospects, and of great applicability.

step in future research (Rodríguez et al., 2009a; 2009b)

comparative study).

organization.

beep is heard.

**3.1 Experimental study** 

On the other hand, we have focused and related ADHD with other of our main topics in our work, such as LD in writing. The epidemiological relations between both of the problems, and the theoretical relation, seem symptomatic. This conclusion has no empiric support, which creates a gap that we hope to fill with this chapter, even if it is only a little.

With all previously mentioned facts, we have covered partial conclusions. It has also served as an introduction to explaining the conclusions made from our empiric studies, and as will follow we will explain this in a reflexive way. These conclusions are based on the results in the field studies, and keeping in mind the theoretical conclusions we hope to have answers to out aims.
