Hammill Institute on Disabilities

Attention-Deficit Hyperactivity Disorder (ADHD) and Learning Disabilities Author(s): Cynthia A. Riccio, Jose J. Gonzalez and George W. Hynd Reviewed work(s): Source: Learning Disability Quarterly, Vol. 17, No. 4, Social-Emotional Development (Autumn, 1994), pp. 311-322 Published by: Sage Publications, Inc. Stable URL: http://www.jstor.org/stable/1511127 . Accessed: 03/08/2012 06:30
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ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) AND LEARNING DISABILITIES

Cynthia A. Riccio, Jose J. Gonzalez, and George W. Hynd
Abstract. The overlap between Attention-Deficit Hyperactivity Disorder (ADHD) and learning disabilities is consistently reported in the literature. The relationship between attention and cognitive and behavioral functioning makes it difficult to disentangle behavioral from cognitive symptoms in children with learning disabilities. Historically, research on ADHD in children with learning disabilities has been wrought with methodological inconsistencies and is further confounded by the comorbidity of learning disabilities and ADHD. This article reviews the research specific to the relationship between learning disabilities and attention deficit disorders, both historical and current. Implications for future research relative to the increased specificity of the association between these disorders is discussed, with a focus on the need to decrease the heterogeneity of the populations studied by using subtypes of both learning disabilities and ADHD.

HISTORICAL PERSPECTIVE To fully appreciate the dilemma facing researchers studyingchildrenwith learningdisabilities (LD) and/or Attention-DeficitHyperactivity Disorder (ADHD), it is important to understand the histories of these disorders.Controversysurrounding the relationship between ADHD and LD can be traced to the turn of the centurywith the amalgamation of both disorders within the categorizationof MinimalBrain Damage (MBD) (Epstein, Shaywitz, Shaywitz, & Woolston, 1991). Gradually,the concept of MBD was recognized as vague, overinclusive, and of little or no prescriptivevalue (Barkley,1990; Shaywitz& Shaywitz, 1991). With the elaborationof researchdiagnosticcriteria, described initially in the Diagnostic and Statistical Manual II (DSM II:American Psychiatric Association [APA], 1968) and later in DSM III(APA, 1980) and DSM III-R (APA, 1987), significantadvances were made in differentiating attention deficits and hyperactivityfrom learning disabilities and replacing the classification of MBD by more circumscribed learningand behav-

ior disorders.Beginning with the DSM III,learnwere categorizedas Specific Develing disabilities opmental Disabilitieswhile attention deficit disorders were categorized with DisruptiveDisorders of Children,a distinctionthat was maintainedin the DSM III-R (APA, 1980, 1987). Despite these advances in diagnostic nomenclature, the intrinsicrelationshipbetween attention and cognitive and behavioral functioning makes it difficultto disentangle behavioralfrom cognitive symptoms in children affected with either disorder(Epsteinet al., 1991). This difficulty becomes increasingly evident in this review of CYNTHIAA. RICCIO,Ph.D., is a post-doctoral fellow, School of Professional Studies, University of Georgia. JOSE J. GONZALEZ,M.A., is a doctoral student, Educational Psychology/School Psychology, Universityof Georgia. GEORGEW. HYND, Ed.D., is Research Professor, School Psychology and Special Education, Universityof Georgia.
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current diagnostic nomenclature and issues as relevantto ADHD and LD. well as the literature While previous changes in diagnosticclassification were intended to separate ADHD and learning disabilities, the more recent definition of learning disabilities offered by the Interagency is Committee on LearningDisabilities (ICLD) criticized for having the opposite effect, that of again confusing the issues involved with these disorders. In its report on the status of learning the disabilities, ICLDcontinuedthe historicalpreare sumption that learningdisabilities due to central nervous system dysfunction (ICLD, 1987). However, the ICLD definition added two new components to the definitionof learningdisabilities, thereby blurringthe distinctionbetween attention deficit disorders and learning disabilities attained in the DSM III. ICLD defined learning as disabilities a "genericterm that refers to a heterogeneous group of disordersmanifestedby significant difficultiesin the acquisition and use of listening,speaking, reading,writing,reasoning or mathematicalabilities,or of social skills."(ICLD, 1987, p. 222). The addition of "socialskills"to the definition has met with some criticism(Fomess & Kavale, 1991). One aspect of this criticismis that the use of social skillsdeficitsas a diagnosticcriterionfor learningdisabilitiesblursthe boundariesbetween learningand behavior disordersonce again (Forness & Kavale, 1991). A second added component of the ICLDdefinitionwas that learningdisabilities may co-exist with attention deficit disorder,furtherblurringpossible distinctionsbetween the disorders. As with the definitionand report of the ICLD, definitions of learning disabilities(e.g., National Joint Committee on Learning Disabilities [NJCLD]; Hammill, Leigh, McNutt, & Larsen, 1981; Wyngaarden, 1987) continue to lack accepted operational criteria (Hynd, Marshall, & Gonzalez, 1991), althoughacknowledginga neurologicalbasis of learningdisorders,their heterogeneity, and pervasivenature. of Changes in the diagnosticclassification attention deficitdisordersin the revisionof the DSM III may also contributeto the confusion. In the DSM between AttentionDeficit III,criteriadistinguished Disorder without Hyperactivity(ADD/WO) and Attention Deficit Disorder with Hyperactivity (ADD/H). Behavioral measures, particularly teacher ratingscales, reliably and meaningfully dif312 Learning Disability Quarterly

ferentiatechildreninto these subtypes(Edelbrock, Costello, & Kessler, 1984; Hynd, Lorys-Vemon, Semrud-Clikeman,Nieves, Huettner, & Lahey, 1991; Lahey, Schaughency, Frame & Strauss, 1985; Lahey, Schaughency, Hynd, Carlson, & Nieves, 1987). However, the DSM III-Rblurred the distinctionbetween subtypesinto what is now referredto as ADHD, despite the research supportingthe existence of the subtypes, at least behaviorally.Accumulatingevidence suggests that childrenwith ADD/WO are at significantrisk for academic failure (Berry, Shaywitz, & Shaywitz, 1985; Hynd et al., 1991; Sandoval & Lambert, 1984-1985). It is suggested, however, that it is the hyperactivity,rather than attentionaldifficulties, that is being used as a markerto identifychildren as ADHD or LD (Berryet al., 1985; Sandoval & Lambert,1984-1985). Current school identification procedures rely or heavilyon the presence of hyperactivity other behavior(Epsteinet al., 1991). The externalizing implicationis that childrenwho may have purely attentionaldifficulties,and as a result experience concurrentacademic difficulties,but are not hyperactive, may not be identified.Or if identified, they will be identified as LD. Therefore, unADD/WO may represent an underidentified, of childrenwho are at significant derservedgroup risk for long-term academic, social, and emotional difficulties (Epstein et al., 1991). It has been suggested that ADD/WO might actually represent inattention that might accompany or occur secondarily to nonverbal learning disabilities (Barkley,McMurray, Edelbrock,& Robbins, 1987). The controversy regardingthe existence of distinct subtypes within ADHD as well as the difficulty of differentiating between attentional disordersand learningdisabilitiesmay reflect the overlap between the construct of attention and both cognitive and behavioral domains (Shaywitz,Schnell, Shaywitz,& Towle, 1986). While attempting to separate ADHD from recent clarification the staof learningdisabilities, tus of ADHD as a handicappingcondition by the United States Department of Education (DOE) acknowledged the possible co-existence of ADHD with other handicapping conditions (Davila,Williams,& MacDonald, 1991). Specifically, the DOE acknowledged awareness that ADHD can resultin learningproblems;yet at the same time, the DOE did not feel that ADHD needed to be added as a separate disabilitycate-

gory nor as a specific learningdisability. It is first argued that in those children for rewhom ADHD (a chronic or acute impairment) in limited alertness, special education and sults related services can be provided on the basis of ADHD within the "other health impaired"category. Yet, it is clearlystated that medicaldiagnosis of ADHD alone is not sufficientto render a child eligible for services. Identificationof what constitutes ADHD as a chronic or acute impairment is not, however, operationallydefined but indicatedas a full and individual evaluationof the child's educational needs. The DOE further stated that childrenwith ADHD are also eligible for services under the category of learning disabled or emotionallydisturbedif they satisfy the specific category criteria (Davila et al., 1991). Consequently,the DOE acknowledgedthe possible co-existence of ADHD and learningdisability in some children. Methodological Issues As a resultof definitionalchanges and a lack of consensus on diagnosticcriteriafor both LD and ADHD, there has been a paucity of research utichildren lizing well-defined,non-system-identified with learning disabilities, wherein diagnoses of both LD and ADHD are made on the basis of rigorouscriteria(Epsteinet al., 1991). Studies on the personality and behavioral characteristicsof childrenwith LD, as well as studies with children with ADHD, are markedby inconsistenciesin diagnostic methodologies (August & Garfinkel, 1989; Bender, 1987; Biederman, Newcorn, & Sprich, 1991; Epps, Ysseldyke, & Algozzine, 1983; Halperin & Gittelman, 1982). Not only are there differences in measures used to assess cognitive, academic, attentional, and psychosocial variables(Biedermanet al., 1991), there are also inconsistencies in the methodology, or the criterion, used in diagnosing LD, which may result in identification of differing groups of children (Kamphaus, Frick, & Lahey, 1991; Semrud-Clikeman,Biederman, Sprich-Buckminster, Lehman, Faraone, & Norman, 1992). Additional methodological problems occur in the operational definition of attention (Anthony, Mersky, Ahearn, Kellam, & Eaton, 1988; Fletcher, Morris, & Francis, 1991). Thus, research studies vary in the manner in which they define and measure this construct(e.g., sustained attention, focused attention, span of apprehension, attentionalshift),yet are frequentlyreferred

to in the literatureunder the global term of "attention" (Fletcheret al., 1991). These inconsistencies may underlie the conflicting results surroundingpersonalityand behavioralproblems in childrenwith LD as well as cognitive impairment associated with children with ADHD. Additionally, the co-occurrenceof LD with ADHD further clouds results of comparisons between the two groups. With these limitationsin mind, research on the relationshipbetween ADHD and LD will be reviewed. SHARED CHARAC1tEKISTICS OF CHILDREN WITH ADHD AND CHILDRENWITH LD It has been suggested that learning disabilities involve a number of components, includingcognitive, attentional, and behavioral deficits (Copeland & Wisniewski, 1981; Coplin & Morgan, 1988; Kavale& Nye, 1985). Generally,research consistentlydemonstratesthe presence of attentional and behavioral problems in children with learning disabilities,including hyperactivity and impulsivity(Bender, 1985a, 1985b, 1986; Cullinan, Epstein, & Lloyd, 1981; Hiebert, Wong, & Hunter, 1982; McKinney& Feagans, 1983, 1984; Swanson, 1981). Literatureon sustained and selective attention as well as distractibility childrenwith learning in disabilities indicates that, at least descriptively, children with LD often show attentional deficits (Douglas & Peters, 1979; Hallahan & Reeve, 1980; Kupietz, 1990). Impulsivityas a descriptive characteristic also been demonstratedin has children with LD (Campbell, Douglas, & Morganstem, 1971; Walker,1985). Psychosocial Functioning Research exploring personality subtypes of children with LD using cluster analysis consistently identifiesa subgroupwho demonstratesattentional and/or mild hyperactivity problems (Fuerst,Fisk, & Rourke, 1989, 1990; McKinney & Speece, 1986; Williams,Gridley,& FitzhughBell, 1992). For example, McKinney and Speece's (1986) cluster analysis of 47 children with LD resulted in five subtypes of behavior low problems:conduct problems,withdrawal, frequency of positive behavior, attentional deficits, and global behavior problems. Although all children had learning disabilitiesbased on a simple discrepancyformula,the group identifiedas having attentional and global behavior problems
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demonstratedthe poorest achievement outcomes & (McKinney Speece, 1986). In the absence of a control group, however, the extent to which these subtypes are particular to childrenwith LD cannot be determined. Further, the presence of these particularsubtypes has not been replicated in other studies using similarmethodologies (Fuerstet al., 1989, 1990; Williamset al., 1992). Overall,given the range of psychosocial subtypes identifiedacross studies, it can be concludedthat childrenwith LD comprise a heterogeneous population in terms of psychosocial functioning, with some members demonstratingbehaviors that are consistent with ADHD (Fuerst et al., 1989; McKinney & Speece, 1986; Williamset al., 1992). Academic Functioning Studies comparing the academic achievement of childrendiagnosed as ADHD with that of controls consistently support the notion that significantly more childrenwith ADHD experience academic achievement problems and that they may remain impaired in academic areas as they get older (August & Garfinkel, 1990; Cantwell, 1978; Cantwell & Satterfield, 1978; Fischer, Barkley,Edelbrock,& Smallish, 1990; Holborow & Berry, 1986a; Lambert & Sandoval, 1980; McGee, Williams,Moffitt,& Anderson, 1989). It has not yet been determinedwhether school failure in children with ADHD is related to attention/hyperactivity,cognitive deficits (leaming disabilities), or a combination (Biederman et al., methods 1991). Research utilizingfactor-analytic has identifiedseparate LD and hyperactivity factors in academic achievement problems. However, no single study has addressed both cognitive and behavioralfactors simultaneously (Lahey et al., 1988; Lahey, Stempniack, Robinson, & Tyroler, 1978; Mason & Wenck, 1989). Others have identified language-baseddeficits in reading disability a common thread (August as & Garfinkel, 1989, 1990). Further,it has been arguedthat there are few differencesbetween the two groups (Ackerman,Anhald, Dykman,& Holcomb, 1986; Felton, Wood, Brown, Campbell, & Harter, 1987; Halperin, Gittelman, Klein, & Rudel, 1984; Share & Schwartz, 1988). For example, Ackerman and colleagues compared three groups of children(readingdisabled, ADD with hyperactivity, ADD withouthyperand with normalcontrolstudents. Each group activity) consisted of 24 children, with reading disability
314 Learning Disability Quarterly

diagnosed based on IQ/achievement (word recognition) discrepancy, and ADD diagnosed based on the Conners' Teacher Questionnaire hyperkinesisindex and DSM III. Based on the unidimensional diagnosisof reading disabilityand ADD, all three clinical groups differedfrom controlsin memory for low-imagery as opposed to high-imagerywords as well as in of computationalefficiency (automatization math facts). Although a more conservative diagnostic procedure would have included multimethod, multisetting, and multimeasure assessment, results of this study as well as others (Feltonet al., 1987; Halperin et al., 1984) indicate similarities and a possible relationshipbetween learningdisabilitiesand ADHD. ADHD-LEARNINGDISABILITIES RELATIONSHIP resultsof many investigations indicate Although a relationship between LD and ADHD, the nature of such a relationshiphas not been well defined (Cantwell& Baker, 1991; Epstein et al., 1991; Shaywitz & Shaywitz, 1991). Three hypotheses are most frequentlyoffered regardingthe attentional and behavioral problems of children with LD. First,it has been suggestedthat their inattention, increased hyperactivity, and self-control problems may be related to, and presumablybe the result of, difficulties with academic performance (Merrell,1990; Torgesen, 1988). In particular,it has been suggestedthat inattentionmay be a nonspecific behavior resulting from the child'sreactionto learningdifficulty over time (August & Garfinkel, 1990; Weinberg & Emslie, numberof children 1991). However, a substantial with learningdisabilities not demonstrateattendo tional deficitsor hyperactivity response to acain demic frustration (Epsteinet al., 1991). Second, it has been hypothesizedthat inattention and hyperactivityprecede and impede academic performance (August& Garfinkel,1990). this Although, intuitively, seems likely,there is insufficient evidence to show that ADHD itself leads directly to learning problems. Besides, many childrenwith ADHD do not have learning disabilities (Epsteinet al., 1991). Third, it has been suggested that learning disabilitiesand ADHD are separate entitiesthat may co-occur (August & Garfinkel, 1990; Silver, 1990; Torgesen, 1988). It has not yet been establishedwhether this co-occurrenceis the result

of differencesin underlyingneurologicalfunctioning or underlying cognitive deficits per se or, more likely,differencesin underlying neurological functioning that result in common cognitive deficits in a subgroup of each of these populations (Epsteinet al., 1991; Shaywitz& Shaywitz, 1991). Research on this third hypothesis will be discussedin more detail. Comorbidity of The comorbidity ADHD and learningdisabilities is consistentlyreported in the literature(August & Holmes, 1984; Baker & Cantwell, 1990; Cantwell& Baker, 1991; Cantwell& Satterfield, 1978; Epstein et al., 1991; Holborow & Berry, 1986a; Lambert & Sandoval, 1980; SemrudClikeman et al., 1992; Shaywitz & Shaywitz, 1991). Some findings have uncovered such extensive overlaps that it has been suggested that the disorders may be indistinguishable(Prior & Sanson, 1986). Others have noted that the two disordersmay be independent,but can overlapin some individuals (Silver,1990; Torgesen, 1988). Silver (1990) suggested that the relationship between attentional problems and hyperactivity in a child or adolescent with a learningdisability is one of comorbidity with associated disorders (e.g., ADHD). Also, it has been reportedthat up to 20% of childrenwith LD are co-diagnosed as having ADHD (Halperin et al., 1984; Silver, 1981), while up to 65% of childrenwith LD, depending on age and sex, may demonstratedifficulties with inattention (Epstein, Cullinan, & Nieminen, 1984). Other studies have demonstratedthat among childrenwith significantleaming difficulty, 41% scored above criterion on measures of hyperactivity (Holborow & Berry, 1986a, 1986b; Safer & Allen, 1976). Baker and Cantwell (1987a, 1987b) studied the prevalenceof psychiatricand learningdisabilities in a sample of 600 childrenwith identified speech-language impairment(mean age of 5.6). At initialevaluation, 19% of the childrenwere diagnosed as ADD/H while 7% were diagnosed as learing disabled-both diagnoses were based on DSM IIIcriteria. Cantwelland Baker (1991) reportedthat of the 300 of these childrenwho were followed for 4-5 years, 91 were diagnosed as learning disabled while 53% met DSM IIIcriteriafor ADHD. Further, when subsamples of the initial group were drawn, with and without learning disability,and matched for age and PerformanceIQ levels, 63%

of the subsample with LD were diagnosed as ADHD compared to only 30% of the matched comparison group (Cantwell & Baker, 1991). Criterion for learning disabilitywas based on a discrepancy formula between Performance IQ levels and a single academic screener; ADD/H was diagnosedby a childpsychiatrist accordingto DSM IIIcriteria.Neither the exclusionarycriteria, if any, nor the methods utilizedby the child psychiatristare clearlyidentified(Baker& Cantwell, 1987a, 1987b; Cantwell& Baker, 1991). Conversely, when the subject population is childrenwith ADHD, the comorbidityof learning and ADHD ranges from 10% to 92% disabilities (Anderson,Williams,McGee, & Silva, 1987; August & Garfinkel, 1990; August & Holmes, 1984; Frick, Kamphaus, Lahey, Loeber, Christ, Hart, & Tannenbaum, 1991; Halperin et al., 1984; Holborow & Berry, 1986a; Lambert & Sandoval, 1980; McGee & Share, 1988; Semrud-Clikemanet al., 1992; Silver, 1981). The variabilityin results can be attributedto differences in selection criteria, sampling, and measurement instruments,as well as inconsistencies in criteriaused to define ADHD and LD in various studies (August & Garfinkel, 1989; Biederman et al., 1991; Halperin& Gittelman,1982). Semrud-Clikeman and colleagues (1982) reviewed previous studies of comorbidityand the ways in which learning disabilitieswere defined. Then, using three different methods of defining learningdisability,they studiedthe prevalence of learning disabilitiesin 60 ADHD children (mean age = 9.9), 30 childrenwho demonstratedacademic problems (mean age = 11.5), and 36 normal control children (mean age = 10.1). Based on a liberaldefinitionof LD (IQ/achievementdiscrepancy > 10), 38% of the subjectswith ADHD were identifiedas learningdisabled. Using two, more stringent definitions of LD (IQ/achievementdiscrepancy> 20; achievement standard score < 85, and IQ/achievementdiscrepancy > 15), the prevalencerates droppedto 23% for one method and 10% for the other. Further, the childrenidentifiedas LD by one of the more stringentmethods were not necessarilyidentified used affect by the liberalmethod. Thus, the criteria not only the prevalencerate, but also the children identified et (Semrud-Clikeman al., 1992). In addition to studies demonstrating that ADHD and LD can, and do, co-occur in some children, the underlyingnature of this co-occurVolume 17, Fall 1994 315

rence, in terms of a neurological basis and/or cognitive deficits, has also been investigated. In characattemptingto delineate the differentiating teristicsof LD and ADHD children,extensive research has been conducted comparing the two groups, and often also a third group of children identifiedas havingboth disorders. NEUROLOGICAL/ NEUROPSYCHOLOGICALBASIS Neurological Basis Spreen (1989) suggested that both learning disabilities and ADHD, or at least some forms of them, may have a common origin in neurological dysfunction. Evolving from ideas advanced by Strauss and Lehtinen (1947) and Cruickshank (1967) regarding the child with MBD, research continues to provide insight into the neurological and neuropsychologicalunderpinnings specific of as well as ADHD (Galaburda & learningdisability & Zappulla, Kemper, 1979; Greenblatt, Bar, & 1983; Hynd, Marshall, Gonzalez, 1991; Hynd & Semrud-Clikeman, 1989a, 1989b; Hynd, Semrud-Clikeman, Lorys, Novey, Eliopulos, & Lyytinen, 1991; Jernigan, Hesselink, Sowell, & Tallal, 1991; Larsen, Hoien, Lundberg,& Odegaard, 1990; Obrzut, Morris, Wilson, Lord, & Caraveo, 1987; Rourke, 1989; Semrud-Clikeman & Hynd, 1990; Semrud-Clikeman,Hynd, Novey, & Eliopulos,1991). A number of neuroanatomically based hypotheses have been advancedabout the brainregions that may be involved (e.g., be dysfunctional)in childrenwith ADHD and LD. Generally, these theories have implicated subcorticalstructures important in arousal, control of attention, and regulationof motor control (Laufer,Denhoff, & Solomons, 1957; Satterfield & Dawson, 1971). Others have proposed involvement of both subcorticaland corticofrontalsystems (Dykman, Ackerman, Clements, & Peters, 1971; Hynd et al., 1990; Mattes, 1980; Voeller& Heilman, 1988a, 1988b). Research specific to a common neurological basis for ADHD and learningdisabilities only has become possible with improved technology. Thus, recent neuroimaging studies have found that neither ADHD nor LD children demonstrated the frontal asymmetry typically found in normal controls (Hynd et al., 1990; Voeller & Heilman, 1988a, 1988b). Both the ADHD and the LD children had significantly smaller right
316 Learning Disability Quarterly

frontal widths than the normal control children. Further, comparison of left and right frontal widths suggested symmetry in the children with LD and those with ADHD in contrast to asymmetry in the controls. Additional research is needed in this area, however, to resolve the question of a shared underlyingneurologicalbasis for ADHD and LD. Neuropsychological and/or Cognitive Basis Based on neuropsychological measures, and interpretedas indicativeof underlyingneurological dysfunction,it has been concluded that both LD and ADHD childrenpresent problems of attentional performance (August & Garfinkel, 1990; Bryan & Bryan, 1978; Douglas & Peters, 1979; Dykman et al., 1971; Fleischer, Soodak, & Jelin, 1984; Levine, Busch, & Aufseeser, 1982; Rosenthal & Allen, 1978). LD children, however, are reported as having more difficulty with selective attention while children with ADHD have more problemswith sustainedattention (Cherry& Kruger,1983; Richards,Samuels, Turnure,& Ysseldyke, 1990; Tarnowski, Prinz, & Nay, 1986). Althoughit has also been suggestedthat the attentional problems of children with LD may diminish with age (Kupietz,1990), studies of selective attention have shown that both childrenand adultswith learningdisabilities demonstrateddifficulty on dichotic listeningtasks (Bowen & Hynd, 1988; Hynd, Cohen, & Obrzut, 1983; Hynd, Obrzut,Weed, & Hynd, 1979; Obrzut,Hynd, & Obrzut, 1983; Obrzut, Hynd, Obrzut, & Pirozzolo, 1981). Consequently,attentionalprocesses seem to be impairedin adultswith LD much the same as in childrenwith LD. In additionto variabletypes and extent of attentionaldeficits,the presence of a languagedisorder both LD and ADHD chilappears to characterize dren. It has been argued that language disorders and learning disabilities represent a continuum and are often only distinguished the child'sage by (Catts, 1989, 1991; Kamhi & Catts, 1986, 1989; Liberman& Shankweiler,1985; Vellutino, 1977, 1979), with languagedeficitsbeing the underlyingproblem in the majorityof childrenwith LD (Newhoff, 1990; Paul, 1992). In a study of children with LD, Gibbs and Cooper (1989) found that 91% demonstrated language impairments. In follow-up studies with children with language disorders, up to 45% of

the preschoolers followed had been identifiedas LD (Baker & Cantwell, 1982, 1987a, 1987b, 1990). Further, consistent with these findings, neurolinguisticdeficits have been noted among children with reading disabilities in particular (Hynd& Hynd, 1984). disorConversely,the most frequentpsychiatric with deficits in speech and lander associated guage is attention deficit disorder (Baker & Cantwell, 1987, 1990; Beitchman, Hood, & Inglis, 1990; Beitchman, Hood, Rochon, & Peterson, 1989; Beitchman, Nair, Clegg, Ferguson,& Patel, 1986; Love & Thompson, 1988). For example, Baker and Cantwell (1990) found that 37% of the children initiallyidentifiedas having speech and languagedeficitswere identifiedas attention deficit disordered on follow-up. Conversely, Love and Thompson (1988) noted that childrenwith atten48.3% of the clinic-diagnosed tion deficit disordersdemonstratedsome type of languagedisorder(expressiveand/or receptive). These findingsare consistent with other studies demonstratinga high incidence of language disorders in childrenwith attention deficit disorders (Chess & Rosenberg, 1974; Cohen, Davine, & Meloche-Kelly, 1989; Gualtieri, Koriath, van Bourgondien, & Saleeby, 1983). As such, linguistic development may represent a common thread between some LD and ADHD childrenat a cognitive level. At higher corticallevels, evidence suggests that some children with specific learning disabilities also demonstrate difficultywith executive functioning and/or strategic problem-solving (Douglas, 1980; Gioia, 1992; Levin, 1990; Snow, 1992), previously suggested as characteristicof children with ADHD and attributed to frontal lobe function (Benson, 1991). Thus, it has been hypothesized that dysfunctionalmental flexibility and planning skills necessary for strategic problem-solvingare pervasiveacross more traditional learning disabilitysubtypes and that this may be another factor contributing disruptedacademic to and/or social performance(Snow, 1992). Research on a neuropsychologicalsubtype of learning disabilityspecific to executive functiondeficitsis relatively ing/organizational recent; confurther research is warranted (Gioia, sequently, 1992). As with other aspects of researchon the association between learningdisabilities ADHD, and for these disorders and diagnostic methodology their frequent co-occurrence makes it difficultto

replicateresultsof researchin cognitioncomparing these disorders (McGee& Share, 1988). DISCUSSION AND IMPLICATIONSFOR FUTURE RESEARCH The importance of providingvalidatedcriteria for diagnosis of attention deficit disorders and learning disabilities cannot be overstated. Methodologicalproblems and inconsistent diagnoses, as well as prevalentcomorbidityof attentional deficits/hyperactivity with learningdisabilities make it difficult to interpret and replicate researchwith these populations.Further,conflicting findingsdue to variancesin samples, heterogeneity of the samples, and differingdiagnostic methods cloud and impede the advances in intervention-centeredassessment. In this regard, better and more consistent classification/diagnostic strategiesneed to be developed. Further examination of the attentional processes of homogeneous groups contained in ADHD and LD is also warranted. Research clearly indicates that there are subtypes of LD (e.g., Coplin & Morgan, 1988; Fisk & Rourke, 1983; Fuerst et al., 1989; Hooper & Willis, 1989; Hynd & Cohen, 1983) and ADHD (e.g., Hynd et al., 1991; Lahey et al., 1987; Lyon, 1985). The association may exist only between certain of these subtypes and/or for specific types of attentionaldeficits. Use of subtypes for comparison is necessary in studyingthe relationship between the disorders due to the heterogeneity of the populationsthat demonstrateboth disorders. In contrast, multivariateprocedures, which are frequentlyused, assume homogeneity of groups; violationof this assumptioncan invalidate statisticalfindings(Mason& Wenck, 1989). Longitudinalprospective research of subtypes of both disorders, which follows children from early years through childhood and examines the becontinuingor discontinuinginterrelationships tween ADHD and learningdisabilities,is needed to clarifythe relationship.Only such studycan effectivelydocumentthe hypothesisthat attentional deficits and/or hyperactivityresult from continued academic frustration conversely,that acaor, demic difficultyresults from attentional deficits, and determine the prevalence of each occurrence. Differentialdiagnosis is fundamentalto exploring the causes of disablingconditions as well as to providing specific interventions. A more deVolume 17, Fall 1994 317

tailed understanding of the neurologic and/or cognitive dysfunctions associated with these groups should enhance continued development of appropriate assessment and intervention strategies. With advanced technology and improved methodology/diagnostic criteria, the question of an underlyingneurologicalbasis may be resolved. Additionalresearch in cognitive functioningas it relates to both LD and ADHD is also needed. of Increasedunderstanding cognitive functioning, and in language areas particularly is criticalto designing aporganization/planning, propriate intervention programs for children in co-occurwith ADHD. whom learningdisabilities
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