Patient Education and Counseling 58 (2005) 187191 www.elsevier.

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Attention decit and hyperactivity disorder (ADHD) and learning disabilities (LD): adolescents perspective
Uzi Brooka,*, Mona Boazb
a

Department of Pediatrics, Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Holon 58100, Israel b Epidemiology Unit, Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Holon 58100, Israel

Received 24 February 2004; received in revised form 7 August 2004; accepted 23 August 2004

Abstract Three hundred and eight pupils in the age group 1218 years were interviewed and examined. They had been diagnosed as having attention decit and hyperactivity disorder (ADHD) and learning disabilities (LD), and were attending a high school devoted to special education. Their classication into subgroups was as follows: ADHD inattentive (I) = 22.1%, ADHD hyperactivity/impulsivity (HI) = 12.3% and combined = 42.2%. Only 25% of them were treated by methylphenidate (Ritalin). Ninety-four percent of them were diagnosed with comorbidity of learning disabilities. Thirty-four percent of them reported being severely stressed when going to school and sitting in class. Their complaints were: tiredness and excessive needs to sleep, frequent quarrelling with close friends, feeling different from other classmates and having low self-esteem (SE). They complaint that their parents dont understand them. Things that irritated them the most were being lied to and coercion by others. The authors suggest to consider ADHD/LD as neurobehavioral disability. It is mandatory to prepare them for adult life with proper social skills and a suitable occupation. # 2004 Elsevier Ireland Ltd. All rights reserved.
Keywords: Attention decit and hyperactivity disorder (ADHD); Learning disabilities (LD); Adolescents perspective

1. Introduction Attention decit and hyperactivity disorder (ADHD) is a neuro-psychiatric syndrome [1]. It remains the most common problem in childhood. The reported prevalence among school pupils varies between 2 and 17% [2], and among children in the community is 810% [3]. Among boys, it is three times higher than among girls [3,4]. Among etiology is a genetic factor with a DNA variation in the serotonin system [5]. In ADHD children, the rate of glucose metabolism in basal ganglions and in the frontal cortex is reduced [6]. Their symptomatology includes: inattention, hyperactivity, impulsivity, disorganization, academic underachievement and behavioral difculties [3]. These adolescents may experience troublesome interpersonal relationships
* Corresponding author. Tel.: +972 502 8422; fax: +972 35028421. E-mail address: brookuzi@post.tau.ac.il (U. Brook).

with family members, as well as with peers and their selfesteem (SE) is low [7,8]. The disturbance is neuropsychological with poor inhibitory control and executive function difculties [9,10]. The diagnosis is based upon symptoms cited in DSM IV [11]. ADHD is accompanied by the comorbidity of the following: oppositional deant disorder (ODD) (35%), conduct disorder (26%), anxiety (26%) and depression (18%). These adolescents are at high risk to become addicted to cigarettes, alcohol and drugs [12,13]. They have difculties in their social life and feel frustrated, with frequent quarrelling with parents, siblings, friends and teachers [14,15]. As for learning disability (LD), 6.5% of children in the US are diagnosed with it. It is accompanied by a high rate of absenteeism from school [16] and low academic achievement [17]. Seventy-ve percent of them will have social skill difculties [18]. Their quality of life (QOL) is problematic. Their interfamilial relationship will suffer as well [19].

0738-3991/$ see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2004.08.011

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U. Brook, M. Boaz / Patient Education and Counseling 58 (2005) 187191 Table 1 Study participant data of all pupils (n = 308) Age (years) Sex ratio (boys:girls) (%) Living conditions (private bedroom) (%) Practicing sports activities (after school) (%) Keeping domestic pets (%) Daily TV viewing (h) Intermittent or regular smoking (but not heavy) (%) Drinking alcoholic beverages (not severe alcoholics) (%) Offered drugs (by peers) and/or consumed them experimentally (%) 15.4 1.7 56.8:43.2 62.7 58.1 49.5 3.2 1.0 27.1 22.4 21.4

Dagan et al. proclaim that sleep patterns of ADHD children have different architecture, which can explain their tiredness and low energy during the day [20]. They suffer from aggressive behavior and their self-esteem is low [21,22]. 1.1. Aims of the study The aims of the study were: (1) to design the prole of ADHD/LD adolescents and (2) to learn about their selfperception.

2. Methods Three hundred and eight pupils studying in middle and high schools involved with special education were interviewed and examined. All pupils who learn in that school suffer from ADHD/LD, but their intelligence is normal. Their educational and medical les were checked, including learning difculties and psychological reports compiled by specialists outside of school. Pupils were asked to complete individual questionnaires with 73 items during the meeting with a school physician. The original number of items in questionnaire composed by the authors was reduced from 109 to 73 after judge validity by pediatricians, psychologists, social workers, teachers and educational advisors. The statistical analysis was done by the Epidemiological Unit of the hospital. ADHD/LD pupils conrmed receiving any explanation from professional or educational advisors about their difculties, and/or advices on how to cope with them. 3.1. Personal knowledge about ADHD/LD Their knowledge concerning ADHD/LD came from: (1) recognizing identical classmate (46.1%), (2) discussions with advisors at school (41.6%) and (3) the media, which included: viewing TV programs (25.3%), reading articles in newspapers/periodicals (13.6%) and reading books covering these topics (11%). 3.2. Adolescent perspectives According to their personal feeling and understanding, the areas of most importance to ADHD/LD adolescents included the following: (1) family (16.7%), (2) academic education (11.9%), (3) friends (10.9%), (4) good health (8.9%) and (5) money (6%). They become angry with the following events: (1) lies, (2) constraints, (3) anger and insult, (4) teachers perpetual criticism, (5) being ordered about, (6) quarrelling with siblings, (7) frequent quarrelling with parents, (8) indifference and not being listened to, (9) unjustied accusations and (10) being awakened from sleep when really tired.

3. Results Table 1 shows the demographic and social activities, in which the ADHD pupils were involved. Approximately, a quarter of adolescents were tied to addiction (cigarettes, alcohol or drugs). Table 2 shows the subgroups of ADHD and their comorbidities. More than half of adolescents loose self-control and had outbursts even after minimal stressors. Table 3 summarizes the data concerning school and learning disabilities. LD is a frequent nding (94%) among ADHD adolescents. The sociobehavioral perspective as described by the pupils is presented in Table 4. More than two-third of adolescents emphasize their need to receive everything immediate, and having difculties to postpone desires. Concerning relationships with parents, pupils reported feeling that parents: (1) are disappointed and angry with them (43.2%), (2) dont understand them or their difculties (42.2%) and (3) arent doing enough for them (35.4%). ADHD/LD pupils reported that they are receiving some encouragement and support from: (1) parents (43.2%), (2) friends (19.7%), (3) other family members (17.5%), (4) teachers (17.1%) and (5) siblings (8.9%). Only 43.5% of

Table 2 Subgroups of ADHD and their comorbidities (n = 308) Diagnosis of ADHD (%) Subgroups (%) ADHD inattentive (I) ADHD hyperactivity/impulsivity (H-I) ADHD combined Episodes of emotional outbreaks and loss of self-control (%) Treated by Ritalin (present or past) (%) Comorbidity (%) LD Depression Anxiety Fatigue 76.4 22.1 12.3 42.2 54.2 25 94.2 58.8 48 37

U. Brook, M. Boaz / Patient Education and Counseling 58 (2005) 187191 Table 3 Learning disabilities (LD) and school data of all pupils (n = 308) Prevalence of LD among all pupils (%) Subgroup areas of learning difculties (%) Reading (dyslexia) Reading comprehension Writing (dysgraphia) Mathematics (dyscalculia) Foreign languages Needs more time for completion of examinations Feeling stressed in class Complaining that teachers dont understand them Parents criticize him/her for not investing more effort in learning Marks (average) 94.2 51.3 51.6 55.8 63 71.8 48.4 34.1 51.6 60.1 68.9 13.2

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Table 4 Sociobehavioral prole as described by AD/LD pupils Difculties in postponing needs and satisfaction (%) Crying during an outbreak episode (%) Excessive fatigue (low energy) (%) Disorganization and loss of objectiveness (%) Feeling extreme isolation and having no friends (%) Self-image (%) Low Average High Feeling different from others (peers) (%) 68.2 53.9 37 36.4 7.8 16.2 52.3 29.8 31.8

3.3. How to help ADHD/LD adolescents Adolescents suggestions on how to help ADHD/LD pupils included the following: (1) individualized personal psychological support and receiving personal help with learning (38.7%), (2) teachers should treat them with understanding and without criticism, angry or pity (17.2%), (3) encouragement and participation in support groups therapy (14.6%), (4) modied form of examinations (with fewer questions and more time) (8.8%), (5) more participation in social activities (including sports, music computers, etc.) (4.2%), (6) reduce quantity of homework to minimum, (7) establishment of special learning centers at school with experienced teachers, (8) permission to leave class for short periods everytime when feeling stressed and nally, (9) teachers should listen with patience to pupils complaints and prepare them to suitable occupations in future life.

4. Discussion and conclusion 4.1. Discussion The symptomatology of ADHD/LD and its severity vary from one adolescent to another. The present study outlines the sociobehavioral self-prole of the ADHD adolescents.

The boy to girl ratio in the present study was 57:43, while in other studies, it is between three- and six-fold for boys. Biederman et al. [4] and Wilens et al. [23] explain this as bias due to the under-diagnoses of ADHD among girls and to their less disturbances in classes. We shall emphasize some points: (1) the ADHD-combined subtype is the main group and (2) 54% of ADHD adolescents still suffer from recurrent outbreaks, impulsivity and loss of control episodes. It is surprising that only 25% of these pupils were treated by Ritalin. Many studies have shown the positive inuence of Ritalin with improved concentration and upon behavior [24], increased academic achievements, improved childs QOL [25], improved self-esteem [26] and decrease of interfamilial tension [27]. More than a third of these adolescents suffer from excessive fatigue and needs of more hours of sleep. Their low energy hadnt been investigated and resolved until now. As for their addiction, alcohol consumption was preponderant for a quarter of ADHD pupils drink. The connection between ADHD and addictions was emphasized in other studies [23,28,29]. Regarding learning disabilities, 94% of ADHD adolescents suffer at the same time from LD. They are faced at school with difculties as result of their learning disabilities. The homework becomes a suffering task. Their average marks are low; 94% feel despair with their own ability and academic achievements. Their recurrent absences from school and disturbances during lessons can be explained by their frustration. Fifty-two percent feel their teachers dont understand them or their difculties; these teachers frequently accuse them for lack of motivation. Thirty-four percent conrm that they are stressed and feel impatient while sitting in class. Heiligenstein et al. pointed out that their learning disabilities will continue in following years [17]. Haza et al. add that these adolescents with academic difculties will have problems in their future employments, and will periodically change their places of work as result of difcult adaptation [30]. In respect to their economic status, ADHD/LD families will have nancial difculties. The monthly costs include: medications (Ritalin and other SSRI-neuroleptics), prolonged psychological/psychiatric consultation, private lessons and extracurricular activities etc. Chan et al. conrmed that the nancial costs of families coping with their childs ADHD were signicantly higher in comparison to expenses incurred by regular families without any chronic diseases [31]. The daily schedule and activities of ADHD/LD adolescents include: (1) watching TV for an average of 3.2 h, mainly pop music on MTV, (2) half of them would spend time with a domestic pet (principle dogs and cats and (3) 58% would participate in sport activities. Maedgen et al. point out that these adolescents suffer from social dysfunction and emotional impairment with aggressive behavior [32]. The interfamilial relationships are disturbed in these families. Parents are angry with them, as they

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U. Brook, M. Boaz / Patient Education and Counseling 58 (2005) 187191

interpret their unacceptable behavior as intentional. However, even with these beliefs, most parents feel they are not doing enough for their difcult children [33]. These children are most of the time angry with these parents accusing them for misunderstanding and lack of support. The quarrels with siblings are frequent (42%). Kendall pointed out that siblings of ADHD children feel victimized in these situations [34]. The relationship of ADHD children with their friends is characterized by tension, quite a lot of conict and quarrels. Their frustration increase their anxiety, depression and mood changes, and impel them towards CD, delinquency and substance abuse. Miller-Johnson et al. point out that ADHD with aggression and peer rejection can be a predictor of subsequent development of future CD [35]. Rey et al. [36] mention that a poorer family environment can serve as a predictor for CD and addictions. This stormy environment of an ADHD/LD adolescents hurts their own and their familial QOL [37]. Smith shows that the adolescent, as well as his family, needs time to understand and accept that being different with special needs doesnt necessarily mean being inferior in their society [33]; these authors recommend for the family to be patient and not treat these adolescents harshly; they recommend strengthening their abilities and giving them frequent positive feedback for good behavior. Hechtman et al. pointed out that, during the years in which families are faced with severe problems and difculties, these trials and tribulations decrease after the subject grows up and leaves the parental home [27]. Regarding self-image, one third of ADHD/LD adolescents consider themselves to be different and out of place in most situations in comparison with their peers. In the present study, 52% reported the value of their self-esteem is identical and 16% reported it as inferior to the average students around them. Most investigators nd that the SE of ADHD children is lower [21,26,38]. Andrews et al. pointed out that negative social interaction and absence of rm relationships will decrease their SE. On the other hand, positive changes in their occupation, as well as regular work status, will improve their SE [39]. ADHD/LD adolescents expect family members to accept them as equals and to support them. Academic achievements come in second place of importance for them. In the third place for these adolescents, comes friends and friendships. They would like to be accepted as equals in society, as well as be able later to develop satised relationships with the opposite sex. Theses ADHD/LD adolescents display a deep sensitivity to lies. They are sensitive and hurt by hostility towards them coming from peers or adults around them. They can easily discern those who have empathy towards them and those who are critical and hostile towards them. Personal aspirations of ADHD/LD adolescent include receiving support for their ADHD/LD difculties by experienced professionals. They entreat the teachers not to berate, or pity them. The learning program of the ADHD/LD pupils should use advanced methods of teaching, with memory enhancement

aids. Homework should be minimal. The examinations should just cover the main essential and important topics, so that these pupils can receive passing grades in spite of their disabilities; they prefer to be involved in more social activities. This program should prepare them for life with suitable skills and occupation.

5. Conclusions Although the IQ of these adolescents is normal, they are neurologically disabled. We should consider them as adolescents with special needs. The key of the problem in our opinion is their low self-esteem, as they feel different and inferior with their classmates. We should explain and encourage them, trying to help them to build a better and higher self-esteem, and at the same time, strength their positives skills. 5.1. Practice implications Because of being functionally limited and disabled, these adolescents should be considered to have special needs. The Ministry of Education and Health should keep parents, teachers and professionals dealing with ADHD/LD pupils informed and updated in these topics. The use of Ritalin by LD pupils should be recommended and increased. Pupils suffering from emotional or behavioral comorbidity should be helped by psychological or psychiatric specialists familiar with ADHD/LD, and receive private lessons by experienced teachers on a one-to-one basis. ADHD/LD pupils should also participate in supportive groups during school or after run by psychologists or social workers who are familiar with these issues. Steps should be taken to remove negative stigma of these pupils having ADHD/LD and attending special education centers. Finally, it is important to prepare them for adult life with proper social skills and a suitable occupation.

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