Baydalaof Attention Disorders Journal et al. / ADHD in Aboriginal Children 10.

1177/1087054705284246

ADHD Characteristics in Canadian Aboriginal Children

Lola Baydala
University of Alberta and Misericordia Hospital

Journal of Attention Disorders Volume 9 Number 4 May 2006 642-647 2006 Sage Publications 10.1177/1087054705284246 http://jad.sagepub.com hosted at http://online.sagepub.com

Jody Sherman Carmen Rasmussen

University of Alberta

Erik Wikman
Misericordia Hospital

Henry Janzen
University of Alberta
Objective: The authors examine how many Aboriginal children attending two reservation-based elementary schools in Northern Alberta, Canada, would demonstrate symptoms associated with ADHD using standardized parent and teacher questionnaires. Method: Seventy-five Aboriginal children in Grades 1 through 4 are tested. Seventeen of the 75 (22.7%) Aboriginal children demonstrated a match on parent and teacher forms, with T-scores greater than 1.5 standard deviations from the mean on the Conners ADHD Index, Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) Hyperactive/Impulsive Index, DSM-IV Inattentive Index, and/or DSM-IV Total Combined T-score. Results: The number of Aboriginal children found to have symptoms associated with ADHD is significantly higher than expected based on prevalence rates in the general population. Conclusion: These findings suggest either a high prevalence of ADHD in Aboriginal children or unique learning and behavioral patterns in Aboriginal children that may erroneously lead to a diagnosis of ADHD if screening questionnaires are used. (J. of Att. Dis. 2006; 9(4)642-647) Keywords: ADHD; aboriginal children; learning style

DHD is the most common childhood psychiatric disorder, with an estimate of between 3% to 10% (Sgrok, Roberts, Grossman, & Barozzine, 2000) in school-age children. ADHD has been defined as a developmental disorder characterized by inattention, impulsivity, and hyperactivity. These characteristics may result in impairment of academic and/or social functioning, especially in an environment that fails to address the childs unique learning style and interests (Barkley et al., 2002). The cause of ADHD is unknown but may involve a combination of biological, often genetically determined neurochemical disturbances and environmental disadvantages (Sandberg, 1996). More recently, the characteristics of ADHD have been evaluated within the framework of evolutionary biology and viewed as an adaptive response to environmental challenges (Hartmann, 1996). Increased motor activity, scanning and rapidly shifting attention, and impulsivity may have provided a selective advantage for early hunter-gatherer or response-ready

societies, many of whom are represented by indigenous populations. This is in contrast to agriculturally based or problem-solving societies in whom ADHD characteristics present a disadvantage (Jensen et al., 1997). This theory is supported by an association between the 7R allele of the DRD4 dopamine receptor gene and ADHD (Olson, 2002). The 7R allele of the DRD4 gene is significantly younger than other DRD4 alleles, suggesting that it may have provided a selective evolutionary advantage for some populations (Mercugliano, 1999). If the characteristics of ADHD provided a historical selective advantage for indigenous people, then we would expect to find a significantly greater number of aboriginal children, who are more recent descendants of huntergatherer populations, to exhibit characteristics similar to those of children with ADHD. Our study is a pilot project
Authors Note: Aboriginal refers to First Nation, Metis, and Inuit. Address correspondence to Lola Baydala, 3 West Child Health Clinic, Misericordia Hospital, 1694087 Ave., Edmonton, Alberta, T5R 4H5; e-mail: lbaydala@cha.ab.ca.

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designed to determine how many Aboriginal children attending two reservation-based schools in Northern Alberta, Canada, would demonstrate symptoms associated with ADHD using standardized parent and teacher questionnaires.

Method
The study was developed in association with each Aboriginal community in an attempt to develop a better understanding of their childrens learning styles and challenges. Consent was obtained from each child, their parents, teachers, the school, and community elders. The study results were discussed and reviewed with elders to ensure that the information obtained and the conclusions that were made were acceptable to each community prior to publication.

the Wechsler Intelligence Scale for Children3rd edition (WISC-III) to assess IQ and the Wechsler Individual Achievement Test2nd edition (WIAT-II) to measure academic achievement. Fetal Alcohol Spectrum Disorder screening was completed by a pediatrician using the Diagnostic Guide for Fetal Alcohol Syndrome and Related Conditions (Astley & Clarren, 1999). CRS-R:L. The CRS-R:L was used to screen children for symptoms of ADHD. The subscales on the CRS-R:L provide measures for various behavioral characteristics, including oppositionality, cognitive problems, inattention, hyperactivity, anxiety, perfectionism, social problems, and psychosomatic tendencies. A parent and teacher for each child were asked to complete the long version forms and return them in a sealed envelope to the school. The forms were then scored to determine if the child was in the critical range on specific composite indicators of ADHD behaviors. T-scores more than 1 and 1.5 standard deviations above the mean (M = 50, SD = 10) were considered to be critical. Children were considered to have symptoms associated with ADHD if they had a T-score of 65 or more on both the parent and teacher forms on one or more of the following subscales: the Conners ADHD Index, the DSM-IV Inattentive Index, the DSM-IV Hyperactive/Impulsive Index, or the DSM-IV Total T-score. WISC-III. The WISC-III, a measure of cognitive abilities, was administered individually to each child. IQ scores, with a mean of 100 and a standard deviation of 15, were calculated for the following domains: Full Scale IQ, Verbal IQ, and Performance IQ. Verbal IQ comprises six verbal subtests: information, similarities, arithmetic, vocabulary, and digit span. Performance IQ comprises six performance subtests: picture completion, coding, picture arrangement, block design, object assembly, and symbol search. All subtests are scaled with a mean of 10 and a standard deviation of 3. Full Scale IQ is a composite of all subtests. Canadian norms were used. WIAT-II. The WIAT-II, a measure of academic achievement, was administered individually to each child. As with the WISC-III, the WIAT-II yields several composite scores that comprise various subtests, all of which have a mean of 100 and a standard deviation of 15. The reading composite is made up of word reading, reading comprehension, and pseudoword decoding subtests; the mathematics composite consists of numerical operations and math reasoning subtests; the written language composite comprises spelling and written expression subtests; and

Participants
Parental or guardian informed consent was obtained from 86 Aboriginal (48 male and 38 female) children from Grades 1 through 5. This represented a recruitment rate of approximately 50%. The majority (77) of these children were from two Aboriginal schools on two reserves in Alberta, Canada, and the rest (9) either resided on these reserves or in the surrounding area and were recruited through school representatives. Complete parent and teacher Conners rating scales were completed on 75 children (43 males and 32 females). Of these 75 children, 30 were in Grade 1, 10 were in Grade 2, 21 were in Grade 3, 13 were in Grade 4, and 1 was in Grade 5. Eleven of the 86 children (5 male and 6 female) that were initially recruited had teacher Conners ratings, but the parent forms were not completed. All of the children who participated were Stoney or Cree, known descendents from hunter-gatherer populations (Mandelbaum, 1979).

Materials and Procedures

Parent and Teacher Conners Rating ScalesRevised: Long Version (CRS-R:L) were used to determine whether each child met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) symptom criteria for ADHD. The diagnostic utility of the Conners questionnaire has been previously described (Conners, 1999). Individual academic achievement and cognitive abilities were assessed to look for an associated learning disability that may have exacerbated inattentive behaviors. A registered psychologist and psychology graduate students administered

644 Journal of Attention Disorders

the oral language composite is made up of listening comprehension and oral expression subtests. The total composite score comprises all the subtests. United States norms were used for comparing performance, as Canadian norms were not published at the time of data analyses. Demographic Questionnaire. A parent or guardian for each child was asked to fill out a questionnaire and return it to the school in a sealed envelope. Questions on the form were directed at finding out general information about each child, including current grade; birth date; treaty status; language; prenatal information, such as alcohol, cigarette smoke, and drug exposure; and current health information, such as medication use, medical diagnoses or health problems, and behavioral or learning concerns. Fetal Alcohol Syndrome [FAS] Screening. The Diagnostic Guide for FAS and Related Conditions was used to measure FAS facial features (palpebral fissures, philtrum, and upper lip), growth deficiency, and brain dysfunction (Astley & Clarren, 1999). On each measure, the child was given a rank code of 1 for none, 2 for mild, 3 for moderate, and 4 for severe.

Figure 1 Percentage of Males and Females Who Met the Various Symptom Criteria for ADHD Using the Conners Rating ScaleRevised: Long Version

35 30 25 males females

Percentage

20 15 10 5 0 Conners' Inatt. Hyper/Impul. Total t any ADHD

Symptom Subscales of ADHD (CRS -R:L)

tistically significant. Thirty-two percent of the girls and 16.3% of the boys in the sample met at least one of the four ADHD subscales criteria.

WISC-III
Analyses of variance (ANOVA) were used to compare the Full Scale IQ of children with ADHD symptoms to children without ADHD symptoms. The Full Scale IQ of children with ADHD symptoms (M = 80.00, SD = 16.69) did not differ from those without ADHD symptoms (M = 82.05, SD = 10.71), F(1, 74) = .37, p = .55. Performance across subtests was examined to see whether the Aboriginal children with ADHD symptoms performed similar to other samples of children who have been diagnosed with ADHD. Caucasian children with ADHD show consistent patterns on the WISC-III, with specific subtests being associated with lower performance rates. Specifically, children with ADHD generally score low on digit span, arithmetic, coding, symbol search, and information (Schwean & Saklofske, 1998). The Aboriginal children who met ADHD symptom criteria did not show patterns that are common in other children with ADHD. For instance, among Aboriginal children with ADHD symptoms in our study, the lowest subtests were arithmetic and comprehension, which were more similar to Aboriginal children without ADHD symptoms than to nonAboriginal children diagnosed with ADHD. Furthermore, of the verbal subtests, non-Aboriginal children diagnosed with ADHD typically perform the poorest on digit span, whereas digit span was the highest verbal subtest for the Aboriginal children both with (M = 7.24, SD = 2.28) and without ADHD symptoms (M = 8.24, SD = 2.77).

Results
CRS-R:L
Seventeen of the 75 children (22.7%) with complete CRS-R:L data scored greater than 1.5 standard deviations above the mean (T-score above 65) on at least one of the four ADHD symptoms subscales (95% confidence interval: 13.5% to 32.5%) in two separate settings, home and school (see Figure 1). Of those 17 children, 10 children (58.8%) met symptom criteria on the Conners ADHD Index, 12 children (70.6%) met criteria on the DSM-IV Inattentive Index, 10 children (58.8%) met criteria on the DSM-IV Hyperactive/Impulsive Index, and 12 children (70.6%) met criteria for the DSM-IV Total T-score. Of the additional 11 children who had complete teacher rating data only, 4 had a T-score above 65 on at least one of the four ADHD symptom subscales. It is important to note that although behavioral rating in at least two settings are a necessary component of diagnosing ADHD, the number of children with symptoms associated with ADHD may have been higher if the parent forms for these additional 11 children were completed. For each of the four ADHD subscales, the proportion of girls meeting criteria was higher than that of the boys, (2 = 2.35, p = .13), although this difference was not sta-

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Table 1 Pattern of Performance on WIAT-II Subtests Across Aboriginal Children With and Without ADHD Symptoms and Non-Aboriginal Children With ADHD
Group Non-Aboriginal ADHD Aboriginal ADHD symptoms Aboriginal no ADHD symptoms Highest Subtests Listening comprehension Oral expression Pseudoword decoding Written expression Oral expression Spelling Lowest Subtests Written expression Spelling Listening comprehension Reading comprehension Listening comprehension Reading comprehension

Note: WIAT-II = Wechsler Individual Achievement Test2nd edition. The information for the non-Aboriginal ADHD sample is from standardized norms from the WIAT-II Examiner Manual.

WIAT-II
Analyses of variance (ANOVA) were used to compare the academic performance of children with and without ADHD symptoms. The pattern of performance across the WIAT-II subtests was similar across Aboriginal children who met ADHD symptom criteria and those who did not. The total composite score for the Aboriginal children with ADHD symptoms (M = 85.00, SD = 17.27) did not differ from the Aboriginal children without ADHD symptoms (M = 86.68, SD = 11.23), F(1, 71) = .22, p = .64. In contrast, Aboriginal children meeting ADHD symptom criteria did not perform similar to a standard non-Aboriginal sample of children with ADHD (Weschler, 2002). For instance, subtests with the lowest and highest performance rates were more similar for the Aboriginal children with and without ADHD symptoms, but both differed from non-Aboriginal children with ADHD. Specifically, Aboriginal children with and without ADHD symptoms did poorest on listening and reading comprehension subtests, although listening comprehension is typically the highest subtest in non-Aboriginal children with ADHD (see Table 1). Similarly, the Aboriginal children with ADHD symptoms had the highest performance on the written expression subtest, even though this is generally the worst subtest for non-Aboriginal children with ADHD.

hol exposure, the number of children who met ADHD symptom criteria would have decreased from 22% to 16%.

Learning Disabilities
An individual assessment of each childs IQ and academic achievement was completed to identify children with a learning disability, which may have prevented them from focusing attention and staying on task. Learning disabilities have been shown to exacerbate the key symptoms of ADHD (Barkley, Anastopoulos, & Guevremon, 1991; Schachar, 1991). In addition, children with ADHD have a significantly increased risk of learning disabilities compared with psychiatric and normal controls (Frick, Lahey, & Kamphaus, 1991). A learning disability was defined as an achievement score of more than 1.5 standard deviations below the level predicted by IQ. None of the children in our study who met ADHD symptom criteria had an associated learning disability. This was unexpected and may have occurred as a result of IQ measures underpredicting the true cognitive potential of Aboriginal children (McShane & Plas, 1982).

Discussion
Clinical Implications
The estimated prevalence of ADHD in the general population is 7% to 10% in boys and 3% in girls ages 4 to 11 (Sgrok et al., 2000). Twenty-three percent of the Aboriginal children we evaluated scored greater than 1.5 standard deviations above the mean on at least one of four ADHD symptoms subscales in two separate settings, home and school, based on the parent and teacher Conners questionnaires. The percentage of girls with ADHD symptoms (32%) was higher than boys (16%), in contrast to pre-

Prenatal Alcohol Exposure

Five of the children who met ADHD symptom criteria and 3 of the children who did not had prenatal alcohol exposure of greater than one drink per month. No group differences in prenatal alcohol exposure were evident. None of the 17 children with ADHD symptoms met the diagnostic criteria for FAS. If we removed those 5 children with ADHD symptoms who had some prenatal alco-

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vious studies in non-Aboriginal children that have found a much higher prevalence of ADHD in boys (Barkley, 1990). The hyperactive/impulsive subtype of ADHD is more common in boys and is associated with disruptive behaviors that may result in more frequent referrals than girls who more commonly present with ADHD inattentive type. Referral bias was not a factor in our study and may account for the higher percentage of inattentive ADHD symptoms in Aboriginal girls. The prevalence of ADHD in Aboriginal children has not been clearly defined. Using the behavior checklist developed by Achenbach, a significant increase in attention problems in adolescent American Indian males was found (Fisher, Bacon & Storck, 1998). In another study of American Indian adolescents, Beals et al. (1997) found the prevalence of ADHD to be 10.6%. In this study, adolescents were interviewed using the Diagnostic Interview Schedule for Children, and parent and teacher input were not obtained. A selective advantage for ADHD characteristics in Aboriginal populations may account for the high percentage of ADHD symptoms in the children we studied. Increased motor activity allows one to constantly explore his or her environment and identify new opportunities. Rapidly shifting attention improves ones ability to monitor dangers and threats, and impulsivity provides for quick decision making and response to environmental cues (Jensen et al., 1997). ADHD is one of the most inheritable of all medical conditions. A child of a parent with ADHD has a greater than 50% chance of having ADHD (Biederman, Faraone, & Lapey, 1992). The DRD4 human dopamine receptor gene has been found with increased frequency in individuals with ADHD and may account for this strong inheritance pattern (Allen, 2002). A particular version of the receptor known as the 7R allele is significantly younger and more common than other DRD4 alleles, suggesting that it may have had a selective advantage for hunter-gatherers, including Aboriginal populations (Ding et al., 2002). Characteristics of the population we studied suggest that ADHD symptoms in Aboriginal children may be representative of unique learning and behavioral patterns typical of Aboriginal children rather than true ADHD. Performance on the WIAT-II and the WISC-III indicate that the Aboriginal children with ADHD symptoms did not fit the same learning and cognitive patterns typical of children diagnosed with ADHD. Instead, the Aboriginal children with ADHD symptoms performed more like other Aboriginal children without ADHD symptoms than non-Aboriginal children with ADHD. Regardless of whether the patterns we identified are secondary to ADHD or a unique learning style, Aborigi-

nal children may find it difficult to achieve in a classroom that relies on current models of teaching. In a recent review of Aboriginal learning styles, it was noted that Aboriginal children have preferences for and succeed at visual-spatial processing and creative arts and classrooms that support experimental and interactive learning (Rasmussen, Sherman, & Baydala, 2005). It is interesting that these teaching methods are also incorporated in the management of children with ADHD. It is important to note that although we found a higher than expected number of children who met ADHD symptom criteria, children with ADHD symptoms must be differentiated from those who have been diagnosed with ADHD. A diagnosis of ADHD requires that five diagnostic criteria be met (Frances et al., 1994). Meeting criteria based on Conners ADHD symptom subscales places children either at risk for ADHD or indicates an above average correspondence with DSM-IV diagnostic criteria but does not in itself confirm the diagnoses of ADHD (Conners, 1999). The higher than expected number of Aboriginal children who met ADHD symptom criteria based on screening questionnaires suggests either a higher prevalence of ADHD in Aboriginal children from the communities we studied or unique learning and behavioral patterns that may erroneously lead to diagnoses of ADHD if screening questionnaires alone are used. Children from the two communities we studied may not be representative of all Aboriginal communities in Canada. This was the first study of its kind, and research with a larger sample incorporating all of the DSM-IV criteria is required. In summary, we found a high percentage of ADHD symptoms in Aboriginal children from two Aboriginal communities in Northern Alberta, Canada, using screening questionnaires. These children were Cree and Stoney known descendants from indigenous hunter-gatherer populations. Differences between Aboriginal children with ADHD characteristics and non-Aboriginal children with ADHD suggest that the pattern of learning in some Aboriginal children may represent a unique learning style that may erroneously lead to a diagnosis of ADHD. Future studies that incorporate all of the DSM-IV criteria and evaluate the presence or absence of the 7R allele of the DRD4 dopamine receptor gene are required to further differentiate ADHD from a unique pattern of learning in Aboriginal children.

References
Allen, A. (2002). ADHD: Phenotypes and pathophysiologies. Advanced Studies in Medicine Emerging Trends in the Diagnosis and Management of ADHD, 2, 906-909.

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American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Astley, S. J., & Clarren, S. K. (1999). Diagnostic guide for fetal alcohol syndrome and related conditions: The 4-digit diagnostic code (2nd ed.). Seattle: University of Washington Press. Barkley, R. A. (1990). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: The Guilford Press. Barkley, R. A., Anastopoulos, A. D., & Guevremon, D. C. (1991). Adolescents with ADHD: Patterns of behavioral adjustment, academic functioning, and treatment utilization. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 752-761. Barkley, R. A., Cook, E. H., Diamond, A., Zametkin, A., Thapar, A., Teeter, A., et al. (2002). International consensus statement on ADHD. Clinical Child & Family Psychology Review, 5, 89-111. Beals, J., Piasecki, J., Nelson, S., Jones, M., Keane, E., Dauphinais, P., et al. (1997). Psychiatric disorder among American Indian adolescents: Prevalence in northern plains youth. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1252-1259. Biederman, J., Faraone, S. V., & Lapey, K. (1992). Comorbidity of diagnosis in attention-deficit hyperactivity disorder. Child and Adolescent Psychiatric Clinics of North America, 1, 335-360. Conners, C. K. (1999). Clinical use of rating scales in diagnosis and treatment of attention-deficit/hyperactivity disorder. Pediatric Clinics of North America, 46, 857-870. Ding, Y. C., Chi, H. C., Grady, D. L., Morishima, A., Kidd, J. R., Kidd, K. K., et al. (2002). Evidence of positive selection acting at the human dopamine receptor D4 gene locus. Proceedings of the National Academy of Sciences of the USA, 99, 309-314. Fisher, P. A., Bacon, J. G., & Storck, M. (1998). Teacher, parent and youth report of problem behaviors among rural American Indian and Caucasian adolescents. American Indian and Alaska Native Mental Health Research, 8, 1-23. Frances, A., Pincus, H. A., First, M. B., Andreasen, N. C., Rush, A. J., Barlow, D. H., et al. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Frick, P. J., Lahey, B. B., & Kamphaus, R. W. (1991). Academic underachievement and the disruptive behavior disorders. Journal of Consulting and Clinical Psychology, 59, 289. Hartmann, T. (1996). Beyond ADD. Hunting for reasons in the past and present. Grass Valley, CA: Publishers Group West. Jensen, P. S., Mrazek, D., Knapp, P. K., Steinberg, L., Pfeffer, C., Schowalter, J., et al. (1997). Evolution and revolution in child psychiatry: ADHD as a disorder of adaptation. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1672-1681.

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Lola Baydala is an associate professor for the Department of Pediatrics at the University of Alberta, Edmonton, Alberta, Canada. Jody Sherman is a graduate student for the Department of Psychology at the University of Alberta, Edmonton, Alberta, Canada. Carmen Rasmussen is a research associate for the Department of Pediatrics at the University of Alberta, Edmonton, Alberta, Canada. Erik Wikman is a psychologist working at the Misericordia Community Hospital and is an adjunct assistant professor in the Department of Educational Psychology at the University of Alberta, Edmonton, Alberta, Canada. Henry Janzen is a professor in the Department of Educational Psychology and is director of the Faculty of Education Clinical Services at the University of Alberta, Edmonton, Alberta, Canada.