Linguistic profile in children with a double diagnosis of attention deficit and hyperactivity disorder and developmental language disorder

doi:10.21203/rs.3.rs-2482871/v1

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Linguistic profile in children with a double diagnosis of attention deficit and hyperactivity disorder and developmental language disorder

https://doi.org/10.21203/rs.3.rs-2482871/v1

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Recently, comorbidity and the number of double diagnosis cases of attention deficit hyperactivity disorder (ADHD) and developmental language disorder (DLD) have increased. This study aimed to know the linguistic profile that the children of such cases present. Our sample included 24 participants between 6–11 years old, divided into three groups: ADHD; DLD; double diagnosis of ADHD and DLD. We administered the Celf-4 Language Test with the areas: core language, receptive language, expressive language, language content, language memory and working memory. Our results revealed that the children with double diagnosis performed better than individuals with DLD in Core Language, Expressive Language and Language Memory, but worse than the children with ADHD. These data demonstrate that the presence of DLD determines linguistic differences. The coexistence of ADHD does not predispose to having a different linguistic profile.

Attention deficit hyperactivity disorder

Double diagnosis

Language

Developmental Language Disorder

children

In clinical practice, the coexistence of several disorders is increasingly encountered. This is the case with the relationship between attention deficit hyperactivity disorder (ADHD) and Developmental Language Disorder (DLD). ADHD is one of the most frequently found neurodevelopment disorders in children and adolescents (De la Barra, Vicente, Saldivia & Melipillan, 2015), and is characterised by attention deficit, hyperactivity and impulsiveness. For this coexistence, the DSM 5 classification (APA, 2013) indicates 5% for schoolchildren, with an 8% peak for children aged 6–9 years. These figures are age-dependent and lower with adolescence, with a prevalence of 2.5% in adulthood. It is defined as developmental language disorder (DLD) to designate those other children that the severe affectation in oral language occurs without an associated disorder or a clear explanation that justifies (Andreu, Ahufinger, Igualada & Torrent, 2021; Bishop, Snowling, Thompson, Greenhalgh & Catalise Consortium, 2016, 2017). The prevalence of DLD is around 6% and 7% for children aged 5 years or more (Mendoza, 2016; Temblin et al., 1997).

Some studies conducted in the last decade have evidenced between approximately 10% and 40% of cases in children and adolescents with ADHD + DLD symptoms (Mueller & Tomblin, 2012; Peets & Tannock, 2011; Williams & Lind, 2013). Conti-Ramsden, Bishop, Clark, Norbury & Snowling (2013) state that ADHD is a similar disorder to DLD as regards its prevalence, and it is considered comparable to DLD as far as the severity of its impact is concerned.

Regarding the linguistic profile, certain similarities and differences between both disorders can be found. For example, people with DLD have great difficulty in correctly developing expressive syntax (Durrleman & Delage, 2016; Roy et al., 2013; Zwitserlood, Weerdenburg, Verhoeven & Wijnen, 2015) when using verbs in different tenses (Grinstead et al., 2014; Rispens & De Bree, 2014), and with morphological markers (Domahs, Lohmann, Moritz & Kauschke, 2013; Geurts & Embrechts, 2008; Rothweiler, Chilla & Babur, 2010). In both disorders, not only do individuals make these mistakes in syntactical production, but they also syntactical understanding (Montgomery, Evans, Gillam, Sergeev & Finney, 2016). In ADHD, morphosyntax also appears as one of the most altered areas (Flake, Lorch & Milich, 2006). People diagnosed with ADHD perform morphological expression tasks worse (Brook & Boaz, 2005). These three areas are related mainly to the syntactic domain and indicate special difficulty when organising language, as other studies have suggested (Delgado-Mejía, Etchepareborda, Bakker & Rubiales, 2013; Miranda-Casas, Ygual-Fernández & Rosel-Remirez, 2004; Väisänen, Loukusa, Moilanen & Yliherva, 2014).

People with ADHD have some problems in the form and structure that language takes (Rapin & Dunn, 2003). Their vocabulary is more limited (Barini & Hage, 2015; Gremillion, Smith & Martel, 2017), and they have less capacity for semantic processing (Segal, Mashal & Shalev, 2015; Tannock, Martinussen & Frijiters, 2000). Individuals with DLD develop altered vocabulary (Laws et al., 2014; Rice & Hoffman, 2015), and face specific semantic difficulties (Schulz, 2009; Sheng & Mcgregor, 2010). However, some significant differences apparently exist in this semantic area because children with ADHD have fewer semantic-type problems than their peers with DLD (Cartes, 2017).

Redmond (2004) supports measure of lexical diversity, average sentence length and morphosyntactic development were worse in children with DLD in compared to children with ADHD and Typical Development (TD). Although very few studies can be found to date, this line applies to people with ADHD + DLD (Baker & Cantwell, 1992). More recently, Redmond, Ash & Hogan (2015) conducted an investigation to compare the clinical linguistic characteristics of people with ADHD + DLD compared to children with DLD and children with TD. Measures of nonword repetition, sentence recall, and tense marking were collected from 57 seven- to nine-year-old children. The results show that the presence DLD affect the linguistic level of people with double diagnostic. Some research indicates that morphosyntactic level would be conditioned by working memory in the case of DLD but not in ADHD (Stanford & Delage, 2020). In addition, scientific evidence shows that working memory deficits in people with DLD limit their processing capacity to use complex morphosyntax (Delage & Frauenfelder, 2020).

We investigated in-depth the linguistic characteristics of people with the studied double diagnosis and compared them to the profile of the groups with a single diagnosis. The purpose of this research was to know the linguistic profile of children with ADHD + DLD compared to children with ADHD and children with DLD. Our objective is to know the linguistic differences that exist between people with a double diagnosis and with a simple diagnosis (DLD and ADHD) in order to be able to better guide the interventions that are carried out in the clinical context.

Participants

The current study included 24 children aged 6–11 years, who were divided into three groups. These three groups were paired in chronological age and mental age terms (Intelligence Quotient). All participants with ADHD were taking medication prescribed by the neurologist and psychiatrist at the time of assesment. The first group comprised eight children with ADHD, with a diagnosis confirmed by a specialist (chronological age was 8.70 years, SD = 1.86; IQ = 91.0; SD = 11.9; 5 males, 3 females). This specialist was a clinical psychologist and the diagnosis was made based on the DSM 5 criteria. The second group included eight people diagnosed with DLD (chronological age: M = 8.56, SD = 1.14; IQ = 92.3, SD = 10.1; 5 males, 3 females). In this case, the diagnosis was determined by a speech and language therapist, following the criteria established in the Catalise project (Bishop et al., 2017). The third group was formed by eight people with the double diagnosis (chronological age = 8.50, SD = 1.92; IQ = 93.3, SD = 11.5; 4 males, 4 females). No significant inter-group differences were found (chronological age: F = .030, p > .05; CI: F = 2.98, p > .05) in an ANOVA analysis. All participants were monolingual Spanish speakers.

Materials

The participants’ mental age was obtained using the WISC-IV Scale [37]. For the linguistic evaluation, the complete version of the standardised CELF-4 test was used: Spanish Clinical Evaluation of Language Fundamentals-4 (Wiig, Secord & Semel, 2006). CELF is able to very accurately identify subjects with DLD (Aguado et al., 2015). Some authors indicate that this is because the specificity and sensitivity of CELF is 89% and 100%, respectively, and its corresponding cutoff points in relation to standard deviations of -1.5 are crucial questions to correctly identify DLD (Wood et al., 2016). CELF 4 (2006) is a tool that is individually administered. It allows individuals’ strong and weak points to be identified, the seriousness of the disorder to be established, and enables subjects with DLD to be diagnosed and followed up. It provides recommendations for efficient interventions (Carvallo et al., 2014) which, in turn, permit the clinical decision-making process to be reflected (Semel et al., 2006).This test is administered to populations aged from 5 to 22 years old to evaluate the level of language in several areas: core language, receptive language, expressive language, language content, language memory and working memory.

Procedure

Different ADHD and DLD associations and private clinics were contacted to meet the people with the double diagnosis, and to verify if they were interested in participating in this study. When centres accepted and the sample subjects had been confirmed, informed consent documents were forwarded to parents to confirm participation. Informed consent was approved by the corresponding university’s Ethics Committee. After this document was signed, the mental age and language evaluations were made. All participants were evaluated individually during two sessions.

Once the fieldwork was completed, all the information gathered was processed, in order to systematize it and make it comprehensible. The data were analyzed with the statistical package IBM SPSS Statistics (version 22.0 SPSS for Windows; SPSS Inc., Chicago, IL., USA). The results were expressed in medium scores and 95% confidence intervals. The significance level was set at 0.05. An ANOVA analysis was carried out with the different language areas and evaluated groups. As variances were the same, the Bonferroni method was followed in all statistic analysis to compare the results among the three groups. The results revealed differences in all the language areas among the three study groups. Medium scores in languages area can be observed in Table 1.

Table 1

Medium scores in languages areas
Areas	ADHD	ADHD + DLD	DLD
Core Language	102.75 (1.47)	83.75 (12.85)	66.12 (11.84)
Receptive Language	95.75 (18.42)	79.50 (11.80)	72.25 (13.60)
Expressive Language	111.87 (13.71)	85.12 (9.12)	69.87 (9.07)
Content Language	94.0 (16.27)	107.75 (18.94)	80.75 (14.05)
Language Memory	100.50 (15.83)	83.00 (10.50)	66.12 (8.90)
Working Memory	106.87 (18.49)	87.37 (19.78)	82.75 (13.20)
Note: Standard deviations are given in parentheses.

Significant differences were observed among the three groups in Core Language area (F(1,21) = 14.24, p < .001). The ADHD group obtained better results than the children in the double diagnosis group (p = .035). Significant differences were found for the group of children with DLD, who performed worse in this area than the ADHD group (p = .000).

Intergroup differences were found in the Receptive Language area (F(1,21) = 5.23, p < .05). Data revealed that the ADHD group of children obtained significantly better results than the children with DLD (p = .014), but no differences appeared between the ADHD and DLD groups and the double diagnosis group. Differences also appeared among the three groups in the Expressive Language area (F(1,21) = 30.66, p < .001). The DLD group obtained lower scores than the other two groups Differences were found for the group of children with the double DLD + ADHD diagnosis (p < .05) and, in turn, for the children diagnosed only with ADHD (p < .001). Significant differences were also observed in the children with the double diagnosis and for those only with ADHD (p < .001).

These data were similar to those in the Language Content area (F(1,21) = 5.32, p < .05). No significant differences were found between the group with the double diagnosis and the ADHD and DLD groups, but appeared between the last two groups (p < .05).

Once again, the data were similar in the Language Memory area (F(1,21) = 16.10, p < .001), and the best scores went to the ADHD group,followed by the double diagnostic groupand finally by the DLD group). Significant differences appeared between the double diagnosis group and the ADHD (p < .05) and DLD (p < .05) groups.

Finally, the results in the Working Memory area fell in line with the previous areas (F(1,21) = 4.33, p < .05). There were no significant differences between the group with the double diagnosis and the two other single diagnosis groups, but differences between the ADHD and DLD groups were observed (p > .05).

The results generally revealed that the language skills of children with DLD were worse than for the double DLD + ADHD diagnosis and ADHD groups, which confirms what other studies have found. Nonetheless, Javorsky (1996) stated that people with a double DLD + ADHD diagnosis have more syntactic problems. The current study verified that the results of this group were better than those in the group diagnosed only with DLD.

For the children and adolescents with the double DLD + ADHD diagnosis, the most altered areas are those related to syntax and language memory, such as core language and expressive language. In line with other research works, having ADHD means that the individuals with the double diagnosis have better syntactic development results than those diagnosed only with DLD (Helland, Lundervold, Heimann & Posserud, 2014). This made us wonder if the presence of DLD would mean that these people would encounter more difficulties when developing language skills than children and adolescents with ADHD, particularly with skills related to morphosyntaxis (Hutchinson, Bavin, Efron & Sciberras, 2012). Linguistic performance in all areas is generally better in ADHD children than in children with the double diagnosis and those diagnosed only with DLD. What this determines is that, even though syntactic difficulties appear for individuals with ADHD, their severity is not like that corresponding to DLD. However, work contradicts other studies conducted in Spanish, which state that no significant differences exist between ADHD and DLD groups in syntax terms (Paredes-Cartes, 2015), particularly as far as language memory is concerned (Geurts & Embrechts, 2008).

In areas related to language content, we found no differences between the individuals with the double diagnosis and the other groups. However, their results were better than those in the DLD group and worse than those obtained by the ADHD group. The only other similar research work published to date is by Javarosky (1996), who evaluated four groups of children using the Peabody PPVT-III picture vocabulary test: ADHD, Language Disorder-TL, ADHD + TL and Typical Development. It revealed that none of these four groups, including the control group, presented significant semantic differences and difficulties, whereas our study found significant differences between the ADHD and DLD groups (Miranda-Casas, Ygual-Fernández & Rosel-Remirez, 2004). This informs us that, although people with ADHD have serious problems with tasks involving semantic organisation (Miranda, Ygual, Mulas, Roselló & Bo, 2002), the semantic aspect was more altered in the DLD group. In adults, Alt & Gutmann (2009) compared college students with spoken and written language disorders, with or without ADHD to their peers with typical language and attention on a task tapping the fast mapping of semantic features and word forms. Probes immediately after presentation of the novel objects and names revealed poorer recognition of both semantic features and word forms on the part of the DLD + ADHD group as compared to the typical group. The students with language disorders but no attention problems scored between the two other groups and differed from neither (McGregor, Arbisi-Kelm, Eden & Oleson, 2020).

With receptive language, understanding seems another strong point for people with the double diagnosis compared to those diagnosed only with DLD. In this case, the fact that ADHD is present implies improved results. Previous research (Baker & Cantwell, 1992) suggests that only 34% of people with the double ADHD + DLD diagnosis aged between 6–15 years have problems with comprehension language as opposed to 58% with shortcomings in expressive language. In ADHD, language comprehension difficulties are apparently related to attention deficit characteristics (Bellani, Moretti, Perlini & Brambilla, 2011), and are considered a weak point of ADHD patients’ language (Bignell & Cain, 2007 and Wassenberg et al., 2010). Once again, our results were significantly better compared to the people diagnosed only with DLD. Children with the comorbidity (ADHD with DLD) show a different pattern of challenges with the language than do children with DLD and who are not diagnosed with ADHD.

In short, our data open up a new research line that allows to examine in detail the linguistic characteristics of people with the double ADHD + DLD diagnosis for whom very little information exists. These results are very important for clinical practice because they demonstrate that linguistic difficulties are determined mainly by the presence of DLD. The coexistence of ADHD does not predispose to have a different linguistic profile. These results are in line with the research carried out by Redmond, Ash and Hogan (2015). These authors considered as a possibility that ADHD status functioned as a clinically protective factor for children with DLD. The suggestion of protective effects associated with ADHD + DLD comorbidity aligns with the results of Zhang and Tomblin (2000). However, it must be taken into account that there are still very few children who present the double diagnosis. Therefore, due to the size of the sample, we must be cautious when interpreting the results. It would be necessary to increase the sample size in order to make a generalization of the data obtained.

Therefore, it is important to analyse diagnoses to set the bases for possible linguistic intervention by considering: the existence of two diagnoses or more is becoming increasingly frequent (Graham &Tancredi, 2019); they might be compatible with one another; they are present in different language development situations.

Ethics approval and consent to participate

The study was conducted according to the guidelines of the Declaration of Helsinki. The Clinical Research Ethics Committee of the Integrated Area of Talavera de la Reina has issued a favorable opinion. Ethical approval for the study has been obtained by the Clinical Research Ethics Committee of the Integrated Area of Talavera de la Reina with the reference 56/2021. Written informed consent to participate was obtained from all subjects and/or their legal guardian(s).

Consent to publish

N/A

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Funding

No funding

Acknowledgement

We appreciate the participation of families and people with Developmental Language Disorder and Attention Deficit and Hyperactivity Disorder

Authors Contribution

Conceptualization, E.M.-S., P.L.-R., N.P.-G.; methodology, E.M.-S., P.L.-R. and N.P.-G.; software, E.M.-S. and P.L.-R.; formal analysis, E.M.-S. and P.L.-R.;Investigation, E.M.-S. and P.L.-R.; writing—original draft preparation, E.M.-S. and P.L.-R.; writing—review and editing, E.M.-S. and P.L.-R.; supervision, E.M.-S. and P.L.-R.

All authors have read and agreed to the published version of the manuscript

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No competing interests reported.

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Linguistic profile in children with a double diagnosis of attention deficit and hyperactivity disorder and developmental language disorder

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