ORIGINAL ARTICLE

Attention deficit hyperactivity

disorder and mild learning
disabilities: a case study
Susan Young, Department of Psychology, Institute of Psychiatry, De Crespigny Park, Denmark Hill,
London SE5 8AF, UK and John Newland Islington Learning Disabilities Partnership, 1 Lowther Road,
Islington, London N7 8SL, UK

Summary The pervasive use of ‘challenging behaviour’ as an explanatory concept has precluded
the development of alternative ways of construing the actions of people with learning
disabilities. Moreover, possession of a challenging behaviour label has facilitated the
segregation of individuals into specialist service provision. The present case study
illustrates how an inclusive account can be developed using concepts from main-
stream psychological activity. The development of alternative accounts also has
implications for the design of interventions. It is argued that the process of developing
alternative accounts may ultimately result in the redundancy of ‘challenging beha-
viour’ as an explanatory concept.
Keywords Attention deficit hyperactivity disorder, challenging behaviour, mild learning
disabilities

Secondly, the aetiology of challenging behaviour is not

Introduction
typically understood in developmental terms. Even if child-
Is it time to challenge the use of the term ‘challenging hood history is considered as a factor, the lack of adequate
behaviour’? Practitioners will be familiar with the prevalence documentation that follows many adults with learning dis-
rates of seriously challenging behaviour, which is estimated abilities into adult services precludes adequate assessment.
at 10–15 people per 100 000 population in the UK (Emerson The functional analysis that is generally undertaken usually
et al. 1987); with the range of behaviour checklists which can considers only the existing environmental determinants with
quantify challenging behaviour (e.g. Harris et al. 1994; Rojahn a view to modifying current relationships to reduce the
et al. 1997); and with the methods for formulating and frequency or intensity of the challenging behaviour (Samson
intervening (e.g. Clements 1997). However, the term ‘chal- & McDonnell 1990). The significance of the fact that the
lenging behaviour’ is now often used as an explanatory behaviour has resisted previous behavioural interventions
construct in contrast to its original use as a descriptive is often minimized.
term. When the term ‘challenging behaviour’ is used to There is a third and potentially more significant issue. The
explain behaviour, it potentially masks other more salient expression of psychological distress can be different in peo-
explanations. For example, post traumatic stress disorder is ple with learning disabilities compared to the-non-disabled
often used in the non-disabled population to account for population. Failing to identify that different expression and
disturbed behaviour, but is not routinely considered for attributing distress to ‘challenging behaviour’ can lead to
people with learning disabilities. The conclusion can be alternative accounts not being considered. For example, a
drawn that, while people with learning disabilities are proposed formulation may be that challenging behaviour is a
experiencing similar underlying psychological distress to form of communication. However, if communication is con-
that of non-disabled groups, they are not offered a similar sidered only within a behavioural framework, then the pre-
service because of the terminology used to describe those sence of an underlying physiological disorder will continue
needs. to be missed.

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74 S. Young and J. Newland

The following case study attempts to illustrate the linkages On the basis of these findings, some authors have sug-
that need to be considered in developing alternative accounts gested that ADHD and learning disabilities are indistin-
of ‘challenging behaviour’. The case study concerns a young guishable (Silver 1981; Prior & Sanson 1986), although
man with mild learning difficulties who was diagnosed with there is support for distinguishing two separate populations
attention deficit hyperactivity disorder (ADHD) at 17 years (Biederman et al. 1991). Research that compares subgroups of
of age. This is a common disorder of childhood. While there children with ADHD, learning disabilities, and comorbid
are studies which report hyperactive behaviour in the learn- ADHD and learning disabilities has found few differences
ing disabilities literature for children (e.g. Christensen 1975), between the subgroups in terms of behavioural and socio-
it is very rare for ADHD to be reported for adults with demographic characteristics, and response to stimulants
learning disabilities. However, there is no reason to assume (Ackerman et al. 1979; Halperin et al. 1984). The confusion
that the prevalence rates should not also apply to this latter may be partly the result of an emphasis on the definitional
group. Using the diagnostic criteria in the Diagnostic and issues surrounding learning disabilities rather than a focus
Statistical Manual of Mental Disorders, 4th edn (DSM-IV; APA on the behavioural expression of the core features. It could be
1994), the generic prevalence rate for ADHD is estimated to argued that the core features are expressed differently as a
be 3–5%. Similar prevalence rates within the population of result of variation in a population with learning disabilities.
adults with learning disabilities should be expected. There In the light of current research, it is premature to make firm
are few guidelines for the diagnosis of ADHD in adulthood. conclusions about these distinctions in adulthood.
However, there is likely to be a similarity with diagnoses for The level of personal documentation available in the fol-
children, namely, inattentive, impulsive and hyperactive lowing case study was such that early childhood factors
behaviours must be pervasive across two or more settings, could be incorporated into a functional analysis in a mean-
and have caused impairment before the age of 7 years. ingful way. While there is a need for longitudinal studies,
Additionally, there must be clear evidence of clinically sig- typically these are usually preceded by the reporting of
nificant impairment in social, academic or occupational relevant case histories. The present paper describes the
functioning. Support for the adult diagnosis comes from developmental course of a young man with mild learning
the finding that, while some children lose the core features disability and the core features of ADHD.
through the maturational process (Mendelson et al. 1971),
long-term prospective studies show that others continue to
Case study
be impaired by the core features of inattention, impulsive-
ness and restless behaviour, and experience significant pro-
Salient personal history
blems with the negative features associated with the disorder
(Hechtman 1996). Associated factors include antisocial and John was born prematurely with low birth weight. He suf-
criminal behaviour, personality disorder, peer relationship fered from hypothermia and jaundice, and was slow to thrive
problems, academic failure and low self-esteem (Weiss et al. in his early months. Nevertheless, his physical health was
1985; Weiss & Hechtman 1986; Lambert 1988; Mannuzza et al. generally good. John’s early developmental milestones were
1989, 1993; Taylor et al. 1996). average. His parents divorced when he was 3 years old. John
The core features of ADHD are widely reported in the maintained contact with his father and his older brother, who
learning disability literature, but are not attributed to ADHD resided with his father. His mother subsequently remarried
(Emerson 1995; Jones & Eayrs 1993). The question then arises and had a further six children. When he was 5 years old, John
as to how to interpret the distinctions. Some conceptual was described as having been hyperactive and inattentive
confusion may arise from assuming that the differential from an early age. It was reported that he was not allowed to
diagnosis is between learning disabilities and ADHD, stay for school lunch because he ran around the dining room
whereas it is in fact between ADHD and other functional throwing ‘anything in reach’ around. As a consequence, his
behaviour problems. For example, Cantwell & Baker (1991) mother gave up her job in order to care for him. John’s 5-year
examined the prevalence and types of psychiatric disorders medical noted that he had a poor concentration span, imma-
and learning disorders found in children with speech and ture motor development, poor pencil grip and hyperactive
learning impairments (SLIs). In the above authors’ sample of behaviour. Following this medical, he was referred to a
600 children with SLIs aged between 1 and 16 years London hospital because of his behavioural problems.
(mean ¼ 5.6 years), they reported that 19% of children with When John was 8 years old, a Statement of Special Educa-
SLIs had ADHD (representing the most common psychiatric tional Need (SSEN) said that he had learning disabilities and
diagnosis). Seven per cent of children with SLIs had learning was failing to achieve in a mainstream school setting. It
disabilities, of whom 40% had ADHD (again the most com- stated that John required a high level of individualized
mon psychiatric diagnosis). The conclusion was that, while teaching support within a small class size in order to pro-
ADHD is common in children with SLIs, it is more prevalent gress academically. It further recommended that he required
in children with learning disabilities. teaching from staff accomplished ‘at forming positive

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 Attention deficit hyperactivity disorder 75

relationships with children like John, who have found life at dog he would be OK. Whether these two wishes are
school (and at home) continually frustrating because they realistic I did not know but they seemed to be signals
seem not to be able to gain the attention they feel they that he feels lonely and in need of friends and that he
require, for themselves or their learning’. An assessment wanted something that he could call his own.’
by an educational psychologist at this time described John
Approximately one year later, John’s SSEN review
as: being distractible in class with poor concentration and
reported that John was making slow progress academically:
self-control; having an inability to sustain concentration and
effort; disruptive during activities; a ‘vulnerable learner’ ‘He tends to destroy his work if he makes a simple
with potentially average abilities but minimal attainments; mistake. . . [H]is confidence has improved but he still
too hasty in response, and with a perpetual urge or reflex to opts out of work at every opportunity.’
be ‘up and doing’; and having underdeveloped skills and
His behaviour was often disruptive and oppositional, and
unstructured thinking patterns. The report concluded that
he was regularly playing truant:
John required individual teaching support and small class
groups, and additional help to form positive relationships ‘[H]e calls out obscene comments to other pupils, light-
with peers. It was recommended that a change in school ing matches and fires whenever the opportunity arrives.
provision to a boarding facility would better support his He behaves abominably when on school transport,
academic and personal development. walking around the vehicle, rocking the vehicle and
At 12 years of age, John was placed in a small residential generally causing as much disruption as he possibly
school for children with learning and behavioural difficul- can. He fights and provokes other boys, breaks windows
ties. His SSEN annual review documented that he was in a and damages furniture if he is not restrained.’
one-year chronologically younger group of five pupils
After several exclusions, John was eventually expelled
because of his level of academic functioning. John was also
from the school for causing criminal damage.
receiving art psychotherapy on an individual-session basis.
When he was 17 years old, John was referred for assess-
He was noted to be an affectionate and likeable person at
ment at a national adult ADHD clinic based at a London
times, although these qualities were overshadowed by his
hospital. His performance on Raven’s Matrices (Raven et al.
problematic attention-seeking behaviour. These behaviours
1976) gave him an estimated IQ of 65. The information from
prevented John from functioning satisfactorily within the
an interview with John’s mother and the documentation
residential setting (as they had in a mainstream setting), and
relating to his educational history all confirmed that he
also from forming positive relationships with both adults
had experienced considerable problems with inattention,
and peers. Particular problems identified included his need
impulsiveness and hyperactivity from a young age. Formal
for his demands to be met immediately and his inability to
psychological assessment, information from his mother and
tolerate sharing adult attention with other children, often
self-report all indicated that these early cognitive and beha-
resorting to ‘extreme’ attention-seeking behaviours. When
vioural difficulties had not abated in late adolescence. On the
confronted by unsatisfactory performance or failure on a
basis of the assessment, John was formally diagnosed as
task, John became angry and frustrated. His immature atti-
having ADHD.
tudes and behaviours were considered to be restricting his
progress both academically and socially: such behaviours
were perceived to result in ‘inappropriate social behaviour Functional analysis
with peers’ which caused him to be ostracized by his fellow
Functional analysis has been defined by Samson and McDon-
pupils.
nell (1990) as:
When John was 14 years old, oppositional conduct pro-
blems were becoming an issue; for example, school refusal ‘A method of explaining a phenomenon which involves
and uncooperative behaviour. He was reported to be avoi- the generation of hypotheses from both observable and/
dant of tasks and poorly motivated. John was becoming or unobservable data. It attempts to explain and predict
socially isolated. He had few interests and those he did have the functions(s) of a phenomenon through an examina-
were solitary (e.g. gardening and swimming). An educa- tion of the relationships that contribute to it.’ (p. 261)
tional psychologist wrote:
Using the above definition as a template, the relationship
‘I did ask him to do some reading and writing with me between challenging behaviour and ADHD can be exam-
when I was on my own with him. He did not want to and ined. In the present case study, the phenomenon is the
declined even to dictate a sentence to me about anything ‘challenging behaviour’ reported by the schools. The expla-
that he liked. He did, however, volunteer that he wanted nation and prediction of the phenomenon is given by four
to live with his father because he did not have any accepted broad categories which relate behaviour function-
friends near to home. He also said that if he had a ally to the environment, sensory stimulation, social attention

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76 S. Young and J. Newland

seeking, physical reinforcement and demand avoidance childhood behavioural difficulties. Secondly, a more detailed
(Carr & Durand 1985). On the basis of the content of the concern with personal history and the retention of salient
detailed personal history, it is likely that the rationale for documentation is required in order that alternative accounts
John’s behaviour at the time was hypothesized to be: social can be formulated. Finally, the parameters which define
attention seeking when he was 8 years of age; demanding traditional expressions of psychological distress need to be
sensory stimulation when he was 12; demand avoidant at 14; explored in relation to their variation in people with learning
and motivated to obtain physical reinforcement at 15 years. It disabilities. Longitudinal research in the area would make a
is probable that his teachers would have implemented a significant contribution to all three concerns.
variety of behavioural strategies while he was at school.
However, these strategies alone did not enable John to exert References
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