Abstract
Zusammenfassung. Kinder mit einer Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) zeigen häufig akademische Minderleistung mit unklarer Ursache. Neben den Kernsymptomen der Störung haben Kinder mit ADHS typischerweise eine geringere Selbstkontrollkapazität, d. h. eine mangelnde Fähigkeit, automatisch auftretende Reaktionsimpulse zu unterdrücken oder zu modifizieren. In der Normalpopulation wurde mehrfach gezeigt, dass eine höhere Selbstkontrollkapazität mit besseren akademischen Leistungen einhergeht. Daher wird in der vorliegenden Studie der Einfluss der Selbstkontrollkapazität auf den Zusammenhang zwischen einer ADHS-Diagnose und Schulleistungen untersucht. 44 Kinder mit und 59 Kinder ohne ADHS im Alter von 7 bis 13 Jahren, für die jeweils ein Elternteil die Schulleistung und die Selbstkontrollkapazität einschätzte, wurden untersucht. Kinder mit ADHS hatten eine niedrigere Selbstkontrollkapazität und signifikant schlechtere Schulleistungen als Kinder ohne ADHS. In einer Mediationsanalyse zeigte sich, dass der Effekt von ADHS auf die Schulleistung vollständig durch die Selbstkontrollkapazität vermittelt wurde. Alle Befunde galten auch bei Kontrolle von Intelligenz. Die Ergebnisse sprechen dafür, dass nicht das Vorliegen einer ADHS-Diagnose für schlechtere Schulleistungen verantwortlich ist, sondern die mit der Störung einhergehenden Selbstkontrolldefizite. Diskutiert werden Diagnostik und Trainierbarkeit von Selbstkontrolle bei Kindern mit ADHS sowie Implikationen der Befunde für die Praxis, mit besonderem Augenmerk auf den Umgang mit Selbstkontrolldefiziten im schulischen Unterricht. Einschränkend muss festgehalten werden, dass alle berichteten Variablen nur durch die Eltern eingeschätzt und im Querschnitt erhoben wurden.
Abstract.Background & Aims: Attention-Deficit/Hyperactivity Disorder (ADHD) is a frequent neurodevelopmental disorder in childhood with a worldwide prevalence of 3 to 7 % (Skounti et al., 2007). Children with ADHD suffer from inattentiveness, are hyperactive, and impulsive. These ADHD symptoms lead to impairments in relationships with peers or within the family. In addition to these problems, children with ADHD show poor academic and educational outcomes compared with children without ADHD. They achieve lower grades, and are more likely to repeat a grade, be suspended or expelled from class, or take part in special educational services compared with children without ADHD. Children with ADHD typically have a lower general cognitive ability than regularly developing children. Furthermore, they do not perform academically at the level predicted by their IQ. Therefore, a reduced general cognitive ability cannot be the primary cause of their impaired academic achievement. Several mechanisms have been proposed to be responsible for the lower performance of children with ADHD: attention deficits (Rapport et al., 1999) and deficits in executive functions (EF; Willcutt et al., 2005). Children with ADHD and poor EF received lower results in academic achievement tests as compared to children with ADHD and average EF (Biederman et al., 2004). However, not all individuals with ADHD are affected by EF impairments. Taken together, neither inattention nor deficits in EF are sufficient to explain academic underachievement associated with ADHD.
However, self-control predicts academic achievement more strongly than intelligence (Duckworth & Seligman, 2005).Self-control is the ability to alter one’s own responses. It allows people to control their own thoughts, impulses, and emotions, but also to overcome undesirable habits and to be persistent in tasks. Thus, self-control encompasses a broader domain of abilities than EF. As children with ADHD have lower self-control, for example when they have to delay gratification or to regulate their emotions (Sonuga-Barke, 2002), self-control might be a promising candidate to explain the academic underachievement in ADHD.
Hence, the aim of the present study was to investigate the relation between ADHD-diagnosis, academic achievement, and self-control. We assumed that (a) children with ADHD show lower academic achievement and (b) have lower self-control than children without ADHD. Finally, we hypothesized that (c) self-control deficits mediate the relation between ADHD und lower academic achievement.
Methods: Data was collected from a German sample, consisting of 115 children aged between 7 and 13 years participating with one parent in a larger study that assessed biological and psychosocial family-related influences on the ability to delay rewards and on risky decision-making in children with ADHD. Children were recruited from schools, local child psychiatric outpatient centers, and a clinic for child and adolescent psychiatry. To be included in the sample, children had to have (a) an IQ ≥ 70, (b) no pervasive developmental disorder, autism, or psychotic disorders, and (c) a birth weight ≥ 2500 g. Children were assigned to the ADHD group if they had a prior clinical diagnosis of ADHD and were on ADHD-specific medication (e. g., Methylphenidate), or if they had a prior clinical diagnosis of ADHD and scored on at least two standardized ADHD screening or diagnosis instruments above the cut-off score, or had no prior clinical diagnosis of ADHD but scored on at least three standardized ADHD screening or diagnosis instruments. These measures included a standardized clinical interview (Kinder-DIPS; Schneider, Unnewehr & Margraf, 2009), the attention problem scale of the Child Behavior Checklist (CBCL; Arbeitsgruppe Deutsche Child Behavior Checklist, 1998; cut-off: Tscore > 67), the hyperactivity scale of the Strengths and Difficulties Questionnaire (SDQ; Woerner, Becker & Rothenberger, 2004; cut-off: score > 5), and the overall scale of the German ADHD symptom list (FBB-ADHS; Döpfner et al., 2006; cut-off: Stanine score > 6). Children were included in the control group if they had no prior diagnosis of ADHD and scored on no more than one of the standardized screening or diagnosis instruments for ADHD. Based on this procedure the final sample for our analyses was reduced to N = 103 with 44 children being in the ADHD group (Mage = 10.38 years, SDage = 1.66 years; 8 girls) and 59 children in the control group (Mage = 9.81 years, SDage = 1.56 years; 18 girls). Academic achievement in German, mathematics, and science was rated by the parents using items from the CBCL (Arbeitsgruppe Deutsche Child Behavior Checklist, 1998) and self-control was measured using the parent-rating version of the Self-Control Scale (SCS-K-D; Rauch et al., 2014). In addition, we assessed children's intelligence applying the CFT 20-R (Weiß, 2006), behavioral inhibition by a Flanker task (Eriksen & Eriksen, 1974), risky decision-making by a modified Game of Dice task (Brand et al., 2005), self-reported behavioral inhibition by the BIS-subscale from the BIS/BAS scales (Strobel et al., 2001) and children's inattention rated by the parents using the inattention-subscale from the FBB-ADHS (Döpfner et al., 2006).
Results: As expected, children with ADHD had lower self-control scores, t(99) = −8.15, p < .01, d = 1.64 and poorer academic achievement, t(99) = −2.89, p < .01, d = 0.55 than children without ADHD. A mediation analysis was conducted to analyze the interrelation of diagnosis, self-control, and academic achievement. In separate regression models, ADHD tended to predict academic achievement, b = −0.28, β = −0.18, t(96) = −1.85, p = .07, R2 = .16, and predicted self-control, b = −1.02, β = −0.60, t(96) = −7.41, p < .001, R2 = .44. When academic achievement was predicted simultaneously by diagnosis and self-control, self-control remained significant, b = 0.22, β = 0.24, t(95) = 2.04, p < .05, whereas diagnosis did not, b = −0.05, β = −0.03, t(95) = −0.27, p = .79. This model explained 20 % of the variance in academic achievement. Intelligence was controlled for in all models. A bias-corrected bootstrap 95 % confidence interval (CI) based on 20 000 bootstrap samples indicated a significant indirect effect of diagnosis on academic achievement through self-control, b = −0.23, β = −0.14, 95 % CI: −.4943 – −.0013. Together, the three regression models demonstrated a complete mediation of the relation between diagnosis and academic achievement. As both self-control and academic achievement have been assessed with parental ratings, further mediation analyses with the covariates as mediators were conducted to account for common-method variance. The indirect effects for each of those models did not reach statistical significance.
Discussion: Children with ADHD showed lower self-control scores and lower academic achievement. The relation between diagnosis and academic achievement was mediated through self-control, which means that deficits in self-control are associated with academic underachievement in children with ADHD. For inattention, the objective assessment of children's behavior (i. e., Flanker task, Game of Dice task) and children's self-reported behavior (i. e., inhibition) no mediation effects were found. Hence, a common method bias can be excluded.
At least two approaches to improve academic achievement of children with ADHD can be derived from our findings: (a) to strengthen self-control in children with ADHD in particular and (b) to reduce self-control demands in class. Self-control could be strengthened by interventions using self-monitoring, self-instructions, or by directly practicing self-control in everyday tasks. Dividing tasks into subunits, reducing task length, or giving immediate feedback could reduce demands on self-control. Finally, another possible way to both reduce self-control demands as well as to support and strengthen self-control are if-then plans that link a specific situation to an instrumental goal-directed behavior leading to an automatized release of the desired behavior as soon as the situation occurs (Gollwitzer, 1999).
As a limitation, it needs to be noted that in our main mediation model all variables were assessed only by parent reports. Further studies might want to use standardized school achievement tests and teacher ratings as well as objective self-control measures in addition to parent reports. Although the results showed no group differences in class level and type of school, these variables should be addressed in further studies to determine if different class levels or school types have different requirements in self-control. Furthermore, differences in different educational systems should be focused on. Another restriction is the cross sectional study design that is generally not suitable to test causal assumptions of a mediation model.
To sum up, the poor academic achievement of children with ADHD is related to self-control deficits associated with the disorder, which underlines the need to strengthen self-control in children with ADHD.
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