Why do I have to repeat myself, I told you ten times already.

Out with it already! You better have a better explanation than that.

How was school today? And don’t say ‘nothing much,’ something must have happened.

Managing ADHD is never about addressing attention or impulsivity alone. ADHD represents a deficit in executive function, a skill set that includes attention, impulse control… and far more. Seen as a disorder of self-regulation, ADHD potentially impacts anything that requires planning and coordination, from sleep and eating habits to laying out a long-term science project all the way to how someone speaks and listens in conversation.

Executive function acts as our ‘brain manager’ in coordinating our thoughts, actions and ability to plan. It is responsible for sorting through all the complex information we encounter, from paying attention to the right voice in a classroom to organizing responses in the midst of a rapidly-paced discussion. Comprehensive ADHD care requires a broad view of the often subtle effects it has on life, addressing its impact wherever it shows. One of the more commonly overlooked aspects of ADHD is its direct effect on communication.

Talk the Talk

The Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 is the standard diagnostic manual for clinicians in the fields of child development and mental health. Recently updated (although not yet released), the new version divides communication into three components: speech, language and pragmatics. These skills are defined as follows:

Speech comprises everything that goes into producing sounds. Common speech concerns include articulation disorders (unexpected inability to produce specific sounds), stuttering and stammering.

Language is the meaning of words and how we put them together. It includes vocabulary, grammar and narrative discourse along with corresponding receptive language abilities. Under the present system, common diagnoses in this area are expressive language delays (such as using fewer words or sentences than expected) and receptive language delays (understanding less than expected for age).

Pragmatic language represents all the nonverbal nuances that facilitate everyday conversation, and broadly includes anything regarding the social side of communication. It includes all the unspoken aspects of communication, like reading faces and monitoring tone of voice, as well as adapting ourselves to different situations (such as speaking to a teacher versus a peer). Skills such as understanding gestures, non-literal meetings (such as metaphor, irony and sarcasm), and detecting the emotional meaning behind a change in facial expression depend on an intuitive grasp of pragmatics.

Speech and ADHD

Studies show that children with ADHD are at risk for articulation disorders, which affect their ability to produce letter sounds appropriate for their age. Beyond that, they also commonly have differences in fluency and vocal quality when speaking. One study even detected ADHD through these speech differences. Compared to peers with learning disabilities alone, children with ADHD showed increased volume and variability in pitch when talking, along with particular patterns such as increased number of vocal pauses.

Children with ADHD produce more vocal repetitions or word fillers as they try to organize their thoughts, somewhat similar to a stammer. This can lead to impatience and misunderstandings from others, especially children, as they generally don’t have the same patience and perspective as adults. A response in the classroom may be along the lines of, “It’s a story abou … um… a story… um… um… it’s about … akidwhofliesakite… um.”

Communication and ADHD

Children with ADHD process language differently as well. For starters, they are at increased risk for significant language delays. Even without specific delays, because of distractibility and related ADHD symptoms, they are more likely to get off-topic when speaking. They also frequently struggle to find the right words and put thoughts together quickly and linearly in conversation. Errors in grammar as they compose sentences also may occur, because of planning difficulties present even when underlying skills in this area are intact. All these ADHD- related symptoms, with or without actual language delays, may impact the ability to communicate effectively.

In ADHD, listening comprehension can be impaired directly, in particular because of difficulty handling rapidly-spoken language or managing distracting, noisy environments like a party or a busy classroom. Again, this is true even when a child doesn’t have an actual language delay; they have the capacity to understand, but because of ADHD, miss details in both conversation and stories. When listening, they may lose track of conversational threads entirely or miss details, and therefore fail to register vital bits of information. These same gaps frequently come across as oppositional behavior when a request appears intentionally ignored instead of not being heard in the first place. These patterns also relate to the reading comprehension difficulties often found with ADHD.

Paying attention to the thread of conversation can become even more problematic for a child with ADHD in groups or when in a noisy situation.The ability to retain focus on a single speaker and to transition between speakers is challenging. This has social implications, leading some children with ADHD to find it easier to get along one-on-one rather than in a group. Distracting classrooms, when multiple activities occur simultaneously, may make it particularly difficult for a child with ADHD to engage.

ADHD also often makes it hard for a child to manage large clumps of conversation all at once. While another 8-year-old may be able to handle hearing as many as twelve words at a clip with good understanding, with ADHD, seven or eight might be the maximum. Anything larger, and information begins to be dropped.

These types of problems in understanding spoken language are often incorrectly labeled as an ‘auditory processing disorder.’ There is nothing wrong with the actual auditory pathway; the information gets in, but executive function impairments mismanage it. The brain manager is asleep on the job again, jumbling the details about what’s being said.

Pragmatics and ADHD

Pragmatic language, as noted above, encompasses all the social mores related to spoken language and nonverbal communication. Core ADHD symptoms undermine this aspect of communication all on their own. Blurting out answers, interrupting, talking excessively and speaking too loudly all break common communication standards, for example. People with ADHD also often make tangential comments in conversation, or struggle to organize their thoughts on the fly. Even for those with advanced vocabularies and understanding for age, these pragmatic difficulties may get in the way of social success.

These pragmatic difficulties are similar to, but not the same, as found in a child with autism. In autism, the underlying issue is that children do not intuitively grasp the social world — which includes pragmatic language delays.Unlike those with ADHD, however, children with autism have an intrinsic developmental delay in a far wider array of social and communication skills.

With ADHD, the ability to understand nonverbal language and social interactions as a whole is most likely intact. They recognize nonverbal communication for what it is, and understand basic rules of communication such as ‘wait your turn to reply.’ Due to distractibility, impulsiveness or other executive function impairments they may fail to follow those same rules at any particular moment, or even notice social cues at all; many will meet criteria for a new DSM-5 category of ‘social (pragmatics) communication disorder.’ So while autism causes a more pervasive impairment in social judgment, because of lapses in pragmatic skills ADHD can undermine social abilities in children all on its own.

Actions Speak Louder Than Words

What can we do to help with ADHD and communication? Look for potential language delays. Intervene when needed. And as adults, adapt our own communication style as much as possible.

• Evaluate for specific delays through direct testing, and then initiate appropriate interventions when indicated.

• Wait until you gain your child’s full attention before making a request or starting a conversation; otherwise, details will likely be missed. Help transition their attention by using a brief marker, such as “Joseph, I have a question for you.” If it is helpful, engage them physically through gently touching their shoulder or a similar approach, and then try to maintain eye contact as well. The same technique (perhaps without the physical touch) equally supports adults with ADHD.

• Address pragmatic concerns for kids struggling socially as behavioral intervention alone may not be enough, through working with a therapist familiar with this aspect of communication.

• Offer ‘extended time’ in conversation, allowing children who may be struggling to pull their thoughts together. Give them ample time to settle themselves and organize their responses.

• Pause often and parse language into shorter segments when speaking to someone with ADHD. Annunciate clearly, and use gesture language such as counting bullet points on your fingers. Without judgment or condensation, rephrase or repeat yourself when needed. Consider having children restate what they’ve understood from what you’ve said.

*Many thanks to Dr. Rosemary Tannock, as this posting quotes extensively from her presentation on the same topic at the recent CHADD conference in San Francisco.