Ulla Ek presentationsbilder vid föreläsning den 9 september 2010.

1. Barn med uppmärksamhets-
inlärnings- och
koncentrationssvårigheter
Data från en longitudinell,
populationsbaserad studie
Ulla Ek, leg psykolog, professor

2. Arbetslaget
• Elisabeth Fernell
• Kirsten Holmberg
• Studenter på psykologprogrammet
• Joakim Westerlund
• Barntandläkarsektionen vid KI- My Blomqvist
och Göran Dahllöf
• Personal vid skolhälsovården i Sigtuna- Märsta
• Och 591skobarn från åk4 till åk 9

3. Vad är unikt med projektet?
• ”School based” inte clinic based
• Litet bortfall
• Multi disciplinärt
• Longitudinellt
• Svenska förhållanden

4. Beteendeproblem hos barn och
ungdomar:
Vanligt är: uppmärksamhets- och koncentrationssvårigheter
Över- eller underaktivitet
Svårt med omställning och flexibiltet
Utbrott
En del fyller kriterierna för diagnos
Andra inte
Symptomen kan variera över tid i barnets liv
ADHD…. ADD t.ex
Ofta undersöks inte bakomliggande kognitiva
orsaksfaktorer(Barkley)

5. Datainsamlingen
Syfte:
Att identifiera barn med beteende och
inlärningsproblem- rapporterat från hem och
skola- och försöka spåra kognitiva korrelat som
möjlig förklaring

6. Metod
Utökad hälsokontroll i åk 4
Screeningformulär till föräldrar och lärare(2x2)
Lärarintervju
Inklusionskriteria för fortsatt studie:
Conners´+ EF formuläret över 1/3 av max från
både hem och skola
el.
Utfall på ett formulär + dokumenterade
svårigheter

7. 10%?
Nej 175 barn uppfyllde kriterierna=34%!!
Föräldrarna inbjöds till att delta (med sitt barn) i en
klinisk studie: föräldraintervju, DSM- intervju
avseende ADHD, psykologbedömning
med WISC, Jag tycker jag är samt Bar i Lan.
Lärarintervju
Återkoppling:
Miniutlåtande från psykologen
Uppföljning av skolhälsovården.
Ev. vidare utredningar

8. 144 barn kom att ingå
• 44 flickor
• 100 pojkar
• 9 gick i specialklass (4MMR)
• 3 gick i ”långsam studietakt”
• 2 i autismklass
• 4 i liten grupp
• Övriga i vanlig grundskoleklass

9. Behavioural and learning problems in schoolchildren
related to cognitive test data
Acta Paed 2004; 93: 976-981.
• KOGNITIV KARTLÄGGNING AV GRUPPEN
• IQ < 70 8 pojkar 10 flickor
• 70-84 31 pojkar 12 flickor
• 85-115 57 pojkar 21 flickor
• >115 4 pojkar 1 flicka
• VFI och POI över 90
• UI och SI 1 sd under medelv.
• Vad var tankeväckande?

10. Cognitive strengths and deficits in schoolchildren with
ADHD
Acta Paed 2007;96: 756-761
• 32 barn ADHD
• 10 sub-treshold ADHD.
• 102 BLP en blandning av
koncentrations/inlärnings och
beteendeproblem. Några barn med andra
diagnoser.

12. • When analysing the 13 subscales of the WISC III for the entire group of 144 children
(42/102) on a group basis, the lowest scores, were obtained with the Arithmetic,
Coding, Information, Digit span (ACID), and Symbol search indicating that the
“screen positive” children in the population, regardless of whether or not they had
actually received a diagnosis of ADHD or not, have specific problems with attention,
processing speed, auditory sequencing and working memory.
• On an individual basis a complete or incomplete ACID profile was equally common
in the two groups, being found in about 1/5 of the children, in the two groups
comprised of those who had screened positive.
• .. Thus, the cognitive weakness reflected in this specific (and very common)
cognitive profile seems to play a role in various developmental disorders, as an
underlying factor.

13. Svårigheterna
• The lowest scores in both groups were found
on subscales reflecting working memory,
planning and fluency (Information, Arithmetic,
Digit span, Coding and Symbol Search).

14. Resurserna då?
• The FSIQ, VIQ, PIQ and the four Kaufman indices were almost
identical for the children in the groups comprised of those
determined to have ADHD and those without. The highest
scores for both groups were obtained for the Verbal
Comprehension index, reflecting certain vocabulary-related
tasks, reasoning, problem solving and abstract verbal thinking
and the Perceptual Organization Index, reflecting non-verbal
abilities and a capacity for spatial reasoning. This finding is in
accordance with those of Lovecky (2004), who emphasised
the relative talents of children with ADHD, specifically some
verbal abilities, capacities that are frequently
overlooked.

15. Vad lärde vi oss?
• 1.
• 2
• 3
• ?
• ?

16. Self-esteem in children with attention and/or learning
deficits:the importance of gender
Acta Paed 2008;97:1125-1130
• Findings regarding the nature of self-esteem in
children with attention deficit hyperactivity disorder
(ADHD) are contradictory. Hoza et al, for example,
reported that children with ADHD tended to
overestimate their own competence, reporting an
inflated estimation of self-worth, called positive
illusory bias. Furthermore, they overstated their
perceptions of themselves most strongly in areas
where they had the greatest skill deficit

17. • The authors commented that “because
children with ADHD chronically encounter
setbacks and failures in a variety of areas, they
may be especially inclined towards a thinking
style characterized by positive illusions”

18. • Edbom et al. reported, from a prospective
longitudinal twin study, a long-term
relationship between ADHD-symptoms and
low self-esteem. High score of ADHD
symptoms at age 8 was related to low self
esteem, according to the “I think I am” self-
esteem-scale, at age 13.

19. Hypotes
• Our hypothesis when embarking on this study
was that children with ADHD/subthreshold
ADHD would report lower self-esteem than
the reference group.

20. Resultat
We found negative correlations between the
teachers’ ratings of both impulsive/restless
behaviour and emotional lability and the
children’s own ratings of their physical
appearance. Thus, children who were
considered to be restless, impulsive and
emotionally labile did not feel good about
their self-image, their looks and their body.
This was especially salient for the girls.

21. Flickorna
• The girls in our study (irrespective of ADHD or
BLD) reported lower self-esteem in terms of
mental well-being, and relationship with
parents and others, when compared to the
boys in the study. The problematic behaviour
of these children, reported by teachers and
parents, probably result in more troublesome
relations with friends, teachers and parents,
something that might effect the self-esteem in
girls more heavily than in boys.

23. The Conners´ 10 item scale: findings in a total
population of Swedish 10-11 year-old children
Acta Paed 2009;98:828-833
• To present normative data for the Swedish
version of the Conners´10-item scale, to
validate the scale by comparing children with
and without ADHD, to explore the factor
structure of this scale and to investigate
behavioural characteristics and gender
differences among 10-11-year old children, as
rated by parents and teachers respectively.

24. Method
• Parents and teachers rated 509 10-11-year old
children (261 boys and 248 girls) from a
population-based cohort in a Swedish
municipality.

25. En två faktorstruktur
• The Conners´ 10-item scale discriminated very well between
children with and without ADHD.
• Confirmatory factor analyses confirmed a two-dimensional
structure of the scale with items measuring restless/impulsive
behaviour in one factor and items measuring emotional
lability in another.
• An ANOVA revealed that parents and teachers reported
different behavioural characteristics in boys as compared to
girls.

26. Lärarna ser inte flickorna?
• The parents seem to perceive a more varied behavioural
repertoire and are able to identify both the restless/impulsive
behaviour and the low frustration tolerance of the girls. The
teachers, on the other hand, seem to overly attend to
disruptive behaviours and overlook more inattentive
behaviours. Girls with attention spectrum disorders are less
likely to be referred for relevant assessments, presumably
because their behaviour is less disruptive and therefore has a
reduced impact on their environment compared to boys. We
speculate that the lag for diagnosing girls with ADHD might be
a consequence of their problems being more invisible in the
class-room setting.

27. Tandläkarstudierna
• Videostudie av barn i undersöknings
situationen
• Cortisol
• Karies och tandhälsa
• Tandläkar rädsla
• Alla finns publicerade European Journal of
Oral Sciences

28. How do children with attention deficit
hyperactivity disorder interact in a clinical dental
examination ? A video analysis
Blomqvist M, Augustsson M, Bertlin C, Holmberg K,
Fernell E, Dahllöf G, Ek U.
Eur J Oral Scy 2005; 113; 203-209

29. Genomförande
• Ca 200 barn videofilmades ”i stolen”
• Detaljerad analys av 22 barn med ADHD och
47 kontroller genomfördes
• Första fasen analyserades med avseende på
interaktion
• Språklig och icke- språklig kommunikation
skattades av 2 skattare.

30. Resultat
• Signifikant fler initiativ speciellt med annat
fokus eller oklart fokus
• Färre verbala responser och fler uteblivna
responser
• Fler ”missing responses” och lägre grad av
samordning fråga- svar
• Längre latens- mindre samordning!

31. Academic performance of adolescents with
ADHD and other behavioural and learning
problems- a population- based longitudinal
study
• Ek U, Westerlund J, Holmberg,K och Fernell E
• Insänd till Acta för bedömning

32. Hur gick det i skolan?
• 536 av 591 slutbetyg fanns hos SCB
• Bortfall: särskola, ännu ej avslutat gymnasiet
eller Waldorfskola
• 3 grupper:
ADHD/ subtr. ADHD 39 st
BLP 80 st
Jämförelsegruppen 417 st

33. Meritpoäng max. 16 x 20= 320
• ADHD 147.44
• BLP 158.94
• Jämförelsegruppen 216.15

34. Möjlighet söka vidare ?
• Godkända betyg i Svenska, Engelska och
Matematik
• ADHD 72%
• BLP 68%
• Jämförelsegruppen 92%

35. Underprestera i förhållande till
optimal kognitiv förmåga ?
BLP IQ – 26 percentilen
Meritpoäng 22 percentilen
ADHD IQ – 26 percentilen
Meritpoängen 16 percentilen

38. Underpresterar
Ett barn med ADHD behöver en IK som ligger 2
standardavvikelser över medelvärdet för att
nå samma betygssumma som genomsnittet!
Barkley bl.a. nämner risker för underprestation
men vi har inga direkta studier på det.

39. Vad har jag lärt mig av det här?
• Ekonomin
• Tvärprofessionellt samarbete
• 34%!
• Profilen! Hur fånga resurserna ?
• Beteendet- flickor/pojkar- lärare/föräldrar
• Det är en utsatt grupp
• Utmaningen- den ligger i skolan