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Journal of Child Psychology and Psychiatry 48:5 (2007), pp 455–463 doi:10.1111/j.1469-7610.2006.01710.x

The relationship between attention, executive

functions and reading domain abilities
in attention deficit hyperactivity disorder
and reading disorder: a comparative study
Barbara Bental1 and Emanuel Tirosh1,2
1
The Hannah Khoushy Child Development Center, Bnai Zion Medical Center, Haifa, Israel; 2Faculty of Medicine,
Technion – Israel Institute of Technology, Haifa, Israel

Background: Co-morbidity of attention deficit hyperactivity disorder (ADHD) and reading disorder (RD)
is frequent. The objective of this investigation was to assess the potential uniqueness of co-morbid
ADHD + RD and extend existing findings to the Hebrew language. Method: A parallel group design
with post-hoc analysis of group differences was employed comparing four groups of children (19 ADHD,
17 RD, 27 ADHD + RD, and 23 controls) on reading measures, attention and executive functions (EF) as
well as functions of phonemic awareness and rapid naming. Forward stepwise regressions were run in
order to delineate significant relationships between phonemic awareness, rapid naming, attention and
EF with outcome variables of reading. Results: The co-morbid group shared the basic characteristic
impairments in attention and executive functions with the pure ADHD group and in reading domain
functions with the pure RD group. In addition, this group showed unique deficits in rapid naming and a
more severe impairment in working memory. Forward stepwise regression pointed to associations be-
tween executive functions and word reading accuracy in children with ADHD, in contrast to associa-
tions between linguistic functions and word accuracy in non-ADHD. Conclusion: The combination of
cognitive deficits in the subgroup of children with both ADHD and RD and the relationship between
accuracy in word decoding and executive functions shown for the ADHD groups point to a distinct
clinical profile of the co-morbid condition. Attention and EF should be considered in the diagnosis of RD
and in the remediation protocol. Keywords: Attention deficit hyperactivity disorder (ADHD), reading
disorder (RD), co-morbidity, executive functions (EF), word decoding, rapid naming.

Reading disorder (RD) and attention-deficit/hyper-
activity disorder (ADHD) are two of the most common
disorders in the population of school-age children.
Conclusive evidence of cross-sectional studies points
to a double dissociation between attention/control
core deficits in ADHD (Felton, Wood, Campbell, &
Harter, 1987; Pennington, Groisser, & Welsh, 1993;
Willcutt et al., 2001) and an impairment of visual
and verbal processing, especially phonological pro-
cessing and rapid naming in RD (Stanovich, 1988;
Purvis & Tannock, 1996; Wolf, Bowers, & Biddle,
2000). However, several studies showed a less clear
distinction between core deficits in the two disorders
(Carte, Nigg, & Hinshaw, 1996; Tannock, Martinus-
sen, & Frijters, 2000; Rucklidge & Tannock, 2002).
At least two biases are listed in most studies when
interpreting the results:
1. Hidden co-morbidity as a confounding factor,
especially a co-morbid impairment of linguistic
functions in ADHD (Cohen et al., 2000; Wu,
Anderson, & Castiello, 2002). Therefore an
increase of homogeneity across groups and the
use of mutually exclusive definitions for group
assignment are recommended (Tirosh & Cohen,
1998; Willcutt et al., 2001).
2. The difficulty of interpreting performance in terms
of underlying attention/control functions and
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domain specific abilities, as both have influence
on the outcome measure (Denckla, 1996a).
Estimates of co-occurrence of ADHD and learning
disability range from 10% to 50%; most frequently,
co-morbidity is observed in the area of reading (Ric-
cio & Jemison, 1998). Recent studies point to core
deficits of both domains within the same child. Some
studies show that the co-morbid group is most im-
paired on both underlying functions in the domain of
attention/control and phonological/linguistic func-
tions when compared with the two exclusive dis-
orders (Willcutt et al., 2001; Nigg et al., 1998).
Tannock et al. (2000) and Rucklidge and Tannock
(2002) point to specific additional cognitive deficits
in rapid naming in children and adolescents with
both disorders and raise the issue of a unique cog-
nitive subtype. Purvis and Tannock (1996) suggest
that the co-morbid group is less impaired on the
language measures than the pure RD group and
thus point to the possibility that the reading dis-
ability in the co-morbid group might be caused by a
different combination of deficits and their inter-
action.
The current study sought to further investigate the
profile of attention/control functions and reading
domain functions and the nature of their relation-
ship in a co-morbid sample of boys with ADHD + RD

456 Barbara Bental and Emanuel Tirosh
using a full four parallel group design and including
only children with normal oral language processing
abilities. Mutually exclusive definitions are used for
group membership. The reading diagnostic meas-
ures are narrowed to specific decoding elements of
word accuracy and text fluency.
While the above-mentioned studies were carried
out in an English-speaking population, this invest-
igation is conducted in Hebrew, a language that uses
an alphabetical script like English. But this script
differs from the English script in its ‘orthographic
depth’, that is, the consistency of letter-phoneme
mapping, as well as the textual arrangement. In the
pointed script, which is used in this study, there is
an almost perfect regular phoneme–grapheme cor-
respondence (shallow orthography), in contrast to
English which is widely regarded as exceptional in its
degree of irregularity (deep orthography). Studies
that address reading in different alphabetical written
languages have shown a shared base for reading
performance, i.e., phonological abilities and rapid
naming, but the level of ‘orthographic depth’ influ-
ences the strength of the correlation of rapid naming
and reading performance (Wolf et al., 2000). In the
pointed script in Hebrew, phonological decoding is
the main route of the decoding process, influenced
by phonological abilities and rapid naming (Share,
2004). Therefore, the study in Hebrew can specific-
ally shed light on the involvement of these compo-
nents in the reading performance in the co-morbid
group.
Our hypotheses were the following:
1. The cognitive profile of ADHD + RD shows unique
deficits not shared by either one of the pure-
groups.
2. The reading impairment in the co-morbid group is
particularly linked to deficits in rapid naming and
less correlated with phonological deficits.
Method
Participants
The participants were 86 boys in grades two to six,
between 7.9 and 11.7 years of age, who were at the
time of the study enrolled in regular classes of public
schools: ADHD (N ¼ 19), RD (N ¼ 17), ADHD + RD
(N ¼ 27), and Control (N ¼ 23). The subjects of the
study groups were consecutively referred to the child
development center, because of poor academic per-
formances and/or problems in attention. Children
with other health problems, neurological or psychi-
atric co-morbidity as defined by the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition
(DSM-IV; American Psychiatric Association, 1994),
were not included in the study. The diagnostic process
aimed to identify four groups with distinctive charac-
teristics of attention and reading, while keeping the
distribution of the descriptive variables (age, grade,
intelligence, and receptive language) similar over
group boundaries.
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Inclusion criteria
Intellectual functioning was assessed with the Voca-
bulary and Block Design Tests of the Wechsler Intelli-
gence Scale for Children (WISC-R, Hebrew version;
Wechsler, 1976) primarily to rule out mental retarda-
tion. The subject had to have a z-score of more than )1
in the verbal domain (scaled score >7) in order to be
included in the study.
Receptive oral language skills were estimated with
the Hebrew version of the Test for the Reception of
Grammar (TROG; Bishop, 1982). A cutoff point of
80-standard score was considered for inclusion.
Diagnostic criteria for group assignment
For the ADHD groups, neuro-developmental pediatri-
cians carried out the clinical assessment of ADHD. The
assessment was based on a parent interview, which
covered the developmental as well as health history of
the child and other family members. The behavior was
assessed with a particular focus on the symptoms of
ADHD (DSM- IV), Conners Parent and Teacher Rating
Scales (Conners, 1997) as well as a neurological and
neurocognitive examination and interview of the child.
Only children with an affirmed DSM-IV diagnosis of
ADHD, i.e., the presence of six or more symptoms in at
least one of the two symptom groups of inattention
(DSM-IV, 1) or hyperactivity-impulsivity (DSM – IV, 2)
as well as a Conners Teacher Rating Scale score of 1.5
standard deviation from the mean on one of the
attention components, were included in the study
groups (ADHD or ADHD + RD). None of these children
had any other major neuro-psychiatric or sensory
disorders (DSM-IV). None of the participants was on
medication while being tested. Those children whose
scores on the diagnostic reading tests (see below) were
above the 25th percentile were selected for the pure-
ADHD group.
For the RD groups an experienced learning disability
specialist assessed the reading level of all children
using the Nitzan Diagnostic Battery for Reading
Performance in Hebrew (Nitzan Diagnostic Battery;
Shalem & Lachman, 1998). A definition of low
achievement, below the 25th percentile in grade-
appropriate tasks of both single word decoding and
text reading, or lower than the 15th percentile on
either one, was used to classify children with RD.
Both measures were used in light of recent research
pointing to subgroups in reading disability in terms of
word reading accuracy and text reading fluency (Wolf
et al., 2000; Lovett, 1984). Those children whose
school record did not indicate an attention-behavior
problem and whose DSM-IV parental questionnaire as
well as the Conners Parent Rating Scale confirmed the
absence of problems in the domain of attention were
selected for the pure-RD group.
Children of the control group were matched for age,
grade and school district. Consequently, no significant
differences in educational exposure or socioeconomic
status were expected. The DSM-IV parental question-
naire, the Conners Parent Rating Scales and the dia-
gnostic reading tests were used to confirm the absence
of problems in attention, behavior and reading. Their
scores did not reach the diagnostic criteria of either
Ó 2007 The Authors

disorder. All parents and children gave their informed
consent to participate in the study.
Procedure
ADHD status was assessed in two separate meetings
prior to the testing session. Afterwards participants
were invited to take part in the actual testing session,
which lasted about 90 minutes.
Measures
Reading domain measures. In addition to the two
criteria measures, non-word decoding accuracy (a
measure of phonological decoding) and spelling accur-
acy were tested in order to assess the range of the
decoding/encoding abilities. A measure of reading
comprehension was added as an additional marker of
language abilities. Non-word decoding was assessed
with the Nitzan Diagnostic Battery, spelling accuracy
was assessed with a task of writing sentences by dic-
tation from the Test of Hand Writing Quality (Eres &
Porush, 1997). Reading comprehension was estimated
with grade-appropriate texts and related four-choice
questions that were derived from the Report of Reading
Performance of Elementary School Age Children
(Hadar, Bigman, Bental, & Lerner, 1994).
Measures of phonological processing/rapid nam-
ing. The phonemic blending and initial consonant
deletion tests from the Nitzan Diagnostic Battery were
employed to measure the child’s phonological process-
ing skills. Percentile scores for the phonemic blending
test and raw scores of correct answers for the phonemic
deletion test were included in the analyses. Rapid
naming was assessed by the Rapid Automatized Nam-
ing Test (RAN) (Denckla & Rudel, 1974) of digits. The
time (in seconds) used for the naming entered the
analyses.
Measures of executive functions (EF). For the do-
main of executive functions, tests of response inhibi-
tion, planning, rule abstraction/set shifting, working
memory and word fluency were included in accordance
with Pennington and Ozonoff’s (1996) summary of
executive function measures.
Response inhibition: The Matching Familiar Figures
Test (MFFT; Kagan, 1965) was used to assess inhibitory
control and impulsivity of response in a task that re-
quires effortful visual search (Pennington et al., 1993).
Percentile scores for both average reaction time for the
first response and number of errors were assessed by
the use of the percentile norms for the American pop-
ulation (Kagan, 1965).
Planning: Porteus Maze (PMT; Porteus, 1973) was
used for the assessment of planning and motor control.
It has an extensive validation in identifying ADHD (Nigg
et al., 1998).
Strategic problem solving, rule abstraction, set shift:
The Wisconsin Card Sorting Test (WCST; Heaton,
Chelune, Talley, Kay, & Curtiss, 1993) was included as
a measure to assess organized searching, utilizing en-
vironmental feedback to shift cognitive sets, directing
behavior toward achieving a goal, and modulating
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Attention and reading in ADHD + RD 457
impulsive behavior (Pennington et al., 1993; Snow
1998). The follow-through procedures were modified in
one respect: when the subject continued with the 11th
card using the same category, the examiner said, ‘no,
not correct any more’ instead of only ‘not correct’. This
approach was adapted in order to assure that the par-
ticipant understood that the old rule was no longer
valid. So his continuing within the same set was a clear
case of perseveration (Denckla, 1996b). The following
measures were derived: percent errors, percent
perseverative errors, percent conceptual level re-
sponses, number of trials for 1st category, number of
trials to complete task and number of categories.
Working memory: Two tests that differ in their de-
mand for semantic (listening sentence span) and
phonological (listening number span) processing were
used: 1. The listening sentence span test employed
sentences used by Leather and Henry (1994), trans-
lated into Hebrew, and the number of words recalled in
their correct order. 2. In the listening number span test
(Share, 1996), subjects were requested to listen to a
sequence of digits and remember the last digit of every
sequence. Then, after a signal, the subjects recalled the
last digit of each sequence in order.
Word fluency: Animal Retrieval and Food Retrieval
Tests (Wiig & Semel, 1976; Denckla, 1996a) were
included to measure verbal fluency under semantic
constraints. Number of words retrieved in 60 seconds
and number of sub-categories used were scored as
measures of organized strategic retrieval (Denckla,
1996a).
A standardized sequence of tests was chosen to
alternate between tasks of written language and tasks
of executive functions throughout the series and to
alternate between tasks of longer and shorter duration.
Statistical analyses
A principal component analysis (PCA) was conducted to
determine and separate specific dimensions of atten-
tion/control functions. Fifteen variables of executive
functions together with three measures of the Conners
parent rating scale entered the analysis: seven variables
of the performance on the WCST (percent errors, per-
cent conceptual level responses, number of trials to
complete test, number of categories completed, percent
non-perseverative errors, percent perseverative errors,
number of trials to complete 1st category), two variables
of the MFFT (errors, reaction time), three variables of
the Conners Parent Rating Scale (components B, D, F),
two verbal working memory measures (sentence span,
number span), three measures of word fluency (animal
retrieval, food retrieval, number of categories used in
animal retrieval), and the age adjusted quotient of the
performance on the PMT. The factors extracted by the
Varimax rotation method with Kaiser normalization
were used to compute factor scores.
One-way analyses of variance (ANOVA) and post-hoc
analyses of group differences were conducted to identify
group differences on reading domain functions as well
as on attention/control functions. A Duncan Multiple
Range Test (p < .05) set the criterion adopted for the
detection of post-hoc group differences. Two compar-
isons were run – one with detailed multiple variable
comparisons to screen for all the differences, and one
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458 Barbara Bental and Emanuel Tirosh

using the derived factor scores for the attention/control
functions. The factor scores were also employed in a
multinomial regression to assess predictive accuracy of
group membership and in stepwise forward regressions
to delineate linkage between attention/control func-
tions, phonological abilities and rapid naming with
outcome variables of reading and spelling. The six
factor scores and z-scores of the two phonological tests,
rapid naming, TROG and WISC-R vocabulary were used
to determine group membership. The control group was
defined as the reference group, for which all coefficients
were set to zero. In the forward stepwise regressions
nine variables, i.e., six factor scores of attention/control
functions, and z-scores of the phonological deletion,
phonological synthesis and rapid naming, as well as
z-scores of age, TROG, and Vocabulary and a constant
term were entered as independent variables. As
dependent variables, z-scores of three reading and one
spelling function, i.e., reading text fluency, word de-
coding accuracy, non-word decoding accuracy, and
spelling accuracy, were used. Two versions of the
regressions were run, one combining all groups, and
one where the two ADHD groups (ADHD, ADHD + RD)
and the two non-ADHD groups (Control, RD) were
evaluated separately. Entry was allowed up to a signi-
ficance level of 10%, and the removal criterion was set
at 15%.
Results
Table 1 summarizes the descriptive statistics for
each group. Age, grade and intelligence measures
did not significantly differ among the four groups.
The expected differences in reading measures and
scores of the parental DSM-IV resulting from the
initial diagnostic classification are shown.
Other significant group differences were found in
the accuracy of decoding non-words (p ¼ .0006) and
spelling (p ¼ .0001) in that both RD groups showed
significant impairments. Reading Comprehension
did not differ among the four groups (p ¼ .32).
Table 2 shows the pattern of correlations of the
PCA. Six factors were extracted with Eigenvalues
ranging from 5.64 to 1.07 accounting for a total
variance of 76.74. Given the nature of the tests the
loading of these factors could be assigned to the
following dimensions of attention/executive func-
tion: Factor 1 – strategy, rule abstraction, set
shifting, Factor 2 – attention, hyperactivity, Factor 3
– verbal fluency, Factor 4 – response inhibition,
effortful visual search, Factor 5 – planning and
Factor 6 – working memory. It should be noted,
however, that Factors 5 and 6 also load heavily on
Factor 1.
Table 3 contains the results for the variables of
attention/control functions, rapid naming and
phonological abilities as related to the four dia-
gnostic groups using the factor scores for the atten-
tion/control measures. The comparison of the
profiles revealed that the profile of the co-morbid
group combined the deficits of both pure groups, i.e.,
a deficit in attention/hyperactivity and a deficit in
phonological deletion. The level of these shared def-
icits was not significantly increased in the co-morbid
group. In addition, the ADHD + RD group showed a
unique deficit for rapid naming and a more severe
deficit in verbal working memory when compared
with the other study groups.
A comparative analyses using all of the measures
of the EF tasks showed that a deficit in planning
(age-adjusted quotient of the performance on the
PMT) was shared by the two ADHD groups, while an
impairment in set shift (WCST percent perseverative
errors) was shown only in the pure-ADHD group. In
addition, the variables related to the sentence span
task of working memory significantly separated the
co-morbid from the RD group, whereas those from
the digit span task did not.
Using multinomial regression, 81% of the parti-
cipants were classified correctly by employing the
underlying functions of reading and attention/con-
trol functions as independent variables, see Table 4.
The co-morbid group was classified correctly with
95.2% and clearly separated from both pure clinical
groups.
Results of the stepwise regression of the whole
study population, shown in Table 5, suggested the
following associations: Rapid naming and phono-

Table 1 Means and standard deviation of the four groups on descriptive and diagnostic measures

Controls (1) ADHD (2) RD (3) ADHD + RD (4)

(n ¼ 23) (n ¼ 19) (n ¼ 17) (n ¼ 27)

Variable Mean SD Mean SD Mean SD Mean SD F(3,82) Contrastsa

Age 9.75 1.03 9.76 .96 9.96 1.20 9.24 .96 2.10
Grade 3.74 .96 3.63 1.01 4.12 1.41 3.41 1.12 1.08
WISC-Block 13.6 3.73 11.72 2.95 11.00 3.69 11.96 2.36 1.80
WISC-Voc. 11.83 1.75 11.00 2.06 11.19 1.47 10.48 1.98 2.06
TROG 103.26 11.23 101.58 12.82 96.35 8.31 95.48 10.72 2.75* 1 > 4
DSM-1 1.26 1.36 6.84 1.50 2.12 2.03 6.30 2.00 68.59** 2,4 > 3,1
DSM-2a .70 .97 5.42 2.57 .76 .83 3.80 1.65 31.45** 2,4 > 3,1
DSM-2b 1.57 1.44 2.32 1.16 .71 .77 1.67 .96 11.01** 2,4 > 3,1
Text fluency 60.49 27.81 57.26 21.97 11.62 11.93 17.31 20.75 33.41** 1,2 > 3,4
Word accuracy 68.85 23.58 52.93 32.99 29.85 31.92 26.32 33.22 11.4** 1,2 > 3,4
a
Duncan Multiple Range Test, p < .05, WISC-Block ¼ WISC-R Block Design, WISC-Voc ¼ WISC-R Vocabulary, *p < .05, **p < .001.

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Attention and reading in ADHD + RD 459

Table 2 Principal component analysis of attention/control functions

Components

Measure 1 2 3 4 5 6

WCST – percent error .92 .29 ).16 .04 ).07 .00

WCST – percent conceptual response .87 .31 ).23 .01 ).09 .02
WCST – number of trials to complete test ).84 ).27 .15 ).06 .25 .06
WCST – number of categories completed .79 .37 ).09 ).05 .05 .01
WCST – percent non-perseverative errors .69 .10 ).13 .08 ).43 .24
WCST – percent perseverative errors .68 .31 ).10 ).03 .33 ).34
Conners Parents component F ).49 .77 .11 .25 .13 .09
Conners Parents component D ).24 .73 .12 .29 .15 .13
Conners Parents component B ).52 .67 .11 .22 .07 .11
Categorical retrieval: animals .23 ).02 .77 .21 .03 ).01
Categorical retrieval: food .38 ).10 .71 .07 ).23 ).25
Number of subcategories - animal .26 .15 .55 .05 ).10 ).41
MFFT – errors .24 ).36 ).20 .76 .01 ).03
MFFT – reaction time ).21 .36 .19 ).73 ).26 .09
WCST – number of trials for 1st category ).49 ).10 ).03 .41 ).52 ).05
Porteus Maze – age equivalent score .45 ).30 .06 ).06 .48 ).16
Working Memory – Sentence Span test .44 ).18 .28 .13 .24 .56
Working Memory – Number Span Test .46 ).21 .37 ).08 .01 .53
Eigenvalue of component 5.64 2.54 1.87 1.59 1.11 1.07
Percent of variance explained 31.32 14.11 10.40 8.81 6.16 5.93

Bold numbers in a column indicate most prominent loadings to a corresponding factor.

Table 3 Means and standard deviation of the four groups on attention/control functions (6 factor scores), rapid naming and
phonological abilities

Comparison (1) ADHD only (2) RD only (3) ADHD + RD (4)

(N ¼ 23) (N ¼ 13) (N ¼ 17) (N ¼ 27)
Measure Mean (SD) Mean (SD) Mean (SD) Mean (SD) F(3,82) Contrastsa

Strategy, Rule .29 (1.07) ).21 (1.02) ).13 (1.02) ).08 (1.0) .945
Abstraction, Shift
Attention, Hyperactivity ).83 (.70) .76 (.61) ).58 (.86) .56 (.81) 22.35** 1,3 < 2,4
Verbal fluency .10 (1.05) .13 (1.06) .00 (.86) ).18 (.80) .47
Response inhibition, .15 (.96) .10 (1.08) ).05 (1.06) ).14 (.98) .39
Effortful visual search
Planning .32 (.50) ).37 (.98) .09 (.72) ).17 (1.42) 1.77
Working memory .34 (1.05) .43 (1.07) ).14 (.68) ).46 (.94) 3.9* 4 < 1,2
Rapid naming 25.04 (4.59) 27.89 (4.89) 29.00 (7.28) 35.04 (7.57) 10.46** 4 > 1,2,3
Phonemic deletion 5.35 (1.61) 3.89 (1.85) 3.88 (1.87) 3.37 (1.84) 5.86* 1 > 2,3,4
Phonemic synthesis 48.4 (28.23) 34.06 (24.66) 40.96 (35.13) 46.29 (28.84) 1.21
a
Duncan Multiple Range Test, *p < .01, **p < .0001.

Table 4 Multinomial regression: predicted group membership

Percent correct Control (N ¼ 23) ADHD + RD (N ¼ 23) RD (N ¼ 13) ADHD (N ¼ 14)

68.8% 0 1 4 11 ADHD (N ¼ 16)

60.0% 3 1 9 2 RD (N ¼ 15)
95.2% 0 20 0 1 ADHD + RD (N ¼ 21)
90.9% 20 0 2 0 Contro Control (N ¼ 22)
81.1% 31.1% 29.7% 20.3% 18.9% Overall percentage

Table 5 Stepwise regression, no group-dependence: coefficients

Age TROG Voc F1 F2 F3 F4 F5 F6 Pde Psy RAN R2

Text fluency ).430 (.105)* .185

Word accuracy ).316 (.108)* ).303 (.103)* .270 (.106)* .234
Non-word accuracy .244 (.102)* .244 (.105)* .320 (.106)* .257
Spelling accuracy ).341 (.107)* .277 (.107)* .252

*Significance level p < .05, Voc ¼ WISC-R Vocabulary, Pde ¼ Phonemic deletion, Psy ¼ Phonemic synthesis, F1–6 ¼ Factor 1–6.

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460 Barbara Bental and Emanuel Tirosh

.219

.298

.298

.305
logical deletion were associated with reading fluency,

R2
phonological decoding and spelling. Word reading
accuracy, one of the two diagnostic measures for a

).462 (.163)*
).400 (.131)*
reading deficit, was associated with components of

RAN
attention/hyperactivity and working memory, but
not with rapid naming and variables of phonemic
synthesis and deletion. Non-word reading accuracy
was associated with phonemic deletion, with re-

Psy
sponse inhibition and working memory. All these
associations were found significant at the 5% level.

).535 (.141)*
.398 (.154)*

.366 (.148)*
The entered variables accounted for 18.5% of vari-
ance in text reading fluency, 23.4% of variance in

Pde
word reading accuracy, 25.7% of variance in non-
word reading accuracy, and 25.2% of variance in
spelling accuracy. Noticeable, oral language vari-

).287 (.141)*
ables of TROG and Vocabulary did not remain sig-

.451 (.160)*

.357 (.160)*
nificant in the final regression, i.e., TROG and

F6
Vocabulary did not account for the variance in the

*Significance level p < .05; Voc ¼ WISC-R Vocabulary; F1–6 ¼ Factor 1–6; Pde ¼ Phonemic deletion; Psy ¼ Phonemic synthesis.
reading and reading related scores in the study
population.
Table 6 shows the results of the group-specific

).611 (.225)*
regressions, i.e., separating the analysis for the

F5
ADHD groups (ADHD, ADHD + RD) from the ana-
lysis for the non-ADHD groups (Control, RD). The
association of rapid naming with text reading flu- Table 6 Stepwise regression non-ADHD (Controls, RD) and ADHD (ADHD, ADHD + RD) groups: coefficients
ency, seen in the whole study population, applied

.302 (.137)*
also for both subgroups of ADHD and non-ADHD F4
separately. In contrast, the associations of phon-
emic deletion with non-word reading and spelling,
found in the whole study population, applied only
for the non-ADHD subgroup of RD and Controls,
F3

whereas working memory was associated with non-

word reading and spelling in the ADHD subgroup
F2

of ADHD and ADHD + RD. Also for the measure

F1

of word decoding accuracy both groups showed

very distinct associations different from each other:
.268 (.129)*

for the non-ADHDs phonemic deletion and working

memory entered the regression, whereas for the
Voc

ADHDs response inhibition/effortful visual search

but none of the underlying variables of the read-
ing domain was associated with word reading
TROG

accuracy.
).508 (.145)*

Discussion
Age

The literature to date pointed to core-deficits of the

language and executive domain in children with
ADHD + RD, i.e., to true co-morbidity. However, it is
Non-ADHD

Non-ADHD

Non-ADHD

Non-ADHD

still not decided if the co-morbid group should be

Group

considered to be a unique subgroup (Willcutt et al.,

ADHD

ADHD

ADHD

ADHD

2005). In addition, there is little discussion so far as

to the probable cumulative effect of the two disorders
of ADHD and RD within the same child. High incid-
Non-word accuracy

Spelling accuracy

ence of co-morbidity of ADHD with oral language

Word accuracy

deficits (Tirosh & Cohen, 1998) makes the inter-

Text fluency

pretation of links between reading domain abilities

and attention/control functions in ADHD difficult.
Therefore, special care was taken in the present
study to include only children with oral sentence
Ó 2007 The Authors
Journal compilation Ó 2007 Association for Child and Adolescent Mental Health.

processing skills in the normal range. In addition,
this study investigated ADHD + RD co-morbidity in
Hebrew, which differs from English in its almost
perfect grapheme–phoneme mapping.
Analyses of the test results indicate that all groups
were comparable in intellectual, oral language
functions and reading comprehension. Thus the
difference in reading performance in all groups un-
der study can be related to specific decoding func-
tions and excludes a more general language deficit.
In addition, the co-morbid group was comparable to
the pure clinical groups in the respective test results
of reading and attention. This finding suggests that
co-morbidity was not related to the severity of one of
the disorders.
The starting point for the investigation of a clinical
subtype is delineating the clinical phenomenology. A
disorder presented as co-morbidities should not only
share primary deficits of the pure clinical disorders
but also differ in at least one component from all the
pure forms of the co-morbidities (Angold, Costello, &
Erkanli, 1999). For the comparison of the four study
groups on attention/control functions we used de-
rived factors constituted of different test variables. It
should be noted, however, that the variables of
Factors 5 and 6 (planning and working memory re-
spectively) also loaded heavily on Factor 1 and
therefore are not representing an exclusive narrow
cognitive function. The present study shows that the
co-morbid group shared primary deficits of both
pure clinical groups of RD and ADHD. In comparison
to both pure clinical groups, the co-morbid group
showed a unique deficit in rapid naming and was
more severely impaired on verbal working memory. A
unique impairment in rapid naming of alphanumeric
symbols in the co-morbid group is in line with find-
ings in other studies in children as well as in ado-
lescents (Tannock et al., 2000; Rucklidge &
Tannock, 2002). Also, a deficit of verbal working
memory was shown in the co-morbid group in
Rucklidge and Tannock’s study (2002), although this
deficit was shared by the pure-RD group. In our
study it was the severity of the deficit that separated
the co-morbid from the other study groups.
The areas of impairment in ADHD + RD, i.e., rapid
naming and working memory, which have been
shown to be robust into adolescence and are depic-
ted in languages with different ‘orthographic depths’,
suggest potential uniqueness of the co-morbid con-
dition. This hypothesis should be further investig-
ated according to the parameters that are suggested
by Cantwell (1995): psychosocial factors, demo-
graphic factors, biological factors, family genetic
factors, family environmental factures, natural his-
tory and intervention response subtypes disorders.
The results of the regression analyses corroborate
previously conceived models of exclusive deficits that
affect performance in the co-morbid group in a
cumulative way (August & Garfinkel, 1990; Tannock
et al., 2000). Whereas in the non-ADHD groups word
Ó 2007 The Authors
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Attention and reading in ADHD + RD 461
decoding is associated with phonological-linguistic
functions of phonemic deletion and verbal working
memory, in accordance with numerous studies (e.g.,
Stanovich, 1988; Swanson, 1996; Rucklidge & Tan-
nock, 2002), in the ADHD groups (ADHD and
ADHD + RD) no associations with linguistic func-
tions are shown for word decoding accuracy, but
instead links with EF of response inhibition/effortful
visual search. This relationship was revealed for the
pointed script of Hebrew, whose visual textural out-
line is very different from English: while the con-
sonants are represented by letters, the vowels are
encoded in the form of dots and strokes (diacritics)
placed below, inside, or above consonant letters (¼
/m/e/sh/a/l/e/m/ ¼ pay). The structure of com-
plex words differs too: unlike in English, in which
complex words are combined by affixation in a linear
manner, keeping the base itself as an individual unit
(pay, payment), in Hebrew the word base is com-
bined by two morphemes – the root and the vocal
pattern – which are interwoven with each other in
a non-linear manner (/m/e/sh/a/l/e/m/ ¼ pay,
/t/a/sh/l/u/m/ ¼ payment). This complex visual-
spatial structure of conjugated and declined words
might put a particularly high demand on attention/
control functions for the processing to take place
accurately. Future studies in other languages should
reveal how the characteristics of the written code
influence the relationship of executive functions and
reading functions in ADHD.
The study included one measure of spelling accur-
acy in a task of writing sentences by dictation. Task
performance in terms of spelling accuracy was
similarly impaired by both reading-disabled groups,
RD and ADHD + RD. The regression analyses poin-
ted to a link between working memory and spelling
accuracy, which was unique to the ADHD status.
Willcutt et al. (2005) found that ADHD was associ-
ated with a deficit in an orthographic coding choice
task. Although the interpretation of these associ-
ations is still unclear owing to the nature of the tests
– writing by dictation might depend especially on
working memory functions, while performance of a
choice format task is especially influenced by func-
tions of control – both studies point to the domain of
spelling as another area of uniqueness in
ADHD + RD, which should be further investigated.
In conclusion, the present study extends findings
to the Hebrew language and points out that the
cognitive-behavior profile of the co-morbid group,
showing deficits of both pure groups, a more severe
impairment in verbal working memory and a unique
deficit in rapid naming, is depicted in languages with
different orthographic depths. In addition, it is
shown that reading performance is linked in ADHD
to rapid naming and to executive functions rather
than to linguistic functions of phonological process-
ing. The current results underscore the need to as-
sess deficits in working memory and rapid naming
when evaluating RD status. Low rapid naming speed
 14697610, 2007, 5, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2006.01710.x by CAPES, Wiley Online Library on [05/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
462 Barbara Bental and Emanuel Tirosh

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Manuscript accepted 27 July 2006