What is a Specific Learning Disability?
Specific Learning Disability [formerly termed a Learning Disability] SLD is the term currently used to describe a neurological condition that interferes with an individual's ability to store, process or produce information. Such disabilities affect both children and adults. The impairment can be quite subtle and may go undetected throughout life. But learning disabilities create a gap between a person's true capacity and his day-to-day productivity and performance.
Specific Learning Disabilities refer to a heterogeneous group of disorders manifested by significant difficulty in the acquisition and use of listening, speaking, reading, writing, reasoning or mathematical abilities. These disorders are intrinsic to the individual, due to central nervous system (neurological) dysfunction and may occur across the life-span. An individual can have marked difficulties at some tasks while excelling at others. Some common Specific Learning Disabilities include dyslexia (difficulty with words), dyscalculia (difficulty with numbers) and dysgraphia (difficulty with written expression).
Specific Learning Disabilties may be manifested in some of the following ways:
Visual Problems: difficulty that the brain has with handling information that the eyes see. These are not conditions that will be eliminated by the use of glasses or contact lenses.
- poor visual memory (not remembering faces, words, people's names, reversals in writing ( 41 instead of 14),
- visual perception (difficulty in seeing the difference between similar objects such as b and d)
- figure ground discrimination (inability to find the signature place on an application form)
- visual tracking (inability to follow a line on a page)
Auditory Problems: related to the processing of information that we hear.
- Auditory memory (difficulty in remembering what has been said, information or instructions)
- Auditory discrimination (trouble noting differences between similar sounds or words- for example, bee and pea or seventeen for seventy)
- Auditory sequencing (confusion with number sequence, lists, or directions)
- Auditory figure ground (difficulty hearing sounds over background noises)
Motor Problems: related to various motor functions of the body.
- eye hand co-ordination (difficulties with handwriting)
- fine motor/muscle control (difficulty using pencil, pen, scissors)
- large motor/muscle control (clumsiness, difficulties in certain physical activities)
Organizational Problems: poor ability in organizing time or space, or sequencing
- Poor ability to organize time (missing deadlines, poor sense of time)
- Poor ability to organize tasks (misunderstanding the steps required to carry out a particular task such as planning a party or a move)
- Poor ability to organize space (difficulty in organizing a closet, desk, or laying out a page in a written document)
- Impairment of executive function (difficulty in analysing, applying information in a new way or adapting to new circumstances)
Conceptual Problems: understanding abstract concepts, complex language, consequences and social cues.
- difficulty in interpreting non-verbal language (such as facial expressions or body language)
- difficulty in understanding figures of speech (such as idioms, metaphors or similes)
- difficulty in anticipating the future (difficulty with predicting consequences, purchase something today with borrowed money, may do something impulsive without considering the consequences)
- Rigid thinking (inability to see that flexibility is required to deal with a situation, will not 'see' things in shades of grey but only in black and white)
- Poor social skills and peer relations (difficulty in maintaining eye contact during a conversation, using an inappropriate tone of voice or language, lacking the social graces)
It is estimated that 10-15% of the general population have Specific Learning Disabilities. Because of the very nature of the disability and because most children spend at least ten years of their lives in school, the most frequently noted signs are related to school performance. However, it is important to remember that a specific learning disability is not confined to school hours and may be identified during the preschool years.
In most cases, parents rarely realize that anything is amiss until the child enters school. In some cases, the parents may have suspected for some time that something was different about this child. If parents, teachers, and other professionals discover a child's learning disability early and provide the right kind of help, it can give the child a chance to develop skills needed to achieve in school and to lead a successful and productive life.
A recent US National Institutes of Health study showed that 67% of young students who were at risk for reading difficulties became average or above average readers after receiving intensive reading support and remediation help in the early grades.
What is AD/HD?
Attention Deficit Hyperactivity Disorder (AD/HD) is a condition that becomes apparent in some children in the preschool and early school years. It is hard for these children to control their behavior and/or pay attention. It is estimated that between 3 and 5 percent of children have AD/HD. This means that in a classroom of 25 to 30 children, it is likely that at least one will have AD/HD.
AD/HD was first described by Dr. Heinrich Hoffman in 1845. A physician who wrote books on medicine and psychiatry, Dr. Hoffman was also a poet who became interested in writing for children when he couldn't find suitable materials to read to his 3-year-old son. The result was a book of poems, complete with illustrations, about children and their characteristics. "The Story of Fidgety Philip" was an accurate description of a little boy who had attention deficit hyperactivity disorder. Yet it was not until 1902 that Sir George F. Still published a series of lectures to the Royal College of Physicians in England in which he described a group of impulsive children with significant behavioral problems, caused by a genetic dysfunction and not by poor child rearing-children who today would be easily recognized as having AD/HD. Since then, several thousand scientific papers on the disorder have been published, providing information on its nature, course, causes, impairments, and treatments.
A child with AD/HD faces a challenging but not insurmountable task ahead. In order to achieve his or her full potential, he or she should receive help, guidance, and understanding from parents, guidance counselors, and the education system. This document offers information on AD/HD and its management, including research on medications and behavioral inter-ventions, as well as helpful resources on educational options.
What are the Characteristics/Symptoms of AD/HD?
The principal characteristics of AD/HD are inattention, distractibility, hyperactivity, and impulsivity. These symptoms appear early in a child's life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional.
A child who "can't sit still" or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a "discipline problem," while the child who is passive or sluggish may be viewed as merely unmotivated.
These children may have different types of AD/HD. All children are sometimes restless, sometimes act without thinking, and sometimes daydream the time away. When the child's hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, AD/HD may be suspected. But because the symptoms vary so much across settings, AD/HD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom.
According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), there are three patterns of behavior that indicate AD/HD. People with AD/HD may show several signs of being consistently inattentive. They may have a pattern of being hyperactive and impulsive far more than others of their age. Or they may show all three types of behavior. This means that there are three subtypes of AD/HD recognized by professionals. These are the predominantly hyperactive-impulsive type (that does not show significant inattention); the predominantly inattentive type (that does not show significant hyperactive-impulsive behavior) sometimes called ADD-an outdated term for this entire disorder; and the combined type (that displays both inattentive and hyperactive-impulsive symptoms).
What is Hyperactivity-Impulsivity?
Hyperactive children always seem to be "on the go" or constantly in motion. They dash around touching or playing with whatever is in sight, or talk incessantly. Sitting still at dinner or during a school lesson or story can be a difficult task. They squirm and fidget in their seats or roam around the room. Or they may wiggle their feet, touch everything, or noisily tap their pencil. Most outgrow their over-activity in adolescence but continue to experience a sense of restlessness as teenagers under adults. They often report needing to stay busy and may try to do several things at once.
Impulsive children seem unable to curb their immediate reactions or think before they act. They will often blurt out inappropriate comments, display their emotions without restraint, and act without regard for the later consequences of their conduct. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they're upset. Even as teenagers or adults, they may impulsively choose to do things that have an immediate but small payoff rather than engage in activities that may take more effort yet provide much greater but delayed rewards.
Some signs of hyperactivity-impulsivity are:
- Feeling restless, often fidgeting with hands or feet, or squirming while seated
- Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected
- Blurting out answers before hearing the whole question
What is Inattention?
Children who are inattentive have a hard time keeping their minds on any one thing and may get bored with a task after only a few minutes. If they are doing something they really enjoy, they have no trouble paying attention; however, focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.
Homework is particularly hard for these children. They will forget to write down an assignment, or leave it at school. They will forget to bring a book home, or bring the wrong one. The homework, if finally finished, is full of errors and erasures. Homework is often accompanied by frustration for both parent and child.
The DSM-IV-TR gives these signs of inattention:
- Often becoming easily distracted by irrelevant sights and sounds
- Often failing to pay attention to details and making careless mistakes
- Rarely following instructions carefully and completely losing or forgetting things like toys, or pencils, books, and tools needed for a task
- Often skipping from one uncompleted activity to another.
Children diagnosed with the Predominantly Inattentive Type of AD/HD are seldom impulsive or hyperactive, yet they have significant problems paying attention. They appear to be daydreaming, "spacey," easily confused, slow moving, and lethargic. They may have difficulty processing information as quickly and accurately as other children. When the teacher gives oral or even written instructions, this child has a hard time understanding what he or she is supposed to do and makes frequent mistakes. Yet the child may sit quietly, unobtrusively, and even appear to be working but not fully attending to or understanding the task and the instructions.
These children don't show significant problems with impulsivity and overactivity in the classroom, on the school ground, or at home. They may get along better with other children than the more impulsive and hyperactive types of AD/HD, and they may not have the same sorts of social problems so common with the combined type of AD/HD. So often their problems with inattention are overlooked. But they need academic support just as much as children with other types of AD/HD, who cause more obvious problems in the classroom.
How is the Diagnosis of AD/HD Made?
Some parents see signs of inattention, hyperactivity, and impulsivity in their toddler long before the child enters school. The child may lose interest in playing a game or watching a TV show, or may run around completely out of control. Because children mature at different rates and are very different in personality, temperament, and energy levels, it's important to get an expert's opinion on whether or not the behavior is appropriate for the child's age. This can be done by a paediatrician knowledgeable about AD/HD, a child psychiatrist or a child psychologist who holds a Ph.D. in educational, clinical or developmental psychology.
AD/HD may be suspected by a parent or caretaker or may go unnoticed until the child runs into problems at school. Given that AD/HD tends to affect functioning most obviously in school, it is sometimes the teacher who first to recognizes that a child is over-active or inattentive and may point it out to the parents and/or consult with the school psychologist. Because teachers work with many children, they come to know how "average" children behave in learning situations that require attention and self-control. However, teachers sometimes fail to notice the needs of children who may be more inattentive yet quiet and cooperative, such as those with the predominantly inattentive form of AD/HD.
Who can make the Diagnosis?
In a best-practice model, the diagnosis is made by a team of professionals with training in AD/HD or in the diagnosis of mental disorders. Child psychiatrists and child psychologists who hold their Ph.D. degrees, developmental/behavioral pediatricians, or paediatric neurologists are those most often trained in differential diagnosis.
What is the difference in qualifications amongst all the medical professionals?
Knowing the differences in qualifications and services can help the family choose someone who can best meet their needs. There are several types of specialists qualified to diagnose and treat AD/HD.
Child psychiatrists are medical doctors who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any needed medications.
Child psychologists who hold a Ph.D. qualification in educational, developmental or clinical psychology,are also qualified to diagnose and treat AD/HD. They carry out educational-psychological assessments which help to identify the presence of specific learning disabilities and other disorders that may co-exist with AD/HD. They also provide therapy for the child and help the family develop ways to successfully manage the disorder. Psychologists are not medical doctors and must rely on the child's physician to do medical exams and prescribe medication.
Neurologists, medical doctors who work with disorders of the brain and nervous system, can also diagnose ADHD and prescribe medicines. Unlike psychiatrists and psychologists, neurologists do not usually provide therapy for the emotional aspects of the disorder.
Within each specialty, individual doctors and mental health professionals differ in their experiences with AD/HD. So in selecting a specialist, it's important to find someone with specific training and experience in diagnosing and treating the disorder.
Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. Among possible causes of AD/HD-like behavior are the following:
- A sudden change in the child's life-the death of a parent or grandparent; parents' divorce; a parent's job loss
- Undetected seizures, such as in petit mal or temporal lobe seizures
- A middle ear infection that causes intermittent hearing problems
- Medical disorders that may affect brain functioning
- Underachievement caused by learning disability
- Anxiety or depression.
What causes AD/HD? - Myths and Reality.
One of the first questions a parent will have is "Why? What went wrong?" "Did I do something to cause this?" There is little compelling evidence that AD/HD can arise purely from social factors or child-rearing methods. Most substantiated causes fall in the realm of neurobiology and genetics. This is not to say that environmental factors may not influence the severity of the disorder, and especially the degree of impairment and suffering the child may experience, but that such factors do not seem to give rise to the condition by themselves.
a. Environmental Agents
Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for AD/HD in the offspring of that pregnancy. As a precaution, it is best during pregnancy to refrain from both cigarette and alcohol use.
Another environmental agent that may be associated with a higher risk of AD/HD is high levels of lead in the bodies of young preschool children. Since lead is no longer allowed in paint and is usually found only in older buildings, exposure to toxic levels is not as prevalent as it once was. Children who live in old buildings in which lead still exists in the plumbing or in lead paint that has been painted over may be at risk.
b. Brain Injury
One early theory was that attention disorders were caused by brain injury. Some children who have suffered accidents leading to brain injury may show some signs of behavior similar to that of AD/HD, but only a small percentage of children with AD/HD have been found to have suffered a traumatic brain injury.
c. Food Additives and Sugar
It has been suggested that attention disorders are caused by refined sugar or food additives, or that symptoms of AD/HD are exacerbated by sugar or food additives. In 1982, the National Institutes of Health held a scientific consensus conference to discuss this issue. It was found that diet restrictions helped about 5 percent of children with AD/HD, mostly young children who had food allergies. A more recent study on the effect of sugar on children, using sugar one day and a sugar substitute on alternate days, without parents, staff, or children knowing which substance was being used, showed no significant effects of the sugar on behavior or learning.
In another study, children whose mothers felt they were sugar-sensitive were given aspartame as a substitute for sugar. Half the mothers were told their children were given sugar, half that their children were given aspartame. The mothers who thought their children had received sugar rated them as more hyperactive than the other children and were more critical of their behavior.
d. Genetics
Attentional disorders often run in families, so there are likely to be genetic influences. Studies indicate that 25 percent of the close relatives in the families of AD/HD children also have AD/HD, whereas the rate is about 5 percent in the general population. Many studies of twins now show that a strong genetic influence exists in the disorder.
Researchers continue to study the genetic contribution to AD/HD and to identify the genes that cause a person to be susceptible to AD/HD. Since its inception in 1999, the Attention-Deficit Hyperactivity Disorder Molecular Genetics Network has served as a way for researchers to share findings regarding possible genetic influences on AD/HD.
e. Recent Studies on Causes of AD/HD.
Some knowledge of the structure of the brain is helpful in understanding the research scientists are doing in searching for a physical basis for attention deficit hyperactivity disorder. One part of the brain that scientists have focused on in their search is the frontal lobes of the cerebrum. The frontal lobes allow us to solve problems, plan ahead, understand the behavior of others, and restrain our impulses. The two frontal lobes, the right and the left, communicate with each other through the corpus callosum, (nerve fibers that connect the right and left frontal lobes).
The basal ganglia are the interconnected gray masses deep in the cerebral hemisphere that serve as the connection between the cerebrum and the cerebellum and, with the cerebellum, are responsible for motor coordination. The cerebellum is divided into three parts. The middle part is called the vermis.
All of these parts of the brain have been studied through the use of various methods for seeing into or imaging the brain. These methods include functional magnetic resonance imaging (fMRI) positron emission tomography (PET), and single photon emission computed tomography (SPECT). The main or central psychological deficits in those with AD/HD have been linked through these studies. By 2002 the researchers in the NIMH Child Psychiatry Branch had studied 152 boys and girls with AD/HD, matched with 139 age- and gender-matched controls without AD/HD. The children were scanned at least twice, some as many as four times over a decade. As a group, the AD/HD children showed 3-4 percent smaller brain volumes in all regions-the frontal lobes, temporal gray matter, caudate nucleus, and cerebellum.
This study also showed that the AD/HD children who were on medication had a white matter volume that did not differ from that of controls. Those never-medicated patients had an abnormally small volume of white matter. The white matter consists of fibers that establish long-distance connections between brain regions. It normally thickens as a child grows older and the brain matures.
Although this long-term study used MRI to scan the children's brains, the researchers stressed that MRI remains a research tool and cannot be used to diagnose AD/HD in any given child. This is true for other neurological methods of evaluating the brain, such as PET and SPECT.
Isn't it normal for children to be hyperactive and easily distractible? What makes this a disorder?
It's true that young children are more hyperactive, more easily distractible, and misbehave more frequently than older children or adults. This is a normal part of growing up. As the AD/HD criteria state, a disorder may be present when the behaviors are significantly different from other children of the same age.
How do I know if all of my child's learning and behaviour problems are caused by AD/HD? Could he/she have other problems as well?
This is an important question. Up to 65% of children with AD/HD may have another disorder as well. Fifty percent of children with AD/HD have co-existing Specific Learning Disabilities. Forty percent may have Oppositional Defiant Disorder, a syndrome in which a child is resistant to authority. Twenty percent may have a mood disorder, such as anxiety or depression. Another twenty percent may have Conduct Disorder, a disorder in which a child disregards the law. Seven to ten percent may have Tourette's syndrome, a disorder in which a child has "tics" in which he/she involuntarily moves or speaks.
What are the treatments for AD/HD?
Dr. Thomas Brown, a noted authority in AD/HD discusses this in his book Attention Deficit Disorder:
"The most important aspect of treatment for [AD/HD] is education of the patient and family about the nature
of the disorder and how it can be treated. Education does not change the chemical problems underlying executive function impairments [inattention, impulsivity, time management and fine motor difficulties], but if the patient and the patient's family do not adequately understand the uses and limitations of medications and other treatment options, they may jump into use of interventions that are not safe or helpful...Because AD/HD is essentially a chemical problem in the brain, it makes sense that, in the vast majority of cases, the most effective way to alleviate its impairments is to change relevant aspects of the brain's chemistry. Additional treatments may be quite useful, but the most effective treatment for AD/HD is almost always well-managed medication (see the Multimodal Treatment Study of Children with AD/HD {MTA Cooperative Group 1999}, sponsored jointly by the National Institute of Mental Health and the U.S. Department of Education).
At present there is no cure for [AD/HD], but there are medication treatments that have been demonstrated safe and effective in alleviating symptoms of AD/HD in 80-90% of children, adolescents and adults who have the disorder. Just as eyeglasses do not repair the patient's eyes and cure impaired vision, so medications that alleviate AD/HD do not cure problems of brain chemistry that cause these impairments: the improvements last only as long as the medication is active in the body.
Although there is a vast body of evidence that certain medications alleviate many symptoms of AD/HD, medicine alone is not sufficient treatment for some with AD/HD...Many children and adolescents need systematic help - behavior management strategies, coaching and sometimes individual or family therapy - to develop more adaptive patterns of behaviour."
In school, treatment support can include accommodations such as extended time for tests and examinations, placement in the front of the classroom, and more frequent reports from teachers.
Can adults have AD/HD? Is medication an appropriate treatment?
Yes, as many as 60% of those diagnosed with AD/HD as children will carry the diagnosis into adulthood. Over 75% of adults with AD/HD will benefit from medication.
What are some common signs of a Specific Learning Disability or an Attentional Disorder?
All children exhibit some of the following behaviours and characteristics at times. The presence of one or two of these signs may not be significant, but a cluster of these behaviours requires further assessment.
In Infancy
- Trouble with nursing, sucking or digesting
- Resistance to cuddling and body contact
- Lack of, or excessive response to sounds or other stimulus
- Trouble following movements with eyes
- Unusual sleep patterns
- Delays in sitting, standing, walking
- Absence of creeping and crawling
- Little or no vocalization
- Irritability
Preschool
- Speaks later than most children and has immature speech patterns
- Slow vocabulary growth, often unable to find the right words, pronunciation problems
- Difficulty rhyming words
- Trouble learning numbers, alphabet, days of the week, colors, shapes
- Extremely restless and easily distracted
- Trouble interacting with peers
- Difficulty following directions or routines
- Difficulty with dressing
- Fine motor skills slow to develop
- Exaggerated response to excitement or frustration
- Tendency to trip, or bump into things
- Cannot skip, has trouble bouncing and catching a ball
Grades K-4
- Slow to learn the connection between letters and sounds
- Confuses basic words (run, eat, want)
- Makes consistent reading and spelling errors including letter reversals (b/d), inversion (m/w), transposition (felt/left), and substitutions (house/home)
- Transposes number sequences and confuses arithmetic signs (+, -, x, /, =)
- Slow to remember facts
- Slow to learn new skills, relies heavily on memorization
- Impulsive, difficulty planning
- Unstable pencil grip, poor printing, writing
- Trouble learning about the concept of or telling time
- Poor coordination, unaware of physical surroundings, prone to accidents
- Difficulty cutting with scissors, coloring and printing inside lines
- Cannot tie laces, button clothes, or get dressed
- Reads but does not comprehend
- Difficulty playing with more then one child at a time, may prefer to play alone
- Difficulty remembering the names of things: the seasons, the months, streets, etc.
- Does not understand the difference between 'up and down'; 'top and bottom'; 'in and out'; 'front of and behind; etc.
Grades 5-8
- Reverses letter sequences (soiled/solid, left/felt)
- Slow to learn prefixes, suffixes, root words and other spelling strategies
- Avoids reading aloud
- Trouble with word problems
- Difficulty with handwriting
- Awkward, fist-like, or tight pencil grip
- Avoids writing compositions
- Slow or poor recall of facts
- Difficulty making friends
- Trouble understanding body language and facial expressions
- Difficulty expressing ideas and relating events in sequence
Grades 9-12
- Continues to spell incorrectly, frequently spells the same word differently in a single piece of writing, laborious handwriting
- Avoids reading and writing tasks
- Difficulty with putting thoughts on paper
- Trouble summarizing
- Trouble with open-ended questions on tests
- Weak memory skills
- Difficulty adjusting to new settings
- Works slowly
- Poor grasp of abstract concepts
- Either pays too little attention to details or focuses on them too much
- Misreads information/lacks logic, poor reasoning ability
- Vulnerable to peer pressure, often the 'scapegoat' in situations
- Difficulty organizing and/or concentrating on homework
- Rarely relates past events or experiences in sequence or detail
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