Introduction
School is the “workplace” for children and adolescents.
Successful school performance is essential for psychological growth
and development. Social competency and social skills are developed,
then shaped within the family and in school but practiced and mastered
in school. Thus, development of a positive self-image and self-esteem
is based on successes in school. Feedback from school concerning
academic performance and social interactions influences parents’
images of their sons or daughters. Thus, if something interferes
with success in school, the impact will affect the emotional, social,
and family functioning of this individual.
Learning Disabilities (LD) and/or Attention Deficit Hyperactivity
Disorder (ADHD) are two major reasons children and adolescents might
do poorly in school. Each is a different disorder with unique areas
of difficulty, etiology, diagnostic process, and treatment. It is
estimated that between five and ten percent of all students will
have LD and that between three and five percent of all students
will have ADHD. These are not uncommon disorders.
As professionals, it is critical that you recognize the behaviors
and clinical findings that would suggest such problems and that
you know how to help parents as they seek the necessary evaluations
to confirm the diagnosis and get appropriate interventions. Your
diagnostic skills, guidance, and advocacy are essential. Early recognition
and intervention are critical. The price for the individual when
these disorders are not recognized is significant and can last a
lifetime. This information will help you help the patients in your
practice.
Learning Disabilities
Definition:
Public school systems use the term, ‘Learning Disability.’
The medical classification system uses the term ‘Learning
Disorder.’ When working with parents and schools, it is best
to use ‘Learning Disability.’
A learning disability is a neurologically-based processing disorder
resulting from “faulty” wiring in the cortex. Depending
on what part of the cortex is affected, the student will have problems
with learning, language, and/or motor function. These processing
difficulties might involve understanding or using language, spoken
or written, resulting in an imperfect ability to listen, think,
speak, read, write, spell, or do mathematical calculations. Individuals
with learning disabilities are of at least average intellectual
ability or higher. They struggle in school because of these processing
problems.
Learning disabilities might impact learning to read, write, or
do basic math or reading comprehension, written language, or more
complex math. Learning disabilities might impact the student’s
ability to organize materials and thoughts or to plan a task and
carry out that plan. Thus, some problems are apparent in the earliest
school years; some are not apparent until late elementary school;
and still others show up in middle or high school. In any grade,
the presenting problem is struggling with school work, possibly
with failing grades. You might hear that homework is a battle every
night. Unfortunately, some teachers and parents blame the victim.
They complain that your patient is lazy or unmotivated. But, if
you know what to ask, you will find that there are reasons for these
struggles.
It may be tempting to reassure parents by saying, “don’t
worry . . . he will outgrow it.” Please do not do this unless
you are sure the problems reflect a developmental delay and you
know they will fade with time. With LD, they do not. The “let’s
wait” approach loses valuable time when intervention could
be critical.
You must find out the reasons for the presenting problems. This
child or adolescent might have a learning disability, a language
disability, or a motor disability. To be more specific:
Learning Disability: Reading problems might involve learning
to read. Here, the student must first learn to put letters and sounds
together, blending the word. Later, words are recognized as a whole
(sight reading). Finally, by third grade, individual words are not
focused on; lines are scanned; and thoughts come into the brain,
(reading comprehension). After third grade, students must be fluent
readers so they can focus on content.
Writing problems might involve handwriting. The student
has a fine motor problem and writes slowly and with difficulty,
often with a different grip. By third grade, the focus shifts to
spelling, grammar, punctuation, and capitalization; and problems
might be noted in these areas. Later, the focus is on composition
and the richness of thoughts and words as well as an organized flow
of thoughts.
Math starts with knowing numbers and then learning basic
addition and subtraction. Later come multiplication and division
and, still later, fractions, decimals, and other complex concepts.
Some students might have difficulty understanding and learning these
concepts. Others who might have difficulty with the written language
aspect of math, such as putting the steps down on the page in the
right place and in the right sequence, might make careless errors.
Language Disability: A student with this disability might
have difficulty quickly processing what is heard. Parents have to
speak slower and get eye contact. Multiple instructions cannot be
given. The child often misunderstands what is said. Some have difficulty
when they speak. In a spontaneous situation where thoughts are organized
before speaking, they do well. However, in a demand situation where
they have to answer a question or explain something, they struggle
to get their thoughts organized or find the right words
Motor Disability: A student with motor problems might have
difficulty with fine motor planning (coloring, cutting, writing,
buttoning, zipping, tying) and/or with gross motor planning (running,
jumping). Some may have difficulty with visual-motor (eye-hand)
activities required when doing certain visual spatial tasks or when
catching or hitting a ball. In addition, this child might have difficulty
with vestibular function, manifested by weak upper trunk muscles
and possibly by difficulty learning to ride a bike. Finally, some
may show tactile sensitivity, not liking to be held or cuddled or
not liking cloths that are felt to be too rough. This total clinical
picture of motor problems is called Sensory Integration Dysfunction.
Suspecting a Learning Disability: Parents might complain
that their child or adolescent is doing poorly in school, getting
bad grades, possibly acting out frustrations with inappropriate
behaviors or by avoiding homework. This history is suggestive of
a learning disability. A five minute ‘systems review’
can help you decide if more studies are needed. Much as in any systems
review, the physician follows a logical set of questions based on
known possible problems. Any positive answer leads to more in-depth
questioning. A negative answer leads to the next general question.
Systems Review for Learning Disabilities
Start with questions relating to basic skills.
Reading: Is reading something you like to do or have to
do? How well do you read? Do you have trouble sounding out each
word? Do you understand what you read? Do you ever skip words or
lines or read the same lines twice? Do you get to the end of the
page or chapter and not know what you have read? With older students,
ask: Do you get papers back and find that you misread questions
or instructions? Do you have problems with word problems in math?
Writing: How is your handwriting? Do you prefer to print
or to use cursive? Do you find that you cannot write as fast as
you are thinking? When you look at what you have written, do you
see errors in spelling, grammar, punctuation, or capitalization?
Can you copy material from the board fast enough? With older students,
ask: can you take notes as the teacher is talking? Can you write
an organized paper with good thoughts?
Math: Depending on grade level, ask if the student understands
what the teacher is doing. Does the student know the times tables?
Does he make mistakes like writing ‘21’ for ‘12’
or putting numbers in the wrong column? Is there a problem with
word problems?
Next, ask questions relating to the processing skills needed to
learn.
Sequencing: When you speak or write, do you sometimes have
difficulty getting everything in the right order? You might ask
the child to name the months of the year. Then, ask what comes after
May. Does she answer easily or does she need to go back to January
and count forward? Ask if he has difficulty using the dictionary
and remembering the order of the alphabet.
Abstraction: Do you understand jokes when your friends tell
them? Do you sometimes get confused when you hear something? Do
people say that you did not understand what they said?
Organization: What does your notebook look like? How about
your binders and papers? Is everything falling out or in the wrong
place. What about your desk? Backpack? Locker? Bedroom? Do you lose
things or forget things? Do you do your homework but forget to turn
it in? Do you have difficulty organizing your thoughts when you
speak? When you write? Do you have problems planning time so that
things get done?
Memory: Do you find that you can learn something at night
and then go to school the next day and forget what you learned?
Do you learn best by listening to people or by reading?
Diagnosis of a Learning Disability
Once an LD is suspected, the diagnosis is established through a
battery of testing called a Psycho-educational Evaluation.
There are three parts to these studies. First is an IQ test. Of
importance is the student’s intellectual potential plus any
inconsistencies between each part of the test. Next is a battery
of achievement tests to clarify where the student’s academic
skills are. Finally, a test or group of tests looks at processing
abilities or disabilities. These combined data usually clarify whether
the individual has an LD and, if so, where the problems as well
as the strengths are. The results will also clarify the best interventions
to use.
Many school systems currently use a discrepancy model to decide
if a student is eligible to receive services because of a learning
disability. There must be a specific degree of difference between
intellectual ability and performance. Thus, a student might have
processing problems (a learning disability) but not be eligible
for services because he or she is “not far enough behind to
qualify.” When this happens, parents may have to find someone
outside the school system to do the assessment.
The public school system should do the psycho-educational evaluation.
To facilitate this action, write a report explaining why your clinical
findings suggest an LD. Have the parents give this report to the
principal of their neighborhood school with their own letter requesting
the testing. The principal should activate a meeting of school professionals
to decide if they agree to do such testing. If they agree, the testing
is done. If they do not, you might advise the parents to appeal
this decision or to get the testing done privately.
Interventions:
We do not know how to rewire the brain. Thus, the goal is habilitation.
Professionals trained in areas of special education work on learning
disabilities. Speech-language therapists work on language disabilities.
Occupational therapists help with motor disabilities. These services
should be provided by the school system either within general education
or in a special education program.
These interventions attempt to remediate those disabilities that
can be improved by using specific approaches and to help the student
develop compensatory strategies. In addition, it is essential that
general education teachers know how to develop accommodations in
the curriculum, teaching method, and environment so that the student
can succeed using his abilities rather than be penalized because
of his disabilities. Parents will also need to learn what accommodations
they should provide when helping with homework.
As with any other disorder, parents need to be educated. It is
important to explain what LD is. Parents can be referred to organizations,
websites or reading materials that will help.
Legal Rights of Parents:
The Federal Law, The Individuals with Disabilities Education
Act (IDEA), requires schools to recognize students who might
be having difficulty. These students are to be screened. If problems
are found, students are to be tested. Following the testing, a team
of professionals meets to see if the student meets the criteria
to be eligible for identification as having a learning disability
and, thus, eligible for services. Parents are to be part of each
step of these processes.
If a student qualifies, the school professionals develop an Individualized
Education Program (IEP) and present it to the parents. This plan
identifies the areas of difficulty, how each will be addressed,
and how progress will be measured. If parents agree and sign this
IEP, the plan is put into place.
Often parents need help in understanding their child or adolescent’s
needs and their rights under IDEA. They may need an advocate to
help. If the family physician cannot provide this help, it is important
to know where to refer parents to get such help. They can contact
their State
Learning Disabilities Association at http://ldaamerica.org/state_chapters/index.asp
or State
Parent Training and Information Center at http://www.taalliance.org/centers/.
In Summary
Academic and attentional problems result in school problems. They
also impact the emotional status of the child or adolescent and
the functioning of the family. Not uncommonly, there are also social
problems. The consequences are serious and dysfunctional for the
individual and the family. As with any other medical disorder, the
price of missing the diagnosis and, thus, delaying treatment is
significant and can have an impact throughout the person’s
life.
It is critical for the primary care physician to be aware of these
disabilities and to know how to screen for their possible presence.
Once such disabilities are suspected, a more detailed review should
clarify whether further studies are needed. Once diagnosed, appropriate
treatment must be started and monitored.
About the Author:
Dr. Silver, a Child and Adolescent Psychiatrist, is in private
practice in the Washington, D. C. area. He is Clinical Professor
of Psychiatry at Georgetown University Medical Center. Prior to
his current activities, he was Acting Director and Deputy Director
of the National Institute of Mental Health of the National Institutes
of Health. Prior to his positions at the National Institute of Mental
Health he was Professor of Psychiatry, Professor of Pediatrics,
and Chief of the Division of Child and Adolescent Psychiatry at
the Robert Wood Johnson School of Medicine.
For more than thirty years his primary areas of research, clinical,
and teaching interest have focused on the psychological, social,
and family impact of a group of related, neurologically-based disorders—Learning
Disabilities, Language Disabilities, Sensory Integration Dysfunction,
and Attention Deficit Hyperactivity Disorder.
He has more than 150 publications, including the popular book,
The Misunderstood Child: A Guide for Parents of Children with
Learning Disabilities now in its third edition. His other books
include, Attention Deficit Hyperactivity Disorder: A Clinical
Guide to Diagnosis and Treatment For Health and Mental Health Professionals
in its second edition and Dr. Larry Silver's Advice to Parents
on Attention Deficit Hyperactivity Disorder in its second edition.
He is active with the Learning Disabilities Association of America,
and served as President for two years. In 1992 he received this
Association's highest award, The Learning Disabilities Association
Award, for outstanding leadership in the field of Learning Disabilities.
In 1996 he received the American Academy of Child and Adolescent
Psychiatry's Berman Lifetime Achievement Award for his contributions
to the study and treatment of Learning Disabilities.
The material presented here is from Dr. Silver's book and offered
via LDA with his permission.
Attention-Deficit/Hyperactivity Disorder. A Clinical Guide to
Diagnosis and Treatment for Health and Mental Health Professionals.
Third Edition, American Psychiatric Publishing, Inc., Washington,
D.C. 2004
Watch for Dr. Silver’s Attention Deficit /Hyperactivity
Disorder (ADHD) Information for Pediatricians and Other Physicians
coming soon!
|
