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Larry B. Silver
What's Wrong with This Picture?
You take your child to your family doctor because he is always tired and lacks his old energy. Your doctor notes that the lining inside his eyelids is pale and concludes that he has iron deficiency anemia. A prescription for iron is given.
What's Wrong with This Picture?
Your child is struggling in school. The teacher notes that she is often off task and must be refocused on her work. You see your family doctor who listens to these problems and suggests, Why don't we try her on Ritalin (Adderall, Dexedrine, Strattera...)?
WHAT IS WRONG??
Behavior is not a diagnosis. Clinical observations do not make a diagnosis. In each case, there are important observations that suggest a specific problem. However, before treatment is started it is critical to clarify what the specific cause for these observations might be. Clearly the doctor in the first case would get blood studies plus other studies before concluding that your child is anemic, why, and what treatment to use.
This didactic approach is just as critical in making the diagnosis of learning disabilities. Yes, your child or adolescent might be struggling in school, resisting homework, and feeling frustrated. But, these behaviors could be caused by anxiety, depression, academic weaknesses, family stress, or a poor school environment. These behaviors might also be caused by Attention Deficit Hyperactivity Disorder (ADHD). It is essential for the school professionals and you to clarify the reason(s) for the presenting problems. This is done by getting a thorough school history. Initially, the school staff might try additional teaching interventions. If there is no significant response to these interventions, formal testing might be needed. Learning disabilities is a neurologically based disorder. It is important to document that it exists in order to design the necessary interventions.
What Else Is Wrong With This Picture?
If a child has a specific form of anemia, the physician knows to look for other possible problems that often coexist with this form of anemia. This is called co-morbidity, meaning problems that statistically are very likely to exist when a specific problem exists. Your doctor knows that all problems must be identified and treated. This thorough approach is just as essential for learning disabilities. Once the diagnosis of learning disabilities is made, it is essential that all other problems often associated with learning disabilities be considered. If they present, each must be addressed. If they are not looked for, they could be missed.
What Are the Co-morbid Conditions Associated with Learning Disabilities?
Fifty percent of individuals with learning disabilities will also have ADHD. Thus, it is important to explore if this problem might also exist. Your child might be doing better with proper special education intervention but still not be able to sit and focus. What are the clues that your child also might have ADHD? Such children show one or more of three types of behaviors. Some are fidgety, restless, and very active - called hyperactivity. Some have difficulty blocking out unimportant sounds or visual stimuli and, thus, have difficulty staying on task - called inattention or distractibility. And, some might have difficulty thinking before they speak or act - called impulsivity. As with learning disabilities, there are many reasons children might show these behaviors. They might have problems with anxiety or depression or they might have areas of academic weakness. ADHD is the result of a neurologically based disorder in a different area of the brain than learning disabilities. The child is born with these problems. These behaviors have existed since early childhood and exist in most settings. In contrast, if these observed behaviors are the result of a situational problem, resulting in anxiety or depression, they will start at a certain time or occur in specific situations. Thus, to establish the diagnosis of ADHD, one must document a chronic and pervasive history. This is why the diagnosis of ADHD requires three steps:
- showing that the behaviors exist.;
- showing that they have existed since at least age six;
- showing that they occur in two or more life situations.
Current descriptions are not enough. If you take your child to your family doctor, commenting that he can not sit still or pay attention in class and this doctor says, Why don't we try medication, think twice. How do you know that the behaviors are not due to anxiety, depression, or academic frustration? A more detailed history is necessary to confirm that the problems are chronic and pervasive, to finalize this diagnosis.
Fifty percent of children and adolescents with learning disabilities will also have a language disability or sensory integration disorder. If you suspect that your child does not fully understand oral communication or has difficulty finding the right words or organizing thoughts when speaking, a speech-language evaluation is necessary. Should a language disability exist, speech-language therapy will be needed. If your child has problems with motor coordination, knowing his/her position in space, or balance, possibly added to by sensitivity to touch, your child might have sensory integration dysfunction. An occupational therapy evaluation will be needed and occupational therapy might be necessary.
Fifty percent of individuals with learning disabilities will have what are called regulatory problems. They have difficulty regulating their emotions. Some might struggle with anxiety, possibly having panic attacks. Some might experience periods of depression. Others might have problems with anger control. And, still others might have trouble regulating their thoughts and behaviors, called obsessive-compulsive disorder. Many have two or more of these regulatory problems. Finally, some might have problems regulating motor behavior and have a tic disorder. These regulatory problems are the result of faulty wiring in another area of the brain than that involved with learning disabilities or ADHD. They are often apparent from early childhood. Thus, if your child has any of these problems (and possibly more than one) and has had these problems since early childhood and if they occur during any month and in any setting (i.e., they are chronic and pervasive), it is essential to have your child evaluated for a possible regulatory disorder. These problems with regulation of emotions are the result of a deficiency of a different neurotransmitter than with ADHD and medication can be helpful.
Some individuals with learning disabilities may not have regulatory problems. However, they do show emotional and behavioral problems that are probably a consequence of the frustration and failures they have been experiencing. Under stress, some children get rid of the emotional pain by externalizing their problems. They blame others and take no responsibility for their behaviors. Thus, they feel no anxiety or depression. (But all who care are anxious and depressed.) We call this externalizing of problems Oppositional Defiant Disorder or Conduct Disorder. Others keep the pain inside and become anxious and worried or depressed and discouraged. Since they let themselves feel the frustrations and pain, they have a poor self-image and low self-esteem. They might show clinical evidence of anxiety or depression. Unlike the regulatory problems, these behaviors usually begin at a certain time: e.g., third grade or middle school, and seem to occur in certain situations such as in class or when doing homework. They are not chronic or pervasive.
Some students or adults with learning disabilities will have peer problems or social skills problems. If so, these problems might be a result of their behaviors prior to recognition and getting help. It is hard to get rid of old reputations and old patterns of relating. These individuals might need help to learn or relearn how to function better. For others, these peer or social skills problems might have other causes. These causes need to be clarified in order to do the best intervention.
There is also the family. When one person in the family is hurting, everyone feels the pain. You or your spouse might be in trouble. Either might be overwhelmed with your child's behaviors or in conflict on how to handle the behaviors. These tensions might result in marital problems. Siblings may have paid a price prior to diagnosis and treatment. They might need help. Or, the whole family might be dysfunctional and need help.
What Can Make This Picture Right?
A proper diagnosis is made by documenting the presence of a learning, language, and/or motor disability. Then, you, along with either the family physician or a mental health professional, need to explore if there might be evidence of one or more of these co-morbid conditions. Does ADHD also exist? Does your child or adolescent have emotional or behavioral or social difficulties. If so, might they be the result of a biologically driven disorder (regulatory problems) or might they be the result of the frustrations and failures caused by the learning disabilities? Are there any family problems?
It is essential to treat your total child in his or her total environment. To do this requires more than appropriate educational interventions. It requires exploring to learn if other possible problems might exist and, if so, addressing these problems. Without addressing all of your child's problems, the outcome is often less than successful.
Your family doctor, school professionals, or mental health professionals might not know of these co-morbid conditions. Each might focus only on his or her area of interest or expertise. Therefore, you must be informed so that you ask questions and insist on a full evaluation process before finalizing treatment planning.
To Summarize
Fifty percent of individuals with learning disabilities will also have one or more of the following:
- Language Disability, Sensory Integration Dysfunction
- ADHD
- Neurologically Based Regulatory Problems (Anxiety Disorder, Depression, Anger Control Problems, Obsessive-Compulsive Disorder)
- Tic Disorder
- Emotional, social, and/or family problems resulting from the frustrations and failures experienced.
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Larry Silver, MD, is a child psychiatrist in private practice in the Washington, DC, area and a past president of LDA.
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