adhd and ld written report

8/14/2019 ADHD and LD Written Report

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Pearly Gwen V.Lantajo

BSOTIV

Intro clin

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LEARING DISA

BILITY

ATTENTION-DEFICITDISORDERS


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ATTENTION-DEFICIT DISORDERS

ATTENTION-DEFICIT / HYPERACTIVITY

DISORDER

Attention-deficit disorder is characterized by a developmentally

inappropriate poor attention span or age-inappropriate features of

hyperactivity and impulsivity or both. To meet the diagnostic criteria the

disorder must be present for at least six months, cause impairment in

academic or social functioning, and occur before the age of 7 years.

According to the fourth edition of Diagnostic and Statistic Manual of MentalDisorders (DSM-IV), the diagnosis is made by confirming numerous

symptoms in the inattention domain or the hyperactivity-impulsivity domain

or both. Thus a child may qualify for the disorder with symptom of

inattention only or with symptom of hyperactivity and impulsivity but not

inattention. Some children exhibit multiple symptoms along both dimensions.

Accordingly, DSM-IV lists three subtypes of attention-deficit / hyperactivity

disorder: predominantly inattentive type, and combined type. And additional

criterion in DSM-IV that was not present in the revised third edition of DSM

(DSM-III-R) is the presence of symptoms in two or more situations, such as at

school, home, and work.

Attention-deficit / hyperactivity disorder has been identified in the

literature for many years under a variety of terms. In the early 1900s

impulsive, disinherited, and hyperactive childrenmany of whom had

neurological damage cause by encephalitiswere grouped under the label

hyperactive syndrome. In the 1960s a heterogeneous group of children

with poor coordination, learning disabilities, and emotional labiality but

without specific neurological damage were described as having minimal

brain damage. Since that time other hypotheses have been put forth to

explain the origin of the disorder, such as a genetically based condition

reflecting and abnormal level of arousal and poor ability to modulate

emotions. That theory was initially supported by the observation that

stimulant medications help produce sustained attention and improve thechilds ability to focus on a given task. Currently, no single factor is believed

to cause the disorder, although many environmental variables may

contribute to it and many predictable clinical features re associated with it.

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EPIDEMIOLOGY

Reports on the incidence of ADHD in the United States have varied

from 2 to 20 percent of grade-school children. A conservative figure is about

3 to 5 percent of prepubertal elementary school children. In Great Britain the

incidence is reported to be lower than in the United States, less than 1

percent. Boys have a greater incidence than do girls, with the ratio being

from 3 to 1 to as much as 5 to 1. The disorder is most common in first born

boys. The parents of children with ADHD show an increased incidence of

hyper kinesis, sociopathy, alcohol use disorder. Although the onset is usually

by the age of 3, the diagnosis is generally not made until the child is in

elementary school and the formal learning situation requires structured

behavior patterns, including developmentally appropriate attention span and

concentration.

ETIOLOGY

The causes of attention-deficit / hyperactivity disorders are not known.

The majority of children with ADHD do not show evidence of gross structuraldamage in the central nervous system (CNS). Conversely, most children with

known neurological disorders caused by brain injuries do not display

attention deficit and hyperactivity. Despite the lack of a specific

neurophysiologic or neurochemical basis for the disorder, it is predictably

associated with a variety of other disorders that affects brain function, such

as learning disorders. The suggested contributing factors for ADHD include

prenatal toxic exposures, prematurely, and prenatal mechanical insult to the

fetal nervous system.

Food additives, colorings, preservatives, and sugar have also been

suggested as possible causes of hyperactive behavior. No scientific evidence

indicates that those factors cause attention-deficit / hyperactivity disorder.

Genetic Factors.

Evidence for a genetic basis for attention-deficit / hyperactivity

disorder includes the greater concordance in monozygotic twins than in

dizygotic twins. Also, siblings of hyperactive children have about twice the

risk of having the disorder as does the general population. One sibling may

have predominantly inattention.

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Biological parents of children with the disorder have a higher risk for

attention-deficit / hyperactivity disorder than do adaptive parents. When

attention-deficit / hyperactivity disorder coexists with conduct disorder in the

child, alcohol use disorders and antisocial personality disorder are more

common in the parents than in the general population.

Brain Damage .

It has long been speculated that some children affected by ADHD

received minimal and subtle brain damage to the CNS during their fetal and

prenatal periods. Or the brain damage may have been cause by adverse

circulatory, toxic, metabolic, mechanical, and other effects and by stress and

physical insult to the brain during early infancy caused by infection,

inflammation, and trauma. Minimal, subtle, and sub clinical brain damage

may be responsible for the genesis of learning disorders and ADHD. No focal

(soft) neurological signs are frequent.

Computed tomography (CT) heads scan in children with attention-

deficit / hyperactivity disorder show no consistent findings. Studies using

positron emission tomography (PET) have found decreased cerebral blood

flow and metabolic rates in the frontal lobes areas of children with attention-

deficit / hyperactivity disorder compared with controls. One theory is that thefrontal lobes in children with attention-deficit / hyperactivity disorder are not

adequately performing their inhibitory mechanism on lower structures,

leading to disinheriting.

Neurochemical factors .

Many neurotransmitters have been associated with attention-deficit

and hyperactivity symptoms. In part, in findings have come out of the use of

many medications that exert some positive effects on the disorder. The most

widely studies drugs in the treatment of attention-deficit / hyperactivity

disorder, the stimulants, affect both dopamine and nor epinephrine, leading

to neurotransmitter hypotheses that include possible dysfunction in both the

adrenergic and the dopaminergic system. Stimulants increase

catecholamines by promoting their release and by blocking their uptake.

Stimulants and some tricyclic drugsfor example, desipramine (Norpramine)

reduce urinary 3-methoxy-4-hydroxyphenylglycol (MHPG) which is a

metabolite of norepinephrine. Clonidine (Catapres), a norepinephrine

agonist, has been helpful in treating hyperactivity. Other drugs that have

reduced hyperactivity include tricyclic drug and monoamine oxidase4


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inhibitors (MAOIs). Overall, no clear-cut evidence implicates a single

neurotransmitter in the development of attention-deficit / hyperactivity

disorder, but many neurotransmitters may be involved in the process.

Neurophysiologic Factors.

The human brain normally undergoes major growth spurts at several

ages: 3 to 10 months, 2 to 4 years, 6 to 8 years, 10 to 12 years, and 14 to 16

years. Some children have a maturational delay in the sequence and

manifest symptoms of ADHD that appear to be temporary. A physiological

correlate is the presence of a variety of nonspecific abnormal

electroencephalogram (EEG) patterns that are disorganized and

characteristic of young children. In some cases the EEG findings normalize

over time.

Psychosocial factors.

Children in institution are frequently overactive and have poor

attention spans. Those signs result from prolonged emotional deprivation,

and they disappear when derivational factors are removed, such as through

adoption or placement in a foster home. Stressful psychic events, a

disruption of the family equilibrium, and other anxiety-inducing factors

contribute to the initiation or the perpetuation of ADHD. Predisposing factorsmay include the childs temperament, genetic-familial factors, and the

demands of society to adhere to a reutilized way of behaving and

performing. Socioeconomic status does not seem to be a predisposing factor.

D IAGNOSIS

The principal sign of hyperactivity should alert clinicians to the possibility

of ADHD. A detailed prenatal history of the childs early developmental

patterns and direct observation usually reveal excessive motor activity.

Hyperactivity may be seen in some situations (for example, school) but not

in others (for example, one-to-one interviews and watching television), and it

may be less obvious in structured situations than in unstructured situations.

However, the hyperactivity should not an isolated, brief, and transient

behavioral manifestation under stress but should have been present over a

long time. According to DSM-IV , symptoms must be present in at least two

settings (for example, school, home) to meet the diagnostic criteria for

attention-deficit / hyperactivity disorder (Table 39-1).

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TABLE 39-1

D IAGNOSTIC CRITERIA FOR ATTENTION -DEFICIT / HYPERACTIVITY

D ISORDER

A. Either (1) or (2):

(1) Inattention: six (or more) of the following symptoms of

inattention have persisted for at least six months to a degree

that is maladaptive and inconsistent with developmental level:

(a)often fails to give close attention to details or makes

careless mistakes in schoolwork, work, or other activities

(b)often has difficulty sustaining attention in tasks or play

activities

(c) often does not seem to listen when spoken to directly

(d)often does not follow through on instruction and fails to

finish schoolwork, chores, or duties in the workplace (not

due to oppositional behavior or failure to understand

instructions)

(e)often has difficulties organizing tasks and activities(f) often avoids, dislikes, or is reluctant to engage in tasks

that require sustained mental effort (such as schoolwork

or homework)

(g)often loses things necessary for tasks or activities (e.g.,

school assignments, pencils, books, or tools)

(h)is often easily distracted by extraneous stimuli

(i) is often forgetful in daily activities

(2)Hyperactivity-impulsivity: six (or more) of the following

symptoms of hyperactivity-impulsivity have persisted for at least

six months to a degree that is maladaptive and inconsistent with

developmental level:

Hyperactivity

(a)often fidgets with hands or feet or squirms in seat

(b)often leaves seat in classroom or in other situation in

which remaining seated is expected

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(c) often runs about or climbs excessively in situation in

which it is inappropriate (in adolescents or adults, be

limited to subjective feelings of restlessness)

(d)often has difficulty playing or engaging in leisure

activities quietly

(e)is often on the go or often acts as if driven by a motor

(f) often talks excessively

Impulsivity

(g)often blurts out answer to question before the questions

have been completed

(h)often has difficulty awaiting turn

(i) often interrupt or intrudes on others (e.g., butts into

conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused

impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more

settings (e.g., at school [or work] and at home).

D. There must be clear evidence of clinically significant impairment issocial, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a

pervasive developmental disorder, schizophrenia, or other psychotic

disorder, and are not better accounted for by another mental disorder

(e.g., mood disorder, anxiety disorder, dissociative disorder, or a

personality disorder).

Code based on type:

Attention-deficit / hyperactivity disorder, combined type : if both

criteria A1 and A2 are met for the past 6 months

Attention-deficit / hyperactivity disorder, predominantly inattentive

type : if criterion A1 is met but criterion A2 is not met for the past 6 months

Attention-deficit / hyperactivity disorder, predominantly

hyperactive-impulsive type : if criterion A2 is met but criterion A1 is not

met for the past 6 months

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Coding note : For individuals (especially adolescents and adults) who

currently have symptoms that no longer meet full criteria, in partial

remission should be specified.

Other distinguishing features of ADHD are short attention span and easy

distractibility. In school, children with ADHD cannot follow instructions and

often demand extra attention from their teachers. At home, they often do

not follow through on their parents requests. They act impulsively, show

emotional lability, and are explosive and irritable. The DSM-IV diagnostic

criteria for attention-deficit / hyperactivity disorder are given in Table 39-1.

Children who have hyperactivity as a predominant features are more

likely to be referred for treatment than are children with primarily symptoms

of attention-deficit. Children with the predominantly hyperactive-impulsive

type of ADHD are more likely to have stable diagnosis over time and are

more likely to have concurrent conduct disorder than are children with the

predominantly inattentive type without hyperactivity.

Disorders involving reading, arithmetic, language, and coordination my

be found in associated with ADHD. The childs history may give clues to

prenatal (including genetic). Natal and postnatal factors that may haveaffected the CNS structure or function. Rates of development, deviations in

development, and parental reactions to significant or stressful behavioral

transitions should be ascertained, as they may help the clinician determine

the degree to which parents have contributed to or reacted to the childs

inefficiencies and dysfunctions.

School history and teachers reports are important in evaluating

whether childrens difficulties in learning and school behavior are primarily

due to their attitudinal or maturational problems or to their poor self-image

because of felt inadequacies. Those results may also reveal how the children

have handled those problems. How they have related to siblings, to peers, to

adults, and to free and structured activities gives valuable diagnostic clues to

the presence of ADHD and helps identify the complications of the disorder.

The mental status examination may show a secondarily depressed

mood but no thought disturbance, impaired reality testing, or inappropriate

affect. The child may show great distractibility, perseveration, and a

concrete and literal mode of thinking. Indications of visual-perceptual,

auditory perceptual, language or cognition problems may be present.

Occasionally, evidence appears of a basic, pervasive, organically based

anxiety, often referred to as body anxiety.8


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A neurological examination may reveal visual-motor-perceptual or

auditory-discriminatory immaturity or impairments without overt signs of

disorders of visual or auditory-acuity. Children may how problems with motor

coordination and difficulties in copying age-appropriate figures, rapid

alternating movements, right-left discrimination, ambidexterity, reflex

asymmetries, and a variety of subtle no focal neurological signs (soft signs).

The clinician should obtain an EEG to recognize the child with frequent

bilaterally synchronous discharges resulting in short absence spells. Such a

child may react in school with hyperactivity out of sheer frustration. The child

with an unrecognized temporal lobe seizure focus can present a secondary

behavior disorder. In those instances, several features of ADHD are often

present. Identification of the focus requires EEG obtained during drowsiness

and during sleep.

CLINICAL FEATURES

ADHD may have its onset in infancy. Infants with ADHD are unduly

sensitive to stimuli and are easily upset by noise, light, temperature, and

other environmental changes. At times, the reverse occurs, and the childrenare placid and limp, sleep much of the time, n appear to develop slowly in

the first months of life. It is more common, though, for infants with ADHD to

be active in the crib, sleep little, and cry a great deal. ADHD children are far

less likely than are normal children to reduce their locomotor activity when

their environment is structured by social limits. In school, ADHD children may

rapidly attack a test but answer only the first two questions. They may be

unable to wait to be called on in school and may respond for everyone else.

At home, they cannot be put off for even a minute.

Children with ADHD are often explosively irritable. The irritability may

be set off by relatively minor stimuli, which may puzzle and dismay the

children. They are frequently emotionally labile, easily set off to laughter or

to tears, and their mood and performance re apt to be variable and

predictable. Impulsiveness and an inability to delay gratification are

characteristic. They are often accident-prone.

Concomitant emotional difficulties are frequent. The fact that other

children grow out of that kind of behavior but ADHD children do not grow out

of it at the same time and rate may lead to adults dissatisfaction and

pressure. The resulting negative elf-concept and reactive hostility are

worsened by the childrens recognition that they have problems.9


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The characteristics of children with ADHD most often cited are, in

order of frequency, (1) hyperactivity, (2) perceptual, (3) emotional lability,

(4) general coordination deficit, (5) disorders of attention (short attention

span, distractibility, perseveration, failure to finish things, inattention, poor

concentration), (6) impulsivity (action before thought, abrupt shifts in

activity, lack of organization, jumping up in class), (7) disorders of memory

and thinking, (8) specific learning disabilities, (9) disorders of speech and

hearing, and (10) equivocal neurological signs and EEG irregularities.

About 75 percent of children with ADHD fairly consistently show

behavioral symptoms of aggression and defiance. But, whereas defiance and

aggression are generally associated with adverse interfamily relationships,

hyperactivity is more closely related to impaired performance on cognitive

test requiring concentration. Some studies claim that some relative of

hyperactive children show features of antisocial personality disorder.

School difficulties, both learning and behavioral, are common,

sometimes coming from concomitant communication disorders or from the

childrens distractibility and fluctuating attention, which hamper their

acquisition, retention, and display of knowledge. Those difficulties are noted

especially on group tests. The adverse reactions of school personnel to thebehavior characteristic of ADHD and the lowering of self-regard because of

felt inadequacies may combined with the adverse comments of peers to

make school a place of unhappy defeat, which may lead to acting-out

antisocial behavior and self-defeating, self-punitive behaviors.

D IFFERENTIAL D IAGNOSIS

A temperamental constellation pan should be first considered.

Differentiating those temperamental characteristics from the cardinal

symptoms of ADHD before age 3 is difficult, mainly because of the

overlapping features of normally immature nervous system and the

emerging signs of visual-motor-perceptual impairments frequently seen in

ADHD.

Anxiety in the child needs to be evaluated. Anxiety may company

ADHD as a secondary feature, and anxiety by itself may be manifested by

overactivity and easy distractibility.

Many children with ADHD had secondary depression in reaction in

continuing frustration over their failure to learn and their consequent low-self

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esteem. The condition must be distinguished from a primary depressive

disorder, which is likely to be distinguished by hypoactivity and withdrawal.

Frequently, conduct disorder and ADHD, since a child may be unable to

read or do mathematics because of a learning disorder, rather than

inattention. However, attention deficit/hyperactivity disorder often coexist

with one or more learning disorder, include reading disorder, mathematics

disorder, and disorder do written expression.

COURSE AND PROGNOSIS

The course of ADHD is highly variable. Symptoms may persist into

adolescence or adult life, they may remit at puberty, or hyperactivity may

disappear, but the decreased attention span and impulse-control problems

may persist. The overactivity is usually the first symptom to remit and

distractibility the last. Remission is not likely before the age of 12.If

remission does occur, it usually between the age of 12 and 20.Remission

may be accompanied by a productive adolescence and adult life, satisfying

interpersonal relationship, and few significant sequelae. The majority of

patients with ADHD, however, undergoes partial remission and is vulnerableto antisocial and other personality disorder and mood disorders. Learning

problem often continue.

In about 15 to 20 percent of cases, the symptoms of ADHD persist into

adulthood. Those with the disorder may show diminished hyperactivity but

remain impulsive and accident-prone. Although their educational

attainments are lower than those of persons without ADHD, their early

employment histories are not different from those of persons with similar

educations.

Children with ADHD whose symptoms persist into adolescence are at

high risk for developing conduct disorder. Approximately 50 percent of

children with conduct disorder will develop antisocial personality disorder in

adulthood. Children with both ADHD and conduct disorder are also at risk for

developing a substance-related disorder.

Overall, the outcome of ADHD in childhood seems to be related to

the amount of persistent conduct disorder and chaotic family factors.

Optimal outcomes may be promoted by meliorating the childrens aggression

and by improving family functions s early as possible.

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TREATMENT

Pharmacotherapy .

The pharmacological agents for ADHD are the CNS stimulants,

primarily dextroamphetamine (Dexedrine), methylphenidate, and pemoline

(Cylert).

Psychosocial therapies:

These are treatment approaches that focus on the behavioral,psychological, social and work/school problems associated with the illness.Psychosocial therapies that may be used for ADHD include:

Special education: This is a type of education that is structured tomeet the child's unique educational needs. Children with ADHDgenerally benefit most from a highly structured environment and use of routines.

Behavior modification: This includes strategies for supporting goodbehavior and decreasing problem behavior by the child.

Social skills training: This can help the child learn new behaviors,such as taking turns and sharing, that will enable him or her to betterfunction in social situations.

Support groups:

Support groups are generally made up of people with similar problemsand needs, which can help with acceptance and support. Groups also canprovide a forum for learning more about a disorder and the latest approachesto treatment. These groups are helpful for adults with ADHD or parents of children with the disorder.

Many children with ADHD also suffer from sensory processing disorder,a neurological underpinning that contributes to their ability to pay attentionor focus," explains Koenig. "They either withdraw from or seek out sensorystimulation like movement, sound, light and touch. This translates intotroublesome behaviors at school and home.Therapy techniques appeal to the

three basic sensory systems: The tactile system controls the sense of touch,the vestibular system controls sensations of gravity and movement and theproprioceptive system regulates the awareness of the body in space.

Therapy is tailored to each child's needs and can involve techniques, such aslightly or deeply brushing the skin, moving on swings or working with anexercise ball.

The goal of ADHD treatment is to prevent failure in school, familyproblems and poor self-esteem. If not addressed early, the disorder cantrouble sufferers into adulthood.

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Learning Disorders

R EADING DISORDER

Reading disorder characterized by an impaired ability to recognize

words, slow and inaccurate reading, and poor comprehension in the absence

of low intelligence or significant sensory deficits. The relatively common

school-age childhood disorder seems to run in families and is often

associated with disorder of written expression, mathematics disorder, or one

of the communication disorders. In addition, children with attention

deficit/hyperactivity disorder have a high risk for reading disorder. Over the

years, a variety of labels have been used to describe reading disabilities

including, dyslexia, reading backwards, learning disability, alexia,

and developmental world blindness. The term dyslexia was used

extensively for a number of years to describe a reading disability syndrome

that often included speech and language deficits and right-left confusion.When it became evident that reading disorder is frequently accompanied by

disabilities in other academic skills, the use of the term dyslexia

diminished, and general terms, such as learning disorder, began to be

used.

EPIDEMIOLOGY

An estimated 4 percent of school-age children in the United States

have reading disorder; prevalence studies find rates ranging between 2 and

8 percent. Three to four times as many boys as girls are reported to have

reading disability in school and clinically referred samples. The rate for boys

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may be inflated, since boys with reading disorder are apt to be picked up

because of their increased behavioral difficulties. Adults with reading

backwardness or reading retardation reportedly show no sex difference in

the frequency of the disorder.

ETIOLOGY

No unitary cause is known for reading disorder; given the many

associated learning disorders and language difficulties, reading disorder is

probably multifactorial. One recent study found an association between

dyslexia and birth in the months of May, June, and July, suggesting that

prenatal exposure to a maternal infectious illness, such as influenza, in thewinter months may contribute to reading disorder.

Reading disorder tends to be more prevalent among family members

of persons affected by the disorder than in the general population, leading to

the speculation that the disorder may have a genetic origin. However,

familiarity and twin studies have not supplied definitive evidence to support

that theory.

A high incidence of reading disorder tends to be found among childrenwith cerebral palsy who are of normal intelligence. A slightly increased

incidence of reading disorder is seen among epileptic children. Complications

during pregnancy, prenatal and perinatal difficulties, including prematurity;

and low birth weight are common in the histories of children with reading

disorder.

Secondary reading disorder may be seen in children with postnatal

brain lesions in the left occipital lobe resulting in right visual field blindness.

The disorder may also be seen in children with lesions in the splenum of the

corpus callosum that blocks the transmission of visual information from the

intact right hemisphere areas to the left hemisphere.

Reading disorder may be one manifestation of developmental delay

and maturational lag. Temperamental attributes have been reported to be

closely associated with reading disorder. Compared with non-reading

disordered children, children with reading disorder often have more difficulty

in concentrating and attention span.

DIAGNOSIS

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The main diagnostic feature of disorder is reading achievement below

the persons intellectual capacity. Other characteristic features include

difficulties the recall, evocation, and sequencing of printed letters and words;

and processing of sophisticated grammatical constructions; with the making

of interferences. Clinically, the observer is impressed by between emotional

and specific features. The experience of school failure seems to conform

preexisting doubts that some children have about themselves.

The energy of this children is so bound to their psychological conflicts

that they are unable to use their assets. The diagnostic of reading disorder

cannot be established without confirmation by a standardized reading

achievement test, and pervasive developmental disorders and mental

retardation must be ruled out.

Psychoeducational test

The diagnostic battery may include a standardized spelling test, the

writing of a composition, the processing and the use of oral language, and

design copying, a judgment of the adequacy of pencil use. A screening

projective battery may include human figure drawings, picture-story tests

and sentence completion. The evaluation should also include a systematic

observation of behavior variables.

CLINICAL FEATURES

Reading disorder is usually apparent by age 7. Sometimes reading

disorder for in the early elementary grades, particularly when it is associated

with high scores on intelligence test. In those cases the disorder may not be

apparent until age 9 or later.

Reading disorder children may have errors in their oral reading. The

faulty reading is characterized by omissions, additions, and distortions of

words. Such children have difficulty in distinguishing between printed letter

characters and sizes, specially those that differ only in spatial orientation and

length of line. The problems in managing printed or written language may

pertain to individual letters latters, sentences, and even a whole page. The

childrens reading speed id slow often with minimal comprehension. Most

children with reading disorder have an age appropriate ability to copy from a

written or printed text, but nearly are poor spellers.

Associated problems include language difficulties, shown often as

impaired sound discrimination and difficulties in properly sequencing words.15


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The reading-disorder child may start a word in the middle or at the end of a

printed or written sentence. At times, such children transpose letters that are

to be read because of a poorly left-to-right tracking sequence. Failure in both

memory recall and sustained elicitation results in the poor recall of letter

names and sounds.

Most children with reading disorder dislikes reading and writing and

avoid them. Their shame and anxiety is heightened when they are

confronted with demands that involve printed language.

Most reading disordered children who do not receive remediation

education have a sense of shame and humiliation because of their continuing

failure and subsequent frustration. Those feelings become more intense as

time progresses. Older children tends to be angry and depressed, and they

exhibit poor self-esteem.

DIFFERENTIAL DIAGNOSIS

Deficits in expressive language and speech discrimination are usually

present and may be severe enough to warrant the additional diagnosis or

expressive language disorder or mixed receptive/expressive languagedisorder. Disorder of written disorder is often present. Visual perceptual

deficits are seen in about 10 % of cases.

Reading often accompanies other emotional and behavior disorders,

especially attention-deficit/hyperactivity disorder,conduct disorder, and

depressive disorders, particularly in older children and adults.


Even without any remedial assistance, many reading-disordered children

acquire a little information about printed language during the first two years

in grade school. By the end of the first grade, some have learned how to

read a few words. However, if no remedial education intervention by the

third grade, the children remain reading impaired. Under the best

circumstances, a child is classified as being at risk for a reading disorder

during the kindergarten year or in the first grade.When remedial education is instituted early, it can sometimes be

discontinued by the end of first or second grade. In severe cases and

depending on the pattern of deficits and strengths, remediation may be

continued into the middle and high school years. Children who have either

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compensated satisfactorily or recovered from early reading disorder are

overrepresented in families with socioeconomically advantaged

backgrounds.

TREATMENT

The prevailing view of the biologic correlates of reading disabilities is

that it is phonolinguistic problem. Interventions that increase phonological

awareness are an essential first step in the remediation of learning

disabilities. Reading by definition requires that the printed word be identified

and decoded prior to it being understood. Thus a deficit in phonemicawareness even in an individual with otherwise intact cognitive proficiency

will not allow an individual to use their higher-order cognitive-linguistic skills

to access the meaning of text.10 Despite some emerging research to

suggest an independent contribution of visual processing deficits to dyslexia

the overwhelming consensus among investigators in the field is that the core

problem in developmental dyslexia is a phonologic deficit.

Research suggests that there is a subgroup of children with languagedysfunction, which is

secondary to defective temporal processing of auditory stimuli and to deficits

in speech discrimination. Computer games have been devised in which the

intensity of the consonant sounds are enhanced relative to the vowels and in

which the duration of the speech signal is prolonged. After one month of

training children working with these computer programs have been reported

to improve in their language test scores by as much as 2 years and these

changes are maintained for at least 6 weeks post intervention.

Mathematics Disorder

Mathematics disorder is a disability in performing arithmetic skills that

are expected for a persons intellectual capacity or educational level.

Arithmetic skills are measured by standardized, individually administered

tests. The lack of expected mathematics ability interferes with school

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performance or daily life activities, and the difficulties are in excess of

impairments associated with any existing neurological or sensory deficits.

Mathematics disorder has been around for many decades, as

evidenced by the many terms that have been applied to it. Past terminology

includes Gerstmann syndrome, dyscalculia, congenital arithmetic

disorder,acalculia, and developmental arithmetic disorder.

EPIDEMIOLOGY

Prevalence of mathematics disorder has not been well studied and can

be only roughly estimated to be 6 % of school-age children who are not

mentally retarded. The extent to which educational limitations influence thatnumber is not clear. Data do suggest that children with mathematics

disorder are likely to exhibit language disability. The disorder may be

common in girls than in boys.

ETIOLOGY

The cause of mathematics disorder is not known. An early theoryproposed a neurological deficit in the right cerebral hemisphere, particularly

in the occipital lobe areas. Those regions are responsible for processing

visual-spatial stimuli that, in turn, are responsible for mathematical skills.

However, the validity of that theory has received little support in subsequent

neuropsychiatric studies.

The current view is that the cause is multifactorial. Maturational,

cognitive, emotional, and socioeconomic factors account in varying degrees

and combinations for mathematics disorder. Compared with reading,

arithmetic abilities seems to be more dependent on the amount and the

quality of instruction.

DIAGNOSIS

In a typical mathematics disorder, a careful inquiry into the childs

school performance history reveals early difficulties with arithmetic subjects. The definite diagnosis can be made only after the child takes an individually

administered standardized arithmetic test and scores markedly below the

expected level, considering the childs schooling and intellectual capacity as

measured by standardized intelligence test. A pervasive developmental

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disorder and mental retardation should be ruled out before confirming the

diagnosis of mathematics disorder.

CLINICAL FEATURES

Many children with mathematics disorder can be classified during the

second and third grades in elementary school. The affected childs

performance in handling basic number concepts, such as counting and

adding even one- digit numbers, is significantly below the age-appropriate

norms, but the child shows normal intellectual skills in other areas. During

the first two to three years of elementary schools, a child with mathematics

disorder may appear to make some progress in math by relying on rotememory. But soon, as arithmetic progresses into complex levels requiring

discrimination and manipulation of spatial and numerical relations, the

presence of the disorder becomes conspicuous.

Some investigators have classified mathematics disorder into several

categories: (1) difficulty in learning to count meaningfully, (2) difficulty in

mastering cardinal and ordinal systems, (3) difficulty in performing

arithmetic operations, (4) difficulty in envisioning clusters of objects asgroups. In addition, affected children may have difficulties in associating

auditory and visual symbols, understanding the conservation of quantity,

remembering sequences of arithmetic s steps and choosing principles for

problem-solving activities.

DIFFERENTIAL DIAGNOSIS

Arithmetic difficulties seen in mental retardation are accompanied by a

generalized impairment in overall intellectual functioning. In usual cases of

mild mental retardation, arithmetic skills may be significantly below the

expected level, given the persons schooling and level of mental retardation.


Untreated children with a moderate mathematics disorder and those

children whose arithmetic difficulties cannot be resolved by intensive

remedial interventions may have complications, including continuing

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academic difficulties, poor self-concept, depression and frustration. Those

complications may then lead to reluctance to attend school, truancy or

conduct disturbance.

TREATMENT

Currently, the most effective treatment foe mathematics disorder is remedial

education. Project MATH, a multimedia self-instructional in-service training

program has been successful for some children with mathematics disorder.

Poor coordination may accompany the disorder, physical therapy and

sensory integration activities may be helpful.

D ISORDER OF W RITTEN E XPRESSION

Writing skills that are severely below the expected level of the persons

age, intellectual capacity, and education. The impairment interferes with the

school performance and with the demands of writing for everyday life, and

the disorder is not due to a neurological or sensory deficit. The componentsof writing disability includes: poor spelling, errors in grammar, punctuation

and poor hand writing.

EPIDEMIOLOGY

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The prevalence of the disorder is unknown but has been estimated at 3- 10

percent of school age children. The male to female ratio is unknown. Some

incidence that affected children are frequently from families with a history of

the disorder.

ETIOLOGY

According to one hypothesis, the disorder results from the combined effects

of one or more of the following: expressive language disorder, mixed-

receptive-expressive language disorder, and reading disorder. This view

implies the possible existence of a neurologic and cognitive defects or

malfunction somewhere in the central-processing areas of the brain.

Hereditary predisposition to the disorder has been suggested by empirical

findings that most children with the disorder has relatives withy the disorder.

Temperamental characteristics may also play some role in the disorder of

written expression, especially such as short attention span and easy

distractibility.

D IAGNOSIS

Diagnosis of the disorder is based on the persons consistently poor

performance on composing written text including handwriting and impaired

ability to spell and to place words substantially in coherent sentences.

Performance is marked below the persons intellectual capacity, as

confirmed by an individual administered standardized expressive writing

test. (TOWL) Test of Written Language. Diagnostic Evaluation of Writing

Skills, and Test of Early Writing Language (TEWL).

CLINICAL FEATURES

Children with the disorder of written expression have difficulties early in

grade school in spelling words and expressing their thoughts according to

age-appropriate grammatical norms. Their spoken and written sentences

contains an unusually large number of grammatical errors and poor

paragraph organization. During and after the second grade, the children

commonly make simple grammatical errors in writing a short sentence.

Example, they fail to start the first letter of the first word of the sentence21


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with a capital letter and to end a sentence with a period, despite constant

reminders.

As they grow older and progress into higher grades in school, such

childrens spoken and written sentences become conspicuously primitive,

odd, and inferior to what is expected of students of their grade level. Their

word choices are erroneous and inappropriate: their paragraphs are

disorganized and not in proper sequence; and spelling correctly becomes

increasingly difficult as their vocabulary becomes more abstract and larger.

Associated features of written disorder includes refusal to go to school and to

do assigned written homework, poor academic performance in other areas,

general disinterest in school work, truancy, attention deficit and conduct

disturbance.

Most children with the disorder become frustrated and angry because of

their feeling of inadequacy and failure in their academic performances. They

may have a chronic depressive disorder as a result of their growing sense of

isolation, estrangement and despair.

TREATMENT

Writing disorders are related primarily to language disturbances and the

remediation of the language disorder is essential to treatment. Handwriting

disorders (dysgraphia) are felt to be secondary to deficits in fine motor movements.

The treatment of dysgraphia has centered on remediation of the fine motor skills

needed for writing and less emphasis has been given to treating possible underlying

motor sequencing, visuospatial, or attentional deficits.

Intervention strategies in schools for children with dyslexia, dyscalculia and

dysgraphia are centered on instruction of specific cognitive strategy techniques.

The purpose ofthese techniques is to teach students strategies or tricks to

overcome specific deficits. These cognitive strategy techniques are combined with

study skill instruction in areas such as time management, learning to keep notes or

lists, how to listen to key points in a lecture, and retention strategies to improverecall of material studied.14 Specific recommendations

to promote positive behavior and remediate specific deficits are also available for

children with the neuropsychologically defined nonverbal learning disability

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adhd and ld written report

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