Overview of Learning Disabilities
DEFINITIONS:
● Learning disabilities are an operational term that refers to a heterogeneous pattern of learning
disorders. The population of affected children and adults who are identified may experience
difficulties, sometimes inexplicable in the acquisition of reading, listening, writing, reasoning, or
mathematical skills.
“Specific learning disability” means a disorder in one or more of the basic psychological
processes involved in understanding or in using language, spoken or written, which may
manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical
calculations.
The term includes such conditions as:
★ Perceptual handicaps
★ Brain injury
★ Minimal brain dysfunction
★ Dyslexia
★ Developmental aphasia (difficulty in communicating)
The term does not include children who have learning problems that are primarily the result of:
★ Visual
★ Hearing
★ Motor handicaps
★ Intellectual disability
★ Emotional disturbance
★ Environmental, cultural, or economic disadvantage
Learning disabilities including those related to vision encompass many more problems than reading
dysfunction. An individual with reading dysfunction is one whose achievement in reading is significantly
lower than expected. Many of the vision-related problems related to reading dysfunction can be
eliminated completely with direct optometric intervention. Some forms of reading dysfunction however
can only be partially improved with optometric intervention.
CLASSIFICATION:
➔ Reading dysfunction can either be classified as non-specific (general) or specific (dyslexia)
➔ Dyslexia according to Griffin is a coding problem involving written language that results in poor
reading, spelling, and writing. It is not a primary comprehension problem but reading
comprehension is secondarily affected if the coding of words is poor. The coding problem of
dyslexia is thought to be due to neurologic dysfunction or a differential brain function.
➔ Dyslexia affects the individual's ability to decode words but not his or her comprehension of a
story read aloud, assuming adequate intellectual ability. The decoding problem may be due to a
lack of educational exposure, poor education, environment, lack of motivation, and other causes
that result in general reading dysfunction.
CAUSES OF GENERAL READING DYSFUNCTION:
➢ Low intelligence (Full-scale IQ<80)
➢
➢
➢
➢
➢
➢
➢
Educational deprivation (does not attend school regularly)
Sociocultural deprivation or differences (english may be 2nd or 3rd language)
Primary emotional or mental health problems
Visual problems (High uncorrected hyperopic astigmatism)
Auditory problems (poor auditory discrimination)
Sensory intergration problems (Poor AVIS)
Attention problems (ADHD)
LEARNING TO READ VS LEARNING TO READ:
❖ Early phases of learning to read place demand on visual perception factors
➢ Recognition
➢ Matching
➢ Recall of shapes
➢ Ability to deal with directional concepts
❖ Contribution decreases as shift takes place from work analysis to comprehension
❖ Other visual factors increase in importance as relative contribution of visual perception
decreases:
➢ Binocular vision dysfunction increases
➢ Accommodative dysfunction increases
STEPS IN THE READING PROCESS:
● Reading is a complex developmental process that follows certain stages:
○ The child acquires decoding skills in word recognition
○ The decoding vocabulary increases
○ Knowledge of concepts and comprehension of ideas merge
○ The older child increases the capacity to grasp meaning and appreciate the style of written
passages
○ Beyond 7th grade a mature reader should be able to interpret, evaluate and reflect on the
meaning of what was read
OPTOMETRIC INVILVEMENT RELATING TO WORD RECOGNITION IN THE READING PROCESS:
● Visual acuity and lens applications
● Peripheral awareness
● Eye position maintenance
● Eye movements
● Accommodation
● Vergences
● Visual perception
● Visual motor integration
● Auditory visual integration
● Visual linguistic cognitive coding of written words
LEARNING TO READ:
● Major emphasis on word recognition and recall
● Large type with few words on each page
● “Look and say” methods of teaching place premium on visual memory
● Phonic methods require careful scrutiny of internal details of individual words
● Activity usually does not extend over long periods
● Writing may be utilized to reinforce reading
Visual factors:
★ Accurate oculomotor control
★ Visual form perception and visual discrimination, including the ability to deal with directional
orientation
★ Visual memory
★ Accommodation and binocular vision are usually not critical factors
★ Ability to integrate visual and auditory stimuli’
★ Eye-hand coordination becomes important when writing is used as a re-enforcer for reading
READING TO LEARN:
● Longer reading assignments
● Smaller type
● Context cues become increasingly important to word recognition
● Phonic and linguistic cues are more readily available
● Word analysis becomes more automatic with less need to depend primarily on form perception
● Emphasis shifts to comprehension and speed
Visual factors:
★ Accommodation and binocular vision become more important
★ Oculomotor control in important to keep place and preserve continuity of input
★ Form perception plays a decreasing role
VISUAL DISORDERS AFFECTING READING PERFORMANCE:
● Hyperopia
● Convergence insufficiency
● Poor fusional vergence reserves
● Fixation disparity
● Hyperphoria
● Anisometropia
● Accommodative dysfunctions
● Poor saccadic movements
● Inefficient visual perceptual processing
Oculomotor control in learning
Beginner reading:
● Needs attention to internal details of
words requiring precise oculomotor
control
● Accurate sequential inspection of
words is necessary for utilization of
Sophisticated reading:
● Less dependence on precision eye
aiming to attend to internal details of
words because more methods can be
utilized to identify words
● Oculomotor control becomes
phonic analysis
● Oculomotor control is related to the
ability to maintain attention
important for keeping place
● Omissions, substitutions and
‘careless’ errors may be attributed to
inaccurate oculomotor control
● Reading comprehension can be
adversely affected by poor oculomotor
control
● One compensation for erratic
oculomotor control is to slow the
reading rate to avoid errors
Accommodation in learning
Beginner reading:
● Large type utilized
● Blur rarely reported even if
accommodation is deficient
● Most lessons are of short duration,
minimizing the effects of fatigue from
accommodative problems
● Short attention span more likely than
blur or asthenopia
Sophisticated reading:
● The emphasis in reading shifts from
decoding to speed and
comprehension
● Smaller type and longer time at
reading make accommodation very
important
● Fatigue often manifests as primary
symptom
● Abrupt decline in reading efficiency as
a function of time at task
● Intermittent blur may be reported
● Asthenopia present when patient
persists at reading despite
accommodative inefficiency
● Mild brow headaches
● Symptoms avoided by not reading
● Accommodative spasm may develop
as adaptation among those who
persist reading despite asthenopia
Binocular vision in reading
Beginner reading:
● Emphasis on decoding and not
sustaining fixation
● Binocular vision problems may not
always be a major factor even when
present
● Binocular fusion problems can
interfere when there is great
emphasis on workbooks with lengthy
Sophisticated reading:
● Reading emphasis is on speed and
comprehension
● Ability to sustain fixation becomes
important
● Binocular dysfunctions present more
frequently as the workload increases
● Comprehension is adversely affected
and then there may be a need for
assignment
● Asthenopia symptoms are rare
● Avoidance, short attention span or
disruptive behaviour are more
common
excessive rereading
● Reading in a moving vehicle can
produce nausea
● Headaches may be more severe than
with accommodative problems and
may be occipital as well as frontal or
temporal
● Loss of place may occur specifically
with large phoria
● Supression is an adaptive response
that can permit reading despite a
binocular deficiency
● There may be an inverse relationship
between the degree of binocular
vision problem and the influence on
reading
● Smaller and less obvious deficiencies
in binocular vision can seriously
reduce reading efficiency
Symptoms and reading problems in uncorrected hyperopia:
Symptoms and reading problems in uncorrected astigmatism:
ETIOLOGY OF READING DYSFUNCTION:
➔ Genetics
◆ Family history is very significant in predicting whether a child will become reading or
learning disabled
◆ May be increased by complications of pregnancy
◆ Gene on chromosome 15 plays a role in one form of reading disability
◆ Visual-predominated dyslexia prevalence of autosomal dominant inheritance
➔ Nutrition
◆ Many children diagnosed with reading or learning problems are also socially and
economically disadvantaged
◆ Nutrition important for biological and psychological potentialities
◆ Children who have experienced severe malnutrition in the first 2 years of life have
statistically lower intelligence scores at school age than their classmates
◆ Some functional lags (accom etc.) could be a result of mild to moderate protein-calorie
malnutrition
Learning disorders
Neurodevelopmental disorders (previously termed “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence”):
● Autism Spectrum Disorder
● Specific Learning Disorder (encompasses reading disorder, mathematics disorder and disorder
of written expression
● Intellectual Disability (previously termed mental retardation)
● Attention-Deficit/Hyperactivity Disorder
○ Predominantly Hyperactive-Impulsive Type
○ Predominantly Inattentive Type
○ Combined Type
● Motor skills disorder: developmental coordination disorder/dyspraxia
● Communication disorders:
○ Language disorder
○ Speech sound disorder
●
●
●
●
●
●
○ Childhood onset fluency disorder (stuttering)
○ Social communication disorder
Disruptive, impulse control and conduct disorders: Oppositional defiant disorder, anti-social
disorder, pyromania etc.
Aphasia (partial or complete impairment of the ability to communicate resulting from brain injury),
speech and language delay and/or deficit
Dyspraxia (a partial loss of the ability to perform skilled, coordinated movements in the absence
of any associated defect in motor or sensory functions), motor and coordination difficulties
Autism Spectrum Disorder: includes autism, Asperger’s, pervasive developmental disorder
Specific learning disorder: Dyslexia, dyscalculia
Other learning disorders: Other disorders are often diagnosed in educational settings but are not
listed in the DSM-IV. These include Auditory Processing Disorder (verbal skills weaker than nonverbal) or Visual Processing Disorder (spatial skills weaker than verbal)
Specific learning disorder:
● 315.00 (F81.0) With impairment in reading:
○ Word reading accuracy
○ Reading rate or fluency
○ Reading comprehension
■ Note: Dyslexia is an alternative term used to refer to a pattern of learning difficulties
characterized by problems with accurate or fluent word recognition, poor decoding,
and poor spelling abilities. If dyslexia is used to specify this particular pattern of
difficulties, it is important also to specify any additional difficulties that are present,
such as difficulties with reading comprehension or math reasoning.
● 315.2 (F81.81) With impairment in written expression:
○ Spelling accuracy
○ Grammar and punctuation accuracy
○ Clarity or organization of written expression
● 315.1 (F81 .2) With impairment in mathematics:
○ Number sense
○ Memorization of arithmetic facts
○ Accurate or fluent calculation
○ Accurate math reasoning
■ Note: Dyscalculia is an alternative term used to refer to a pattern of difficulties
characterized by problems processing numerical information, learning arithmetic
facts, and performing accurate or fluent calculations. If dyscalculia is used to
specify this particular pattern of mathematic difficulties, it is important also to
specify any additional difficulties that are present, such as difficulties with math
reasoning or word reasoning accuracy.
Specific criteria for learning disability diagnosis (DSM 5):
● Learning Disabilities are a group of disorders characterized by sustained difficulties learning
academic skills (currently or by history), that are not consistent with the person’s chronological
●
●
●
●
age and educational opportunities, and that cannot be explained by an intellectual disability,
sensory impairment, emotional disorder, or lack of adequate instruction.
Academic skills refer to reading accuracy, reading fluency, reading comprehension, written
expression, mathematics calculations, and mathematics problem solving. Multiple sources of
information are to be used to assess academic skills, one of which must be an individually
administered, culturally appropriate, psychometrically sound, norm-referenced measure of
academic achievement.
The use of intelligence tests, tests of cognitive ability, and/or neuropsychological tests may also
be indicated in order to provide more information regarding an individual’s learning disability or
disabilities and to inform interventions.
The adequacy of instruction and the client’s response to evidence-based interventions are to be
considered in making the diagnosis.
Accurate LD diagnosis can only be made through a series of rule-out judgments using
measurement procedures of adequate diagnostic accuracy and concluding with an individual
comprehensive psychological evaluation that includes measurement of IQ to rule out intellectual
disability where it is suspected.
Specific learning disability:
● Significant difficulties in the acquisition and use of listening, speaking, reading, writing,
reasoning, or mathematical abilities.
● Not the result of other conditions such as sensory impairment, intellectual disability, emotional
disturbance, cultural differences, or insufficient or inappropriate instruction.
● Operational definition = discrepancy between intellectual ability and academic achievement
Reading disability:
● Discrepancy between their actual reading performance and expected reading performance (as
predicted by IQ) BUT it uses an exclusionary definition
● Actual cause presumed to be an intrinsic dysfunction of the central nervous system
○ Dyseidesia - visual
○ Dysphonesia - auditory
Classification of reading dysfunction:
● Nonspecific reading dysfunction:
○ Low intelligence
○ Educational deprivation
○ Socio-cultural deprivation
○ Primary emotional or mental health problems
○ Vision problems
○ Auditory problems
○ Sensory-integration problems
○ Attention deficit disorder / attention deficit hyperactivity disorder
○ General health problems such as allergies
Specific reading dysfunction/disability:
In most cases, a specific reading disability is synonymous with dyslexia, which manifests as a deficit in
decoding, encoding and nemkinesia of the symbols of written language caused by a minimal brain
dysfunction or differential brain function leading to problems in reading, writing, and spelling.
Vision problems causing general reading dysfunction:
● Refractive errors, particularly hyperopia and astigmatism
● Double vision due to strabismus
● Vergence problems
● Accommodative problems
● Eye movement problems
● Information processing problems
● Visual auditory integration problems
Two general categories of poor reading performance:
Learning disabilities:
➔ Remedial readers:
◆ The underachievement can be attributed to an identifiable cause such as:
● Economic and social disadvantage
● Lack of adequate instruction
● Emotional problems
● Visual or hearing problems
◆ Can exhibit word recognition or comprehension problems
◆ Remediation involves compensating for instructional deficiencies through school-based
remediation or removal of primary cause
Reading disability:
★ Subtypes of dyslexia present
○ Dysphonesia
○ Dyseidesia
○ Dysnemkinesia
★ Associated with neurological disorganization in the associated cortex supporting one or the other
sensory system or in the language integrative areas such as Wernicke’s area or the angular
gyrus of the left temporal lobe
Dyslexia
 Tendency to make orientation and sequencing errors in both reading and writing.
 DEF: a combination of abilities and difficulties that affect the ;earning process in one or more of
reading, spelling, writing.
 Weaknesses in areas of:
o Speed of processing
o Short term memory
o Sequencing and organization
o Auditory and/or visual perception
o Spoken language
o Motor skills
Persisting factors from early age:




Obvious good or bad days for no apparent reason
Confusion btw directional word such as up/down or in/out
Sequence difficulties: remembering instructions in sequence, later days of week and numbers
Family hx or dyslexia/reading difficulties
Pre-school

Primary-school
Has persistent jumbled phrases e.g.
cobbler for toddler
Use of substitute words e.g. lampshade for
lamppost
Inability to remember the label for known
objects

Difficulty reading and spelling

Reversal of letters and numbers

Omissions and transpositions of letters in
words

Difficulty learning nursery rhymes and
rhyming words

Confuses b and d, on/no, was/saw

Later than expected speech development

Needs to use fingers or marks on paper to
make simple calculations

Poor concentration

Difficulty remembering tables, alphabet,
formulae etc.


Vision, reading and spelling
1. Complains of dizziness, HA and stomach aches while reading (nervous)
2. Confused by letters, numbers, words, sequences, or verbal explanations
3. Repetition, additions, transpositions, omissions, substitutions, and reversals in letters, numbers
or words
4. Complains of feeling and seeing non-existent movement while reading, writing, copying
5. Seems to have difficulty with vision, yet eye exam doesn’t reveal problem
3 TYPES of dyslexia:
1. Dysphonesia: (poor in word attack skills)
a. Auditory linguistic dysfunction
b. Wernicke’s area of the left temporal and parietal lobes (for right handers)
c. Affected coding process: Phonetics (syllabic)
d. Influenced by environment
2. Dyseidesia: (relies on phonetic decoding) ‘
a. Visual-spatial processing deficiency
b. Angular gyrus of left parietal lobe (for right handers)
c. Affected coding process: eidetic (whole word)
d. Genetically inherited in autosomal dominant mode
of transmission
3. Dysnemkinesia:
a. Motor involvement
b. Motor cortex of frontal lobe
c. Affect coding process: motor memory or letter
formations
d. Most strongly influenced by environment
Factors to rule out i.c.o. learning and reading disability:
 Lack of education
 Sensory impairment
 Sociocultural deprivation
Visual correlates of dyslexia:
 Binocular instability
 Low amp of accom
 Reduced stereopsis (influenced by accom and conv, thus if normal conv and accom = think of
dyslexia)
 Meares-Irlen syndrome
 Asthenopia
 Perceptual distortions
 Visual symptoms and Ha are common complaints (not present in every case)
 Vision symptoms often mild, that they don’t require tx, but may contribute to reading problems
Tests to diagnose dyslexia:
1. Dyslexia determinations test (DDT)
2. Border test of reading-spelling patterns
3. The dyslexia screening test (TDS)
Dyslexia learners should be excused from:
1. Reading out loud in class
2. Writing from dictations and copying from board
3. Speed writing from dictation
4.
5.
6.
7.
Writing notes during lesson
Writing on board
Using dictionary
Mnemonic study of timetables
Accommodations for dyslexic learner:
1.
2.
3.
4.
5.
6.
7.
Additional time for tests/exams (15min p.hr.)
Reader
Scribe
Separate venue
Spelling accommodation
Handwriting accommodation
Use of technology: iPad, laptop, text-to-speech software, digital player, C-pen reader
Scotopic sensitivity/ Irlen syndrome (SSS)
 Def: perceptual dysfunction that can be linked to subjective problems with light sources,
lighting, intensity, wavelength and colour contrast.
 They use more energy when reading since they are ineffective readers that see the printed
page different from effective readers
 Problems experienced may lead to:
o Tiredness
o Discomfort
o Inability to pay attention for certain time periods
o Sensitivity to light
o Eyestrain
o Problems to focus
o Unstable print work
o Words that move across page,
o or appear missing
 symptoms similar to those w accom, ocular motility and BV disorders
 50% of reading disabled/dyslexic population have this syndrome
 90% of this group can be helped with Irlen filters that will eliminate discomfort associated with
reading and will improve reading performance
6 major categories of symptoms:
1.
2.
3.
4.
5.
6.
Photophobia
Background distortion
Visual resolution
Scope of focus (incl types of tunnel vision)
Sustained focus
Depth of perception/gross motor activities (difficulty walking up or down stairs)
Controversial: some studies show that there is no scientific base for claims that Irlen lenses improve reading
fluency
Royal Australian and New Zealand College of Ophthalmologists posted a statement saying the following:
1. The use of Irlen lenses in the treatment of reading difficulties is controversial
2. There is no scientific evidence that Irlen syndrome exists or that treatment of reading difficulties with Irlen
lenses work
3. Irlen syndrome is not recognized by the medical community or the World Health Organization (WHO)
4. There is no documented evidence that Irlen lenses are harmful, but may divert time and resources away
from proven strategies which help with reading e.g., explicit phonic instruction
5. RANZCO does not support the use of Irlen lenses.
Temporal processing in reading
Visual system process temporal and spatial information
Temporal nature = movement detection
Important in reading since eye position constantly updated
Temporal component inhibits visible persistence during act of reading
With each new saccade, text afterimage should persist and bleed into image produced by the
next fixation
Magnocellular = switch eyes off when doing
saccade (if not functioning correctly- doubling of
letters, ghosting)
Parvocellular = learn actual letter of word
Pc with poor eye movement control may
have temporal processing deficit
By only making the px track a visual
object will not identify a temporal
problem.
Following symptoms of temporal processing difficulty:
o
o
o
o
o
o
o
o
Movement of words in a printed page
Word or letters running together
Ghostlike doubling of letters and words
Nauseating feeling accompanied by word
Loss of place
Skipping lines
Ill sustained concentration
Unintentional reading of words
movement
ADHD
What is attention deficit hyperactivity disorder?
 One of most common neurodevelopmental disorders of childhood
 First diagnosed in childhood and often lasts into adulthood
 Developmental disorder of self-control
 Signs:
o Poor attention span and impulse control
o Make careless mistakes
o Take unnecessary risks
o Talk too much
o Squirm/fidget a lot
o Difficulty following rules and instructions
o Disorganized: lose things, poor time management
o Poor coordination: messy written work
Types of ADHD
1. Predominantly inattentive presentation: (20-30%)
a. More common in girls
b. Frequently missed
c. Hard to organize task, pay attention to details or follow instructions or conversations
d. Easily distracted and forgets details of daily routines
e. Comorbid w depression
f. Hight suicide rate
2. Predominantly hyperactive-impulsive presentation: (<15%)
a. Fidgets and talks a lot
b. Hard to sit still for long (e.g., to do homework)
c. Smaller children may jump, run or climb constantly
d. Individual feels restless and trouble w impulsivity
e. Which may interrupt others, grab things from ppl, speak at inappropriate times
f. Hard for them to wait their turn or listen to directions
g. May have more accidents and injuries than others
3. Combined presentation: (50-70%)
a. Symptoms of above 2 types are equally present in the person
Diagnosis of ADHD:
 No single test to diagnose
 Other conditions present similarly thus before ADHD dx child has had
o Vision exam
o Hearing test
o EEG to rule out petit mal seizures
 At least 6 signs present for at least 6 months
 Needs to come from more than 1 person
 In addition to following conditions must be met:
o Several inattentive or hyperactive-impulse symptoms present before age 12
o Several symptoms present in 2 or more settings
o Clear evidence that symptoms interfere with social, school or work functioning
o Symptoms are not better explained by another mental disorder (e.g., mood disorder,
anxiety disorder, dissociative disorder, personality disorder)
DSM-5 criteria for ADHD
Inattention (type 1):
 6 or more symptoms of inattention for children up to age 16 years,
 or 5 or more for adolescents aged 17 years and older and adults.
 symptoms of inattention have been present for at least 6 months,
 and they are inappropriate for developmental level:
1. Often fails to give close attention to details or makes careless mistakes in schoolwork,
at work, or with other activities.
2. Often has trouble holding attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or
duties in the workplace (e.g., loses focus, side-tracked).
5. Often has trouble organizing tasks and activities.
6. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long
period of time (such as schoolwork or homework).
7. Often loses things necessary for tasks and activities (e.g. school materials, pencils,
books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
8. Is often easily distracted
9. Is often forgetful in daily activities.
Hyperactivity and Impulsivity (type 2):
 6 or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or
 5 or more for adolescents age 17 years and older and adults;
 symptoms of hyperactivity-impulsivity have been present for at least 6 months to an
extent that is disruptive and inappropriate for the person’s developmental level:
1. Often fidgets with or taps hands or feet, or squirms in seat.
2. Often leaves seat in situations when remaining seated is expected.
3. Often runs about or climbs in situations where it is not appropriate (adolescents or
adults may be limited to feeling restless).
4. Often unable to play or take part in leisure activities quietly.
5. Is often “on the go” acting as if “driven by a motor”.
6. Often talks excessively.
7. Often blurts out an answer before a question has been completed.
8. Often has trouble waiting their turn.
9. Often interrupts or intrudes on others (e.g., butts into conversations or games)
Attention deficit:
➔ Attention is paramount for all reading and learning activities
➔ 3 interrelated behavioral manifestations of attention deficit:
◆ 1. Hyperactivity = excessive level of motor activity
● Prevent child from staying at one task or maintaining orientation to the task
long enough to complete it
◆ 2. Distractibility = responds to extraneous internal or external stimuli
● Failure to maintain and sustain on-task attention
◆ 3. Impulsivity =
● does not pause for appropriate analysis before responding
➔ signs of ADHD:
◆ impaired attention
● Unable to listen or follow instructions
● Unable to finish work
● Unable to sequence (auditory or visual stimuli)
● Does not attend to detail
● Distracted
● Daydreams
● Has poor organizational skills
● Perseverative on task
● Work alone
● Short attention span
◆ hyperactivity
● Squirm
● Can’t stay seated
● Runs/climbs too much
● Can’t play quietly
● Talks excessively
● On the go (engine!)
◆ impulsivity
● Reacts before understanding situation
● Makes careless mistakes
● Low frustration tolerance
● Antisocial behaviour
● Poor planning and judgment
● Failure to finish tasks
● Sloppy work
● Approximations in reading and writing
● Reckless behaviour
● Accident prone
● Impaired sphincter control
● Inability to delay gratification
● Difficulty waiting their turn
● Interrupts others/butts into conversations
● Blurts out answer before question has been completed
◆ seeking of immediate reinforcement
● Unusually sensitive to rewards
● Distressed by both loss of rewards and failure of
expected rewards to appear
◆ poor self-esteem
● Self-esteem negatively affected by their sense of guilt and inadequacy regarding
their substandard academic performance
● Try to conceal by bravado or clowning
● Bolster ego by using praise for effort even if mediocre
● Encourage participation in extra-mural activities
ADHD NOT a benign disorder! (Continues into adulthood = risk)
•
•
32-40% drop out of school
70-80% under achieve
•
•
•
•
•
40% teen pregnancy rate; risky sexual practices
20-30% depressed
More likely to abuse tobacco, alcohol, and drugs
Relationship and marital problems
Speed and have car accidents, endanger their lives
Trends in ADHD:







Common in males (4:1)
5-8% of children, 4% adults
40% outgrow ADHD by adulthood, 60% carry symptoms into adulthood
Not cultural
Prevalence goes up as demand increase
Average intelligence
Cannot manage money well (dt impulsiveness)
ADHD is a neurological disorder that can only really be helped by meds
Brain chemistry
 Decreased neuron to neuron communication
 Norepinephrine (NE) and dopamine (DA) critical to
functioning in post arousal, attention circuits and prefrontal cortex (impulse control)
 NE and DA interact to modulate attention and impulse
control
 NE dysfunction- functional impairment in:
o Learning
o Alertness
o Impulse control
o Memory
o Sustained attention
o Organization
 DA dysfunction- impairments such as:
o Muscle coordination
o Impaired body motion
 Normal re-uptake structures for NE and DA at neuro-synapse = 1million per cell
 in ADHD have 3 million per cell, re-uptake of these neurotransmitters happens too quickly
 another cause of ADHD, can be abnormal post synapse receptors (leads to severe ADHD)
 medications work by blocking e-uptake, thus normalizing NE and DA levels.
Brain structure
 underdeveloped orbital-frontal region:
o inhibits behavior
o sustained attention
o employs self-control and
o employs future planning
 smaller right frontal areas and
 smaller corpus callosum
Brain activity
 electrical activity similar to younger child
 lower brain activity  less blood to frontal brain
 lower overall activity, especially frontal area
Causes of abnormal brain development:
1. substances consumed during pregnancy causing abnormal development of frontal areas and
caudate nucleus:
a. alcohol
b. cocaine
c. nicotine
2. lead exposure
Other causes of ADHD:
1. hereditary:
a. 25% of first-degree relatives
b. 90% identical twins
c. 30% siblings
d. Research for single gene still underway, so far chromosome 9,11, 22 affected
2. Others:
a. Maternal anxiety/stress (cortisol)
b. Post-concussion/injury
c. Post encephalitis
d. Post asphyxiation
e. Prematurity (<30wks)
f. FFA deficiency
3. Myths (DO NOT CAUSE ADHD):
a. Foodstuff, such as sugar
b. Thyroid hormone imbalance
c. Lighting
d. Vestibular system problems
e. Yeast infections
f. Poor parenting
Medications:
 1937, Dr Charles Bradley
 Gave kids Benzedrine (racemic amphetamine – stimulant) for severe HA and noticed it helped
them behave instead and with school performance
 Stimulants:
o Methylphenidate (Ritalin), pemoline (Cylert) and dextro-amphetamine (Dexedrine)
work by increasing arousal in areas of brain which control behaviour.
o Effective in 80% of cases. Short-acting except for Concerta and Ritalin LA (new).
o Contraindicated in:
 Glaucoma (cause increase in IOP),
 cardiovascular disease,
 hyperthyroidism,
 hypertension,
 drug abuse,
 use of MAO inhibitors,
 psychotic disorder
 Side effects of ADHD meds:
1. Decreased appetite
2. Insomnia
3. Anxiousness, irritability
4. Increased heart rate and blood pressure
5. Nervous tics, dry mouth, dizziness,
6. Headaches, hallucinations, alopecia
7. Blurred vision, mydriasis, accommodative disturbances
Dosage and schedule
 Start 5mg Ritalin and change, if necessary, max 60mg
 Give on school days before breakfast and at lunch if schoolwork is main problem (don’t give on
weekends/holidays so child can catch up om eating)
 Give daily if also behaviour, socialization issues
 Children less likely to abuse substances and drop out of school if treated than if left alone
Other medications
1. Anti-depressants: seldom used alone, usually when children have reaction to stimulants.
Increase dopamine and nor-epinephrine secretion. Longer acting (do not stop suddenly).
2. Strattera (atomoxetine): non-stimulant. Increases amount of NE
3. Clonidine: HTN med, in conjunction with stimulant
4. Tegretol, Lithium, Mellant: not often used alone (more for bipolar disorders).
Alternative therapies:
1. Dietary control:
a. 7 studies showed that children had food/additive allergies and atopy
b. However, 2% of ADHD children have food/additive allergies
c. Enzyme-potentiated desensitization by injections help but is risky
2. Sugar eliminations:
a. Some studies show promise, but 3 placebo-controlled studies failed to support for sugar
on its own
3. Nutritional supplements:
a. Amino acids are precursors to serotonin, but supplementation can lead to eosinophilia
so best avoided.
b. Essential fatty acids help form neural membranes and can help if child is deficient
c. Vitamin mega dosing is not recommended dt hepatic toxicity
4. Mineral supplements:
a. Iron excess can cause toxicity
b. Zinc and magnesium can be beneficial
5. Homeopathic therapy:
a. Gingko biloba
b. Hypericum
c. Calmplex
d. Defendol
e. Have had no proper research done
6. Acupuncture, EEG, biofeedback, hypnosis, meditation, perceptual training, vestibular
stimulation:
a. No proper studies done
7. Antifungal tx:
a. Nystatin, no basis
8. Thyroid tx:
a. Only if have thyroid dysfunction
Behavioural Therapy:
 Positive reinforcement
• Works well in conjunction with meds but seldom
sufficient on its own
• Reward/token system
• Punish behavior constructively
• Time out rather than physical punishment
Common Co-morbidities in ADHD:






ODD: oppositional defiant disorder
CD: Conduct disorder
MDD: major depressive disorder
Anxiety disorders
BP: bipolar disorder
Might need more than one type of medication to try control
ADD and ADHD
For a child to be diagnosed with ADHD he must display:
1. a problem for at least 6 months
2. in at least 8 of the following characteristics starting
3. before 7 years of age:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Often fidgets with hands or feet or squirms in seat (in adolescents this may be limited to
subjective feelings of restlessness)
Has difficulty remaining seated when required to do so
Is easily distracted by extraneous stimuli
Has difficulty awaiting turn in games or group situations
Often blurts out answers to questions before they have been completed
Has difficulty following through on instructions from others, such as failing to finish
chores
Has difficulty sustaining attention in tasks
Often shifts from one uncompleted activity to another
Has difficulty playing quietly
Often talks excessively
Often interrupts or intrudes on others
Often does not seem to listen to what is being said
Often loses things necessary for tasks or activities (toys, pencils, books)
Often engages in physically dangerous activities, such as running into the street without
looking
Treatment of ADHD:
•
•
•
•
•
Multidisciplinar h y intervention
Optometric intervention
• Ocular motility therapy
• Visual perceptual therapy
Psychological intervention
• Counseling
• Modifying the behavior
Nutrition
Medical intervention (psycho stimulants)
• Ritalin
• Dexedrine
• Cylert
• Tofranil
• Strattera
 Positive effects of psycho stimulants
 Child is sociable
 Child can learn
 Child can complete tasks
 Negative effects of psycho stimulants
 Temporary appetite reduction
 Nail biting
 Sleep disturbances
 Tension behaviors