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Message from the National Institute of Mental Health
Research conducted and supported by the National Institute of MentalHealth brings hope to millions of people who suffer from mental illnessand to their families and friends. In many years of work with animals aswell as human subjects, researchers have advanced our understanding of thebrain and vastly expanded the capability of mental health professionalsto diagnose, treat, and prevent mental and brain disorders.
Now, in the 1990s, which the President and Congress have declared the"Decade of the Brain," we stand at the threshold of a new erain brain and behavioral sciences. Through research, we will learn even moreabout mental and brain disorders such as depression, bipolar disorder, schizophrenia,panic disorder, obsessive-compulsive disorder, and learning disabilities.And we will be able to use this knowledge to develop new therapies thatcan help more people overcome mental illness.
The National Institute of Mental Health is part of the National Institutesof Health (NIH), the Federal Government's primary agency for biomedicaland behavioral research. NIH is a component of the U.S. Department of Healthand Human Services.
Imagine having important needs and ideas to communicate, but being unableto express them. Perhaps feeling bombarded by sights and sounds, unableto focus your attention. Or trying to read or add but not being able tomake sense of the letters or numbers.
You may not need to imagine. You may be the parent or teacher of a childexperiencing academic problems, or have someone in your family diagnosedas learning disabled. Or possibly as a child you were told you had a readingproblem called dyslexia or some other learning handicap.
Although different from person to person, these difficulties make upthe common daily experiences of many learning disabled children, adolescents,and adults. A person with a learning disability may experience a cycle ofacademic failure and lowered serf-esteem. Having these handicaps--or livingwith someone who has them--can bring overwhelming frustration.
But the prospects are hopeful. It is important to remember that a personwith a learning disability can learn. The disability usually only affectscertain limited areas of a child's development. In fact, rarely are learningdisabilities severe enough to impair a person's potential to live a happy,normal life.
This booklet is provided by the National Institute of Mental Health (NIMH),the Federal agency that supports research nationwide on the brain, mentalillnesses, and mental health. Scientists supported by NIMH are dedicatedto understanding the workings and interrelationships of the various regionsof the brain, and to finding preventions and treatments to overcome braindysfunctions that handicap people in school, work, and play.
The booklet provides up-to-date information on learning disabilitiesand the role of NIMH-sponsored research in discovering underlying causesand effective treatments. It describes treatment options, strategies forcoping, and sources of information and support. Among these sources aredoctors, special education teachers, and mental health professionals whocan help identify learning disabilities and recommend the right combinationof medical, psychosocial, and educational treatment.
In this booklet, you'll also read the stories of Susan, Wallace, andDennis, three people who have learning disabilities. Although each had arough start, with help they learned to cope with their handicaps. You'llsee their early frustrations, their steps toward getting help, and theirhopes for the future.
The stories of Susan, Wallace, and Dennis are representative of peoplewith learning disabilities, but the characters are not real. Of course,people with learning disabilities are not all alike, so these stories maynot fit any particular individual.
At age 14, Susan still tends to be quiet. Ever since she was a child,she was so withdrawn that people sometimes forgot she was there. She seemedto drift into a world of her own. When she did talk, she often called objectsby the wrong names. She had few friends and mostly played with dolls orher little sister. In school, Susan hated reading and math because noneof the letters, numbers or "+" and "-" signs made anysense. She felt awful about herself. She'd been told--and was convinced--thatshe was retarded.
Wallace has lived 46 years, and still has trouble understanding whatpeople say. Even as a boy, many words sounded alike. His father patientlysaid things over and over. But whenever his mother was drunk, she flew intoa rage and spanked him for not listening. Wallace's speech also came outfunny. He had such problems saying words that in school his teacher sometimescouldn't understand him. When classmates called him a "dummy,"his fists just seemed to take over.
Dennis is 23 years old and still seems to have too much energy. But hehad always been an overactive boy, sometimes jumping on the sofa for hoursuntil he collapsed with exhaustion. In grade school, he never sat still.He interrupted lessons. But he was a friendly, well-meaning kid, so adultsdidn't get too angry. His academic problems became evident in third grade,when his teacher realized that Dennis could only recognize a few words andwrote like a first grader. She recommended that Dennis repeat third grade,to give him time to "catch up." After another full year, his behaviorwas still out of control, and his reading and writing had not improved.What is a learning disability?
Unlike other disabilities, such as paralysis or blindness, a learningdisability (LD) is a hidden handicap. A learning disability doesn't disfigureor leave visible signs that would invite others to be understanding or offersupport. A woman once blurted to Wallace, "You seem so intelligent--youdon't look handicapped!"
LD is a disorder that affects people's ability to either interpret whatthey see and hear or to link information from different parts of the brain.These limitations can show up in many ways--as specific difficulties withspoken and written language, coordination, self-control, or attention. Suchdifficulties extend to schoolwork and can impede learning to read or write,or to do math.
Learning disabilities can be lifelong conditions that, in some cases,affect many parts of a person's life: school or work, daily routines, familylife, and sometimes even friendships and play. In some people, many overlappinglearning disabilities may be apparent. Other people may have a single, isolatedlearning problem that has little impact on other areas of their lives.What are the types of learning disabilities?
"Learning disability" is not a diagnosis in the same senseas "chickenpox" or "mumps." Chickenpox and mumps implya single, known cause with a predictable set of symptoms. Rather, LD isa broad term that covers a pool of possible causes, symptoms, treatments,and outcomes. Partly because learning disabilities can show up in so manyforms, it is difficult to diagnose or to pinpoint the causes. And no oneknows of a pill or remedy that will cure them.
Not all learning problems are necessarily learning disabilities. Manychildren are simply slower in developing certain skills. Because childrenshow natural differences in their rate of development, sometimes what seemsto be a learning disability may simply be a delay in maturation. To be diagnosedas a learning disability, specific criteria must be met.
The criteria and characteristics for diagnosing learning disabilitiesappear in a reference book called the DSM (short for the Diagnostic andStatistical Manual of Mental Disorders). The DSM diagnosis is commonly usedwhen applying for health insurance coverage of diagnostic and treatmentservices.
Learning disabilities can be divided into three broad categories:
Each of these categories includes a number of more specific disorders.
Because children do show natural differences in their rate of development,not all learning problems are learning disabilities.DevelopmentalSpeech and Language Disorders
Speech and language problems are often the earliest indicators of a learningdisability. People with developmental speech and language disorders havedifficulty producing speech sounds, using spoken language to communicate,or understanding what other people say. Depending on the problem, the specificdiagnosis may be:
Developmental articulation disorder. Children with this disorder mayhave trouble controlling their rate of speech. Or they may lag behind playmatesin learning to make speech sounds. For example, Wallace at age 6 still said"wabbit" instead of "rabbit" and "thwim" for"swim." Developmental articulation disorders are common. Theyappear in at least 10 percent of children younger than age 8. Fortunately,articulation disorders can often be outgrown or successfully treated withspeech therapy.
Some people have trouble understanding certain aspects of speech.
Developmental expressive language disorder. Some children with languageimpairments have problems expressing themselves in speech. Their disorderis called, therefore, a developmental expressive language disorder. Susan,who often calls objects by the wrong names, has an expressive language disorder.Of course, an expressive language disorder can take other forms. A 4-year-oldwho speaks only in two-word phrases and a 6-year-old who can't answer simplequestions also have an expressive language disability.
Developmental receptive language disorder. Some people have trouble understandingcertain aspects of speech. It's as if their brains are set to a differentfrequency and the reception is poor. There's the toddler who doesn't respondto his name, a preschooler who hands you a bell when you asked for a ball,or the worker who consistently can't follow simple directions. Their hearingis fine, but they can't make sense of certain sounds, words, or sentencesthey hear. They may even seem inattentive. These people have a receptivelanguage disorder. Because using and understanding speech are strongly related,many people with receptive language disorders also have an expressive languagedisability.
Of course, in preschoolers, some misuse of sounds, words, or grammaris a normal part of learning to speak. It's only when these problems persistthat there is any cause for concern.
Academic Skills Disorders:
Students with academic skills disorders are often years behind theirclassmates in developing reading, writing, or arithmetic skills. The diagnosesin this category include:
Developmental reading disorder. This type of disorder,also known as dyslexia, is quite widespread. In fact, reading disabilitiesaffect 2 to 8 percent of elementary school children.
When you think of what is involved in the "three R's"--reading,'riting, and 'rithmetic--it's astounding that most of us do learn them.Consider that to read, you must simultaneously:
Such mental juggling requires a rich, intact network of nerve cells thatconnect the brain's centers of vision, language, and memory.
A person can have problems in any of the tasks involved in reading. However,scientists found that a significant number of people with dyslexia sharean inability to distinguish or separate the sounds in spoken words. Dennis,for example, can't identify the word "bat" by sounding out theindividual letters, b-a-t. Other children with dyslexia may have troublewith rhyming games, such as rhyming "cat" with "bat."Yet scientists have found these skills fundamental to learning to read.Fortunately, remedial reading specialists have developed techniques thatcan help many children with dyslexia acquire these skills.
However, there is more to reading than recognizing. words. If the brainis unable to form images or relate new ideas to those stored in memory,the reader can't understand or remember the new concepts. So other typesof reading disabilities can appear in the upper grades when the focus ofreading shifts from word identification to comprehension.
Children with dyslexia may have trouble with rhyming games, such as rhyming"cat" with "bat."
Developmental writing disorder. Writing, too, involvesseveral brain areas and functions. The brain networks for vocabulary, grammar,hand movement, and memory must all be in good working order. So a developmentalwriting disorder may result from problems in any of these areas. For example,Dennis, who was unable to distinguish the sequence of sounds in a word,had problems with spelling. A child with a writing disability, particularlyan expressive language disorder, might be unable to compose complete, grammaticalsentences.
Because developmental skills build on each other, a person may have morethan one learning disability.
Developmental arithmetic disorder. If you doubt thatarithmetic is a complex process, think of the steps you take to solve thissimple problem:
Arithmetic involves recognizing numbers and symbols, memorizing factssuch as the multiplication table, aligning numbers, and understanding abstractconcepts like place value and fractions. Any of these may be difficult forchildren with developmental arithmetic disorders. Problems with numbersor basic concepts are likely to show up early. Disabilities that appearin the later grades are more often tied to problems in reasoning.
Many aspects of speaking, listening, reading, writing, and arithmeticoverlap and build on the same brain capabilities. So it's not surprisingthat people can be diagnosed as having more than one area of learning disability.For example, the ability to understand language underlies learning speak.Therefore, any disorder that hinders the ability to understand languagewill also interfere with the development of speech, which in turn hinderslearning to read and write. A single gap in the brain's operation can disruptmany types of activity.
"Other" learning disabilities
The DSM also lists additional categories, such as "motor skillsdisorders" and "specific developmental disorders not otherwisespecified." These diagnoses include delays in acquiring language, academic,and motor skills that can affect the ability to learn, but do not meet thecriteria for a specific learning disability. Also included are coordinationdisorders that can lead to poor penmanship, as well as certain spellingand memory disorders.
Nearly 4 million school-age children have learning disabilities. Of these,at least 20 percent have a type of disorder that leaves them unable to focustheir attention.
Some children and adults who have attention disorders appear to daydreamexcessively. And once you get their attention, they're often easily distracted.Susan, for example, tends to mentally drift off into a world of her own.Children like Susan may have a number of learning difficulties. If, likeSusan, they are quiet and don't cause problems, their problems may go unnoticed.They may be passed along from grade to grade, without getting the specialassistance they need.
In a large proportion of affected children--mostly boys--the attentiondeficit is accompanied by hyperactivity. Dennis is an example of a personwith attention deficit hyperactivity disorder-ADHD. Like young Dennis, whojumped on the sofa to exhaustion, hyperactive children can't sit still.They act impulsively, running into traffic or toppling desks. They blurtout answers and interrupt. In games, they can't wait their turn. These children'sproblems are usually hard to miss. Because of their constant motion andexplosive energy, hyperactive children often get into trouble with parents,teachers, and peers.
By adolescence, physical hyperactivity usually subsides into fidgetingand restlessness. But the problems with attention and concentration oftencontinue into adulthood. At work, adults with ADHD often have trouble organizingtasks or completing their work. They don't seem to listen to or follow directions.Their work may be messy and appear careless.
Like young Dennis, who jumped on the sofa to exhaustion, hyperactivechildren can't sit still.
Attention disorders, with or without hyperactivity, arenot considered learning disabilities in themselves. However, becauseattention problems can seriously interfere with school performance, theyoften accompany academic skills disorders.
What causes learning disabilities?
Understandably, one of the first questions parents ask when they learntheir child has a learning disorder is "Why? What went wrong?"
Mental health professionals stress that since no one knows what causeslearning disabilities, it doesn't help parents to look backward to searchfor possible reasons. There are too many possibilities to pin down the causeof the disability with certainty. It is far more important for the familyto move forward in finding ways to get the fight help.
Scientists, however, do need to study causes in an effort to identifyways to prevent learning disabilities.
Once, scientists thought that all learning disabilities were caused bya single neurological problem. But research supported by NIMH has helpedus see that the causes are more diverse and complex. New evidence seemsto show that most learning disabilities do not stem from a single, specificarea of the brain, but from difficulties in bringing together informationfrom various brain regions.
Today, a leading theory is that learning disabilities stem from subtledisturbances in brain structures and functions. Some scientists believethat, in many cases, the disturbance begins before birth.
Errors in fetal brain development
Throughout pregnancy, the fetal brain develops from a few all-purposecells into a complex organ made of billions of specialized, interconnectednerve cells called neurons. During this amazing evolution, things can gowrong that may alter how the neurons form or interconnect.
In the early stages of pregnancy, the brain stem forms. It controls basiclife functions such as breathing and digestion. Later, a deep ridge dividesthe cerebrum--the thinking part of the brain-into two halves, a right andleft hemisphere. Finally, the areas involved with processing sight, sound,and other senses develop, as well as the areas associated with attention,thinking, and emotion.
As new cells form, they move into place to create various brain structures.Nerve cells rapidly grow to form networks with other parts of the brain.These networks are what allow information to be shared among various regionsof the brain.
Throughout pregnancy, this brain development is vulnerable to disruptions.If the disruption occurs early, the fetus may die, or the infant may beborn with widespread disabilities and possibly mental retardation. If thedisruption occurs later, when the cells are becoming specialized and movinginto place, it may leave errors in the cell makeup, location, or connections.Some scientists believe that these errors may later show up as learningdisorders.
By birth, all the basic structures of the brain are present.
Other factors that affect brain development
Through experiments with animals, scientists at NIMH and other researchfacilities are tracking clues to determine what disrupts brain development.By studying the normal processes of brain development, scientists can betterunderstand what can go wrong. Some of these studies are examining how genes,substance abuse, pregnancy problems, and toxins may affect the developingbrain.Genetic factors.
The fact that learning disabilities tend to run in families indicatesthat there may be a genetic link. For example, children who lack some ofthe skills needed for reading, such as hearing the separate sounds of words,are likely to have a parent with a related problem. However, a parent'slearning disability may take a slightly different form in the child. A parentwho has a writing disorder may have a child with an expressive languagedisorder. For this reason, it seems unlikely that specific learning disordersare inherited directly. Possibly, what is inherited is a subtle brain dysfunctionthat can in turn lead to a learning disability.
There may be an alternative explanation for why LD might seem to runin families. Some learning difficulties may actually stem from the familyenvironment. For example, parents who have expressive language disordersmight talk less to their children, or the language they use may be distorted.In such cases, the child lacks a good model for acquiring language and therefore,may seem to be learning disabled.
It seems unlikely that specific learning disorders are inherited directly.
Tobacco, alcohol, and other drug use.
Many drugs taken by the mother pass directly to the fetus. Research showsthat a mother's use of cigarettes, alcohol, or other drugs during pregnancymay have damaging effects on the unborn child. Therefore, to prevent potentialharm to developing babies, the U.S. Public Health Service supports effortsto make people aware of the possible dangers of smoking, drinking, and usingdrugs.
Scientists have found that mothers who smoke during pregnancy may bemore likely to bear smaller babies. This is a concern because small newborns,usually those weighing less than 5 pounds, tend to be at risk for a varietyof problems, including learning disorders.
Alcohol also may be dangerous to the fetus' developing brain. It appearsthat alcohol may distort the developing neurons. Heavy alcohol use duringpregnancy has been linked to fetal alcohol syndrome, a condition that canlead to low birth weight, intellectual impairment, hyperactivity, and certainphysical defects. Any alcohol use during pregnancy, however, may influencethe child's development and lead to problems with learning, attention, memory,or problem solving. Because scientists have not yet identified "safe"levels, alcohol should be used cautiously by women who are pregnant or whomay soon become pregnant.
Drugs such as cocaine--especially in its smokable form known as crack--seemto affect the normal development of brain receptors. These brain cell partshelp to transmit incoming signals from our skin, eyes, and ears, and helpregulate our physical response to the environment. Because children withcertain learning disabilities have difficulty understanding speech soundsor letters, some researchers believe that learning disabilities, as wellas ADHD, may be related to faulty receptors. Current research points todrug abuse as a possible cause of receptor damage.
Problems during pregnancy or delivery.
Other possible causes of learning disabilities involve complicationsduring pregnancy. In some cases, the mother's immune system reacts to thefertus and attacks it as if it were an infection. This type of disruptionseems to cause newly formed brain cells to settle in the wrong part of thebrain. Or during delivery, the umbilical cord may become twisted and temporarilycut off oxygen to the fetus. This, too, can impair brain functions and leadto LD.
By studying the normal processes of brain development, scientists canbetter understand what can go wrong.
Toxins in the child's environment.
New brain cells and neural networks continue to be produced for a yearor so after the child is born. These cells are vulnerable to certain disruptions,also.
Researchers are looking into environmental toxins that may lead to learningdisabilities, possibly by disrupting childhood brain development or brainprocesses. Cadmium and lead, both prevalent in the environment, are becominga leading focus of neurological research. Cadmium, used in making some steelproducts, can get into the soil, then into the foods we eat. Lead was oncecommon in paint and gasoline, and is still present in some water pipes.A study of animals sponsored by the National Institutes of Health showeda connection between exposure to lead and learning difficulties. In thestudy, rats exposed to lead experienced changes in their brainwaves, slowingtheir ability to learn. The learning problems lasted for weeks, long afterthe rats were no longer exposed to lead.
In addition, there is growing evidence that learning problems may developin children with cancer who had been treated with chemotherapy or radiationat an early age. This seems particularly true of children with brain tumorswho received radiation to the skull.
Are learning disabilities related to differencesin the brain?
In comparing people with and without learning disabilities, scientistshave observed certain differences in the structure and functioning of thebrain. For example, new research indicates that there may be variationsin the brain structure called the planum temporale, a language-related areafound in both sides of the brain. In people with dyslexia, the two structureswere found to be equal in size. In people who are not dyslexic, however,the left planum temporale was noticeably larger. Some scientists believereading problems may be related to such differences.
With more research, scientists hope to learn precisely how differencesin the structures and processes of the brain contribute to learning disabilities,and how these differences might be treated or prevented.
New research indicates that there may be variations in the brain structurecalled the planum temporale.
Susan was promoted to the sixth grade but still couldn't do basic math.So, her mother brought her to a private clinic for testing. The clinicianobserved that Susan had trouble associating symbols with their meaning,and this was holding back her language, reading, and math development. Susancalled objects by the wrong words and she could not associate sounds withletters or recognize math symbols. However, an IQ of 128 meant that Susanwas quite bright. In addition to developing an Individualized EducationPlan, the clinician recommended that Susan receive counseling for her lowself-esteem and depression.
In the early 1960s, at the request of his ninth grade teacher, Wallacewas examined by a doctor to see why he didn't speak or listen well. Thedoctor tested his vocal cords, vision, and hearing. They were all fine.The teacher concluded that Wallace must have "brain damage," sonot much could be done. Wallace kept failing in school and was suspendedseveral times for fighting. He finally dropped out after tenth grade. Hespent the next 25 years working as a janitor. Because LD frequently wentundiagnosed at the time when Wallace was young, the needed help was notavailable to him.
In fifth grade, Dennis' teacher sent him to the school psychologist fortesting. Dennis was diagnosed as having developmental reading and developmentalwriting disorders. He was also identified as having an attention disorderwith hyperactivity. He was placed in an all-day special education program,where he could work on his particular deficits and get individual attention.His family doctor prescribed the medication Ritalin to reduce his hyperactivityand distractibility. Along with working to improve his reading, the specialeducation teacher helped him improve his listening skills. Since his handwritingwas still poor, he learned to type homework and reports on a computer. Atage 19, Dennis graduated from high school and was accepted by a collegethat gives special assistance to students with learning disabilities.
How are learning disabilitiesfirst identified?
The first step in solving any problem is realizing there is one. Wallace,sadly, was a product of his time, when learning disabilities were more ofa mystery and often went unrecognized. Today, professionals would know howto help Wallace. Dennis and Susan were able to get help because someonesaw the problem and referred them for help.
When a baby is born, the parents eagerly wait for the baby's first step,first word, a myriad of other "firsts." During routine checkups,the pediatrician, too, watches for more subtle signs of development. Theparents and doctor are watching for the child to achieve developmental milestones.The developmental milestones chart lists a few of these markers and theages and grades that they typically appear.
The classroom teacher may be the first to notice a child's persistentdifficulties in reading, writing, or arithmetic.
Parents are usually the first to notice obvious delays in their childreaching early milestones. The pediatrician may observe more subtle signsof minor neurological damage, such as a lack of coordination. But the classroomteacher, in fact, may be the first to notice the child's persistent difficultiesin reading, writing, or arithmetic. As school tasks become more complex,a child with a learning disability may have problems mentally juggling moreinformation.
The learning problems of children who are quiet and polite in schoolmay go unnoticed. Children with above average intelligence, who manage tomaintain passing grades despite their disability, are even less likely tobe identified. Children with hyperactivity, on the other hand, will be identifiedquickly by their impulsive behavior and excessive movement. Hyperactivityusually begins before age 4 but may not be recognized until the child entersschool.
What should parents, doctors, and teachers do if critical developmentalmilestones haven't appeared by the usual age? Sometimes it's best to allowa little more time, simply for the brain to mature a bit. But if a milestoneis already long delayed, if there's a history of learning disabilities inthe family, or if there are several delayed skills, the child should beprofessionally evaluated as soon as possible. An educator or a doctor whotreats children can suggest where to go for help.
How are learningdisabilities formally diagnosed?
By law, learning disability is defined as a significant gap between aperson's intelligence and the skills the person has achieved at each age.This means that a severely retarded 10-year-old who speaks like a 6-year-oldprobably doesn't have a language or speech disability. He has mastered languageup to the limits of his intelligence. On the other hand, a fifth graderwith an IQ of 100 who can't write a simple sentence probably does have LD.
Learning disorders may be informally flagged by observing significantdelays in the child's skill development. A 2-year delay in the primary gradesis usually considered significant. For older students, such a delay is notas debilitating, so learning disabilities aren't usually suspected unlessthere is more than a 2-year delay. Actual diagnosis of learning disabilities,however, is made using standardized tests that compare the child's levelof ability to what is considered normal development for a person of thatage and intelligence.
Standardized tests compare the child's level of ability to what is considerednormal development for a person of that age and intelligence.
For example, as late as fifth grade, Susan couldn't add two numbers,even though she rarely missed school and was good in other subjects. Hermother took her to a clinician, who observed Susan's behavior and administeredstandardized math and intelligence tests. The test results showed that Susan'smath skills were several years behind, given her mental capacity for learning.Once other possible causes like lack of motivation and vision problems wereruled out, Susan's math problem was formally diagnosed as a specific learningdisability.
Test outcomes depend not only on the child's actual abilities, but onthe reliability of the test and the child's ability to pay attention andunderstand the questions. Children like Dennis, with poor attention or hyperactivity,may score several points below their true level of ability. Testing a childin an isolated room can sometimes help the child concentrate and score higher.
Each type of LD is diagnosed in slightly different ways. To diagnosespeech and language disorders, a speech therapist tests the child's pronunciation,vocabulary, and grammar and compares them to the developmental abilitiesseen in most children that age. A psychologist tests the child's intelligence.A physician checks for any ear infections, and an audiologist may be consultedto rule out auditory problems. If the problem involves articulation, a doctorexamines the child's vocal cords and throat.
In the case of academic skills disorders, academic development in reading,writing, and math is evaluated using standardized tests. In addition, visionand hearing are tested to be sure the student can see words clearly andcan hear adequately. The specialist also checks if the child has missedmuch school. It's important to rule out these other possible factors. Afterall, treatment for a learning disability is very different from the remedyfor poor vision or missing school.
ADHD is diagnosed by checking for the long-term presence of specificbehaviors, such as considerable fidgeting, losing things, interrupting,and talking excessively. Other signs include an inability to remain seated,stay on task, or take turns. A diagnosis of ADHD is made only if the childshows such behaviors substantially more than other children of the sameage.
If the school fails to notice a learning delay, parents can request anoutside evaluation. In Susan's case, her mother chose to bring Susan toa clinic for testing. She then brought documentation of the disability backto the school. After confirming the diagnosis, the public school was obligatedto provide the kind of instructional program that Susan needed.
Some parents may find it helpful to ask someone they like and trust togo with them to school meetings
Parents should stay abreast of each step of the school's evaluation.Parents also need to know that they may appeal the school's decision ifthey disagree with the findings of the diagnostic team. And like Susan'smother, who brought Susan to a clinic, parents always have the option ofgetting a second opinion.
Some parents feel alone and confused when talking to learning specialists.Such parents may find it helpful to ask someone they like and trust to gowith them to school meetings. The person may be the child's clinician orcaseworker, or even a neighbor. It can help to have someone along who knowsthe child and can help understand the child's test scores or learning problems.
What are the education options?
Although obtaining a diagnosis is important, even more important is creatinga plan for getting the right help. Because LD can affect the child and familyin so many ways, help may be needed on a variety of fronts: educational,medical, emotional, and practical.
In most ways, children with learning disabilities are no different fromchildren without these disabilities. At school, they eat together and sharesports, games, and after-school activities. But since children with learningdisabilities do have specific learning needs, most public schools providespecial programs.
Schools typically provide special education programs either in a separateall-day classroom or as a special education class that the student attendsfor several hours each week. Some parents hire trained tutors to work withtheir child after school. If the problems are severe, some parents chooseto place their child in a special school for the learning disabled.
Sometimes parents hire trained tutors to work with their child afterschool.
If parents choose to get help outside the public schools, they shouldselect a learning specialist carefully. The specialist should be able toexplain things in terms that the parents can understand. Whenever possible,the specialist should have professional certification and experience withthe learner's specific age group and type of disability. Some of the supportgroups listed at the end of this booklet can provide references to qualifiedspecial education programs.
Planning a special education program begins with systematically identifyingwhat the student can and cannot do. The specialist looks for patterns inthe child's gaps. For example, if the child fails to hear the separate soundsin words, are there other sound discrimination problems? If there's a problemwith handwriting, are there other motor delays? Are there any consistentproblems with memory?
Special education teachers also identify the types of tasks the childcan do and the senses that function well. By using the senses that are intactand bypassing the disabilities, many children can develop needed skills.These strengths offer alternative ways the child can learn.
After assessing the child's strengths and weaknesses, the special educationteacher designs an Individualized Educational Program (IEP). The IEP outlinesthe specific skills the child needs to develop as well as appropriate learningactivities that build on the child's strengths. Many effective learningactivities engage several skills and senses. For example, in learning tospell and recognize words, a student may be asked to see, say, write, andspell each new word. The student may also write the words in sand, whichengages the sense of touch. Many experts believe that the more senses childrenuse in learning a skill, the more likely they are to retain it.
The student may also write the words in sand, which engages the senseof touch.
An individualized, skill-based approach--like the approach used by speechand language therapists--often succeeds in helping where regular classroominstruction fails. Therapy for speech and language disorders focuses onproviding a stimulating but structured environment for heating and practicinglanguage patterns. For example, the therapist may help a child who has anarticulation disorder to produce specific speech sounds. During an engagingactivity, the therapist may talk about the toys, then encourage the childto use the same sounds or words. In addition, the child may watch the therapistmake the sound, feel the vibration in the therapist's throat, then practicemaking the sounds before a mirror.
Researchers are also investigating nonstandard teaching methods. Somecreate artificial learning conditions that may help the brain receive informationin nonstandard ways. For example, in some language disorders, the brainseems abnormally slow to process verbal information. Scientists are testingwhether computers that talk can help teach children to process spoken soundsmore quickly. The computer starts slowly, pronouncing one sound at a time.As the child gets better at recognizing the sounds and heating them as words,the sounds are gradually speeded up to a normal rate of speech.
Is medication available?
For nearly six decades, many children with attention disorders have benefitedfrom being treated with medication. Three drugs, Ritalin (methylphenidate),Dexedrine (dextroamphetamine), and Cylert (pemoline), have been used successfully.Although these drugs are stimulants in the same category as "speed"and "diet pills," they seldom make children "high" ormore jittery. Rather, they temporarily improve children's attention andability to focus. They also help children control their impulsiveness andother hyperactive behaviors.
The effects of medication are most dramatic in children with ADHD. Shortlyafter taking the medication, they become more able to focus their attention.They become more ready to learn. Studies by NIMH scientists and other researchershave shown that at least 90 percent of hyperactive children can be helpedby either Ritalin or Dexedrine. If one medication does not help a hyperactivechild to calm down and pay attention in school, the other medication might.
The drugs are effective for 3 to 4 hours and move out of the body within12 hours. The child's doctor or a psychiatrist works closely with the familyand child to carefully adjust the dosage and medication schedule for thebest effect. Typically, the child takes the medication so that the drugis active during peak school hours, such as when reading and math are taught.
In the past few years, researchers have tested these drugs on adultswho have attention disorders. Just as in children, the results show thatlow doses of these medications can help reduce distractibility and impulsivityin adults. Use of these medications has made it possible for many severelydisordered adults to organize their lives, hold jobs, and care for themselves.
In trying to do everything possible to help their children, many parentshave been quick to try new treatments. Most of these treatments sound scientificand reasonable, but a few are pure quackery. Many are developed by reputabledoctors or specialists--but when tested scientifically, cannot be provento help. Following are types of therapy that have not proven effective intreating the majority of children with learning disabilities or attentiondisorders:
Although scientists hope that brain research will lead to new medicalinterventions and drugs, at present there are no medicines for speech, language,or academic disabilities.
How do families learn to cope?
The effects of learning disabilities can ripple outward from the disabledchild or adult to family, friends, and peers at school or work.
Children with LD often absorb what others thoughtlessly say about them.They may define themselves in light of their disabilities, as "behind,""slow," or "different."
Sometimes they don't know how they're different, but they know how awfulthey feel. Their tension or shame can lead them to act out in various ways--fromwithdrawal to belligerence. Like Wallace, they may get into fights. Theymay stop trying to learn and achieve and eventually drop out of school.Or, like Susan, they may become isolated and depressed.
Children with learning disabilities and attention disorders may havetrouble making friends with peers. For children with ADHD, this may be dueto their impulsive, hostile, or withdrawn behavior. Some children with delaysmay be more comfortable with younger children who play at their level. Socialproblems may also be a product of their disability. Some people with LDseem unable to interpret tone of voice or facial expressions. Misunderstandingthe situation, they act inappropriately, turning people away.
Without professional help, the situation can spiral out of control. Themore that children or teenagers fail, the more they may act out their frustrationand damage their self-esteem. The more they act out, the more trouble andpunishment it brings, further lowering their self-esteem. Wallace, who lashedout when teased about his poor pronunciation and was repeatedly suspendedfrom school, shows how harmful this cycle can be.
Having a child with a learning disability may also be an emotional burdenfor the family. Parents often sweep through a range of emotions: denial,guilt, blame, frustration, anger, and despair. Brothers and sisters maybe annoyed or embarrassed by their sibling, or jealous of all the attentionthe child with LD gets.
Support groups can be a source of information, practical suggestions,and mutual understanding.
Counseling can be very helpful to people with LD and their families.Counseling can help affected children, teenagers, and adults develop greaterself-control and a more positive attitude toward their own abilities. Talkingwith a counselor or psychologist also allows family members to air theirfeelings as well as get support and reassurance.
Many parents find that joining a support group also makes a difference.Support groups can be a source of information, practical suggestions, andmutual understanding. Self-help books written by educators and mental healthprofessionals can also be helpful. A number of references and support groupsare listed at the end of this booklet.
Behavior modification also seems to help many children with hyperactivityand LD. In behavior modification, children receive immediate, tangible rewardswhen they act appropriately. Receiving an immediate reward can help childrenlearn to control their own actions, both at home and in class. A schoolor private counselor can explain behavior modification and help parentsand teachers set up appropriate rewards for the child.
Parents and teachers can help by structuring tasks and environments forthe child in ways that allow the child to succeed. They can find ways tohelp children build on their strengths and work around their disabilities.This may mean deliberately making eye contact before speaking to a childwith an attention disorder. For a teenager with a language problem, it maymean providing pictures and diagrams for performing a task. For studentslike Dennis with handwriting or spelling problems, a solution may be toprovide a word processor and software that checks spelling. A counseloror school psychologist can help identify practical solutions that make iteasier for the child and family to cope day by day.
Every child needs to grow up feeling competent and loved. When childrenhave learning disabilities, parents may need to work harder at developingtheir children's self-esteem and relationship-building skills. But self-esteemand good relationships are as worth developing as any skill.
Susan is now in ninth grade and enjoys learning. She no longer believesshe's retarded, and her use of words has improved. Susan has become a talentedcraftsperson and loves making clothes and furniture for her sister's dolls.Although she's still in a special education program, she is making slowbut steady progress in reading and math.
Over the years, Wallace found he liked tinkering with cars and singingin the church choir. At church, he met a woman who knew about learning disabilities.She told him he could get help through his county social services office.Since then, Wallace has been working with a speech therapist, learning toarticulate and notice differences in speech sounds. When he complains thathe's too old to learn, his therapist reminds him, "It's never too lateto work your good brain!" His state vocational rehabilitation officerecently referred him to a job-training program. Today, at age 46, Wallaceis starting night school to become an auto mechanic. He likes it becauseit's a hands-on program where he can learn by doing.
Dennis is now age 23. As he walks into the college job placement office,he smiles and shakes hands confidently. After shuffling through a messystack of papers, he finally hands his counselor a neatly typed resume. AlthoughDennis jiggles his foot and interrupts occasionally, he's clearly enthusiastic.He explains that because tape-recorded books and lectures got him throughcollege, he'd like to sell electronics. Dennis says he'll also be gettingmarried next year. He and his fiancee are concerned that their childrenalso will have LD. "But we'll just have to watch and get help early-alot earlier than I did!"
Can learning disabilitiesbe outgrown or cured?
Even though most people don't outgrow their brain dysfunction, peopledo learn to adapt and live fulfilling lives. Dennis, Susan, and Wallacemade a life for themselves--not by being cured, but by developing theirpersonal strengths. Like Dennis' tape-recorded books and lectures, or Wallace'shands-on auto mechanics class, they found alternative ways to learn. Andlike Susan's crafts or Wallace's singing, they found ways to enjoy theirother talents.
Even though a learning disability doesn't disappear, given the righttypes of educational experiences, people have a remarkable ability to learn.The brain's flexibility to learn new skills is probably greatest in youngchildren and may diminish somewhat after puberty. This is why early interventionis so important. Nevertheless, we retain the ability to learn throughoutour lives.
In many cases, an adult with dyslexia can learn to read.
Even though learning disabilities can't be cured, there is still causefor hope. Because certain learning problems reflect delayed development,many children do eventually catch up. Of the speech and language disorders,children who have an articulation or an expressive language disorder arethe least likely to have long-term problems. Despite initial delays, mostchildren do learn to speak.
For people with dyslexia, the outlook is mixed. But an appropriate remedialreading program can help learners make great strides.
With age, and appropriate help from parents and clinicians, childrenwith ADHD become better able to suppress their hyperactivity and to channelit into more socially acceptable behaviors. As with Dennis, the problemmay take less disruptive forms, such as fidgeting.
Can an adult be helped? For example, can an adult with dyslexia stilllearn to read? In many cases, the answer is yes. It may not come as easilyas for a child. It may take more time and more repetition, and it may eventake more diverse teaching methods. But we know more about reading and aboutadult learning than ever before. We know that adults have a wealth of lifeexperience to build on as they learn. And because adults choose to learn,they do so with a determination that most children don't have. A varietyof literacy and adult education programs sponsored by libraries, publicschools, and community colleges are available to help adults develop skillsin reading, writing, and math. Some of these programs, as well as privateand nonprofit tutoring and learning centers, provide appropriate programsfor adults with LD.
What aid does the Governmentoffer?
As of 1981, people with learning disabilities came under the protectionof laws originally designed to protect the rights of people with mobilityhandicaps. More recent Federal laws specifically guarantee equal opportunityand raise the level of services to people with disabilities. Once a learningdisability is identified, children are guaranteed a free public educationspecifically designed around their individual needs. Adolescents with disabilitiescan receive practical assistance and extra training to help make the transitionto jobs and independent living. Adults have access to job training and technologythat open new doors of opportunity.
Increased services, equal opportunity
The Individuals with Disabilities Education Act of 1990 assures a publiceducation to school-aged children with diagnosed learning disabilities.Under this act, public schools are required to design and implement an IndividualizedEducational Program tailored to each child's specific needs. The 1991 Individualswith Disabilities Education Act extended services to developmentally delayedchildren down to age 5. This law makes it possible for young children toreceive help even before they begin school.
Another law, the Americans with Disabilities Act of 1990, guaranteesequal employment opportunity for people with learning disabilities and protectsdisabled workers against job discrimination. Employers may not considerthe learning disability when selecting among job applicants. Employers mustalso make "reasonable accommodations" to help workers who havehandicaps do their job. Such accommodations may include shifting job responsibilities,modifying equipment, or adjusting work schedules.
By law, publicly funded colleges and universities must also remove barriersthat keep out disabled students. As a result, many colleges now recruitand work with students with learning disabilities to make it possible forthem to attend. Depending on the student's areas of difficulty, this helpmay include providing recorded books and lectures, providing an isolatedarea to take tests, or allowing a student to tape record rather than writereports. Students with learning disabilities can arrange to take collegeentrance exams orally or in isolated rooms free from distraction. Many collegesare creating special programs to specifically accommodate theses students.
Programs like these made it possible for Dennis to attend and succeedin college. The HEATH Resource Center, sponsored by the American Councilon Education, assists students with learning disabilities to identify appropriatecolleges and universities. Information on the HEATH center and related organizationsappears at the end of this brochure.
Public agency support
Effective service agencies are also in place to assist people of allages. Each state department of education can help parents identify the requirementsand the process for getting special education services for their child.Other agencies serve disabled infants and preschool children. Still othersoffer mental health and counseling services. The National Information Centerfor Children and Youth can provide referrals to appropriate local resourcesand state agencies.
Counselors at each state department of vocational rehabilitation servethe employment needs of adolescents and adults with learning disabilities.They can refer adults to free or subsidized health care, counseling, andhigh school equivalence (GED) programs. They can assist in arranging forjob training that sidesteps the disability. For example, a vocational counselorhelped Wallace identify his aptitude for car repair. To work around Wallace'slanguage problems, the counselor helped locate a job-training program thatteaches through demonstrations and active practice rather than lectures.
State departments of vocational rehabilitation can also assist in findingspecial equipment that can make it possible for disabled individuals toreceive training, retain a job, or live on their own. For example, becauseDennis couldn't read the electronics manuals in his new job, a vocationalrehabilitation counselor helped him locate and purchase a special computerthat reads boo ks aloud.
Finally, state-run protection and advocacy agencies and client assistanceprograms serve to protect these fights. As experts on the laws, they offerlegal assistance, as well as information about local health, housing, andsocial services.
What hope does research offer?
Sophisticated brain imaging technology is now making it possible to directlyobserve the brain at work and to detect subtle malfunctions that could neverbe seen before. Other techniques allow scientists to study the points ofcontact among brain cells and the ways signals are transmitted from cellto cell.
With this array of technology, NIMH is conducting research to identifywhich parts of the brain are used during certain activities, such as reading.For example, researchers are comparing the brain processes of people withand without dyslexia as they read. Research of this kind may eventuallyassociate portions of the brain with different reading problems.
Clinical research also continues to amass data on the causes of learningdisorders. NIMH grantees at Yale are examining the brain structures of childrenwith different combinations of learning disabilities. Such research willhelp identify differences in the nervous system of children with these relateddisorders. Eventually, scientists will know, for example, whether childrenwho have both dyslexia and an attention disorder will benefit from the sametreatment as dyslexic children without an attention disorder.
Studies of identical and fraternal twins are also being conducted. Identicaltwins have the same genetic makeup, while fraternal twins do not. By studyingif learning disabilities are more likely to be shared by identical twinsthan fraternal twins, researchers hope to determine whether these disordersare influenced more by genetic or by environmental factors. One such studyis being conducted by scientists funded by the National Institute of ChildHealth and Human Development. So far, the research indicates that genesmay, in fact, influence the ability to sound out words.
By studying if learning disabilities are more likely to be shared byidentical twins than fraternal twins, researchers hope to determine whetherthese disorders are influenced more by genetic or by environmental factors.
Animal studies also are adding to our knowledge of learning disabilitiesin humans. Animal subjects make it possible to study some of the possiblecauses of LD in ways that can't be studied in humans. One NIMH grantee isresearching the effects of barbiturates and other drugs that are sometimesprescribed during pregnancy. Another researcher discovered through animalstudies that certain prenatal viruses can affect future learning. Researchof this kind may someday pinpoint prenatal problems that can trigger specificdisabilities and tell us how they can be prevented.
Animal research also allows the safety and effectiveness of experimentalnew drugs to be tested long before they can be tried on humans. One NIH-sponsoredteam is studying dogs to learn how new stimulant drugs that are similarto Ritalin act on the brain. Another is using mice to test a chemical thatmay counter memory loss.
This accumulation of data sets the stage for applied research. In thecoming years, NIMH-sponsored research will focus on identifying the conditionsthat are required for learning and the best combination of instructionalapproaches for each child.
Piece by piece, using a myriad of research techniques and technologies,scientists are beginning to solve the puzzle. As research deepens our understanding,we approach a future where we can prevent certain brain and mental disorders,make valid diagnoses, and treat each effectively. This is the hope, mission,and vision of the National Institute of Mental Health.
What are sources of informationand support?
Several publications, organizations, and support groups exist to helpindividuals, teachers, and families to understand and cope with learningdisabilities. The following resources provide a good starting point forgaining insight, practical solutions, and support. Further information canbe found at libraries and book stores.
Books for children and teens with learning disabilities
Fisher, G., and Cummings, R., The Survival Guide for Kids with LD. Minneapolis:Free Spirit Publishing, 1990. (Also available on cassette)
Gehret, J. Learning Disabilities and the Don't-Give-Up-Kid. Fairport,NY: Verbal Images Press, 1990.
Janover, C. Josh: A Boy with Dyslexia. Burlington, VT: Waterfront Books,1988.
Landau, E. Dyslexia. New York: Franklin Watts Publishing Co., 1991.
Marek, M. Different, Not Dumb. New York: Franklin Watts Publishing Co.,1985.
Levine, M. Keeping A Head in School: A Student's Book about LearningAbilities and Learning Disorders. Cambridge, MA: Educators Publishing Services,Inc., 1990.
Books for adults with learning disabilities
Adelman, P., and Wren, C. Learning Disabilities, Graduate School, andCareers: The Student's Perspective. Lake Forest, IL: Learning OpportunitiesProgram, Barat College, 1990.
Cordoni, B. Living with a Learning Disability. Carbondale, IL: SouthernIllinois University Press, 1987.
Kravets, M., and Wax, I. The K and W Guide: Colleges and the LearningDisabled Student. New York: Harper Collins Publishers, 1992.
Magnum, C., and Strichard, S., eds. Colleges with Programs for Studentswith Learning Disabilities. Princeton, NJ: Petersons Guides, 1992.
Books for parents
Greene, L. Learning Disabilities and Your Child: A Survival Handbook.New York: Fawcett Columbine, 1987.
Novick, B., and Arnold, M. Why Is My Child Having Trouble in School?New York: Villard Books, 1991.
Silver, L. The Misunderstood Child: A Guide for Parents of Children withLearning Disabilities: 2d ed. Blue Ridge Summit, PA: Tab Books, 1992.
Silver, L. Dr. Silver's Advice to Parents on Attention-Deficit HyperactivityDisorder. Washington, DC: American Psychiatric Press, 1993.
Vail, P. Smart Kids with School Problems. New York: EP Dutton, 1987.
Weiss, E. Mothers Talk About Learning Disabilities. New York: PrenticeHall Press, 1989.
"The Scoutmaster's Guide to ADD" Positive People Press, 4741Keet Seel Trail, Tucson, AZ. 85749 (520) 7549-5465
Books and pamphlets for teachers and specialists
Adelman, P., and Wren, C. Learning Disabilities, Graduate School, andCareers. Lake Forest, Learning Opportunities Program, Barat College, 1990.
Silver, L. ADHD: Attention Deficit-Hyperactivity Disorder, Booklet forTeachers. Summit, NJ: CIBA-GEIGY, 1989.
Smith, S. Success Against the Odds: Strategies and Insights from theLearning Disabled. Los Angeles: Jeremy Tarcher, Inc., 1991.
Wender, P. The Hyperactive Child, Adolescent, and Adult. Attention Disorderthrough the Lifespan. New York: Oxford University Press, 1987.
Related pamphlets available from NIH
Facts About Dyslexia National Institute of Child Health and Human DevelopmentBuilding 31, Room 2A32 9000 Rockville Pike Bethesda, MD 20892
Developmental Speech and Language Disorders Hope through Research
National Institute on Deafness and Other Communicative Disorders
Support Groups and Organizations
American Speech-Language-Hearing Association
Attention Deficit Information Network
Candlelighters Childhood Cancer Foundation
Center for Mental Health Services
Children with Attention Deficit Disorders (CHADD)
Council for Exceptional Children
Federation of Families for Children's Mental Health
HEATH Resource Center
Learning Disabilities Association of America
Library of Congress
National Alliance for the Mentally Ill
National Association of Private Schools for
National Center for Learning Disabilities
National Information Center for Children and
Orton Dyslexia Society
To arrange for special college entrance testing for LD adults,contact:
ACT Special Testing (319) 337-1332
SAT Scholastic Aptitude Test (609) 771-7137
GED (202) 939-9490
Most experts agree that a multi-modality approach to treatment of the disorder aimed at assisting the child medically, psychologically, educationally and behaviorally is often needed. This requires the coordinated efforts of a team of health care professionals, educators and parents who work together to identify treatment goals, design and implement interventions, and evaluate the results of their efforts.
Medications used to treat ADHD are no longer limited to psychostimulants such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine) and pemoline (Cylert) which have been shown to have dramatically positive effects on attention, over activity, visual motor skills, and even aggression in 70% or more ADHD children. Within the past several years the tricyclic antidepressant medications, imipramine (Tofranil) and nopramine (Desipramine), have been studied and used clinically to treat the disorder with other types of antidepressants: fluxetine, chlorimipramine, and buproprion much less frequentlyprescribed. Clonidine (Catapress), an antihypertensive, and carbamazepine (Tegretol), an anti-convulsant, have been shown to be effective for some children as well.
Ideally, treatment should also include consideration of the individual's psychological adjustment targeting problems involving self=esteem, anxiety, and difficulties with family and peer interaction. Frequently family therapy is useful along with behavioral and cognitive interventions to improve behavior, attention span, and social skills.
Educational interventions such as accommodations made within the regular education classroom, compensatory educational instruction, or placement in special education may be required depending upon the particular child's needs.
All material in this publication is free of copyright restrictions andmay be copied, reproduced, or duplicated without permission from NIMH; citationof the source is appreciated.
This booklet was written by Sharyn Neuwirth, M.Ed., an education writerand instructional designer in Silver Spring, MD.
Scientific information and review was provided by NIMH staff membersL. Eugene Arnold, M.D.; F. Xavier Castellanos, M.D.; and Judith Rumsey,Ph.D. Also providing review and assistance were Marcia Henry, Ph.D., OrtonDyslexia Society; Reid Lyon, Ph.D., National Institute of Child Health andHuman Development; Jean Petersen, Learning Disabilities Association; andLarry B. Silver, M.D., Georgetown University. Editorial direction was providedby Lynn J. Cave, NIMH.