Developmental Disabilities

GENERAL OVERVIEW The spectrum of developmental disabilities is a group of interrelated chronic neurodevelopmental disorders. It includes cerebral palsy, mental retardation, autism, learning disabilities, communication disorders, anxiety disorders, and attention deficit disorders. These conditions are suspected or noticed at varying stages during childhood. Some conditions, such as Down syndrome, can be recognized prenatally or at birth; other conditions, such as cerebral palsy or autism, may not present themselves until the child fails to meet normal developmental milestones. This phenomenon ma es the nurse!s role in developmental disabilities crucial. The pediatric nurse who understands that the development of the child occurs in an orderly, predictable manner and who is nowledgeable of what the milestones should be may be the first person to recognize the deviation and raise the suspicion to the parent or pediatrician. "ecause there are many confusing and overlapping characteristics for many of these conditions, it is important for the health care provider and family to refer to clinicians who are experienced and nowledgeable in typical and atypical child development to arrive at an accurate diagnosis and arrange an appropriate care plan. #hen a nown condition exists, the nurse should be aware of the predisposing health issues associated with the condition and the resources available to promote optimal growth and development of the child within the family. The following will provide cursory information about some of the more common conditions. It is also important to eep in mind that each child is a child first and will have his own uni$ue abilities as well as challenges within his identified diagnosis. NURSING ALERT %ormal child development is predictable and se$uential. The nurse who is nowledgeable about normal development may be the first person to raise the $uestion that a developmental disability exists. SIGNS OF DEVELOPMENTAL DELAY !ite!ia Fo! Re"e!!al omm#ni$ation an% Fee%in& &eeding difficulties'wea suc ing or poor coordination of suc (swallowing to sustain normal weight gain %o social smile by age ) months %o babbling *ga(ga, da(da+ by age , months %o -ama, Dada *specific+ by age .) months %o name of ob/ect *one word+ by age .) months 0t least .1 words by age .2 months *not /ust repeating+ 3ombines words *eg, me outside, more mil + and uses pronouns by age 4) months 5egression in language at any age 6nresponsive to his name NURSING ALERT

Do not simply reassure the family that normal development 7should8 or 7probably will8 develop. -a e sure that the child is referred for an appropriate evaluation to properly assess the suspected delay and establish a diagnosis if possible. In the presence of a developmental delay, a comprehensive vision and hearing evaluation should also be included. -otor Delay %ot rolling over by age 9 months %ot sitting by age , months %ot wal ing by age .: months %ot stair(climbing by age 4 years ARE OF T'E 'ILD WIT' A DEVELOPMENTAL DISA(ILITY N#!sin& Assessment 5eview the child!s record to determine existing health problems that may cause or affect the developmental disability. 0lways rule out a vision or hearing impairment. 0ssess the family!s understanding of the diagnosis and its ramifications. The parents! experiences, cultural biases, cognitive ability, stage of grief, and physical condition affect their ability to assimilate information provided. It will be necessary to repeat the information. *&or example, a woman who has /ust given birth to a child with Down syndrome will not be able to retain much information until her body returns to a state of homeostasis.+ Determine the developmental age of the child. The pediatric nurse should be familiar with normal developmental milestones, noting the child!s strengths and areas presenting challenges, for example, the communication s ills are at a .4( month level and the gross motor s ills are at a ;9(month level. 3hildren who are found to be functioning at one(half or less of their chronological age have a moderate to severe developmental problem. 0dminister the 3linical 0daptive Test(3linical <inguistic 0uditory -ilestone Scales *30T(3<0-S+. It is a reliable tool that nurses can be trained to use to assess cognitive and communicative development in children at the .( to ;9( month developmental level. It has been found tobe more sensitive than the Denver Developmental Screening Scale because language development is the best early predictor of cognitive abilities lini$al A%aptive Test) lini$al Lin&#isti$ A#%ito!* Milestone S$ales LINI AL LINGUISTI AUDITORY LINI AL ADAPTIVE MILESTONE S ALES+ LAMS, TEST + AT, YesNo A&e+mos, YesNo - Mont. 0lerts to sound *1.:+. =isually fixates momentarily upon red ' ' ' ring *1.:+. ' ' Soothes when pic ed up <ifts chin off table in *1.:+. ' ' ' prone position *1.:+. ' ' / Social smile *..1+. ' ' ' =isually follows ring ' '

Mont.s 0 3ooing *..1+. Mont.s ' ' '

1 >rients to voice *1.:+. Mont.s <aughs aloud *1.:+.

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2 >rients toward bell Mont.s laterally *1.;+. 0h(goo *1.;+. 5azzing *1.;+. 3 "abbling *..1+. Mont.s 4 >rients toward bell Mont.s *..1+, upwardly indirectly *,1 degrees+. 5 Says 7Dada8 Mont.s inappropriately *1.:+. Says 7-ama8 inappropriately *1.:+. 6 >rients toward bell Mont.s upward directly *.21 degrees+ *1.:+. @esture language *1.:+. -7 6nderstands 7no8 *1.;+. Mont.s 6ses 7Dada8 appropriately *1.;+. 6ses 7-ama8 appropriately *1.;+. ->ne word *other than Mont.s 7-ama8 and 7Dada8+ *..1+.

in circle *1.:+. <ifts chest off table in prone position *1.:+. =isually follows ring horizontally and vertically *1.:+. Supports on forearms in prone position *1.;+. =isual threat *1.;+. 6nfisted *1.;+. -anipulates fingers *1.;+. Supports on wrists in prone position *1.;+. ?ulls down rings *1.;+. Transfers *1.;+. 5egards pellet *1.;+. >btains cube *1.;+. <ifts cup *1.;+. 5adial ra e *1.;+. 0ttempts pellet *1.;+. ?ulls out peg *1.;+. Inspects ring *1.;+. ?ulls ring by string *1.;+. Secures pellet *1.;+. Inspects bell *1.;+. ;1(finger scissor grasp *1.;+.

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5ings bell *1.;+. >ver the edge for toy *1.;+. ' ' 3ombines cube(cup *1.;+. ' ' 6ncovers bell *1.;+. ' ' &ingers pegboard *1.;+. ' ' -ature overhand pincer movement *1.:+. ' ' Solves cube under cup *1.:+. ' '

-/ >ne(step command with Mont.s gesture *1.:+. Two(word vocabulary *1.:+. -1 Three(word vocabulary Mont.s *..1+. Immature /argoning *..1+. -3 &our( to six(word Mont.s vocabulary *..1+. >ne(step command without gesture *..1+.

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-5 -ature /argoning *1.:+. ' ' Mont.s A(to(.1(word vocabulary *1.:+ ' ' "ody parts *1.:+. ' ' ?oints to one picture *1.:+. ' ' /41(word vocabulary Mont.s *..1+. ' ' Two(word phrases *..1+. ' ' ?oints to two pictures *..1+. ' ' /1 :1(word vocabulary Mont.s *..1+. ' ' Two(step command *..1+. ' ' 6ses pronouns *I, you, ' ' me+ inappropriately *..1+. 07 6ses pronouns Mont.s appropriately *..:+. ' ' 3oncept of one *..:+. ' ' ?oints to seven pictures ' ' *..:+.

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5eleases . cube in cup *1.:+. ' 3rayon mar *1.:+. ' Solves glass frustration *1.9+. ' >ut(in with peg *1.9+. ' Solves pellet(bottle with demonstration *1.9+. ' Solves pellet(bottle spontaneously *1.9+. ' 5ound bloc in formboard *1.9+. ' Scribbles in imitation *1.9+. ' .1 cubes in cup *1.:+. ' Solves round hole in formboard reversed *1.:+. ' Spontaneous scribbling with crayon *1.:+. ' ?egboard completed spontaneously *1.:+. ' >btains ob/ect with stic *..1+. ' Solves s$uare in formboard *..1+. ' Tower of three cubes *..1+. ' 0ttempts to fold paper *1.A+. ' Borizontal four(cube train. ' Imitates stro e with pencil *1.A+. ' 3ompletes formboard *1.A+. ' Borizontal(vertical stro e with pencil *..:+. ' &ormboard reversed *..:+. ' &olds paper with ' definite crease *..:+.

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Two digits forward Train with chimney *..:+. ' ' ' *..:+. ' ' 03 4:1(word vocabulary Three(cube bridge Mont.s *..:+. ' ' ' *..:+. ' ' Three(word sentence Draws circle *..:+. *..:+ ' ' ' ' ' Three(digits forward %ames one color *..:+. ' ' ' *..:+. ' ' &ollows two Draw(a(person with prepositional commands head plus . other body *..:+. ' ' ' part *..:+. ' ' 5eliability of informant CCCCC *1 D unreliable;. D reliable+. Boon, 0.B., Er., ?ulsifer, -."., F @opalan, 5., et al. *.,,;+. 3linical 0daptive TestG3linical <inguistic 0uditory -ilestone Scale in early cognitive assessment. Journal of Pediatrics, .4;*.+, S.(2. 0ssess the functional level of the child. The #ee&I- is a tool used to trac functional independence in children. It uses the following categories to describe functionH completely dependent, needs some physical assistance, can physically perform the tas but needs verbal cues and coaching, and completely independent. &unctional areas to assess includeH o &eeding. o @rooming and bathing. o Dressing. o -obility. o ?roblem solving. o 3ommunication. 0ssess parents! perception of the child!s development level and the appropriateness of parental expectations. 6se such $uestions as, 7Do you have any concerns regarding things your child is doing or should be doingI8 7#hat age child does your child act li eI8 0ssess parent(child interaction. >bserve and explore bonding and attachment, ability to set appropriate limits, management of behavioral problems, and methods of discipline. 0ssess the need for additional resources, such as financial aid, transportation, and counseling, for long(term support of child and family.

N#!sin& Dia&noses Impaired 0d/ustment related to birth and diagnosis of developmentally disabled child Impaired ?arenting related to multiple needs of child and difficult bonding Ineffective Infant &eeding ?attern related to protruding tongue, poor muscle tone, and wea suc ing Delayed @rowth and Development related to disability Social Isolation related to developmental differences from other children 5is for In/ury related to developmental age

N#!sin& Inte!ventions P!omotin& A%8#stment 0llow the parents access to the infant at all possible times to promote bonding when parents appear ready. &ocus on the positive aspects of the infant and serve as a role model for handling and stimulating. "e cognizant of the grieving process *loss of the anticipated and planned for 7normal child8+ that families experience when a diagnosis is made, and be aware that spouses can be at different stages. 0ccept all $uestions and reactions non/udgmentally, offering verbal and written explanations. ?rovide the family a $uiet place to discuss their $uestions with each other and someone nowledgeable about the condition *primary care provider, clinical nurse specialist+ to support their concerns. >ffer the family the option to ta e advantage of counseling. 0 social wor er or psychologist can help families deal with immediate reactions. -any parents benefit from continuous or periodic support of counseling professionals. NURSING ALERT 3hildren with developmental disabilities and chronic illness are at greater ris of experiencing divorce, child abuse, and neglect than the general population. St!en&t.enin& t.e Role o" Pa!ents Belp the family to realize what strengths they have in caring for their child. The role of the parents is critical; a nurturing, loving environment gives the child the best chance at maximizing potential. 0n individual who grows up at home has mar edly higher adaptive abilities and an increased life span compared with those raised in institutions. Jnlist the help of family and siblings, who can offer valuable support to the parents and child and assist with stimulation activities. Including siblings in the care can help them feel needed and involved, thus strengthening the family. If sibling issues arise, suggest family counseling to address the needs of all family members. Identify resources available to the family, such as parent support groups, early intervention programs, specialty clinics, pediatrician or primary health care provider, financial support programs, and advocacy groups for individuals with developmental disabilities. &or those parents concerned with their ability to care for the child, explore with them their options of adoption or institutionalization in a non/udgmental manner. Establis.in& E""e$tive Fee%in& Te$.ni9#es "e aware that the presence of hypotonia, as in children with Down syndrome; or hypertonia, as in children at high ris for cerebral palsy, can interfere with feeding by compromising suc ing and swallowing.

Demonstrate proper feeding positioning, with the infant!s head elevated, and encourage the parents to always hold the infant during feedings with his head elevated and supported in arms. Try different nipples and bottles to find the easiest for the infant to use without lea age or danger of aspiration. 0llow ade$uate time for feeding, and increase fre$uency of feedings if infant tires easily. >ffer support and guidance for breast(feeding. 5efer to lactation consultant if needed. 3onsider referral for a feeding evaluation to a speech therapist, or to an occupational therapist who has experience wor ing with children and families.

P!omotin& Optim#m G!o:t. an% Development 5efer parents to the Jarly Intervention ?rogram administered by their county so that they can ta e advantage of the educational and support services available for children from birth to age ;. If the condition is identified after age ;, refer parents to the school district in which they reside. Belp the parents to understand the concept of developmental age, and identify the functional level of the child. Determine whether there is consistency between the developmental age of the child and degree of independence. 3ognitive and physical limitations may interfere with emerging independence; however, parents may 7baby8 or overindulge a child who has a disability. #or with parents to set reasonable expectations and tobrea down tas s into simple, achievable steps. 3are should be ta en not to address too many areas at one time so as not to overwhelm the family. 6se appropriate behavior modification techni$ues, such as extinction, time(out, and reward, to achieve cooperation and success. Demonstrate and encourage play with the child at the appropriate level to provide stimulation, and wor toward achieving developmental milestones. P!ovi%in& Meanin&"#l So$ial Inte!a$tion -a e parents aware that recreational and leisure(time experiences are valuable in building social s ills and self(esteem. >ffer suggestions that will be en/oyable and developmentally appropriate for the child. Interaction with developmentally delayed and nondevelopmentally delayed peers is desirable. The Special >lympics is one example of an adaptive program. <ocal programs are also available in many areas. ?raise the child for participation in activities, regardless of whether the child succeeds. Maintainin& Sa"et* #hen handling the infant, provide ade$uate support with a firm grasp because the infant may be floppy due to poor muscle tone.

If hypotonia is accompanied by poor head control and nec strength, position the infant to prevent aspiration should vomiting occur. o Support the infant with a diaper roll, if needed, to maintain position. o 3hange the infant!s position fre$uently. o 3ontinuously chec the environment for the safety needs of this child. 0dvise the parents toH o -aintain appropriate surveillance of the child when coo ing or exposing him to other potential hazards that he may be able to get into but not understand. o Belp the child to read words, such as 7danger8 and 7stop.8 o Teach the child how to call and as for help. o Teach the child to say no to strangers. o ?rovide sex education in a way the child can understand.

NURSING ALERT Teach caregivers to base safety needs on the developmental, not the chronological, age of the child. Famil* E%#$ation an% 'ealt. Maintenan$e 5emind the parents to recognize the child!s routine health care needs and maintain regular follow(up with a primary care provider. o Immunizations o 5egular dental chec ups o =ision and hearing examinations ?rovide guidance and support to parents with their child!s multidimensional treatment plan. -a e sure parents now whom to contact when problems arise. Jncourage parents to develop and maintain a noteboo with a calendar to eep trac of agencies, subspecialists, and professionals who will be involved with their child. It should include such information as business cards, names, addresses, phone numbers, appointment dates, health providers! orders, and insurance information. Teach parents the benefits of a therapeutic home environment. o Develop optimum sleeping, eating, wor ing, and playing routines. o Jnsure ade$uate nutrition. o Divide tas s and expectations into small, manageable parts. @ive only one or two instructions at a time. o Set firm but reasonable limits on behavior and carry through with consistent discipline. o 0void situations that cause excessive excitement, stimulation, or fatigue. o ?rovide an energy outlet through physical activity, vocal outlet, and outdoor play. o 3hannel the need for movement into safe, appropriate activities. Discuss preparation for independent living when appropriate. o Belp the parents identify areas of home responsibilities that may be delegated to the cognitively impaired child.

@uide development of social s ills that will be an asset to later vocational life. o Belp the child to develop a set of attitudes and behaviors that will increase motivation. o 5efer for vocational assistance to 053 *formerly 0ssociation of 5etarded 3itizens+ or other rehabilitative agencies. 5efer for genetic consultation for information about genetics of the disorder, ris in subse$uent pregnancies *parents+ or ris to offspring *patient+, or ris to other relatives as it is warranted by the diagnosis.
o

Eval#ation; E<pe$te% O#t$omes ?arents hold infant fre$uently and see information from health care provider ?arents feed and assist with care of infant Infant feeds for .: to 41 minutes every . to 4 hours; ta es :1 to .11 m< ?arents describe developmental level of child and realistic goals for attainment of next milestones ?arents involved in support group that allows opportunity to safely share feelings involved in raising a child with special needs ?arents and siblings handle the infant safely and provide appropriate supervision DEVELOPMENTAL DISA(ILITIES OGNITIVE DEVELOPMENTAL DELAY 3ognitive developmental delay, also nown as mental retardation, refers to the most severe, general lac of cognitive and problem(solving s ills. The 0merican 0ssociation on -ental Deficiency defines mental retardation as a significant subaverage general intellectual functioning existing concurrently with deficits in adaptive behaviors and manifested during the developmental period. There are many causes and a wide range of impairments. Three percent of the 6nited States population'9.9 million people'are considered mentally retarded. >f every .,111 infants born, ;1 will be classified as mentally retarded before they reach age .2. Pat.op.*siolo&* an% Etiolo&* %o identifiable organic or biologic cause can be found for :1K of children. Identifiable causes includeH o @enetic causes, such as Down syndrome, fragile L syndrome, 0ngelman syndrome, and inborn errors of metabolism such as phenyl etonuria *?M6+. o 3ongenital anomalies, including brain malformations, hydrocephalus, and microcephaly. o Intrauterine influences, such as alcohol and drug exposure, congenital infections, and teratogens. o ?erinatal trauma'birth anoxia, intracranial hemorrhage. o ?ostnatal trauma'head in/uries from falls, automobile accidents. o ?ostnatal infections *meningitis, sepsis+. o Jnvironmental exposure to toxins such as lead; environmental deprivation; and neglect.

The malfunctioning brain is poorly understood in most cases, but physiologic alterations identified in some cases includeH o 3ongenital brain malformations, brain tissue damage, or underdevelopment of the brain as shown by abnormal results of computed tomography *3T+ scan or magnetic resonance imaging *-5I+. o "iochemical or errors of metabolism, in which an absence of an enzyme or hormone produces abnormal brain function or formation, as in ?M6 or hypothyroidism. IN is A: or below; classification has been recently changed to mild and severe and includes both cognitive and functional ability. o The more severe types of mental retardation tend to be diagnosed in early infancy, especially when they coexist with an identifiable syndrome or congenital anomalies. o -ilder forms of mental retardation tend to be diagnosed in preschool years, when language and behavioral concerns call attention to slower development. <imitations in adaptive ability occur in communication, self(care, home living, social s ills, community use, self(direction, health and safety, functional academics, leisure, and wor .

lini$al Mani"estations Developmental delays *failure to achieve age(appropriate s ills+ are evident to some degree in almost all areas. In"an$* 7?oor feeder8'a wea or uncoordinated suc results in poor breast( or bottle( feeding, leading to poor weight gain Delayed or decreased visual alertness and curiosity with poor visual trac ing of face or ob/ects Decreased or lac of auditory response Decreased spontaneous activity Delayed head and trun control &loppy *hypotonia+ or spastic muscle tone NURSING ALERT 0lthough A:K of individuals with mental retardation have no physical signs, they typically achieve motor milestones at a slower rate. To%%le! Delayed independent sitting, crawling, pulling to stand, and independent ambulation. Delayed communication'failure to develop receptive and expressive language milestones. 0lmost :1K of children with mental retardation are identified after age ;, when speech delays manifest themselves. &ailure of the child to ma e progress or show interest in the area of independence in self(feeding, dressing, and toilet training may reflect cognitive impairment.

Short attention span and distractibility. "ehavioral disturbances. 3lumsiness.

Dia&nosti$ Eval#ation &ederal law *?< ,)(.)4'Jducation for 0ll Bandicapped 3hildren and ?< .1.()A9' Individuals with Disabilities Jducation 0ct OIDJ0P+ ensures that each child with a delay or suspected of having a delay has a multidisciplinary evaluation by a team. ?art 3 of ?< .1:(.A called for the creation of statewide, coordinated, multidisciplinary, interagency programs for the provision of early intervention. Jach state has its own definitions and organizational framewor to provide these services. %o single test can diagnose mental retardation. The multidisciplinary evaluation should be individually tailored to the child. R#le o#t senso!* %e"i$its b* assessment o" vision an% .ea!in&= Me%i$al eval#ation s.o#l% in$l#%e p!enatal .isto!*> %evelopmental .isto!*> se9#ential %evelopmental assessments> "amil* .isto!*> an% p.*si$al e<amination= T.e positive "in%in&s %ete!mine t.e %i!e$tion o" t.e in%ivi%#al eval#ation= o 6nusual appearance *dysmorphic features+ warrants evaluation by a genetic specialist. o Bistory consistent with loss of developmental milestones and positive family history warrants wor up for presence of an inborn error of metabolism *diagnosed by blood and urine analysis+ or lead poisoning. o 3hildren with macrocephaly, microcephaly, or neurologic abnormalities may re$uire imaging studies, such as 3T scan or -5I. o JJ@ is indicated for children with seizures. Ps*$.olo&i$al testin& +app!op!iate tests sele$te% b* a $.il% ps*$.olo&ist,; o The "ayley Scales are used to assess children ages 4 months to ; years. This test is weighted on nonlanguage items and is used to assess fine motor, gross motor, language s ills, and visual problem solving. o The -c3arthy Scale offers a 7general cognitive index8 that is roughly e$uivalent to an IN score. o The Stanford("inet Intelligence Scale is used to test children with mental abilities of age 4 and older. o The #echsler ?reschool and ?rimary Scale of Intelligence *#??SI+ *.,,.+ measures mental age of ; to A. o The #echsler Intelligence Scale for 3hildren *#IS3+ III *.,,.+ tests children whose functional age is above a 9(year level. o The =ineland Scale tests social(adaptive abilities'self(help s ills, self( control, interaction with others, cooperation; the 0daptive "ehavior Scale is similar to =ineland but also measures ad/ustment. ompli$ations an% Asso$iate% Fin%in&s Seizures 3erebral palsy Sensory deficits 3ommunication disorders *speech and language+

%eurodevelopmental disorders ?sychiatric illness Specific learning disabilities Jmotional problems

Mana&ement 0n interdisciplinary team evaluation by a developmental pediatrician, clinical psychologist, and counselor is usually the initial step in the management of mental retardation. This type of evaluation can be obtained through a state or private diagnostic and evaluation center, public school, or university(affiliated program. 0ssociated medical problems, such as seizures, poor nutrition, sensory deficits, or dental problems, must be treated to allow the child to maximize his potential. If a treatable cause is identified, such as an inborn error of metabolism, a therapeutic diet can be instituted. Bypothyroidism can be treated with thyroid hormone. 0 family assessment is essential to addressH o &inancial stressors'financial aid may be available through Social Security Income, -edicaid, or state and local programs to help families with children with mental retardation o &amily coping abilities o Support for parents, siblings, and extended family o 5espite services o Support groups o 5ecreational programs, such as the Special >lympics and summer camps o Identification of other affected or at(ris persons and the need for genetic counseling for recurrence ris . The initial evaluation usually leads to recommendations for more targeted evaluations, such as physical therapy, occupational therapy, and social wor assessment. DOWN SYNDROME Down syndrome, or trisomy 4., is the most common identifiable cause of mental retardation and a condition associated with various congenital anomalies. Jach child with Down syndrome has a uni$ue set of genes besides the effects of the extra genes on the chromosome 4., and he will need individualized evaluation. The most common life experience of a child with Down syndrome is to live with the family, participate in infant stimulation and preschool programs, and attend school while receiving support from special education services. 0dults with Down syndrome can function in supported employment programs and live in small groups. <ife expectancy depends on the presence of medical complications; when there are no complications, life expectancy is slightly shorter than average. Pat.op.*siolo&* an% Etiolo&* See 3hapter ), page ;:. lini$al Mani"estations an% Asso$iate% P!oblems

3haracteristic facies'brachycephaly; obli$ue palpebral fissures; epicanthal folds; flat nasal bridge; protruding tongue; small, low(set ears; simian crease of palms

.(year(old with Down syndrome, recently diagnosed with hypothyroidism. 3ongenital heart defects -ental retardation Bypotonia @rowth retardation Scaly, dry s in The table below provides a comprehensive list of potential problems that occur with Down syndrome. Some are identified at birth; others arise and cause difficulties later in the life cycle. ?ercentages are listed that represent occurrence within the Down syndrome population. Do:n S*n%!ome POTENTIAL PRO(LEMS EVALUATION MANAGEMENT

on&enital .ea!t mal"o!mations +ie> AV $anal> VSD> PDA> an% tet!alo&* o" Fallot, +17?,

on&enital GI mal"o!mations +-/?, o ?yloric stenosis o Duodenal atresia, tracheoesophageal fistula

>bserve for color changes, pulse, and respiratory rate at rest and with stress. 0ssess tolerance of feeding for early tiring or fre$uent interruptions in feeding. Jchocardiogram usually done during neonatal period on all infants with DS. >bserve for coughing or vomiting, especially with feedingH bile(stained vomitus suggests lower tract abnormalities; partially digested contents suggest upper tract problem. >bserve bowel movements and for abdominal distention. 5adiographic studies are done. -onitor for weight gain, hair loss, lethargy, short stature, voice changes, and depression *can develop at any time over life cycle+. %eonatal screening includes T;, TSB, T) biannually. >bserve for indication of vision problems, such as head tilt or poor visual trac ing. 6se Teller activity as a visual

Jarly identification and treatment can prevent heart failure and decompensation or poor growth. -edical or surgical intervention correction has minimized mortality from simple cardiac defects. @I reflux *spillage of material from esophagus into the trachea+ can cause arching during feedings, poor weight gain, chronic respiratory problems, allergy and asthma symptomatology, pneumonia and aspiration. -edication management and if needed surgical intervention can occur in the early neonatal period. Thyroid hormone replacement.

'*pot.*!oi%ism +-7)/7?,

Vis#al %e"e$ts
o o o

5efractive errors *A1K+ Strabismus *:1K+ %ystagmus

6ndetected visual deficits can cause failure to achieve developmental milestones and cause permanent loss of

*;:K+
o

3ataracts *;K+

'ea!in& %e"e$ts +37?)67?,; o -ild to moderate conductive hearing loss o Jnlarged adenoids o Sleep apnea

screen tool for those who cannot cooperate with Snellen chart. ?ositive findings in first year of life warrant immediate referral to ophthalmologist. 0ll individuals should be seen by a pediatric ophthalmologist *or one who is s illed in evaluating children+ at age ., and vision evaluations should continue throughout life. 0ssess for curiosity and response to sounds of varying $uality. 0uditory brain stem response assesses hearing in infants. Sound field testing for children older than age .. Tympanometry to assess middle ear function.

vision.

%arrow ear canals and subtle immune deficiencies can cause chronic middle ear infections. Jnlarged adenoids can cause upper airway obstruction especially during sleep. Treatment can range from antibiotics for simple otitis media to myringotomy tubes, adenoidectomy, or hearing loss. ?hysical, occupational, and speech therapy. 0daptive e$uipment gives extra support to head and nec when handling neonate. 0lways eep head elevated for at least . hour after meals. 3hange position regularly. If present,

'*potonia o" in"ants +-77?,

>bserve for floppiness, poor head control, poor oral motor function. Infant should be placed on abdomen periodically while being observed and monitored for potential for suffocation. 0ssess for

Atlanto)o$$ipital an%

atlanto)a<ial s#bl#<ation +%islo$ation o" t.e #ppe! spine %#e to 8oint la<it*, +-2?,

Gait abno!malities +-2?,

Fail#!e to t.!ive

S.o!t stat#!e +-77?,

head tilt; increasing clumsiness, limping, or refusal to wal ; wea ness of arms. L( ray of cervical spine to evaluate for atlanto( axial dislocation at age 4 and then every : years during childhood. ?recise measurements are ta en to document alignment of the s ull and vertebrae. Shifting of the two can cause compression and neurologic damage. ?articipation in Special >lympics and other activities that may re$uire nec flexion should warrant a baseline evaluation. -onitor for onset of limp, leg length discrepancy. Bip L(rays can document dislocation or subluxation. -onitor growth on DS growth chart. -onitor feedings for length of feeding, feeding schedule, loss of feeding by vomiting or poor seal on nipple. -onitor type of formula and caloric content. ?lot growth on DS growth chart. -onitor stages of puberty. Delayed puberty may warrant further investigation.

participation in contact sports and gymnastics is contraindicated. In severe cases, surgery to fuse the vertebrae and occiput and stabilize spinal column.

?hysical therapy and, sometimes, orthopedic surgery are necessary. %utritionist can advise on formula ad/ustments. Therapists can help with positioning and types of nipples used to counteract effects of wea suc ing reflex and large, protruding tongue. 6se of human growth hormone may be considered; this is still controversial.

Obesit* +27?,

-onitor thyroid hormone levels. Serial monitoring of weight. -onitor for amount of exercise, caloric inta e.

Malo$$l#sions +37?)-77?,

Mental !eta!%ation :it. va!*in& %e&!ees "!om mil% to mo%e!ate +-77?, Al@.eime!As disease after age )1 *.:K(;1K+

Sei@#!es +3?,

0ssess for malocclusions, periodontal disease, delayed eruption of teeth. 5egular dental chec ups begin at age 4. 5outine developmental assessment using standardized tools of measurement. 0ssess for decreased cognitive function and loss of memory. -5I or 3T scan shows areas of pla$ue. >nset of seizures is seen primarily during adolescence and middle(age.

>verindulgence by adults or use of food in behavior management increases ris of overeating. <ac of social involvement lead to decreased activity. "ehavior modification is necessary. Jncourage good oral hygiene with proper teeth brushing.

Special education and training.

Increased supervision is needed.

%eurologic evaluation and appropriate antiseizure medications.

Ot.e! p!oblems o 3ommunication disorders o 0lopecia *.1K+ <eu emia *.K+ VSD: ventricular septal defect; AV: atrioventricular; PDA: patent ductus arteriosus; DS: Down syndrome; T3: triiodothyronine; TSH: thyroid(stimulating hormone; T4: levothyroxine; MRI: magnetic resonance imaging; CT: computed tomography.
o

Dia&nosis an% Mana&ement See 3ognitive Developmental Delay, page .A19, for a general approach to assessment.

See Table :9(4 for specific conditions re$uiring medical management related to Down syndrome, such as thyroid or cardiac problems. 0lternative therapies'nutritional and supplemental vitamin therapy for Down syndrome remains controversial, and effects have not been medically proved.

FRAGILE B SYNDROME &ragile L syndrome is the second most common identifiable cause of mental retardation as well as the most common inherited cause. Diagnosis usually is not made until mid( childhood or later. 3hromosome analysis reveals that the long arm of the L chromosome is constricted and appears fragile, but this cannot be detected in all cases; thus, D%0 analysis is preferred for diagnosis. This anomaly is seen more commonly in males; however, females can be symptomatic or may display very mild symptoms. @enetic counseling and testing of family members is necessary to evaluate recurrence ris s. lini$al Mani"estations an% Asso$iate% P!oblems -ild to moderate mental retardation Jlongated face, prominent ears, macrocephaly, high(arched palate -acro(orchidism after puberty 0utistic(li e communication disorders 0ttention deficit, hyperactivity Self(stimulating and self(in/urious behaviors such as hand biting 0ssociated problems, including mitral valve prolapse, seizures, hypotonia, and feeding problems Dia&nosis an% Mana&ement See the table below for specific medical issues related to &ragile L syndrome. F!a&ile B S*n%!ome POTENTIAL PRO(LEMS EVALUATION MANAGEMENT '*potonia o" in"an$* o 0ssess ?hysical therapy, ability to control stimulation program, head and assume feeding adaptations. upright posture.
o

Sei@#!es+/7? o" $ases,

0ssess feeding for efficient suc and coordination of suc Gswallow. 0ssess for 5eferral to neurologist for muscle tremors, diagnosis and deviation of eyes anticonvulsants to treat seizures. to one side, rhythmic /er ing of

Mit!al valve p!olapse+57? o" males,

Sel")stim#latin& be.avio!

'*pe!a$tivit* attention %e"i$its

Dis$ipline p!oblems

omm#ni$ation %iso!%e!s

Poo! a#%ito!* memo!*C a#%ito!* !e$eption

o&nitive %*s"#n$tion o S.o!t)te!m memo!* %e"i$its o Poo! p!oblem)solvin& sDills

the body, and loss of consciousness. 0ssess 0ntibiotics for prophylaxis dyspnea, cyanosis, before invasive procedures to prevent endocarditis. murmur. Jchocardiogram to Treatment of heart failure; surgical repair may be evaluate valve necessary. function. 5ule out "ehavior management source of pain *ie, techni$uesH &ocus on otitis media, tooth replacing undesirable pain+ that may be behaviors with purposeful, causing behavior. meaningful ones, with 5ule out sensory emphasis on positive reinforcement and deficits. extinguishing negative reinforcement. 0ssess "ehavior management and activity of attentionspecial educational techni$ues. span within the context of the developmental age of the child. 0ssess -ales tend to do best in self(contained classrooms social s ills. for children with similar degrees of mental retardation. 0ssess Speech(language therapy can be beneficial. language development *usually wea est area of development+. 0ssess how Speech therapy, behavior child lets needs be modification. nownH cries, gestures, single words, or sentences. 0ssess for Specialized training and appropriateness of education, assisted living. educational placement and child!s reaction to situation.

F#n$tional limitations in sel") $a!e

TURNER SYNDROME Turner syndrome is a genetic disorder found in females. There is an absence of a normal second sex chromosome. The incidence of this syndrome is approximately . in 4,:11 female live births. @enetic analysis reveals a ):, L chromosome constitution. There are typically mosaic variations seen with Turner syndrome. lini$al Mani"estations an% Asso$iate% P!oblems The most prevalent characteristics of Turner syndrome includeH o Short stature, webbed nec , low posterior hairline, edema of the hands and feet

;(year(old with Turner syndrome. %ote the webbed nec .

3ongenital cardiac defects. "road chest with inverted or underdeveloped nipples. Immature reproductive organs, primary amenorrhea. <earning disabilities. Asso$iate% p!oblems in$l#%e; o 3oarctation of the aorta, idiopathic hypertension. o Bearing loss'conductive or sensorineural. o >besity, glucose intolerance. o &eeding problems. o 5enal anomalies.
o o o o

Dia&nosis an% Mana&ement See the table below for specific medical issues related to Turner syndrome. T#!ne! S*n%!ome POTENTIAL PRO(LEMSEVALUATION MANAGEMENT on&enital .ea!t >bserve for color changes, Jarly identification and mal"o!mations; pulse, and respiratory rate at treatment can prevent o In$!ease% rest and with stress. -onitor secondary problems. If blood pressure. 0ssess needed, prophylactic in$i%en$e o" le"t) tolerance of feeding for antibiotic for subacute si%e% .ea!t early tiring or fre$uent bacterial endocarditis. anomalies o Ao!ti$ valve interruptions in feeding. 0n 5eferral to a electrocardiogram should be cardiologist. anomalies done in the neonatal period. o oa!$tation 0 yearly echocardiogram or magnetic resonance imaging o" ao!ta should also be done. Renal an% !enovas$#la! 5enal sonogram should be 5eferral to a anomalies; done to rule out anomalies. nephrologist if a renal o 'o!ses.oe 5outine urinalysis and anomaly is present. culture to screen for urinary -onitor for the Di%ne* o D#pli$ate% tract infection, glycosuria. development of diabetes mellitus. !enal pelvis o Vas$#la! anomalies E%ema in t.e .an%s an% Jdema may persist for ' "eet months or may recur; if recurrence, monitor for renal or cardiac causes. D*smo!p.i$ "eat#!es; ?arents may elect plastic Jnhances the :ebbe% ne$D> "a$e> ea!s surgery to minimize the socialization of females visual defects. with Turner syndrome in school. -ay need additional support or therapy.

N#t!ition; "ail#!e to t.!ive Infants may have inefficient %utrition counseling in t.e in"ant pe!io% an% suc ing and swallowing and encouragement of obesit* in $.il%.oo% reflexes. -onitor growth exercise to maintain utilizing a Turner syndrome appropriate weight. growth chart. 'ea!in& loss Bearing loss may be >titis media should be conductive or sensorineural. treated aggressively to 5outine screening should be minimize potential performed. hearing loss. S.o!t stat#!e an% "ail#!e to ' Jndocrine therapy may %evelop se$on%a!* se< be indicated for growth $.a!a$te!isti$s and development. Bormonal therapy may enhance the development of secondary sex characteristics. In"e!tilit* >varies are strea s of Infertility is generally connective tissue. expected in Turner syndrome. Infertility techni$ues may be able to assist with childbearing. '*pot.*!oi%ism ?eriodic laboratory testing. Thyroid hormone replacement therapy. (e.avio!al p!oblems> ' "ehavioral lea!nin& %isabilities management. Special education. St!abism#s If detected, referral to an ?atching or surgical ophthalmologist is repair. recommended. o&nitive "#n$tion 0verage to slightly below( Special education. average intelligence. ?roblem areas include spatial perception and math functions. Diagnosis may occur prenatally through an amniocentesis, with genetic testing, or any time after birth. 0 preliminary diagnosis may be made based on physical characteristics. This should then be confirmed by genetic testing. 0 diagnosis may not be made until there is a failure to begin menstruation.

PERVASIVE DEVELOPMENTAL DISORDER OR AUTISM SPE TRUM DISORDER ?ervasive developmental disorders or autism spectrum disorders are terms used interchangeably by clinicians to describe the same conditions as specified in the Diagnostic and Statistical -anual of -ental Disorders, &ourth Jdition *DS-(I=+. The

terms apply to neurodevelopmental disorders that cause characteristic behaviors as well as affect communication and impede social interaction. The disorders under this heading include autism, 5ett!s disorder, childhood disintegrative disorder, and 0sperger!s disorder as well as the category labeled ?ervasive Developmental Disorder, %ot >therwise Specified *?DD(%>S+. 06TIS0utism is a complex neurobiological developmental disorder that most typically appears during the first 4 years of life. The diagnosis of autism is based on the display of at least 9 out of .4 symptoms in three categories. The core features of autism must be present for a diagnosis to be madeH social impairment, verbal or nonverbal impairment, and repetitive patterns of behavior. 0utism is a lifelong disorder defined by the individual!s interactive difficulties. It is four to five times more common in males than females. 0pproximately A:K of people with autism are cognitively handicapped. 0utism is seen in approximately 91 to A1 per .1,111 live births. Pat.op.*siolo&* an% Etiolo&* 0 clear cause has not been identified; however, evidence suggests a genetic predisposition. Studies have shown that measles, mumps, and rubella vaccine do not cause autism. <i ewise, thimerosal, a preservative found in many vaccines, does not cause autism. "efore diagnosis, parents may be initially concerned about their infant!s interactions and reactions to various stimuli. Dia&nosis an% Mana&ement Jarly diagnosis leads to earlier interventions, resulting in improved outcomes for these children. The two ma/or diagnostic challenges in the evaluation of 0utism Spectrum Disorder *0SD+ include ma ing the differential diagnosis and searching for the etiologic disorder associated with 0SD. 3omprehensive standardized assessment tools specific for 0SD usually re$uire specialized training; these tools include 305S, 0"3, @illiam, and 0D>S. 0lternative treatments, such as nutrition and vitamin therapy, are being investigated but no definitive research has been conclusive to date. RETTAS DISORDER 5ett!s disorder presents almost exclusively in females, with manifestations following 7normal8 development. The normal period is followed by a loss of previously attained motor s ills and coordination, characteristically seen as loss of purposeful hand s ills. These regressive symptoms begin most commonly in the first or second year of life. Severe delays in expressive and receptive language development as well as psychomotor delays, may occur. 0bnormalities are detected on JJ@ for most children with 5ett syndrome. 0 clinical characteristic correlated with 5ett!s disorder is a decelerated rate of head growth between ages : and )2 months. Pat.op.*siolo&* an% Etiolo&*

There is little information about the etiology and incidence of 5ett!s disorder. The incidence of the disorder is rare. Dia&nosis an% Mana&ement The prognosis of 5ett!s disorder is limited. Some small increases in development and interactions may be achieved in late childhood and early adolescence; however, the disorder is lifelong. See 3ognitive Developmental Delay, page .A.., for a general approach to assessment. 'ILD'OOD DISINTEGRATIVE DISORDER 3hildhood disintegrative disorder follows a period of normal development, as is also seen in 5ett!s disorder. This normal developmental period lasts from ages 4 to .1. The most common age of onset is between ages ; and ). The child begins to experience a significant loss of previously ac$uired s ills. 0reas that may be affected include expressive and receptive language, social s ills or adaptive behavior, bowel and bladder control, and motor s ills. The loss of these s ills generally reaches a point at which they do not disintegrate further; at this point, some limited improvements may be seen. Pat.op.*siolo&* an% Etiolo&* Jtiology is un nown. 3hildhood disintegrative disorder appears to be more common in males. The incidence of this disorder is rare. ASPERGERAS DISORDER 0sperger!s disorder is characterized by poor peer relationships, lac of empathy, and the tendency to be overfocused on certain topics. These children will not see spontaneous interpersonal interactions. 3haracteristically, they are of average to above(average intelligence and have developed normal language s ills in terms of vocabulary and grammar. There are no significant delays in the areas of cognitive development, development of age(appropriate self(help s ills, adaptive behavior, and curiosity about the environment. 3ommon behaviors associated with 0sperger!s disorder include a limited range of interest, strict adherence to routines and rituals, and repetitious motor movements or se$uences. 0sperger!s disorder is one of several developmental disabilities associated with normal intelligence. 0cademic and functional underachievement in the preschool and school(age child with normal intelligence is the common picture. ?roper diagnosis, utilizing a cooperative team effort from several individuals, is imperative to develop an individualized treatment plan. Pat.op.*siolo&* an% Etiolo&* The etiology is un nown. 0sperger!s disorder is commonly not diagnosed until school( age. >ne study showed the prevalence of 0sperger!s disorder to be approximately ; per .,111 children. The male to female ratio is )H.. Dia&nosis an% Mana&ement

3omplete medical review, family history, and physical examination, including vision and hearing assessment and neurologic evaluation to rule out other disorders @enetic evaluation and counseling to identify the presence of recurrence ris s ?sychological testing to determine the exact nature of cognitive and perceptual dysfunctions "ehavioral and social assessment 0ssessment of academic performance -5I and other testing to determine underlying neurologic abnormality >ccupational and physical therapy, speech and language evaluations as necessary School evaluation'school psychologists will obtain IN testing and achievement testing *The teacher!s input is also essential. The focus of a school evaluation is to determine eligibility for services. -ost school systems will provide services only when moderate to severe problems exist. It may be necessary for the family to provide remediation for problems considered mild outside of the educational setting.+

PERVASIVE DEVELOPMENTAL DISORDER> NOT OT'ERWISE SPE IFIED ?DD(%>S is used when the child meets some but not all criteria for the diagnosis of autism. &or example, a young child may not meet all of the diagnostic criteria for an autistic disorder, but the diagnosis may be made later due to the appearance of additional manifestations. ATTENTION DISORDERS AND LEARNING DISA(ILITIES 0ttention disorders and learning disabilities are separate but overlapping problems and may need specific approaches based on the nature of the disability. The term 7learning disabilities8 is defined by the Interagency 3ommittee of <earning Disabilities *.,2A+ as a 7heterogeneous group of disorders manifested by significant difficulties in the ac$uisition of listening, spea ing, reading, writing, reasoning, or mathematical abilities, or of social s ills.8 0n estimated :K to .1K of children *ranging up to ;1K+ have attention deficit hyperactivity disorder *0DBD+; learning disabilities are reportedly present in .4.9K of children by the end of the second grade. -ales are diagnosed twice as commonly as females *girls may go undiagnosed because they are less li ely to exhibit disruptive behaviors+. Pat.op.*siolo&* an% Etiolo&* -ultiple hypotheses exist because the exact causes are un nown; may be genetic. o 0 family trait'other members of the family have similar difficulties. o 3haracteristic of inborn errors of metabolism. o Sex chromosome abnormalities commonly exhibit these traits. %ot shown to be associated with a history of birth trauma or brain damage. Jxposure to prenatal and postnatal factors that might adversely affect brain development and function'lead, alcohol, cocaine, central nervous system *3%S+ infections, low birth weight, and prematurity.

-ay coexist with other disabling conditions, such as spina bifida, cerebral palsy, or seizure disorders. -ay have biomedical, emotional, social, and environmental components. 0DBD is an alteration in the response(inhibition mechanisms of the brain controlled by the frontal cortex and reticular activating system; alteration in neurotransmitter. <earning disabilities'authorities are investigating abnormalities in the parietal lobe of the brain and in the central visual pathways located in the occipital lobe. 0lthough emotional and environmental factors play a role, serotonin deficiency may serve as a physiologic basis for these disorders.

ATTENTION DISORDERS 0ttention disorders are characterized by a cluster of symptoms, including developmentally inappropriate short attention span, impulsivity, and distractibility. Three subtypes of attention disorders are the hyperactive(impulsive type, the inattentive type, and combined. It is a diagnosis of exclusion; other disorders associated with these symptoms must be ruled out before a diagnosis of attention disorder can be made. Bearing and vision impairments, seizures, mental retardation, learning disabilities, adverse effects of medications, lead poisoning, and psychiatric disorders are /ust a few that need to be ruled out. <earning disabilities and 0DBD commonly occur together. lini$al Mani"estations an% Dia&nosti$ Eval#ation Gene!al (e.avio! "ehavior varies slightly based on the child!s age. ToddlersH constant movement, described as 7into everything8; may have focused attention in highly motivated situations. School(ageH fidgety, easily distracted, does not finish tas s, loses things; school achievement is below child!s potential. 0ttention disorders may be diagnosed as late as college(age or adulthood with prominent difficulty to focus. Dia&nosti$ !ite!ia "o! AD'D The child must experience a disturbance for at least 9 months and exhibit 2 of the following .) symptoms. Does the child often fidget with hands or feet or s$uirm in seatI Does the child have difficulty remaining seated when re$uired to do soI Is the child easily distracted by extraneous stimuliI Does the child have difficulty awaiting his turn in games or group situationsI Does the child often blurt out answers to $uestions before they have been completedI Does the child often have difficulty following instructions from othersI Does the child have difficulty sustaining attention in tas s or play activitiesI Does the child often shift from one uncompleted activity to anotherI Does the child have difficulty playing $uietlyI Does the child often tal excessivelyI

Does the child often interrupt or intrude on othersI Does the child often not seem to listen to what is being said to himI Does the child often lose things necessary for tas s or activities at school or at homeI Does the child often engage in physically dangerous activities without considering possible conse$uencesI

Mana&ement M#lti%is$iplina!* App!oa$. 0 multidisciplinary approach, including environmental and behavioral approaches, is the treatment of choice . P.a!ma$olo&i$ T!eatment NS stim#lants a!e e""e$tive "o! 47? to 42? o" $.il%!en :it. AD'D +!ese!ve% "o! $.il%!en ol%e! t.an a&e 4,= o Jffective in decreasing motor activities and increasing attention span and concentration, thereby allowing the child to be more available to learn. o -edications used include methylphenidate *5italin+, dextroamphetamine *Dexedrine+, dextroamphetamine and amphetamine *0dderall+, pemoline *3ylert+, clonidine *3atapres+ and atomoxetine *Strattera+. A%ve!se e""e$ts; o Insomnia may result from increased dosage or if administered too late in the day. o 0norexia, weight loss, hair loss, and temporary growth retardation. o Increased pulse and respiratory rates, nervousness, nausea, and stomachache. o <iver dysfunction *pemoline+H periodic liver function tests are re$uired. o 0ltered effects of many antiseizure drugs and tricyclic antidepressants. o Do not cause euphoric effect or addiction in children N#!sin& Responsibilities an% Famil* E%#$ation 0dminister the drug before brea fast and lunch *sustained(release forms do not re$uire a lunch dose+. #or with school system to ma e sure that the lunch dose is given. 3onsider 7drug holidays8 during vacations and on wee ends to monitor effectiveness and the need for a dosage change; this is especially recommended at the start of each academic school year. Stimulant drugs are not usually given to children younger than age 9. The child is usually started on a small dose, which is gradually increased until the desired response is achieved. Jvaluate the child!s response to the drug by direct observation and consultation with others, such as the parents and teachers. DRUG ALERT Stimulant drugs for attention disorders should be used in con/unction with a comprehensive therapeutic regimen and not as the sole method of treatment. Stimulant

drugs re$uire monitoring and feedbac from the parents and teachers who directly observe the effects. LEARNING DISA(ILITY Difficulties with academic achievement fall under a broad category of learning problems. The cause or influencing factors can be biomedical, developmental, behavioral, emotional, social, environmental, and family issues. The problem may be in the area of reading, math, written expression, motor s ills, and communication disorders. 0ttention deficit, anxiety, and behavioral disorders must be ruled out. lini$al Mani"estations Signs of learning disabilities includeH o School achievement significantly lower than potential. o ?erceptual(motor impairments. o Jmotional lability. o Speech and language disorders. o 3oordination deficits. There can be a wide range of cognitive ability from mild retardation to above( average intelligence. A!eas o" Lea!nin& Disabilities A#%ito!* Pe!$eption 0uditory perception is characterized by difficulty distinguishing between similar sounds or words. This includes the inability to process the sounds into words that have a meaning at a rapid enough rate to be able to follow conversations. Vis#al Pe!$eption =isual perception difficulties involve problems interpreting what is seen. This may include problems recognizing shapes and positions of letters or words. Depth perception may pose a problem to some children with visual perception disorders. Inte&!ative P!o$essin& Integrative processing disabilities encompass, to varying degrees, the inability to se$uence events or facts; comprehend abstract ideas or implied meanings; and organize learned information and apply it to what has been previously ac$uired. Memo!* Disabilities generally affect short(term memory, which stores information that has /ust been perceived for a brief period before it is either discarded or stored in the long(term memory. E<p!essive Lan&#a&e This disorder affects the child!s verbal communication. 3haracteristics depend on the child!s age and the severity of the disorder. <anguage s ills in terms of vocabulary, grammatical content, fluency, and language formulation can be affected. Moto! -otor disabilities can affect either gross motor or fine motor muscle groups. 0 disability affecting the gross motor development can cause children to be 7clumsy.8 These children have a tendency to fall or bump into things and have difficulty running and playing

sports. &ine motor disabilities affect muscles for detailed tas s, such as writing, using scissors, and painting. Mana&ement an% Spe$ial Tea$.in& St!ate&ies &or visual perceptual deficit'present material verbally; use hands(on experience; tape(record teaching sessions. &or auditory perceptual deficit'provide materials in written form; use pictures; provide tactile learning. &or integrative deficit'use multisensory approaches; print directions while you verbalize them; use calendars and lists to organize tas s and activities. &or motor and expressive deficits'brea down s ills and pro/ects into their multiple component parts; verbally describe the component parts; provide extra time to perform; allow the child to type wor rather than use cursive writing. &or highly distractible child'provide a structured environment; have child sit in the front of the class; place child away from doors or windows; decrease clutter on his des . NURSING ALERT Bistorically, preschool and indergarten screening tools have not been accurate in predicting learning disabilities; newer tests of language and memory are better predictors.