Language and Learning Disorders

Dr. Lynda Albertyn Very common 10-20% of a child or adolescent population will have a language and/or learning disorder (L.L.D.) REFERRAL occurs because of: Academic under-achievement Behavioural difficulties at school Conflict at home over homework Emotional/behavioural problems co-morbid with or associated with the learning disorder Somatic complaints Performance anxiety, poor peer relationships, family conflicts, decreased self-esteem are common in children with L.L.D.s. In many, the L.L.D. may not have been recognised and if it is, its bearing on the problems may not have been realised. The primary problem is usually the learning disorder and associated scholastic difficulties, the emotional, social and family problems are secondary. NOT vice versa. These problems are likely to emerge as academic tasks become more complex and as peer interactions and status become more important.

LEARNING DISORDERS
Types of Learning Disorders:
Axis I, DSM-IV, diagnosis includes: Reading Disorder (Dyslexia) Mathematics Disorder Disorders of Written Expression Learning Disorders N.O.S. Developmental Co-Ordination Disorder Communication Disorders: Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Phonological Disorder Stuttering Communication Disorder N.O.S. These disorders are a reflection of a dysfunctional nervous system. This dysfunction results in a discrepancy between the child or adolescents potential ability and his/her actual academic performance as expected for age, schooling and level of intelligence.

The learning problems significantly interfere with academic achievement or activities of daily living that require these skills. Mental Handicap and Learning Disorders are diagnosed by administering standardized tests (e.g. IQ tests and specific Reading and Spelling tests).

CULTURAL FACTORS
Care should be taken that intelligence testing procedures reflect adequate attention to the individuals cultural or ethnic background. Ideally tests should be used in which the individuals relevant characteristics are represented in the standardized sample of the test or by employing an examiner who is familiar with aspects of the individuals ethnic or cultural background.

ONSET
Learning Disorders are diagnosed in childhood at the age at which the function is expected to develop i.e. language disorder at +/- 2 years and reading disorder at school age. The acquired type can onset at any time. Children with high IQ.s may compensate and the disorder only becomes apparent at 9 years old or later when academic tasks become more complex. Mental Handicap is also recognized and diagnosed according to the severity of the condition e.g. severe is diagnosed very early, whereas mild is usually only diagnosed when school failure occurs. All Learning Disorders and mental handicap are present at birth.

LEVELS OF INTELLIGENCE
MENTAL HANDICAP: DSM-IV
IQ of +/- 70 or below. Concurrent deficits or impairments in present adaptive functioning i.e. meeting the standard expected for his/her age by his/her cultural group in at least two of the following skill areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional/academic skills, work, leisure, health and safety. Mild M.H. I.Q. level 50-55 to +/- 70 Moderate 35-40 to 50-55 Severe 25-30 to 35-40 Profound below 20 or 25 In mild M.H. the level of achievement in reading, mathematics or written expression can be significantly below expected levels given the persons schooling. Learning disorder can be diagnosed in those children.

Degree of Mental Handicap Mild

School Age

Adult

Can learn academic skills to +/6th grade level by late teens: can be guided towards social conformity Can profit from training in social and occupational skills: unlikely to progress beyond 2nd grade level in academic subjects. May learn to travel alone to familiar places Can talk or learn to communicate; can be trained in elemental health habits; profits from systematic habit training; unable to profit from vocational training Some motor development present; may respond to minimal or limited training in self-help

Moderate

Severe

Profound

Can usually achieve social skills adequate to minimum selfsupport but may need guidance and assistance when under unusual social or economic stress May achieve self-maintenance in unskilled or semi-skilled work under sheltered conditions. Needs supervision and guidance when under mild social or economic stress May contribute partially to selfmaintenance under complete supervision; can develop selfprotection skills to a minimal useful level in controlled environment Some motor & speech development; may achieve very limited self-care; needs nursing care

DIFFERENTIAL DIAGNOSIS
Normal variations in academic achievement Lack of opportunity, poor teaching or cultural factors such an inadequate schooling. Second language, or different ethnic or cultural background Concurrent emotional or behavioural disorders Environment factors such as an impoverished or disorganized home, abuse or neglect, excessive school absences, frequent school changes. Medical or neurological disorder (including certain medications).

Psychiatric disorders that may lower the I.Q., performance or academic achievement include; ADHD (Attention Deficit hyperactivity Disorder) may perform poorly in certain subtests and thus lower overall I.Q. Mood disorder Anxiety Disorder

RECOGNISING DYSLEXIA (READING AND SPELLING DISORDER)

These children may be puzzling because they have abilities in some areas and difficulties in others: They may have been late in talking and possibly crawling and walking. They may present with poor self-esteem, bad behaviour and physical symptoms such as headaches, stomach aches, bed-wetting and other symptoms that often appear after starting school.

The following may cause difficulty in young dyslexic children: Remembering two or more instructions in sequence. Catching a ball (moving object), although they may be able to manipulate objects (e.g., Lego) quite easily. Dressing in the right order, tying shoelaces and sequencing buttons. Naming objects correctly. Remembering nursery rhymes and jokes. Clapping in rhythm. Recognising similarities in rhyming words or parts of words. Using spoonerisms for example par cark. These difficulties can continue into school and may present as: Particular difficulty in learning to read, write and spell. Reversing figures and numbers e.g. 15 for 51, 6, b, d, or was for saw. Difficulty in learning multiplication tables, musical notation and foreign languages. Failure to recognise a word that has previously been read correctly. Spelling words in different ways, together with the inability to recognise the correct version. Poor concentration when reading and writing. Confusing left and right. A lack of understanding of time and tense. Difficulty in answering questions on paper, although having no verbal difficulty. Tiring more quickly than a normal person because of the greater concentration required. Being disorganised in work and life. Some may present a picture which is normal for a younger child e.g. a 9 year old child may be exhibiting the reading skills of a normal 6 year old child.

AETIOLOGY OF LEARNING DISORDERS

Genetic these problems tend to run in families. The probability of a boy becoming dyslexic if his father is dyslexic can be as high as 50%, it is somewhat lower for a girl. Strong family history of specific language difficulties is common. Neurobiology Recent research has shown abnormalities in various regions of the brain and defects in processing of the visual system. A hostile foetal environment, maternal antibodies, viruses, toxins, drugs and chance all play their part. These alterations are found in the second half of gestation. Disorders of reading, maths and written expression commonly occur together. Reading disorder is often associated with language and phonological disorder. Children with early language disorders, even if they develop normal language later in life, are at risk for learning disorders. Many children outgrow their problems but may never develop a normal skill level in the impaired area.

CO-MORBID DISORDERS
Include: ADHD Conduct Disorder Oppositional Defiant Disorder Anxiety and Mood disorders children fear exposure, humiliation in front of peers, punishment from teachers and parents and being a disappointment, they may become demoralised, avoidant. School drop-outs are 50% greater than average. The sense of frustration and failure occurs in both the child and parents. There is a strong link between school failure and juvenile offending.

ASSESSMENT
Careful description of the childs symptoms and areas of difficulty. Detailed developmental history. Family records from pre-school onwards. Direct or phone interviews with teachers. Child interview about how they see their own problems, conflict with parents or others over school, attitude to peers and socialization. Check vision, hearing. Rule out other physical causes. Psycho-educational testing. Identify areas that need intervention such as conflict with parents over homework, parental accusations that the child is lazy, unmotivated, slow, too playful.

TREATMENT
Must establish realistic goals. Educate where lack of understanding exists about the nature of the childs difficulties.

MULTI-MODAL:
Occupational therapy Speech therapy REMEDIAL teaching Managements/treatment of other co-existing problems e.g. methylphenidate for ADHD. Do what is needed in all areas, but establish priorities. Do not overload the child. These children are especially in need of time for play, sport and socialization. Any area of competence such as soccer or art should be encouraged.

The earlier the intervention the better the outcome e.g. in reading disorder no remedial education before 8 years leaves children reading impaired in later years. The course is stable over time. Children dont catch up over time. The mild L.L.D.s may however, resolve completely. However, untreated or more severe learning disorders can result in a lifetime of frustration, pain and under-achievement.

EPILEPSY AND LEARNING DISORDERS

May be co-existent due to the same underlying neurological abnormality. Medication for the epilepsy may result in drowsiness and cognitive impairment, which presents as a learning disorder. Petit Mal epilepsy may present as a learning disorder as the child misses much of what is being learned due to absence seizures. Temporal Lobe Epilepsy (Partial Complex Seizures) may cause episodes of diminished consciousness and odd moods which can affect learning.

Most children with epilepsy, who are well controlled on medication, do not have learning disorders or mental handicap.