LEARNING DISABILITIES IN CHILDREN

DEFINITION Those [children] with a disorder in the basic psychological process involved in understanding or in using language,spoken or written .the disorder may manifest itself in the imperfect ability to listen, speak,read,write, spell or do mathematics.disorders include perpetual mhandicaps, brain injury, minimal brain dysfunction,dyslexia and developmental aphasia. The term does not include children whose learning problems are primarily the result of visual, hearing or motor handicaps , of mental retardation, of emotional disturbance or of environmental, cultural or economic disadvantage. ( The Law And Disabled People, 1980) Kinsbourne and caplan (1979) subdivided this diagnosis into: Attention deficit disorders& Specific learning disabilities.

ATTENTION DEFICIT DISORDERS

DEFINITION Attention deficit disorders reflect a problem of selecting what to attend to and of maintaining concentration in that area, that is, attention may be over focussed or under focussed. ADHD is a symptom complex characterised by poor ability to attend to a task, motor overactivity and impulsivity. These children are not primarily mentally retarded or autistic. INCIDENCE ADHD affects 3-4% of children in USA. Boys are more affected than girls in the ratio 6:1.ADHD persists into adolescents and adult life. Age of onset is usually before 4 years but diagnosis is made around 3-4 years of age. Statistical data is not available for Indian children, experts agree that it is roughly trhe same % as in the western population. ETIOLOGY Exact cause : unknown

OVERFOCUSSED ADHD When attention is over focussed or compulsive; such children concentrate so long on one thing that they fail to learn enough overall. The problem is in actually encountering the change rather than being unmotivated or cognitively incapable of the change. FEATURES They can think well, but they concentrate too long in one area. They appear socially withdrawn and anxious, fearful. When stressed , they may respond with stereotypic mannerisms such as nail biting, twitching, head banging or rocking. They are quiet and do not seek attention, so their problems are likely to go unnoticed.

UNDERFOCUSSED ADHD Children suffering from this type of attention deficit disorder are overly impulsive and are therefore unable to maintain their focus long enough to learn. Extreme impulsiveness is referred to as hyperactivity or hyperkinesis The problem is not with cognitive capacity or innate intelligence; it is considered an immaturity with respect to intensity and duration of concentration. These children shift their attention very quickly from one task to the next, often with out completing the first. This impulsiveness is noted in any behaviour requiring focussed attention, not limited to learning situation. MANIFESTATIONS Motor behaviour Feeding problems like gulps food, swallows air; resulting in symptoms infantile colic Short sleep periods awakens after a few hours of sleep with out being wet or hungry Intense response to stimuli explores to get into everything, easily distracted and startled, at high risk for injuries Excessive movement difficulty sitting still, constantly shifts positions, tendency to rush everywhere

Problem solving Difficulty maintaining focus does not finish tasks, appears not to listen, moves quickly from one task to next Impulsive decision making decision making process is overtly obvious, jumps to conclusions, poor academic performance

Interactional style Poor peer relations imposes needs on others, socially aggressive, abrupt, controls situations through attention seeking behaviour Poor parental relations responds to discipline with temper tantrums, heedlessness, whining;seems to always be in trouble Low frustration tolerance constantly seeks attention, evokes resentment from others

Delinquent behaviour

Usually develops in adolescents, due to inability to gain attention and peer relations in more appropriate ways

Emotional style Shallow communications inability to focus attention and has poor peer relations, tends to deny problems when they blatantly exist

Egocentric existence Low self esteem

intense response to constant stimuli feels like a dummy, feels unliked, feels cannot do anything well and always being punished

Poor impulse control

cannot control impulses in behaviour, thoughts actions and relationships

MANAGEMENT Parent counselling Provide understanding and direction by preserving the childs self esteem Focus of management: organise life and discipline. Structured behavioural modification program for increasing attention span, proper disciplining should be adopted: child on special program in school.

Treatment Methyl phenidate, dextro amphetamine, magnesium pemoline and tricyclic anti depressants: [ needs liver functions to be monitored] Reduce over activity, increase attention span, improves interaction between child and mother.

HEALTH EDUCATION Explain the problem; help parents to understand the problem and accept the childs condition That the hyperactive behaviour is not intentional. That the attempts to change an energic child into a quiet socially acceptable, may seem and prove to be difficult. These children need to be provided with outdoor activities; play with minimal instruction would be beneficial. Organise the life of these children to get adequate rest and sleep. A structured home schedule for daily activities like wake up time, meal time, bed time etc should be followed with consistency. These children need a carefully planned discipline to be followed. Aggressive behaviour such as biting, hitting, pushing should not be tolerated All risks must be enforced with non physical punishment. Overwhelming situations such as big gatherings should be avoided till child learns to control himself

SPECIFIC LEARNING DISABILITIES [LD]

This group of diagnoses refers to children with a particular deficit in ability to acquire age appropriate reading, arithmetic, language or articulation skills. LD is suspected when there is unexpected underachievement in adequate educational settings. DEFINITION LD is defined as a disorder in one or more of the basic psychological process involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, speak, read, write, spell or to do mathematical calculations. CAUSE According to Kinsbourne And Caplan(1979) , specific learning disabilities are best viewed as resulting from a selective developmental lag. Preasumably the brain area relevant to a specific skill acquisition is slow to mature, so the child is unready and unable to perform the required behaviour. A learning disability is generally considered a lag of 2 years behind grade expectancy in a specific subject area ( walzer and Richmond, 1973) ETIOLOGY Neuro biologic or other intrinsic factors are often implicated in etiology. It is not caused primarily by cultural, educational, environmental and socio economic factors, or by other disabilities ( mental deficiency, visual or hearing impairments or emotional disturbance) Factors associated with increased risk for LD include First degree relative with dyslexia PEM Lead exposure and Pre natal cigarette exposure

MANIFESTATIONS Children with specific learning disabilities usually have a cluster of symptoms, such as Attention deficits (hyperactivity) Impulsiveness Distractability, Labile emotions, Poor motor co-ordination, Perceptual deficits and Poor peer relations.

TYPES OF DEVELOPMENTAL DISORDERS Developmental Developmental Developmental Developmental reading disorder arithmetic disorder language disorder [expressive/receptive] articulation disorder

DIAGNOSIS Identifying discrepancy between ability IQ and achievement

Screening for LD includes: Detailed history : medical & developmental history Physical and neurologiacal examinations, Ancillary diagnostic studies Psychologic evaluation, Informed perceptive interaction with child & Observation of the child during interaction with others

MANAGEMENT Focus is remediation. Special reading programs needs to be designed including use of computers. To learn to read children must discover that spoken words can be broken down into a smaller unit of sound, that letters on the page represent these sounds and written words have the same number and sequence of sounds heard in the spoken word Requires practice in reading stories Allow enough time to decode each word Provision of computers with spelling checkers, tape recorders and recorded books. NURSING MANAGEMENT The overall goals of nursing management for the family are to assist them To achieve a comprehensive understanding of the diagnosis and its sequel To be aware of the laws and available community services for children who have learning disabilities To promote coping strategies to deal with life stresses that may be compounded by a learning disability and for the child To develop internal means of self-control,& To remain free of insults and injuries from the environment

Provide education and support to prevent hopelessness and guilt among the family members Prepare the parents for home care Administer the medications, monitor for adverse reactions and educating the parents to do the same. Family therapy: to help family cope with stress and guilt Need of family members to participate in the therapies Help the parents to obtain support and information from community organisations Parents and other family members should be encouraged to attend a support vgroup Use the family as a resources when caring for the child PROGNOSIS The prognosis for success in school and for later adjustment is related to the age of detection, severity of the disorder, available family support systems, associated emotional problems and access to appropriate educational resourses. Although many learning disabled children have a very difficult time during the school years, by adulthood most of them have learned to cope reasonably well. As adults, however some continue to be impulsive and to have impaired self esteem. Only a minority of adults have serious anti social behaviour or serious psychopathology. PREVENTION The prevention of learning disability lies in the early identification of at risk children, improved detection or diagnostic techniques, and appropriate special education programs to provide the attention they need. BIBLIOGRAPHY Hockenberry .M.J. Wongs Essentials Of Paediatric Nursing,7th edition:Noida,2007 Marlow D R, Redding B.A.Textbook of Paediatric Nursing,6th edition: Noida,2008 Parthasarathy A.IAP Text Book Of Paediatrics,4th Edition: New Delhi , 2010 Ghai O.P. Essential paediatrics, 6th edition:New Delhi,2007 Nelson.Text Book Of Peadriatrics, volume 2: second edition,2008