Learning Disabilities: Part I
The following excerpt is taken from Chapter 9 of Hydrocephalus:
A Guide for Patients, Families, and Friends by Chuck Toporek &
Kellie Robinson, copyright 1999 by O'Reilly & Associates, Inc. For
book orders/information, call (800) 998-9938. Permission is granted
to print and distribute this excerpt for noncommercial use as long
as the above source is included. The information in this article is
meant to educate and should not be used as an alternative for
professional medical care.
Some children with hydrocephalus are affected adversely when it comes to school. Birth defects, brain tumors, trauma, and increases or extreme fluctuations of intracranial pressure (ICP) can cause damage to sensitive areas of the brain that help us learn to speak, read, write, and reason, as well as to perform well in subjects such as math, science, and language development.
What may seem like a routine task to others may seem like an insurmountable task for your child. When a child is confused by what he is supposed to be learning, and is not receiving appropriate instruction to help him meet his educational needs and goals, he may lose interest in school very quickly.
Common learning disorders of children with hydrocephalus include:
- Attention deficit disorder (ADD).
- Nonverbal learning disorder (NVLD).
This section briefly examines these two learning disorders, how they can be diagnosed, and how they affect children and adults with hydrocephalus.
Attention deficit disorder, or ADD, is a mental disorder that is primarily diagnosed in childhood. However, ADD can also be found in adults who probably had the disorder as a child, but it went unnoticed until later in life when it was clinically diagnosed. In children, ADD may also be referred to as attention deficit hyperactivity disorder, or ADHD. There really isn't much of a difference between the two labels; however, ADHD is more commonly used when referring to children who have more hyperactive character traits.
Characteristics of ADD and ADHD
Children and adults with ADD typically have an increased level of hyperactivity and a significantly reduced attention span. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the criteria for diagnosing someone with ADD or ADHD are as follows:
- Inattention. At least six of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
- Often has difficulty sustaining attention in tasks or play activities.
- Often does not seem to listen to what is being said to them.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
- Often has difficulties organizing tasks and activities.
- Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort.
- Often loses things necessary for tasks or activities (e.g., school assignments, pencils, books, tools, or toys).
- Is often easily distracted by extraneous stimuli (such as peripheral noises or people walking by).
- Is often forgetful in daily activities.
- Hyperactivity-Impulsivity. At least four of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that they are maladaptive and inconsistent with developmental level:
- Often fidgets with hands or feet, or squirms in seat.
- Leaves seat in the classroom or in other situations in which remaining seated is expected.
- Often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
- Often has difficulty playing or engaging in leisure activities quietly.
- Often blurts out answers to questions before the questions have been completed.
- Often has difficulty waiting in lines or awaiting his turn when playing games or in group situations.
Additional terms for properly diagnosing ADD/ADHD include:
- Onset must be no later than age seven.
- The above-mentioned symptoms must be present in two or more situations (e.g., at school, work, and at home).
- The disturbance causes clinically significant distress or impairment in social, academic, or occupational functioning.
- Symptoms do not occur exclusively during the course of pervasive personality disorder (PPD), schizophrenia, or other psychotic disorder, and are not better accounted for by mood, anxiety, dissociative, or personality disorder.
Once you or your child has been diagnosed as having ADD or ADHD by a trained psychologist or neuropsychologist, it is important to follow the course of treatment offered. Children and adults who have ADD/ADHD are also at risk for secondary problems. These include behavioral problems and learning disorders (verbal and nonverbal), as well as a variety of interpersonal and social problems as a result of their activities.
Treating ADD requires a variety of different approaches, including medication and psychosocial therapy to help manage abnormal behavioral patterns. The most common form of medication used for treating ADD is Ritalin. Ritalin is a mild stimulant that affects the central nervous system (CNS), and is usually prescribed as part of a comprehensive treatment program.
I was shunted for hydrocephalus in 1956. I was also put on Ritalin in 1963 at the age of 7. My ADD was really out of control. My IQ was tested in the genius range, but I couldn't get any work done, couldn't even stay in my seat. That this might have been even partially attributable to hydrocephalus was not looked into at the time. There just weren't any resources available. Although my ability to organize and pay attention never got much better, I was able to attend a prestigious college and earn a degree.
Parents of children with ADD/ADHD will also need to be instructed on what to do to help change their child's behavioral problems. Additionally, some psychologists recommend family counseling to educate the entire family about what they can do to help the family member with ADD/ADHD.
Shannon's teachers first approached us when she was in kindergarten, saying they thought she had attention deficit disorder (ADD). We didn't really know that much about it, but had heard the term before. We took Shannon to see our family doctor, who recommended we take her to a local psychologist for evaluation. After some testing, the psychologist came back and told us that Shannon indeed had ADD. His first course of action was to place Shannon on Ritalin-SR (slow-release), and recommended some family counseling to help us help Shannon adjust her behavior. At first, we thought this was kind of odd, but it really helped in many different ways.
Early intervention and treatment will ensure that children with ADD or ADHD can overcome many behavioral problems and go on to lead productive, successful lives.
Nonverbal learning disorder, or NVLD, is a type of learning disability that affects the child's academic progress, as well as social and emotional development. A nonverbal learning disorder means that the child has the ability to learn tasks that are explained to him verbally, but has difficulty visualizing complex problems that require intense concentration.
What causes NVLD?
Deficits in the function of the right hemisphere, which can be observed in children with NVLD, could emerge in a variety of ways. If there is any early interruption in the development of the central nervous system (CNS), the right hemisphere is more likely to be compromised than the left. Direct damage to the right hemisphere--through trauma, tumors, and/or seizures--can reduce the hemisphere's ability to function properly, creating a situation where the left side of the brain compensates for most of the learning functions that would normally be performed by the right.
As described in Chapter 1, What Is Hydrocephalus?, the right hemisphere of the brain receives sensory data (things you see, hear, smell, taste, and touch) and is capable of processing this information all at once. When someone talks to you, the right hemisphere not only processes the words that are spoken, but also cues in on any visual responses (such as facial expressions and hand gestures). The combination of words and visual messages gives the spoken words different meanings.
The role of the left hemisphere is for processing instructions and information. Children and adults with NVLD might have a hard time following instructions unless they are presented in a step-by-step manner. For example, your child may need to be told how to do something a few times, or even have detailed instructions written out for him to follow. However, once he has it down and committed to memory, the task can be recalled without him fully understanding the reason why he is doing something a certain way. This is commonly referred to as practiced and rote--if you were to ask your son to tell you how to do something, he can probably recall all of the steps from memory, but may not be able to tell you why each task was done a certain way or in a particular order.
Nonverbal learning disorders are caused by the conflict of message interpretation between the two sides of the brain. The right side of the brain manages the interpretation of visual (or nonverbal) information, while the left side of the brain tries to process the words that are heard. Instead of being able to interpret both the spoken word and visual responses, the right hemisphere cues in only on visual input, and leaves word interpretation to the left hemisphere. Since the left hemisphere isn't able to process visual input, the words heard often go without meaning since the brain has to interpret both speech and visual responses on the same side of the brain. Therefore, in children with NVLD, the right hemisphere becomes involved in understanding anything new or contradictory between the verbal and nonverbal messages.
Characteristics of NVLD
A valid diagnosis of NVLD includes a combined evaluation of learning, academic, social, and emotional issues. While most children with learning disabilities do not have significant problems with normal social and emotional development, others may not be so fortunate. Since some children with NVLD may have difficulties processing words and complex thoughts along with visual responses from the people they are talking to, they might tend to have a difficult time in social situations. Because the pattern of academic strengths and weaknesses may not show up early in life, and difficulties with social relations are not always apparent in very young children, it is often difficult to make a diagnosis of NVLD until the child is in middle to late elementary school (grades 3 to 6, or age 8 to 11).
Children with NVLD have difficulty with mechanical arithmetic, particularly more complex math involving columns, such as long division or complex multiplication problems.
Brian always excelled when it came to English. He was always getting As for his creative writing. But when it came to math, the teachers just couldn't figure him out. Brian had no problem with simple math--adding, subtracting, and basic multiplication or division. This meant he was fine through first, second, and third grade. But when Brian hit fourth grade and started working on long division and multiplication with larger numbers, it was like his brain shut off. You could see it in his face when he was doing his homework. With some math problems, it would take 15 or 20 minutes to figure out the answer on what I saw as a simple multiplication problem. The worst, however, was long division, especially when decimals were involved.
Children with NVLD also have difficulty with word problems or math reasoning, being unable to read a math problem and know what operation to perform. Higher math skills that rely on spatial abilities or seeing the relation between concepts (as with geometry or algebra) are more difficult for children to learn.
Brandon's teacher first thought he had NVLD when he began having difficulty understanding story problems in math class (where they give you a paragraph of information on which to perform mathematical computations). He could read the paragraph quite well and understood there were numbers involved, but couldn't see how to take a number mentioned in one part, multiply it by something in another sentence, and then divide it by a fractional amount of something mentioned in the last sentence.
I always did well with math through elementary school, and even junior high, but when I got into high school, everything changed. In ninth grade, I was required to take algebra. I know algebra is fairly complex, but I really bombed. It was the first time I got a D grade in math my entire life. My parents thought I was slacking off--spending too much time socializing instead of studying--but that wasn't the case. I spent hours toiling over those equations and just couldn't get it. It took me sitting down with a math tutor, who explained everything step by step, before I started to get it. Unfortunately, by the time I got the math tutor, I'd already scored a D and a D+ in the first two quarters.
In addition to having difficulty with language comprehension and math, children with NVLD also have problems in learning and interpreting speech patterns. At first, some children may be slow to learn how to speak, but then show rapid progress, becoming quite verbose. This speech pattern is commonly referred to as "cocktail party syndrome," because although the children are quite talkative, there may be little substance or value to what is being said, and they may speak out of context or for no reason at all. Compared with other children their age, children with NVLD tend to rely more on language to engage and relate to other people, to gather information, and to relieve anxiety. For instance, when young, instead of picking up and manipulating an object new to them, they may instead question an adult about what it is, how it works, etc.
We always thought our daughter, Emily, was like a Chatty-Cathy Doll--just pull her string and let her natter away. When she was younger, we thought it was cute. But as she got older, we started to notice that she was saying things that were inappropriate, particularly when she was around a bunch of new people for the first time.
Humor or sarcasm can also be hard for children with NVLD to appreciate. Sarcasm, which is a mismatch of spoken messages, facial expressions, or tone of voice, requires the child to integrate types of sensory input. As such, they tend to miss the meaning of most jokes because they are missing the verbal and visual cues, and are paying too much attention to piecing together the words that are spoken.
Helping your child progress with NVLD
There are some things you as a parent, or your child's teachers, can do to help your child learn, regardless of the extent of NVLD:
- Children with NVLD do best with instruction that is verbal and descriptive in nature. Instead of showing your child how to work out a particular math problem, instruct him verbally on how to do it step by step.
We started to notice that Brian's math skills improved when we carefully walked him through the math equations step by step. We made a point of explaining each step of how the math problem should be worked out, and why we were doing it that way.
- Assess reading comprehension carefully because good oral reading can hide the extent of weak comprehension. Teach strategies to aid comprehension, such as learning how to identify the topic of a sentence and highlighting important information for later study or review. Tell your child what specific facts he will need to know for a test rather than asking him to determine on his own what important information within the text or lecture he should focus on.
Amy's English teacher noticed she was having trouble with comprehension quizzes after reading almost anything. She worked with Amy after class, showing her how to break the sentences of a paragraph apart separately so she could glean the overall concept that was being discussed.
- Because language concepts can be weak, children with NVLD need to understand terms such as "same" versus "different," part-to-whole relationships (fractions), how to classify or categorize objects, and the difference between cause and effect. In expressive language instruction, they should focus on staying on the topic, listening without interrupting, and recognizing when someone has signaled the end of a conversation.
Jake's biggest problem was not knowing when to shut up. If his teacher or another child got him started on a topic, he would keep going, then head off on a tangent. It was also difficult for anyone to get a word in edgewise. We worked with Jake's teacher on teaching him the proper etiquette for holding a conversation or talking in a public setting, assuring him that he wasn't being bad, just that it would be nice to allow the other person to talk back to him.
- The concept of spatial concepts and relations may also be difficult to grasp for a child with NVLD. The child may need to learn verbal self-instruction for analyzing and reproducing designs. Certain tasks, such as map reading or learning the location of all the capital cities, should be avoided altogether. If telling time on a clock with a face is difficult for your child to learn, try teaching him first how to tell time using a digital clock.
Whenever my wife and I go on vacation, she's the driver and I'm the navigator. I'm the one who sits in the co-pilot's seat with the maps and tells her where and when to turn because maps are too confusing for her to look at. She says that she first noticed this problem when she was a Girl Scout and was trying to learn how to read maps before a camping and hiking trip.
- Written work can be extremely frustrating due to the combination of mechanical problems related to fine motor delays and poor visual spatial relations. Educators and parents alike should aim to reduce the quantity of writing expected and instead allow verbal expression of information. Additionally, by teaching your child computer keyboard skills at an early age, you can help him improve his motor skills.
Mike's IEP (individualized education plan) specifically states that he's to answer questions verbally, rather than in writing. His teacher has noted that this has significantly improved his test scores from before the IEP was implemented.
- Involve your child's school counselor or social worker to foster social development at school. Friendship groups that involve a small number of selected peers are one possible intervention. Teachers can identify which classmates would be most responsive to and supportive of your child. Specific and concrete instruction, such as teaching him how and when to initiate conversations with other children, when and when not to speak, how to make eye contact with the person he is speaking with, and pleasant facial expressions can be very beneficial.
Because Jake was so talkative, and his tangents so lengthy, some of the children in his class began to shy away from him. His teacher helped other kids in his class to understand Jake by first working on one-to-one conversation skills, and slowly bringing in more and more children. She noticed that as more children were added, at least at first, Jake would become more talkative--probably because he didn't feel comfortable in groups. But as they worked on group conversations, Jake started to realize that everything was okay, and he didn't need to blurt out the first thing that popped into his head while someone else was talking. This was a big step forward, and Jake seems to be more comfortable and confident in group situations now.
- Create a supportive environment where your child feels secure and successful. Try to minimize any demands that may highlight your child's weaknesses by being very clear and specific about what you expect. Observe your child carefully in new or complex situations to gain an appreciation of strengths and weaknesses, and set your expectations accordingly.
When playing games that involve the whole family, we like to choose something that won't make Amy feel uncomfortable. For instance, we play games like Pictionary rather than Scrabble, because she has an easier time picturing words in her head than piecing together words from tiles with different letters on them. Not only is she able to see the word, but she can also use her imagination and artistic ability.
- Provide as much positive reinforcement as possible, rather than criticizing your child. Let him know when he is doing something correct or when he is acting appropriately in social situations, and help him make the necessary adjustments in a way that it doesn't hurt his self-esteem.
No matter how frustrating it felt to explain something over and over again to Ben, we would always keep our cool. We always made a point to let him know when he did something right, and corrected him in a constructive way so that he could learn by his mistakes without feeling bad about it.
Nonverbal learning disorder is not widely recognized, and most school personnel may be unsure how to best serve your child's educational, social, and emotional needs. A comprehensive and thorough neuropsychological assessment, performed by a qualified clinician with regular follow-ups, is critical to assuring that appropriate strategies are in place to assist your child in realizing his full potential.