Reading disorders, the most common and best studied of the learning disabilities, account for 80% of all children diagnosed as learning disabled. Children with reading disorders are able to visualize letters and words but have difficulty recognizing that letters and combinations of letters represent different sounds. Most reading disorders involve difficulties with recognizing single words rather than with reading comprehension. The cause often lies in the area of the child’s “phonologic awareness”—difficulty perceiving how sounds make up words. Reading disorders—even including letter reversals—have little to do with vision. These problems make it quite difficult for children to add new words to their reading repertoire and become good readers. While their listening and speaking skills may be adequate, they may have trouble naming objects (such as quickly coming up with the word for “computer” or “backpack”) and/or remembering verbal sequences (such as “The boy saw the man who was driving the red car.”). A smaller group of children also have reading disabilities that involve comprehension, and these children tend to have poor receptive language skills—that is, difficulty understanding language even when it is spoken to them. A reading disorder, depending on how it is defined, is not necessarily a lifelong condition, but these problems do persist into adulthood in at least 40% of children.
Like all other learning disabilities, reading disorders cannot be detected through neurologic tests, such as special examinations, electroencephalograms (EEGs: brain wave tests), or brain scans like computed tomography and magnetic resonance imaging. They are identified when a child’s reading level or language achievement scores are significantly lower than those of his classmates. In assessing reading disabilities, it is important to identify each component of your child’s problem so that specific treatment measures can be applied. It is also important to address the attentional and behavioral aspects of the ADHD so that your child can make optimal progress at school.
Mathematics disorder can be thought of as a type of learning disability in which spoken language is not affected, but computational math is. Children with mathematics disorder also may have difficulties with motor and spatial, organizational, and social skills.
Children with coexisting ADHD, or even ADHD alone, can have additional problems in math—such as delays in committing math facts to memory, the making of careless math errors, rushing through problems and impulsively putting down the wrong answers or not showing their work, and making errors because they misaligned columns during addition or long division. Although math disabilities are about as common as reading disabilities, they are not well studied. It is not known whether math skills stem from the innate abilities of children to understand the concepts of magnitude or quantities and compare numbers, or whether they arise in brain areas that are responsible for language, visual-spatial, or attention and memory systems.
It is generally agreed that children with mathematics disability have a deficit in recalling math facts. Accurate and fluent recall of single digit math facts is felt to be important in freeing up higher brain areas for learning and applying more complex tasks. Children with both reading and math disabilities struggle particularly with word problem-solving.
Written Expression Disorder
Children with written expression disorder can have difficulty composing sentences and paragraphs; organizing paragraphs; using correct grammar, punctuation, and spelling in their written work; and writing legibly. Children with spoken-language problems can develop problems with written language as well as math. Children with ADHD can also have difficulty with taking the mental time to plan their writing, and their handwriting can be immature and sometimes unreadable without necessarily having a written expression disorder. When handwriting problems are more a function of ADHD than a written expression or motor skills disorder, they sometimes improve rapidly and dramatically with appropriate stimulant medication treatment.
Nonverbal Learning Disability
Nonverbal learning disability is a condition that is not yet formally categorized as a disorder but that has been the subject of increasing interest. It is particularly important to consider in children with ADHD because it relates to attentional functioning. It is often difficult to decide whether a child with ADHD has a coexisting NLD or whether he just has an NLD that mimics ADHD—especially the inattentive symptoms.
Nonverbal learning disability accounts for about 5% to 10% of children with learning disabilities. It consists of a cluster of deficits, including poor visuospatial skills, problems with social skills, and impaired math ability. Problems with disorganization, inconsistent school performance, and social problems may lead to an evaluation for ADHD. In some cases this makes children with NLD difficult to differentiate from children with Asperger disorder. General functioning in children with NLD younger than 4 years can be relatively typical or only involve mild deficits. Following this period, children can develop disruptive behavior and may develop hyperactivity and inattention. They are frequently thought of as acting out and hyperactive, and are commonly identified by their teachers as overtalkative, trouble makers, or behavior problems. As they grow older, their high activity level can disappear. By older childhood and early adolescence, problems can tend to be more internal, characterized by withdrawal, anxiety, depression, unusual behaviors, and social skills problems. Interactions with other children may become more difficult, and their faces can seem unexpressive. These behaviors can be accompanied by deficits in how they judge social situations, judgment, and interaction skills. Children with NLD are particularly prone to emotional problems over the course of their development, as opposed to children with other learning disabilities. Nonverbal learning disabilities are less prevalent than languagebased learning disorders. Where it is estimated that about 4% to 20% of the general population have identifiable learning disabilities, it is thought that only 1% to 10% of those individuals would be found to have NLD.
Children with NLD are often not identified until late elementary school or middle school, when the peer problems increase and academic tasks become more complicated. They frequently develop symptoms of depression and anxiety.
As was pointed out earlier in this chapter, children with ADHD frequently experience significant challenges at school and elsewhere that cannot be formally categorized as disabilities or formal disorders. Forty percent of children with ADHD, for example, who do not qualify for a diagnosis of learning disability still experience learning problems that lead to underachievement at school. These learning problems may include
- Inattention and distractibility
- Lack of persistence and inconsistent performance
- A tendency to become easily bored or to rush through or not complete work
- Impulsive responses and careless errors
- Difficulty self-correcting mistakes
- A limited ability to sit still and listen
- Difficulty with time-limited tasks and test taking
- Problems with planning, homework flow, and work completion
- Difficulty taking notes or performing other forms of multitasking
- Difficulty memorizing facts
- Difficulty organizing and producing written work
- Immature and slow handwriting that can also create obstacles in expressive writing
- Difficulty with reading comprehension
Stimulant medications that decrease your child’s ADHD symptoms are likely to help her address many of these problems. Behavior therapy techniques aimed at increasing or decreasing specific behaviors at home and in school can also prove beneficial. Specific behavioral goals, such as improving completion of assignments, can be addressed by understanding your child’s individual strengths and weaknesses and collaborating with school staff in using positive reinforcement, appropriate behavioral techniques, daily report cards, and ongoing monitoring.
Motor Skills Disorder
Motor skills disorder, also known as developmental coordination disorder, is diagnosed when motor skills problems significantly interfere with academic achievement or activities of daily living. It is frequently overlooked in children with ADHD due to its nonspecific cluster of symptoms—yet it can affect children’s lives by interfering with writing and other academic activities or preventing children from participating at their classmates’ level in sports and play. Children with ADHD and other learning disabilities frequently have motor skills disorder as well. Motor skills disorder involves a developmental delay of movement and posture that leaves children with coordination substantially below that of others of their age and intelligence level. These children seem so clumsy and awkward they are rarely picked for teams at school. As the years pass, they tend to fall further behind in terms of motor skills, and their confidence diminishes as a result. By adolescence, most children with motor skills disorder not only perform poorly in physical education classes, but may also have a poor physical self-image and perform below expectations academically.
Motor skills disorder may be first identified when a preschooler or kindergartner is unable to perform age-appropriate skills, such as buttoning buttons and catching a ball, or when an elementary school child struggles with writing or sports activities. A child with motor skills disorder may have difficulty with the mechanics of writing, with planning motor actions, or with memorizing motor patterns. While many young children with ADHD but no motor skills disorder may seem clumsy in their younger years, their awkwardness is related more to inattentiveness or impulsivity than to poor motor control and it is frequently outgrown. However, a child with ADHD and coexisting motor skills disorder may not outgrow his clumsiness.
If your child is diagnosed with developmental coordination disorder, he may be referred to a pediatric occupational therapist for individualized therapy and, particularly if his deficits negatively affect his academic performance or daily skills, be recommended for special gym activities at school to promote hand-eye coordination and motor development and improve specific skills.
Communication disorders—conditions that interfere with communications with others in everyday life—involve not only the ability to appreciate language sounds (phonologic awareness) but also to acquire, recall, and use vocabulary (semantics) and to deal with word order and appropriately form or comprehend sentences (syntax). Subcategories of these disorders have been identified, including expressive language disorder, mixed receptive-expressive disorder, phonologic disorder, articulation (word pronunciation) disorder, and stuttering.
Because there is such a close association between communication and social relationships, these language deficits are often accompanied by social skills difficulties. Children with ADHD without a language disorder may also have difficulties in using language, particularly in social situations. You may notice that your child has problems with excessive talking, frequent interruption, not listening to what is said, blurting out answers before questions are finished, and having disorganized conversations.