Learning Problems | Attention Deficit (ADHD)

Charlie looks around his first grade classroom when it's reading time. He needs frequent reminders to get back to work. His teachers and his parents are puzzled why such a bright boy is having trouble in school. Could it be an attention deficit causing the problem? Could a learning problem cause the inattention? How can they help Charlie succeed?

Learning and attention problems are common and can range from mild to severe. From 5 to 10% of school-age children are identified with learning disabilities (LD). At least 5 to 8% are diagnosed with Attention-Deficit/Hyperactivity Disorder (AD/HD). Many of these children have both. Although the studies vary, 25 to 70% of children with AD/HD have a learning disability and from 15 to 35% of children with LD have AD/HD. There are many children who have milder learning or attentional problems but the additive effects can be significant. Even mild dysfunctions in these critical brain functions can create problems as demands increase in secondary school, college and in life.

Attention and learning are related brain processes, separate but dependent on each other for successful functioning. "Learning" is the way the brain uses and remembers information like a factory taking in raw materials, storing parts and then manufacturing and shipping a finished product. "Attention" involves brain controls which regulate what information gets selected as important and gets acted on.the attention/behavior control system acts like the executives at the factory distributing the "brain energy" budget, setting priorities, deciding what to produce and monitoring quality control. Late shipments or poor quality products could be the result of any number of "glitches" in either system. Minor problems in one system can be compensated for but when both systems are affected failure looms. Sorting out the breakdown points is critical but can be complicated.

Evaluation: Look Beyond Symptoms

Comprehensive assessment is needed as some of the symptoms of learning and attention problems may look similar, at least on the surface. A child may be "distractible" because weak attention controls are unable to filter out unimportant sights or sounds. However, if reading is too difficult the child may look around because it doesn't make sense. A child might be "disruptive" because their behavior controls are weak and they impulsively call out or annoy others. Some children with learning problems may act-up out of frustration or embarrassment. They would rather be considered "bad" than dumb. Other difficulties that can occur with either learning or attention problems might be:

Underachievement despite good potential
Inconsistent concentration
Difficulty with time-limited tasks
Problems with starting/completing work
Messy writing or disorganized papers
Low self-esteem
Problems with peer relations
Behavior problems
Secondary emotional problems due to repeated failure and frustration

Evaluation includes a careful review of a child's history (medical, developmental, behavioral, educational), family situation, current functioning, and appropriate testing. Information is gathered from parents, school records, school staff, medical providers, other professionals and the child. Testing for learning disabilities includes cognitive (IQ) and achievement testing with speech/language, motor skill and other evaluations as needed. Medical consultation with a primary care provider, developmental-behavioral pediatrician, child psychiatrist or neurologist is often needed, especially when attentional, medical, developmental or emotional issues are present. Rating scales are often used to assess behavior or emotional functioning.

Learning Disabilities: Looking for Processing Problems

As learning disabilities reflect the brain's difficulty in processing certain kinds of information, the evaluation process looks for historical clues and evidence of specific patterns of strengths and weaknesses. Children with learning disabilities are more likely to show:

history of developmental delays
family history of learning problems
normal medical evaluation but can have motor coordination issues
language delays that may include mixing up sounds in words (e.g., aminal for animal)
a lot of knowledge but difficulty in expressing ideas clearly
slowness with learning academic readiness skills (e.g., letter identification)
difficulty applying learned skills rapidly and automatically resulting in labored reading and poor reading comprehension
report cards and tests that show consistent pattern of difficulty in one area
individual testing shows distinctive patterns, such as deficits in phonological processing (pulling apart sounds in words) and delays in reading words.
behavioral issues occur when processing weakness are stressed (e.g., too many instructions given at once when deficits in language processing are present).
social problems because language processing impacts negotiation skills or visual-spatial problems result in standing too close to others.

Attention Problems: Looking for Problems in Self-Management

Attention/behavior control problems may range from normal temperament variation to severe Attention-Deficit/Hyperactivity Disorder (AD/HD). AD/HD is the most current term for children who experience levels of inattention and/or hyperactivity and impulsivity that are excessive for their age and causes impaired functioning in more than one setting (home, school, friends, play or work). The three subtypes of AD/HD are the predominantly Inattentive type (formerly called ADD), the predominantly Hyperactive-Impulsive type, and Combined type (with both inattentive and hyperactive-impulsive symptoms).

Children with AD/HD are more likely to show:

normal milestones although sometimes with fine motor delays
a family history of AD/HD, attention or behavioral problems
hyperactivity, when present, noted in preschool but decreases to restlessness as the child ages
impulsivity such as calling out, acting without thinking or excessive talking
difficulty with effortful attention, often more evident once in school
problems with "budgeting" of attention and may over-focus on favored activities
need for frequent prompts or reminders to start or complete routine tasks
problems across multiple situations but with variable severity
difficulty in group or independent work but does well one-on-one
impulsive, "careless" errors and inattention to detail across subjects
problems with listening comprehension or academic "gaps" due to inattention or "superficial grasp" of material
written expression problems are most common
report cards and tests show highly inconsistent grades across subjects
difficulty with organization in and outside of school
tendency to "fade" or drift off during sustained tasks such as reading or chores
low frustration tolerance and lack of persistence unless highly engaged
better scores in testing than performance in the classroom or on homework
testing often shows deficits in "executive functions," such as poor planning or problem-solving
social problems because of annoying behavior and conflict

Succeeding with LD and AD/HD: Targeted Interventions and Positive Supports

Once learning and attention problems are identified a multi-modal management plan should be developed. LD and AD/HD are chronic problems but functioning can be improved with targeted interventions and positive, strength-based approaches.

Children with learning disabilities benefit from specialized instruction targeting their processing deficits in a systematic manner. If they qualify as having a Specific Learning Disability (SLD) under the Individuals with Disabilities Education Act (IDEA) an Individualized Education Program (IEP) is developed to meet their needs.

Interventions for children with AD/HD should include positive behavior management, educational interventions and medication when appropriate. Behavior management at home and school should emphasize increased structure, reinforcement for appropriate behavior and avoid punitive punishments. If AD/HD results in substantial educational impairment they can qualify for an IEP under the Other Health Impaired (OHI) category. If a child with AD/HD doesn't qualify under IDEA but requires supports, modifications or accommodations in the classroom a Section 504 plan may be implemented.

Medication can be an important part of the treatment program for children with ADHD. Medications, such as Ritalin®, Adderall® or Strattera®, improve capacity for sustained, effortful attention and impulse control. However, medications do not teach better skills or extinguish bad behaviors. Appropriate educational and behavioral interventions are still essential. Medications can help a child with ADHD be more available to absorb and apply new skills and to be able to reflect (at least briefly!) before acting. Response to medication cannot be used as a "test" for AD/HD. Only about 70% of children with AD/HD respond to the first medication tried. Even if a child shows behavioral improvement, medication will not address an underlying learning disability. When both LD and AD/HD are present medication can help support the extra "brain work" needed to compensate for processing problems.

The key to long-term success for children with LD and/or AD/HD is a positive attitude and an emphasis on developing strengths. Parents and teachers should foster a resilient, problem-solving approach to life's challenges. Children should have opportunities to devise alternative ways of meeting goals, develop their talents and use their skills to help others. A child should not be limited by their learning or attention differences, but inspired to achieve by using their different strengths and passions.

AD/HD and LD References:

Organizations

National Center for Learning Disabilities
CH.A.D.D. (Children and Adults with Attention Deficit Disorders). The federally funded National Resource Center (NRC) toll-free number (800-233-4050); English and Spanish.
National Association of School Psychologists, NASP Center at 4340 East West Highway, Bethesda, MD 20814

Books for Professionals

Diagnostic and Statistical Manual of Mental Disorders, 4th ed- text revision.: DSM-IV-TR. (2000) Washington, DC: American Psychiatric Association
DuPaul GJ, Stoner G. ADHD in the Schools: Assessment and Intervention Strategies. 2nd ed. , (2003) New York: Guilford Press
Reif, S. How to Reach and Teach ADD/ADHD Students: Practical Techniques, Strategies, and Interventions for Helping Children with Attention Problems and Hyperactivity Revised. (2005) San Francisco: Jossey-Bass
Swanson, HLee (Ed); Harris, Karen R (Ed); et al. Handbook of Learning Disabilities. (2003). New York, NY, US: Guilford Press.

Books for Parents

Levine MD. One Mind At A Time (2002). New York: Simon and Schuster.
Shaywitz S. Overcoming Dyslexia: A New and Complete Science-Based Program for Reading Problems at Any Level MD (2003) New York: Alfred A. Knopf.
Reiff MI, Tippins S. ADHD: A Complete and Authoritative Guide. (2004) Elk Grove Village: American Academy of Pediatrics Press.
Silver, L. The Misunderstood Child: Understanding and Coping with Your Child's Learning Disabilities, 4th Edition (2006) New York: McGraw Hill.

References

Aaron PG, Joshi RM, Palmer H, et al. Separating genuine cases of reading disability from reading deficits cause by predominantly inattentive AD/HD behavior. Journal of Learning Disabilities (2002) 35, 425-435.
American Academy of Pediatrics. Clinical Practice Guideline: Diagnosis and Evaluation of the Child with Attention Deficit/Hyperactivity Disorder. Pediatrics (2000) 105:1158-70.
American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder and Committee on Quality Improvement. Clinical Practice Guideline: Treatment of the School-age Child with Attention-Deficit/Hyperactivity Disorder. Pediatrics (2001) 108:1033-44.
Biederman J, Monuteaux MC, et al. Impact of Executive Function Deficits and Attention-Deficit/Hyperactivity Disorder (ADHD) on Academic Outcomes in Children, Journal of Consulting and Clinical Psychology (2004) 72(5):757-766.
Cutting LE; Koth CW; Mahone EM, Denckla MB. Evidence for Unexpected Weaknesses in Learning in Children with Attention-Deficit/Hyperactivity Disorder Without Reading Disabilities. Journal of Learning Disabilities. (2003) 36(3):257-267.
Fletcher JM, Shaywitz SE, Shaywitz BA. Comorbidity of Learning and ADHD: Separate but Equal. Pediatric Clinics of North America (1999) 46(5):8885-898.
Hazell PL, Carr VJ, et al. Effortful and Automatic Information Processing in Boys with ADHD and Specific Learning Disorders. Journal of Child Psychology and Psychiatry (1999). 40(2):275-286.
Mayes SD, Calhoun SL, Crowell EW. Learning Disabilities and ADHD: Overlapping Spectrum Disorders. Journal of Learning Disabilities (2000) 33(5):417-24.
Miller KJ. Executive Functions. Pediatric Annals (2005)34(4):310-317.
Semrud-Clikeman M. Neuroimaging and Psychopharmacology. School Psychology Quarterly (2005) 20(2):172-186.
Willcutt EG; Pennington BF, et al. A Comparison of the Cognitive Deficits in Reading Disability and Attention-Deficit/Hyperactivity Disorder. Journal of Abnormal Psychology.