Describes on Learning disabilities and morbidness associated with it(mainly ADHD and ASD

1. M.Sc Child Development

2. INTRODUCTION
 Learning disabilities are different neuropsychological or
neurobiological impairments/difficulties.
 Range from mild to moderate to severe
 An individual can have different types of difficulties in
different areas and at different levels of complexity.

3. What is Co morbidity?
“ The extend to which 2 pathological conditions occur
together in a given population”
(Miller-Keane Encyclopedia and Dictionary of
Medicine,2003)
Comorbildity is a situation where 2 or more conditions that
are diagnostically distinguishable from one another tend to
occur

4.  Many studies supports co morbid situations between L.D
,ADHD and ASD
 Social, emotional or behavioural difficulties are also
associated with L.D
 Other comorbidities may include
 Tourette’s syndrome
 Schizophrenia
 Epilepsy
 Language/communication disorders
 Hearing impairment
 Visual disabilities
 Developmental coordination disorder
Learning disabilities can have association with many co
morbidities.

5. Definition
“Brain disorder marked by an ongoing pattern of
inattention and / or hyperactivity-impulsivity that
interferes with the functioning or development”
(National Institute of Mental Health)
 DSM-IV-TR defines ADHD with 2 distinct but correlated
dimensions of symptoms involving inattention and
hyperactivity -impulsivity

6. According to The International Classification of Mental and
Behavioural Disorders 10th revision(ICD 10)(WHO,2015)
 ADHD is defined as Hyperkinetic disorder(HKD) –
a persistent and severe impairment of psychological
development ,characterized by early onset; a combination of
over active, poorly modulated behaviour with marked
inattention and lack of persistent task involvement; and
pervasiveness over situations and persistence over time of
these behavioural characteristics.

7. According to DSM criteria ,2 groups can be found
1.Inattentive 2.Hyperactive-impulsive
 Combined type of ADHD will have 6 of the 9 symptoms in each
section on diagnosis
 If not a combined type- predominantly inattentive(ADHD-1) and
hyperactive (ADHD-H) may be used
Diagnosis of ADHD

8.  Symptoms should be persistent for 6 months(chronic)to a
degree that is maladaptive and inconsistent with developmental
level and differentiated from other mental disorders
 Diagnosis should be done only by a specialist, psychiatrist,
pediatrician or other appropriately qualified health
professionals with training and expertise in diagnosis of ADHD
 After diagnosis ,provide all parents /caretakers with self
instruction manuals and other materials like videos, based on
positive parenting and behavioural techniques.

9. DSM –IV- CRITERIA(2000) FOR ADHD
I. Either A or B
A.INATTENTION
 Fails to give close attention to details or makes careless
mistakes in schoolwork ,work or other activities
 Difficulty in sustaining attention in tasks or play activities
 Does not seem to listen when spoken to directly
 Doesn’t follow through instructions , fails to finish school
work, chores or workplace duties
 Difficulty in organizing tasks and activities
 Loses things necessary for tasks or activities
 Easily distracted by extraneous stimuli
 Often forgetful in daily activities.

10. B.HYPERACTIVITY- IMPULSIVITY
Hyperactivity
 Fidgets with hands/feet or squirms in seat
 Leaves seat in classroom or in other situations
 Runs/climbs excessively where inappropriate (Restlessness)
 Difficulty in playing /engaging in leisure activities quietly
 ‘On the go’ or act as if ‘driven by a motor’
 Talks excessively
Impulsivity
 Blurts out answers before questions have been completed
 Has difficulty awaiting turn
 Interrupts / intrudes on others(eg; interrupts conversations/
games)

11. 2. Some hyperactive or inattentive symptoms that caused
impairment were present before age 7 years
3. Some impairment is present in 2/more
settings(school/home/work place)
4. There must be a clear evidence of significant impairment
in school/social/work functioning
5. The symptoms doesn’t occur during pervasive
developmental disorder, schizophrenia/other psychic
disorders. Symptoms aren't better accounted for by another
mental disorders like mood disorder/anxiety/ personality
disorder.

12. Causes of ADHD
1. Genetic factors
 No single gene of a large effect has been identified in ADHD,
rather several DNA variants of small effect –each increasing
susceptibility of ADHD by small amount have been associated
 The rate of ADHD in families of male probands with ADHD has
been found to be over 7 times the rate of disorder in non-
psychiatric control families(Faraone et. Al,1990)
 Similar increase in risk among relatives of female probands have
also been reported
 A meta analysis of 20 twin studies found a mean heritablity of
0.76(Faraone et.al 2005)
Involves an interplay between genetic and environmental factors

13. 2. Environmental factors
 Biological factors
 Prenatal life, early childhood and brain development adversely
increase risk of ADHD without hyperactivity
 These may include
 Maternal smoking(Linnet et.al,2003)
 Alcohol consumption(Mick et.al 2002)
 Heroin usage during pregnancy(Ornoy et.al,2001)
 Very low birth weight (Bolting et.al,1997)
 Fetal hypoxia,brain injury,exposure to toxins like lead and
deficiency of zinc(Toren et.al ,1996)

14.  Risk factors interact with one another
Eg: The risk factor for ADHD posed by maternal smoking and
L.B.W is strong(Thaper et.al,2003)
 Increased risk of ADHD is associated with epilepsy and other
genetic conditions like neurofibromatosis type 1(Mautner
et.al 2003) and other syndromes like Angelmans,Fragile X-
syndrome etc

15.  Dietary factors
 Food additives ,sugar, colourings and E number
 Supplementation and elimination diets taken without medical
advice
 There is a link between additives & preservatives in the diet
and hyperactivity(Mc Cann et.al,2007)
 Some children with ADHD show peculiar reactions to some
natural foods and /or artificial additives

16.  Psychological factors
 ADHD has been associated with severe early psychosocial adversity,
 For eg, in children who have survived deprived institutional care
(Roy et.al,2000).This may include a failure to acquire cognitive and
emotional control
 Families with young children with ADHD are found to have disrupted
and discordant relationships(Biederman et.al,1992)
 In established ADHD,harsh parenting styles cause oppositional and
conduct problems
 Often, parents themselves may have unrecognized and untreated
ADHD,which may affect their ability to manage a child with disorder

18. Treatment
 Drug treatment is not recommended.
 Health care professionals should make contact with child’s
teacher to explain
 Diagnosis and severity of impairment
 The care plan
 Any special educational needs
 Parent training (group/individual)should be offered
 Active learning strategies should be used and give rewards on
achievement of key elements of learning.

19. Drug treatment
 Pre drug treatment assessment including mental and social
assessment, full family history, and physical examination
(Height,weight,heart rate etc)
 A comprehensive drug treatment plan should include
psychological, behavioral, educational advices and
interventions.
 Methylphenidate, atomoxetine, dexamfetamine-commonly
recommended for management of ADHD
 Drug selection depends on
 Presence of co morbid conditions
 Potential chance of misusing
 Preference of parent/child/guardian.

20. Psychological treatment
 ADHD is often associated with behavioural problems
and other mental disorders like depression, anxiety
,poor self esteem,learning difficulties.
 Helps to reduce the dosage of drug treament
 Improves daily functioning by improving the
behaviour,family and peer relationships.

21. Cognitive therapy
 Self instructional training involving cognitive modeling, self
evaluation, self reinforcement and response cost
 Helps the child to think, plan and behave in a systematic and
goal directed way
 “THINK ALOUD”(Camp and Bash(1981)
Children are encouraged to adopt a 4 point schema when faced
with a problem:
1. What is the problem?
2. What is my plan?
3. Do I use my plan?
4. How did I do?

22.  Adult verbalizes their response-Child talks aloud-whispers-
inner self talk-self evaluation is then encouraged.
 “Self reinforcement” and “response cost” techniques
 Young person may pay penalties for making
mistakes/earns rewards for success in implementing the
strategies taught.(Kendall & Finch,1978)
 Response cost –loss of a potential reinforcer-deductions from
rewards already earned/agreed set of rewards given in
advance

23. Behavioural therapy
 Involves the use of rewards /reinforces to encourage the
child to implement the targeted changes in motor,impulse
or attention control.
 Rewards-
extra time for recreation and leisure activities
Schemas /Tokens like stars/marbles/stickers
Social approval(praise/achievement certificate)
Time out from social reinforcement-child is placed away
for a set of period from others during which they are
expected to be quite and cooperative

24. Parent training
 A behaviour intervention therapy that teaches parents to
use behavioural therapy techniques with their child.
 Helps parents to solve issues that hinder their
effectiveness like poor self confidence, depression,social
isolation, marital difficulties(Scott,2002)
 Teaches principles of child behaviour management
 Increases parental competence and confidence in raising
children
 Improves the parent- child relationship
 Involves structured programmes and curriculum

25. Social skill training
 Aims to teach microskill of social interactions-eye
contact, smiling,body posture(Jacobs,2002)
 Uses cognitive and behavioural techniques
 Problem solving approaches that helps to enhance self
regulation and cope with stress have been
develop(Compas et.al ,2002)

26. Educational Strategies
 Increase active participation through provision of visual motor
tasks.
 Answering to teacher’s questions by writing on card –minimize
delay between the completion of tasks by pupils and feedback from
the teacher
 Maximize opportunities to engage in role play and kinesthetic
learning tasks-increases attention and reduces impulsivity
 Teachers can utilize the ‘talkative’ nature of ADHD child-increase
chance for on task verbal participation .(Zental,1995)
 Reduce teacher-pupil ratio

27.  Nurture groups- small classes with 10- 12 students ,staffed by
2 adults – promising intervention to reduce behavioral
issues(Bennathan and Boxall,2000)
 Modify seating arrangement
 Seat away from the windows and away from the door
 Put the child in front of teacher
 Seats in rows rather than facing one another
 Modify teaching pattern
 Give instructions one at a time repeat as necessary
 Use visual charts,pictures,colour coding
 Create a quite environment
 Create worksheets and tests with fewer items,give short
quizzes

28.  List all the activities before starting a lesson
 Include different kinds of activities and games
 Allow breaks in btween
 After the class summarize all the key points and be
specific about what to take home.

29. Definition and meaning
Complex neurological disorders that have life long effect on
development of various abilities and skills.
According to Diagnostic and Statistical Manual,5th edition,
ASD includes Autism disorders, Pervasive Developmental
Disorder Not Otherwise Specified(PDD-NOS) and Asperger’s
syndrome

30. AUTISM DISORDERS(DSM,IV-TR,APA,2000)
 Onset is seen prior to ageof 3
 ‘Classic autism’
 Abnormal or impaired social interaction, language and
communication skills
 Impaired development in social interaction and communication
and a restricted repertoire of activity and interests.
 4-5times higher in males than in females.
 They show preoccupation with one narrow interest and
following routines
 Abnormalities in cognitive skill development and in posture and
body movement may be present

31.  Named after Hans Asperger.
 Characterized by impaired social interaction and display a
limited field of interest and activities prior to 3 years of age.
 Difficulty in social/occupational functioning
 Speech and language development is near to normal with good
understanding as compared with autism
 No significant delay in cognitive development/in acquiring age
appropriate skills or adaptive behaviours.
ASPERGER’s SYNDROME(DSM,IV-TR,APA,2000)

32.  Restricted ,repetitive patterns of behaviours, interests
and activities-Too much obsessive to one single topic.
 Experience feeling of social isolations –contribute to
anxiety or depression in adolescence
 May have delayed motor development and poor
coordination.

33. PERVASIVE DEVELOPMENTAL DISODER NOT
OTHERWISE SPECIFIED(PDD-NOS)
 Used for children/adults who fall under ASD but do not
fully meet the criteria for autistic disorders
 Characterized by severe impairment in either verbal/non
verbal communication skills or have stereotyped
behaviours/interests and activities
 “Atypical autism”
 Have fewer non-social features of autism like
sensory,feeding, and visuo-spatial problems.

34.  PDD-NOS-3 sub groups
1. A highly functioning group(around 25%)-symptoms largely
overlapping with Asperger’s syndrome, but who differ in
terms of having poor language and mild cognitive
impairment
2. Around 25%-symptoms resemble those of autistic disorder
but do not fully meet the diagnostic signs and symptoms.
3. Around 50% -meets diagnostic criteria for autisitc disorders
but sterotypical and repetitive behaviours are mildly
noticeable.

35. Nature and Characteristics
 Degree of severity will vary from mild to profound .
 All shares triad of difficulties:
1. Impairment in social interaction
Wing & Goud (1979) it is divided into 4
 The aloof-most common-Withdrawn-Poor eye contact-
Appear to be alarmed /indifferent from their peers
 The passive-least common-poor eye contact-accept social attention as long as
it is not too sudden/invasive-show less behavioural problems among other
ASD.
 The active but odd want social contact and try to initiate but get it wrong-
cant work out social rules and their variations according to context.
 The over formated,stilted-not exhibited until adolescence /adulthood-
develops in those who are most able- tries very hard to behave well- stick
rigidly to the social rules

36. 2.Impairment in communication
 Have difficulty in communicating thoughts and needs
verbally and non verbally
 Difficulty in using gestures,eye contact and facial
expression
 Uses speech that is repetitive,echolalic or unusual
language

37. 3.Lack of flexibility of thinking and behaviours
 Displays obsessions with specific themes
 Like order and may line up toys repeatedly
 Engages in unusual behaviours like rocking, spinning, or hand
flapping
 Get extremely upset with routines/ schedules
 Unusual response to loud noises/ other sensory stimuli
 Impaired joint attention and symbolic play skills
 Unable to understand other’s believes,knowledge,emotions,
desires, feelings, or intentions.

38. Diagnosis and identification(DSM –TR-V)
1. Persistent deficits in social communication and social
interaction across multiple contexts
 Deficits in social emotional reciprocity
 Deficits in non verbal communication
 Deficits in maintaining and understanding relationships
2.Restricted,repetitive behavioural or interest patterns
 Stereotyped movements, use of objects or speech
 Insistence of sameness, inflexibility/Fixated interests
 Hypo or hyper reactivity to sensory inputs

39. 3.Symptoms must be present in early developmental
period(may not fully manifest until social demands
exceeds the limited capacity or may be marked by
learned strategies in later life)
4. Impairment in social, occupational or other important
areas of current functioning
5.Intellectual ability should be less than what is expected.
ASD may be diagnosed often between 2-3 years

40. Causes of ASD
Genetic
 The twin study on autism reveals that concordance rate in
monozygotic twins (36%) was greater than in dizygotic twins
(Fobstein and Rutter,1977)
 If cognitive/language disorder was considered the rated
became 82% and 10% among monozygotes and dizygotes
respectively
 If one child has ASD, the risk of the child having it is
approximately 5%
 Advanced age of father may increase the risk of autism

41. Environmental
1.Prenatal environment
 Advanced age in either of the parents
 Diabetes,obesity and hypertension
 use of psychiatric drugs in the mother during pregnancy
 High testosterone levels in amniotic fluid and exposure toUV
waves are associated with autism
 Infectious processes- principle non genetic cause of autism-
exposure to Toxoplasmosis, rubella, cylomegalovirus ,herps)
 Environmnetal agents-Teratogens(Thalidomide, valproic
acid,misoprostol),Alcohol usage


42. 2.Perinatal environment
 L.B.W
 Lack of oxygen during child birth
 Smaller gestation period
3.Postnatal environment
 Gastro intestinal or immune system abnormalities
 Allergies
 Exposure of children to drugs, vaccines, infection ,certain
foods, heavy metals
 Mercury-Sources of mercury are fish,inorgamic substances,
cosmetics and vaccines-thought to cause autism but not very
well validated

43.  Damage of amygdala cells
 Refrigerator mothers- Early childhood traumas and
withholding of parental affection has been linked with
autism.
 Extreme environmental deprivation-decreased social
stimulation can produce a phenotype of autism.
 Autoimmune disease-auto antibodies that targets the
brain and its metabolism may cause autismdue to an
environmental trigger after birth, viral infection via auto
immune mechanism.

44. EDUCATIONAL PROVISIONS

45. Treatment and Education of Autistic and related
Communications of handicapped Children(TEACCH)
 Developed by Eric Schopler(1970s)
 Helps to equip children using their skills, interests and needs,
to lead a productive life in the community
 Develop communication skill and to help individuals to play
and work independently(Jordan et.al,1998)
 A system that provide clear,concreteaningful visual
organization with progressive independence with classrrom
and environment
 Teaches student that environment does have a meaning and
has certain patterns
 Organizes space, the day (time,routine), and activities(pace
and duration)

46.  Developed by Kiyo Kitahara
 Develops independence by continually involving children in
activities which stabilise emotions,improves physical strength and
stimulates the intellect
 Activities occur in group-The staff student ration may be 1:5 to 1:3
 Short and clear Verbal instruction are used
 Emphasize need for physical education to improve concentration
and strength
 Music and visual arts are used to improve communication and to
develop daily living skills
 Lessons progress at the rate of the least able child
 Learning through imitation is encouraged
Daily life therapy(HIGASHI)

47.  Aims at identifying factors that encourage/strengthen
or discourage/weaken behaviour
 Aims to analyze a skill into steps which are used for
teaching
 Clear goal are set and rewards are given on
achievement of these goals
 Instructions are to be provided during waking hours
 Strong emphasis on imitation
BEHAVIOURAL APPROACH(Applied Behavioural
Analysis)(ABA)

48. Other measures
 Sensory integration therapy
 Vitamin therapy-B6 and magnesium –improve attention
and hence learning and behaviour
 Dietary program—Removal of gluten and casein from diet
can improve symptoms of autism ,but further researches
are required(Shattock,2001)