Adulthood

All children with specific learning difficulties improve as they grow. In some, the difficulties resolve completely, while others continue to have some degree of difficulty in the specific areas of learning affected. We still have no way of determining which children will continue to experience difficulty and which will not. Nor do we have reliable figures on the relative proportions of those where the difficulties resolve completely and those where they persist. This chapter provides information and advice for adults with persisting specific learning difficulties. Many people are designed to be better adults than children. A child has little opportunity of selecting those things that he enjoys or finds easier, and to avoid those he dislikes or finds difficult. He is required to be an all-rounder, performing a wide range of activities, many under the critical scrutiny of his teachers and peers. It is daunting to think of what many children are required to do regularly at school: reading aloud, writing something that will be marked (for content, neatness, and spelling), doing arithmetical computations that will be checked, playing competitive sport, performing in a play in public, and playing a musical piece to a critical audience. An adult, on the other hand, can have a successful career and avoid any, or all, of these activities. Many famous people are said to have had a specific learning difficulty as children, but it is very difficult to know for certain if this is true. Nevertheless, many of their stories are highly suggestive of the condition. What they all show, whether they had a specific learning difficulty or not, is that problems with learning in childhood need not be a bar to outstanding achievements in adulthood. There follow some examples. . . . Hans Christian Andersen (1805–1875) . Famous as an author of children’s stories such as ‘The Little Match-girl’ and ‘The Little Mermaid’, his handwriting shows characteristics of specific learning difficulty. . . . . . . Auguste Rodin (1840–1917). Now famous for his sculptures, such as ‘The Thinker’ and ‘The Burghers of Calais’, he was regarded as ‘an idiot’, and ‘ineducable’ as a child. . . .

Arithmetic

Specific difficulties have been described in a number of areas of mathematics, but difficulty in arithmetic has received the most attention. This may be because all children are required to do arithmetical calculations in the early years of school, but can choose alternative subjects later, and it probably also reflects the fact that arithmetical calculations play an important part in everyday life. Another reason may be that arithmetical difficulty following brain damage in adulthood (dyscalculia) is a well-recognized and well-studied entity. This chapter will focus on specific arithmetic difficulty in children, that is, unexplained, significant delay in arithmetic ability. Although specific arithmetic difficulty was once considered rare, there is now evidence that it is not as uncommon as was previously thought. The psychologist may obtain sufficient information about the child’s arithmetical ability from the Arithmetic section (sub-test) of the Wechsler Intelligence Scale for Children (WISC-IV). This is a commonly used intelligence test that can be used for children from 6 years to 16 years 11 months. This test does not require the child to write down the answers. The problems are timed and they relate to various arithmetical skills. Addition, subtraction, multiplication, and division can all be tested. Some problems also require memorized number facts and subtle operations, such as seeing relevant relationships at a glance. The emphasis of the test is not on mathematical knowledge as such, but on mental computations and concentration. The WISC-IV will also give the psychologist information about other abilities, which may shed light on the child’s difficulties. In the Digit Span sub-test, the child’s ability to remember numbers for a short period is tested. In the Comprehension sub-test, verbal reasoning is involved. If, for example, a child has high comprehension but low arithmetic scores, this may suggest that reasoning ability is adequate in social situations, but not in situations involving numbers. If the psychologist wants further information on arithmetic ability, there are a number of tests that specifically test mathematical skills and allow these to be compared with those of other children of the same age.

Writing

When David was 12 years old it became apparent that he was having significant difficulty writing. He struggled on, but his writing did not improve and he was regularly having his work returned by teachers because it was illegible. If he tried to write painstakingly slowly he could produce work that was barely legible, but there was not enough time to do this during examinations. David was very intelligent, an avid reader, an excellent debater, and good at sports. He was well coordinated in every manual task except writing, and was physically healthy. No cause for his difficulty could be found. At high school and university, he was given permission to type his examination papers and obtained excellent results. He is now a professor of law. He still cannot write legibly, but has had many papers and a number of books published. He uses a combination of dictation and typing instead of writing. This chapter deals with the mechanics of handwriting, that is, the formation of letters and their arrangement on the page. In contrast with disorders of reading and spelling, such difficulties have received little attention. This is partly because writing is a skill that cannot be easily evaluated by standardized tests, and partly because significant impairment of writing skill seems to be relatively uncommon. Unfortunately, this lack of knowledge means that children with specific writing difficulty are often misunderstood and maligned. Assessment of writing should form part of a comprehensive assessment, as described in Chapter 2. It is impossible to score a sample of writing in a precise way. In practice, samples of writing are usually evaluated by an experienced tester. Three samples of writing are obtained: a passage of free composition on a particular topic, a piece of dictation, and a copy of some printed material. In the case of the free composition, the child is usually given a limited amount of time, such as five minutes. In the other two tests, he is timed to see how long he takes.

Social and emotional development

There is widespread recognition that children with specific learning difficulties may experience social and emotional problems because of their learning difficulties, but it is often not realized that impairment of social skills may itself be a form of learning difficulty. This is due to a limitation in the way that the brain is able to understand social conventions. This is called a social cognition (or social learning) deficit. In this chapter, I shall first discuss social cognition deficit, and then discuss a number of behaviour problems that may occur as a result of a specific learning difficulty. Social skills, like any other skills, have to be learned. Yet much of what children learn about socially appropriate behaviour is not actually taught to them; they simply pick it up as they go along. Some children of normal intelligence seem to be less able to learn these things, even when taught. This may be their only area of difficulty, but it is commonly associated with other learning difficulties. These children have been accurately described as being ‘socially tone deaf’. They do not pick up the same cues as other children of the same age. They do not seem to predict the social consequences of their actions. They may be uninhibited, undressing in public without the same embarrassment that their peers would experience. They may be overfriendly to strangers. They may frequently say very tactless things without realizing the effect they are having. They often do not read facial expressions and are oblivious to whether someone is angry or upset with them. They may kiss classmates at an age where this is no longer appropriate. They may make unusual sounds in public. They may be insatiable in their activities, not knowing when to stop in the way another child of their age would. Although such behaviour may be apparent to all who meet the child, the people who are most likely to notice it are the child’s peers. With them, the child often sticks out like a sore thumb. This is something that may not be apparent if the child is only observed in a one-to-one relationship at a clinic.

Coordination and clumsiness

Rachel is eight years old. She was slow to crawl and walk. She still cannot pedal a tricycle, fasten small buttons, or tie her laces. She is very poor at sports and is often teased by the other children for her awkward running style. She is a messy eater and washes herself and brushes her teeth with great difficulty. Her mother says that she has a poor sense of direction and still confuses right with left. Rachel’s school work is satisfactory. Her writing is untidy, but if she prints slowly it is legible. Rachel has been tested by a psychologist and found to have some visual perception difficulties, but to be of normal intelligence. Her reading, spelling, and arithmetic are in the average range. A paediatrician has examined Rachel and detected no abnormalities that can account for her clumsiness. The term ‘clumsiness’ will be used in this chapter to refer to unexplained, significant difficulties in the coordination of movement in a child of average, or above average, intelligence. This sort of clumsiness is commonly associated with other forms of specific learning difficulty, such as reading difficulty. This does not mean, however, that most children with specific learning difficulty are clumsy. Many are, in fact, well coordinated. But clumsiness is far more common in children with specific learning difficulty than in other children. Clumsiness is more common in boys and quite often runs in families. The word ‘motor’ is used for movement. Gross motor skills involve large groups of muscles responsible for activities such as walking, running, jumping, hopping, and bicycle riding. Fine motor skills involve the hands and fingers, and are concerned with activities such as writing, drawing, using scissors, and tying knots. There are a number of standardized tests of both gross and fine motor proficiency. These may be performed by a physiotherapist, an occupational therapist, or a doctor. Activities must be carefully observed to detect the presence of tremors and other unusual movements. Balance, strength, tone, reflexes, and ability to interpret certain sensations are all assessed. It is essential that rare, serious conditions associated with poor coordination are excluded by a doctor.

Attention-deficit/hyperactivity disorder and sequential organization difficulties

This chapter deals with two separate areas of learning: attention and sequential organization. Difficulties in either area can occur in isolation or in combination with other forms of specific learning difficulty. The ability to ignore distractions and to focus on one activity at a time is a skill that children usually develop gradually as they grow. It is quite normal for toddlers and pre-school-aged children to be easily distractible, but the ability to channel attention selectively usually increases progressively once children start school. Some children experience significant difficulties in learning to attend. As a result, they are easily distractible and do not persist for long with tasks. If this is a significant problem, it is referred to by the umbrella term ‘attention-deficit/hyperactivity disorder’ (ADHD). This means attention-deficit with or without hyperactivity. Such children may be overactive and impulsive, although this is not always the case. It is this overactivity that has given rise to the term hyperactivity (‘hyper’ is Greek for ‘over’). All children with attention-deficit/hyperactivity disorder experience difficulty with concentration. There are two forms of the condition: one where overactivity and impulsivity are present and the other where these coexisting problems are absent. The two forms of attention-deficit/hyperactivity disorder may be clarified by describing two children, each with one of the forms of the disorder. George is his mother’s third child. She describes him as completely different from the other two. As a baby he slept very little and cried constantly. As a toddler he was always on the go, ‘as if driven by a motor’. Now, aged nine years, his teacher describes him as ‘disorganized, disruptive, and fidgety’. His mother reports that he hardly ever sits still at home. He will not sit through a favourite TV programme or a meal. He is still so disorganized that if she did not help him to dress in the morning, he would not be in time for school. He is also very impulsive. He does not seem to think before he acts. He takes terrible risks and often says the first thing that comes in to his head.

Reading

Specific reading difficulty is the best known, and best studied, form of specific learning difficulty. This is the condition that many refer to as ‘dyslexia’. We will define specific reading difficulty as a significant, unexplained delay in reading in a child of average, or above average, intelligence. A significant delay is usually defined as a reading level more than two standard deviations below the mean for the child’s age (see Chapter 1, p. 5 for the explanation of this term). Specific reading difficulty is, therefore, a form of specific learning difficulty where reading is the particular learning skill affected. Other forms of specific learning difficulty may also be present, particularly spelling, writing, and spoken language difficulties. It should be noted that the diagnosis of specific reading difficulty is based on the degree of delay in reading, rather than on the particular type of errors that the child makes. Much has been made of certain characteristics of children’s reading, such as difficulty in distinguishing ‘b’ from ‘d’, reluctance to read aloud, a monotonous voice when reading, and a tendency to follow the text with the finger when reading. There is nothing diagnostic about these characteristics. They are seen in many children when they first start learning to read (and some are seen in adults when they learn to read a foreign language). The diagnosis of specific reading difficulty should only be made after a comprehensive assessment of intellectual and reading ability, and an exclusion of other causes of poor reading attainment (see Chapter 2). . . . How common is specific reading difficulty? . . . The best evidence for the existence of specific reading difficulty as an entity is given by the results of a study by Professor Michael Rutter and his colleagues, who tested 9–10-year-olds on the Isle of Wight. They first tested the children to determine their intelligence and reading ability. They then studied all the children whose reading was significantly behind that of their peers and found that these could be divided into two groups: those where the delayed reading could be explained by low intelligence and a second group where the children were of normal intelligence and the reading difficulty could not be explained.

Theories of causation

In the definition of specific learning difficulties in the first chapter I emphasized that the delay in learning must be ‘unexplained’. It is, therefore, explicit in the definition that the cause of specific learning difficulties is presently unknown. There are few things more frustrating for a doctor to say, or for a parent to hear, than that the cause of a child’s condition is unknown. There is a natural tendency in such situations to alleviate this discomfort by guessing the cause. This is not necessarily bad, as it is by developing theories and devising experiments to test them that our knowledge advances. But the danger is that in our desire to know the cause with certainty, we may come to believe in a theory so strongly that we think of it as a fact. Theories about specific learning difficulties abound. Most are based on the assumption that there is some impairment of brain function. These theories are not mutually exclusive, since each may explain one step in the chain of events that gives rise to specific learning difficulties, as shown in Figure 3.1. Let us look at these theories one by one. These theories attempt to explain the most fundamental aspect of the condition: its primary cause. It is unlikely that a single factor can be responsible for a specific learning difficulty. Rather, it seems that a number of factors must act together. Such causation is known as ‘multifactorial’. There have been two groups of factors that have been suggested in the causation of specific learning difficulties: genetic factors and environmental factors. There is strong evidence for a genetic factor playing a role in the causation of specific learning difficulties. A number of studies have shown that children with specific learning difficulties are more likely to have a close relative with the same specific learning difficulty. No consistent pattern of inheritance has been described: sometimes it seems to be inherited from the mother, at other times from the father. For all types of such learning difficulty, boys outnumber girls by about three to one.

Spelling

There are three kinds of difficulty that may cause a child’s written work to be incomprehensible. First, specific spelling difficulty, where some words may be so badly spelt that they are difficult to recognize. Secondly, specific writing difficulty, where the handwriting may be so untidy that it is illegible see Figure 7.3, p. 65). And, thirdly, language disorder, where the language used by the child may be so full of errors that it does not make sense. Specific spelling difficulty will be described in this chapter, specific writing difficulty in the next chapter, and language disorders will be described in Chapter 9. . . . What is specific spelling difficulty? . . . specific spelling difficulty can be defined as an unexplained, significant spelling difficulty. A significant difficulty is usually defined as a spelling age more than two standard deviations below the mean for the child’s age (see Chapter 1, p. 5 for the explanation of this term). Specific spelling difficulty is often associated with specific reading difficulty. In some children, specific spelling difficulty is an isolated problem. Although such children will have average reading ability, research studies suggest that subtle reading problems can be detected in such children on special testing. . . . How spelling is assessed . . . There are several standardized spelling tests in general use. These differ in the ways in which they test spelling. Some present the child with words that are part of his sight vocabulary, others present a wider range of words. Tests usually involve spelling from dictation. Some may also involve recognizing whether a printed word is correctly spelt or not. The psychologist will choose the test, or tests, that will provide information about the child’s spelling level, as well as about the nature of his difficulties. For example, a test that shows that a child has difficulties with spelling from dictation, but not with identifying words that are incorrectly spelt, may demonstrate particular problems with word memory. The psychologist will also try to differentiate between the different kinds of spelling errors, such as phonetic, visual, and sequential errors, which are described later in this chapter.

How parents can help — general principles

This chapter provides general guidelines for helping a child with a specific learning difficulty. Advice on providing help in particular areas of learning is given in Part 2 of the book. Parents of children with specific learning difficulties need information on how to teach their child and how to build up his self-esteem. In addition, they need help in coping with their own feelings and those of their other children. Let us look first at parents’ concerns. Parents of a child with specific learning difficulties often feel great anxiety about their child. They worry about how their child will cope at school, both academically and socially. They worry about how he will manage if teased, and if made to feel inadequate. When he gets home from school, they are sensitive to his feelings, saddened by his disappointments, and made anxious about his concerns. Parents often feel guilty about their child’s difficulties, wrongly imagining that they are somehow to blame. They may feel angry much of the time too: angry with teachers who fail to understand their child’s problems, and angry with doctors who cannot explain their child’s difficulties. Many parents feel confused by the wide range of opinions about their child’s condition and the variety of treatments that people suggest. They often wonder whether they are doing enough for their child, and whether there is something more they should be doing. They may feel many other emotions as well. They may be embarrassed by their child’s difficulties, hurt by other people’s insensitive remarks, and overwhelmed by the task of teaching their child to overcome his difficulties. There is no one right way to cope with these feelings; no single prescription that will work for all parents. Most parents do cope and do find that things become easier with time. Many find it helpful to have someone to share their feelings with: a friend, a spouse, or a professional; someone who will listen sympathetically and not be judgemental, or too quick to offer advice. Some parents obtain this support from meeting other parents of a child with a similar difficulty.