Language Disorders

Language Disorders • Learning and language disabilities often go together. • Phonological disorder (bu for blue) • Expressive language disorder (complexity of speech is low) • Receptive language disorder • Language consists of phonemes (sounds) • Perceptual map develops and guides language • Phonological awareness—broad construct • Trouble controlling the rate of speech, misarticulate sounds—commonly l, r, s, z, th, ch • Prevalences—mild in preschool—up to 10%, but by 6 or 7, 2-3% for phonological, 2-3 for expressive, receptive < 3%; • Genetics-50-75% have some family hx • Ear infections • Functional brain connections—dev issue • Before 6, may self-correct, otherwise intervention • Stuttering • Gradual onset 2-7, peaks at 5 • 3% prevalence, 3x as common in boys • Heritability about 71% of variance

Learning Disabilities • LD is defined as a disorder in one or more of the basic psychological processes involved in understanding or using spoken or written language. • May manifest itself in a severe discrepancy between age and ability levels in one or more of the following areas. • Oral expression • Listening comprehension • Reading • Writing • Arithmetic

Discrepancy • Discrepancy between expected grade level and actual functioning—1 or 2 years • Problem—diff between gr 1 & 3 is not the same as 10 & 12 • Discrepancy between intellectual ability and actual functioning • Today—questions remain about necessity of a discrepancy

Diagnoses • 3 primary diagnoses: • Reading disorder (dyslexia) • Mathematics disorder (dyscalculia) • Written expression (dysgraphia) • 4th type has been identified • NVLD—Nonverbal Learning Disability • Difficulties with social perception, spatial skills, time orientation, emotion id, understanding • Not currently in DSM-IV. Some think this is related to Asperger’s and not its own dx • Research in this area is growing

Prevalence • 2-10%, 5% of kids in schools are dx’d with ld • 4% (5-17%) reading • 1% math • <1% writing • 4 of 5 cases of ld are reading or reading in combo with math or writing • Rare to be id’d before kindergarten. Reading-age 7; writing-age 7; Math-age 8—when math is a little more rigorous • Higher iqs tend to be dx’d later • More common in boys than girls-3-5x as common

Comorbidity • Estimates have ranged from 10-92% • 20-25% is probably realistic • Common comorbid problems—language disorder, ADHD • LD/ADHD—more sig impairment in learning than ld alone, less perceptive in social situations

Course of the Disorder • Only 28% of 1st graders with ld still had problems in 3rd grade • 40% drop out of school—1.5x rate of non ld • Early intervention is key—ld does not dissipate on its own

Common Problems to All LD • Knowing how to learn • Study skills • Deficits in basic knowledge (don’t know as many facts) • Increasingly handicapped by deficits • Social skills deficits in ¾ of ld students (Kavale & Forness, 1996) • More isolated, less popular, make – impressions • May not interpret correctly or respond appropriately to others’ nonverbals • Can be easily led into trouble at times

Risk Factors • Kids who believe achievement is related to innate, fixed ability rather than those who believe in effort • Attentional/self-regulation deficits • Emotional/behavioral problems are common in ld kids, but not clear if this is a risk factor • Poverty • Large family size • Limited parental education • Ineffective, overcrowded schools

Protective Factors • Access to success experiences early in education • Teachers with high expectations • Self-efficacy • High expectations in the self • Teachers with unconditional positive regard • Authoritative parenting • Parental involvement in education

Reading Disorder • Requires associating graphemes with phonemes • Simultaneously • Focus attention on printed marks, controlled eye movements • Recognize sounds associated with letters • Understand words and grammar • Build ideas and images • Compare new ideas with what you already know • Store ideas in memory • Not surprising that reading starts slow and laborious • Most common underlying feature—inability to distinguish or separate sounds in spoken words—phonological deficits • Often have trouble learning sight words, especially those that are phonologically irregular • Typical errors • Reversals • Transpositions • Inversions • Omissions • Core deficit is decoding—breaking word apart fast enough to read the whole word • Firth et al 2001

Mathematics Disorder • Difficulty grasping abstract concepts inherent in numerical and cognitive problem solving • Typically problems with numbers and math concepts begin to show up before school • Skills involved in math • Recognizing numbers and symbols • Memorizing facts • Aligning numbers • Abstract concepts like place value and fractions • Core deficits • Arithmetic calculation and math reasoning • Enumerating, comparing, manipulating objects • Reading/writing math symbols • Mental calculations • May indicate underlying neuropsych deficits

Writing Disorder • Involves skills like writing, figure copying, figure rotation • Problems with tasks that require eye/hand coordinate (though gross motor may be ok) • Produce shorter, less interesting, poorly organized essays • Less likely to review spelling, punctuation, grammar to increase clarity • Less well understood than other disorders

Adult Outcome • May find ways to disguise ld • Adult men—with reading ld report ok self-worth, no increased rates of depression, etc • However—even as adults report lower social support from parents and relatives • Adult women with ld—report more adjustment problems • LDs don’t disappear—continue to read slowly, have difficulties with comprehension, make a lot of errors in reading, writing, or math • As a result, those with ld tend to get less skilled jobs

Causes of LD • Social and environmental factors • Limited exposure to reading materials will slow child’s interest in acquiring basic reading skills • Parents with less education • Parents who don’t read to kids • Genetic factors • Some estimates that heritability accounts for 60% of the variance in reading disabilities • Higher rates in MZ than DZ • If a child has ld—35-45% of family members will also have ld • Relationship is not 1:1 between types of ld

Causes • Biological factors • More likely to have experienced prenatal and perinatal complications • Some evidence of chronic middle ear infections before age 4 (leading to deficits in phonological awareness) • Other common bio deficits • Perceptual-motor functioning • Oculomotor functioning • Attention, memory, linguistic processes • ? area on chromosome 6 related to reading ld • Shaywitz et al 2003 • Compared 43 young adults with ld, 27 good readers—all tracked for reading ability from elementary school. Brain scans (fMRI) id’d two types of brain problems.

Prevention and Training • If problem is detected early—by kindergarten—may be able to remediated successfully. • If it goes until later—age 8 or so—response is much lower. Early intervention mean ES about .40 • Several studies—training young children in phonological awareness may prevent later reading problems in those who are at risk—games that involve listening, rhyming, identifying sentences & words, analyzing syllables & phonemes

Treatment • Individual, family tx, & meds—may be helpful for behavioral problems that go with ld • Some approaches get press but don’t work • Early approaches from the 60s or 70s—things like practice in eye/hand coordination or multisensory programs—fallen by wayside because of non-effectiveness—mean ES .15 • Today we have a few approaches we can take • Behavioral intervention—identify academic deficits and modify through feedback, modeling, reinforcement • Direct instruction—pinpoints academic learning tasks and teaches to them • Cognitive approach • Remediation of metacognition and exec functioning in info proc • Phonological training—works on word identification, sounds, etc

General Principles for the Classroom • Time in seat on task • Teachers actively instructing, modeling, guiding—LD kids don’t do well with discovery learning • Individualized instruction • Build in generalization across tasks and time • Incentives tied to specific goals • Try to remediate all deficits—not a single one—improvement in one area may not help another area

Principles for Schools Working with Parents • Send info home to parents about school curriculum, tips for ideal home curriculum • Create a partnership between parents and educators • Strong + leadership in the school • Emphasis on academic learning • High expectations • Continuous monitoring of progress • Incentives and rewards for both academic excellence and for high effort

Pediatric Psychology • Child health psychology • Child’s functioning in relation to physical health and well-being • Several aspects of functioning—consultation-liaison, research, assessment, tx, health promotion, prevention programs • Covers • Adherence to tx regimes • Management of pain and distress • Physical conditions like asthma and diabetes • Pediatric feeding problems • Sleep problems • Eating disorders • Medical rehabilitation

Sleep Disorders • Dyssomnias—difficulty initiating or maintaining sleep or excessive sleepiness (normal sleep is disturbed) • Sometimes parents just perceive more problems or have kids who wake parents up instead of quieting themselves to fall back asleep • 4% in one study of adolescents reported insomnia • Not good evidence for pharmacological agents, but they are used • Behavioral interventions—good sleep hygiene—work better

Sleep Disorders • Parasomnias—disorders of arousal, partial arousal, or sleep-stage transitions • Think of additions to sleep—sleepwalking, talking in sleet, night terrors • Sleepwalking—child sits upright in bed, open unseeing eyes, walks around • May last from a few seconds to 30 min • No later memory of episode • 15% of 5-12 yo have walked in sleep • 1-6% do so persistently • Most occur in 1st 1-3 hrs of sleep

Sleep terrors 1-6% of kids More common in males Usually between 4 and 12 yo Sleep terrors Non-REM sleep 1st 1/3 of night Child wakes with cry or scream and verbalizations are usually present Intense physiological arousal Motor activity, agitation Difficult to arouse Limited for no memory of event Somewhat rare (1-4 or 6%) Contrast with nightmares During REM sleep Middle and later portions of night Verbalizations, if any, are subdued Moderate physiological arousal Slight or no movements Easy to arouse Episodes frequently remembered Quite common Tx of sleep terrors and sleep walking—reduce stress and fatigue, may want to add late afternoon nap Sleep Terrors and Nightmares

Enuresis • 7 million kids • Diurnal—day time—DSM says enuretic if beyond age 5, some say 3 or 4 • Nocturnal—night time—usually 1st 1/3 of night • Prevalence—13-33% of 5 yo—nocturnal • Primary—never been dry—80-85% • Secondary—was dry but stopped, usually between 5 and 6 • When both parents have hx of enuresis—77% of kids met criteria; one parent—42% of kids; concordance—68% of MZ twins, 36% of DZ twins • Causes • Organic—insufficiency of sphincter muscle or chronic diseases like diabetes • Incidence of UTI is higher in bedwetters • Rates vary country to country; more prevalent in low SES groups • No evidence linking it to strict or lax training or to the age training is started • 2001 study—brain dev—more delta waves, fewer alpha waves (immature pattern) • Most kids don’t have additional behavioral problems, but slight increased risk • Tx • Bell and pad—effective in 70-95% of cases, but 40% relapse in 6 mos • Dry bed training—operant—overlearning, reinforcers, nighttime awakening • Full spectrum—both Bell and DBT—relapse of 10% in one year

Encopresis • Must be at least 4 yo • Often show signs of fecal retention and constipation and then lack of control when bowel becomes too full • 1-3% of kids- some estimates as high as 8% • Boys:girls 6:1 • Almost 30% also have enuresis • No link between parents and kids • Small % of kids do this in a manipulative way (intentionally)—need more traditional psych methods • For most kids, tx involves appropriate toilet training and eating habits

Coping with Chronic Illness • Chronic—one that persists longer than 3 mos in a given yr or requires a period of continuous hospitalization of more than one month • About 1/5 of kids with chronic illness are severely limited in their activities • Effects of chronic illness on dev • Adjustment to chronic illness • Overall, kids with chronic illness have risk of psychological dx 2.4x that of healthy kids • Kids with chronic illness accompanied by disability are at greatest risk • Risk is primarily for internalizing, but externalizing is also found • Prevalence of depression is about 9%--most successfully adapt • Possibly through denial—Phipps and Steele (2002)

Effect on Family Members • How parents adjust has a direct impact on how child and sibs adjust • About 10% of parents show sx of PTSD related to child’s dx (Kazak et al 1997) • Kids themselves rarely have PTSD due to dx • Stress factors that parents face • Financial and physical burdens • Changes in parenting roles • Sibling resentment • Child adjustment problems • Social isolation • Frequent hospitalizations • Grief • Parents of chronically medically ill kids—report more distress such as conflict, poor communication, lack of intimacy, lack of + affect • When maternal functioning remains intact, child and family functioning is less impaired

Asthma • Most common childhood disease (38-100/1000) • In parts of WNY, 25% • Accounts for 25% of all days lost due to chronic illness • Unpredictable course • With appropriate tx, asthma improves with age—approx 70% are improved or free of attacks after 20 yrs • Fatality rate low but not absent • 20-70% are non-compliant with tx

Psychology and Causes • Early psychological focus was on causes • 1941 French and Alexander—asthma was viewed to arise from an excessive, unresolved dependence on the mother. • Now we know that there is hyperresponsiveness of the trachea, bronchi, and bronchioles resulting in narrowing of air passages, Result is intermittent episodes of wheezing, coughing, shortness of breath • Causes are complex • Psych factors are not an original cause but • Anxiety may occur in anticipation of or during attacks, which increases the likelihood of attack or severity of attack • Family assistance for disorder—can create age-inappropriate dependency on parents, isolation from peers, increase in behavioral problems

Treatment Adherence Issues • Adherence is best for acute, painful sx • First issue: complexity—prescription of more than one med decreases compliance • Lifestyle changes are more diff to adhere to than med • Second issue: chronicitypoorer adherence • When sx decrease, tend to discontinue some or all med • Third issue: age—compliance is better in middle childhood • Fourth issue: family—family support increases compliance, dysfunctional families decrease compliance • To increase adherence • Visual cues • Verbal and written instructions • Increased med supervision • Intensive education • Self-monitoring programs • Reinforcement procedures

Childhood Cancer • CA is relatively rare, but accounts for largest # of disease-related deaths under 16 • 1/600 kids get cancer. 1/3 of these will not survive. • To check CA cells, kids may have to undergo bone marrow aspiration or spinal tap • As a result, we see a lot of anticipatory anxiety—nausea, vomiting, insomnia, crying days before—takes a long time to learn to cope with it • Factors related to controlling pain and anxiety • Distress in kids under 7 is much higher than older kids (studies est. 5-10x) • Kids with terminal CA are less tolerant • Approachers deal better than avoiders • Strong relationship between child and parent distressparents who emphasize coping rather than being anxious or overly solicitous have kids who do better • Kids cry more when parents are present, but report that it helps them through—may feel like they can let go a bit

Helping Children Cope • Prepare young child—unexpected stress is worse than predictable • Distress is lower when parents use strategies to distract or when they encourage coping techniques • When parents use reassuring statements or apologies, kids experience more distress • But when medical practitioner presents info in a reassuring way, may decrease stress • Coping strategies that emphasize being in control • Filmed modeling • Breathing exercises • Behavioral rehearsal—doll doctor and patient • Positive incentive

Alcohol and Substance Use and Abuse • 114 substance related dx in DSM-IV—can be dx’d in adults or kids and adolescents • Most common • Substance abuse and substance dependence for the following classes • Alcohol • Amphetamine (speed, diet pills, Ritalin) • Cannabis • Cocaine • Hallucinogen (LSD) • Inhalant • Opioid (morphine, heroin, codeine) • PCP • Sedatives • Other (includes steroids) • Dependence only—nicotine, polysubstance

Substance Abuse • Person uses a drug to the extent that he/she is often intoxicated and fails to meet obligations; no physiological dependence • To dx—1 of • Failure to fulfill major obligations • Exposure to physical dangers such as operating machinery or driving drunk • Legal problems • Persistent social/interpersonal problems

Substance Dependence • Physiological dependence—tolerance and withdrawal sx • Tolerance—greater and greater to achieve same effect • Withdrawal—cramps, restlessness, even death • 3 of the following to dx • Tolerance • Withdrawal or taking drug to avoid withdrawal • Uses more or more often than intended • Tried and unable to reduce use • Lots of time in obtaining or recovering from substance • Use continues despite phys problems causes or worsened • Activities given up or reduced b/c of use

Potential Ramifications of Substance Abuse • Poor parent-child communication • Poor parental supervision and discipline • Interpersonal conflict with parents and sibs • Decreased academic performance • Increased emotional and behavioral problems at school • Involvement with deviant peer groups • Increased delinquent and illegal activities • Effects of substance itself—impaired judgment, decreased fine and gross motor skills, overdose

Prevalence • 4/5 seniors, 2/3 10th gr, ½ of 8th gr have used alcohol; 1/3 have hx of binge drinking • 2-6% of adolescents—one or the other dx • Other settings have higher rates • Rates increase with age • Gender—overall similar, but varies by subs. • Females—more debilitated by use than boys; more family dysfunction • Higher rates in lower SES • Diathesis stress model • Children of alcoholic parent are 4-9x more likely to abuse or be dependent on alcohol at some point in life • Risk remains somewhat even if parent stops drinking • Majority do not go on to abuse • Why? Genetics + less than ideal parenting • Parent drinking is also assoc with increased rates of externalizing, even when kids don’t drink

Course of the Disorder • Gateway phenomenon • Sattler 1998—stages to substance use disorder • Experimental • Social • Instrumental (use drug to alter feelings and behavior) • Habitual (ignore other facets of life) • Compulsive stage (focused on gaining access)

Risk Factors • Depression and CD • GAD • Social impairment • Previous substance abuse (relapse is common) • Peer pressure/peer approval of use • Low self-esteem • History of sex activity • Increased rates of stressful life events • Lower academic achievement • Family approval of subs use • Unsupervised time • High sensation seeking • Poverty • School norms for drug use • Disorganized/disenfranchised neighborhood • Early menarche

Protective Factors • Commitment to school/good school attendance • Extracurriculars • Religion • Talking to parents/+ parent-child relationship • Showing + emotions • + role models • Supportive family • Peers who expect achievement • Intolerance of deviant behavior in others • Two parent home (including steps)

Treatment and Prevention • Treatment • Limited research • In general, tough to treat • Average abstaining from substance—38% 6 mos, 32% 1 yr • Most tx is better than no tx • Family tx better than individual for adolescents • Many types of tx—individual, 12 step, etc • Prevention • Live Skills Training—personal and social skills • DARE-ineffective • Interactive more effective than non-interactive • Information and fear alone are not effective • Re-norming

Feeding Disorders • Pica—habitual eating of non-food substances like dirt, paint, paper, fabric, hair, bugs • Very young kids (2-3 yo) and ID • Dx only when persistent • Prevalence info is limited • Among ID--.3-14% in community, 9-25% in institutions • Causes—many proposed—an attempt to satisfy nutritional deficit, parental inattention, lack of supervision, lack of adequate stimulation • Don’t dx before 2 • Tx—reinforce behavior that is incompatible with pica—more invasive—contingent squirts of water to the face, restraining child, facial screening

Feeding Disorders • Rumination—repeated voluntary regurgitation of food or liquid without organic cause • Child exhibits little distress, finds pleasure in this • Can have serious medical complications—even cause death • Most common in infants and ID • In developmentally typical kids, usually appears in 1st yr of life • ID later onset

Anorexia Nervosa • Intense fear of gaining weight or becoming fat is coupled with a refusal to maintain minimal wt. • At least 15 % wt loss without organic cause (usually 25-30%) • Active pursuit of thinness • Distorted body image • Amenorrhea • Two types: Restricting and Binge-eating/purging type—about 30-50% go from restricting to binge/purge • Restrictors are admired • Mortality: 3-21%--about 12x higher than other females age 15-24 • Normal awareness of hunger, but terrified of giving in to impulse to eat • Distorted perception of satiety • Excessive activity

Anorexia Nervosa • 90-95 % of cases are in females • Peak onset between 14-18 • .5-2% prevalence in clinical populations. Higher rates of behaviors when we use an epidemiological approach. • Males tend to fall in a few specific groups—jockeys, wrestlers, models • Medical complications: Hair and nails thin and become brittle, dry skin, lanugo, yellowish tinge to skin, cold all the time, low bp, kidney damage, heart arrhythmias, electrolyte imbalances, osteoporosis

Anorexia Nervosa • Outcome • Varied—may be a single, relatively mild disturbance or chronic • 40% totally recover • 30% considerably improve • 20% unimproved, seriously impaired • Remainder die • Early onset—more favorable prognosis • Poor prognosis—chronicity, pronounced family difficulties, poor vocational adjustment

Anorexia Nervosa • Comorbidity—depression in 50-70%, appear to be separate disorders • OCD also fairly common • Some studies have found increased rates of sexual abuse, but these have generally all been methodologically flawed

Bulimia Nervosa • 1st classified as a disorder in 1980, therefore less research • Two types—purging and non-purging • Some argue that anorexia with binge/purge is just an underweight form of bulimia • Recurrent episodes of binge eating and repeated attempts to lose weight by severe dieting or purging (laxatives, vomiting, exercise) • Typical picture: white female begins overeating around 18 and purging a year later, generally vomiting • May be over or underweight, typically about average • Family hx often includes obesity or alcoholism • Prevalence about 1-3 %, higher rates when we look at # with behaviors • >90% are female • Preoccupied with food, eating, and vomiting so that concentration on other subjects is impaired. May steal food (increased food costs assoc. with binging) • Less time socializing, more time alone than non-bulimics • Terrified of losing control over eating—all or none thinking • Lots of shame, guilt, self-deprecation, and efforts at concealment

Bulimia Nervosa • Personality—different picture than anorexics • More extroverted • More likely to abuse alcohol, steal, attempt suicide • More affectively unstable than depressed • Difficulty with self-regulation • Some evidence of hx of pica • More sexually active than controls, but less interested in sex and enjoy it less • Hx of childhood maladjustment; alienated from family • Higher rates of borderline

Language Disorders