Learning disability

1. Learning disability کارگاه تخصصی توانبخشی شناختی در اختلالات یادگیری از سری کارگاه های آخرهفته های شناختی پاییز 1396 DR . FaezehDehghan OTR. PHD student in neuroscience

2. A mixture of upper case/lower case letters • Irregular letter sizes and shapes • Unfinished letters • Struggle to use writing as a communications tool • Odd writing grip • Many spelling mistakes (Sometimes) • Decreased or increased speed of writing and copying • Talks to self while writing • General illegibility • Reluctance or refusal to complete writing tasks • Crying and stress (which can be created by the frustration with the task of writing and/or spelling. This can also be brought on in dysgraphic students by common environmental sources such as high levels of environmental noise and/or over-illumination). • Experiencing physical pain in the hand and/or arm when writing • Poor use of lines and spaces

3. Writing analysis : • Muscular and postural factors • Gross motor skills • Hand function • Sensory processing issues • Paraxis • Visual perception dysfunction • Audio-visual coding

7. It may seem simplistic to mention posture but it is very important that children are seated with feet securely on the floor and knees and hips bent at a 90º angle. The height of the table should equate to the elbow height when seated. In classrooms today furniture is standard; however we do not have standard-sized children so foot blocks or different furniture may be required. Positioning of paper • The paper should be positioned at a slight angle in alignment with the child’s arm be this a left or right diagonal. Children should be encouraged to hold their paper with the opposite hand, if this proves difficult buy a sheet of thin non-slip matting to position the paper and encourage the placement of the opposite hand by drawing a stencil of the ideal position using a permanent marker pen.

8. The subskills that numerous researchers haveidentified include: • visual perception, • hand-eye coordination • visualmotorintegration • kinesthetic perception • fine motor praxis, andmanual dexterity • Children with handwriting problems often are thoughtor noted to have a delay or breakdown in one or more of thesesubskills • Motor planning or praxis is the ability of the brain to conceive, organize, and carry out a sequence of unfamiliar actions

9. They propose that a primary function of the parietal lobe is to extract sensory information about the external world and one's own body that is useful for the planning and guidance of movements. • This sensory guidance of action may operate in parallel with and independently of perceptual processes evoked by the same sensory inputs.

10. Voluntary Movement Requires SensoryInformation About the World and the Body • To reach out and grasp the cup the motor systemmust solve two basic problems. • First, it has to localize the cup in space and transform this location into a reaching movement of the arm to bring the hand to the cup. Second, it must encode the physical properties of the cup, such as its size and shape, and transform them into a particular grip.

11. Along with information about the target object the motor system requires information about the current state of the arm, including its posture and motion and the position of the hand relative to the target. • the various brain operations required to plan and guide arm movements are implemented in part by interconnected populations of neurons in the primary motor cortex, premotor cortex, and parietal cortex. • The parietal lobe is the principal target of the dorsal visual stream. It has long been implicated in a variety of functions such as the perception of the spatialstructure of the world and the control of directed attention. • As a result, the dorsal visual stream is often called the "where" pathway to distinguish it from the "what“ pathway, the ventral visual stream that projects from the primary visual cortex into the temporal lobe and is involved in the recognition of objects.

12. the parietal lobe has come to be recognized as being heavily involved in the higher cognitive functions of the brain. • The parietal lobe receives incoming somatosensory signals, but, unlike the occipital lobe, is involved in far more than processing a single sensory modality. • The parietal lobe is integral to the perception of external space, body image, and attention. • Information perceived and elaborated by the parietal lobe is submitted to the frontal association areas. • The posterior parietal lobe consisting of BA 7, BA 39, and BA 40, integrates somatosensory signals with signals from the visual, auditory, and vestibular systems (sensorimotor integration).

13. The parietal lobe attends to attractive (salient) environmental targets and locates these targets in terms of map coordinates. • Input from the temporal lobe gives it information about a target’s identity and from past experience, its anticipated weight, texture, and possible value • The parietal lobe formulates motor plans in cooperation with the frontal lobe and subcortical structures to generate eye, head, arm, and hand movements (and presumably leg movements) to intercept these targets. • The motor plans are submitted to the frontal lobes including those areas that act as a repository for socially acceptable behavior • Selective attention

15. Postural-Ocular Control • Postural-ocular control involves activating and coordinating muscles in response to the position of the body relative to gravity and sustaining functional positions during transitions and while moving. • Postural responses are required for any action needed during physical engagement. • Postural control emerges as the individual develops activation and coactivationof muscle groups that support movement. Postural control is dependent not only on adequate muscle tone, coactivation of muscles, and ability to activate muscle synergies but also on adequate ability to integrate sensory information from the vestibular, proprioceptive, visual, and tactile systems. • These systems contribute to our ability to maintain upright and antigravity postures as well as to move efficiently through the environment.

16. Postural-Ocular Control • For example, antigravity postures such as prone extension and supineflexion develop to support the infant’s ability to raise his or her head against gravity and initiate movement. • These provide the basis for more complex postural mechanisms that allow the child to move in and out of a midline position and maintain balance and equilibrium. • Balance and equilibrium are components of postural control that aremodulated by the vestibular, proprioceptive, and visual systems.

17. Praxis • Praxis is the ability to conceive of, plan, and organize a sequence of goal-directed motor actions. Praxis enables us to adapt and react quickly to novel environmental demands in a meaningful and efficient manner. • When engaged in learning a new skill or problem solving a complex action or task, a great deal of praxis is required (once a skill is learned, less praxis is required). • Praxis is developed through meaningful and successful motor interactions with the world (Figure 6.9). Repetition of successful actions encodes the action in a motor engram or ‘‘neural map’’ in our nervous system. We draw upon this ‘‘library’’ of motor engrams when faced with novel situations to plan and organize a response. • The more successful experiences we have, the more motor engrams are available for use to build new motor plans easily and effortlessly. • Well-established engrams allow us to access feedforward processes for automatic and highly skillful actions. • Feedforward refers to information from the senses that facilitate activation of the motor control system prior to use in an action. These motor engrams are therefore the building block of praxis, particularly motor planning, and contribute to formation of body scheme and body awareness.

19. Bilateral Integration and Sequencing • Bilateral integration and sequencing is the ability to use two parts of the body together for motor activities, and is another feature of praxis. • Bilateral coordination and sequencing of actions is built on the immediate perception of the body’s position or movement in space and the ability to use the two sides of the body together. • These skills used in common daily activities such as clapping, riding a bike, or opening a container are dependent on adequate vestibular-proprioceptive processing. • They also rely on lateralized sensory and motor skills including slightly faster and better hearing from the right ear (in right handers), right-left discrimination, crossing the body’s midline, and establishment of hand preferences for tool use. • Bilateral coordination skills serve as the foundation for the development of bimanual skills used in managing fasteners on clothes such as shoe tying and unilateral skills such as writing and throwing. • Related to bilateral integration and sequencing is postural control and bilateral coordination. Postural control forms the foundation for fluid, controlled movement and is essential when performing projected action sequences, that is, a sequence of motor acts put together to accomplish a goal in future time and space such as running to catch or kick a ball or coordinating the position and time to kick a soccer goal or make a basket.

23. برتری طرفی، توانایی گذر از خط وسط، جهت یابی • برتری طرفی : یک آگاهی و اطلاع درونی از این است که بن ما دو سمت دارد و این سمتها متفاوت از هم هستند. برتری طرفی حدود 4 سالگی نمودار میشود . زمانی که برتری طرفی شکل میگیرد کودک میتوان هر سمت از بدن را جداگانه و در هماهنگی با سمت دیگر استفاده کند. • گذر از خط وسط: خط وسط مانند دیواری است که در خط وسط بدن قرار دارد . کودک باید بتواند دست و پای یک سمت را از این دیوار رد کند و به سمت مقابل ببرد. گذر از خط وسط بصورت اتوماتیک رخ میدهد و بعد از آن سوبرتری در کودک شکل میگیرد. • جهت یابی : بکارگیری مفهوم برتری طرفی در محیط بیرونی است جهت یابی به کودک کمک میکند تا مکان اشیا نسبت به خودش و جای خودش را نسبت به اشیا تشخیص دهد . بعد از آن میتواند اشیای را نسبت به هم جهت یابی کند.(درک روابط فضایی)

24. مشکلات ناشی از عدم شکل گیری برتری طرفی و ... زمانی که برتری طرفی شکل نگیرد: خام حرکتی ، عدم شکل گیری درک جهات و... • عدم شکل گیری گذر از خط وسط: • خام حرکتی! • استفاده از چشم راست برای نوستن و خواند در سمت راست و چشم چپ برای خواندن و نوشتن در سمت چپ، حرکت کل بدن با مداد یا خطی که خوانده میشود • گذاشتن کاغذ در سمت راست برای نوشتن یا خواندن، دور زدن دور کاغذ حین نوشتن یا چرخاندن کاغذ • عدم شکل گیری جهت یابی : مشکل در d, b

25. رفلکسهای دوره نوزادی و اوایل کودکی رفلکسهای تونیک گردنی Tonic neck reflex(TNR) رفلکس متفارن گردنی Symmetrical tonic neck reflex (STNR) رفلکس نامتقارن گردنی Asymmetrical tonic neck reflex (ATNR) رفلکسهای لابرینتین تونیکTonic Labyrinthine Reflex (TLR) رفلکس طاقباز لابیرنتین تونیک Tonic labyrinthine prone رفلکس به شکم خوابیده لابیرنتین تونیک Tonic labyrinthine supine

26. رفلکس STNR اگر نوزاد سرش را به عقب برده و بالا بیاورد و به بالا نگاه کند ، بازوهایش باز میشود و پاهایش خم میشود. اگر سرش را خم کند و چانه اش را به سینه نزدیک ، بازوهایش خم میشودو پاهایش باز میشوند اگر رفلکس STNR در کودکان مدرسه ای باقی بماند» وضعیت نشستن کودک پشت میز دچار اشکال میشود زیرا اندامهای فوقانی و تحتانی و سر و گردن کودک با هم هماهنگ و همگام نیستند. بلکه بصورت زنجیره ای و بازتابی هستند . باقی ماندن رفلکس STNR باعث خام حرکتی ، لم دادن روی میز و گذاشتن صورت روی میز حین نوشتن میشود.

27. STNR

28. رفلکس ASTNR • اگر نوزاد سرش را به یک سمت بچرخاند ، در همان زمان بازو و پا همان سمت باز میشوند و بازو و چای سمت مقابل خم میشوند. • این رفلکس باید در 6 ماهگی مهار شود تا کودک به سمت چهار دست وپا رفتن برود

29. اگر رفلکس ATNR باقی بماند: • مشکل هماهنگی چشم – دست: اگر کودک بخواهد به کاغذ نگاه کند ، بازو و آنج باز شده و دست عملکرد ندارد. در نتیجه کودک باید گوشه چشمی نگاه کند! • مشکل در گذر از خط وسط • توانایی تعقیب دیداری مشکل است : استفاده از انگشت و مارکر برای خواندن، گم کردن جایی که میخوانده یا کپی میکرد. • Mixed-handedness above 8 years of age

31. Visual perception • Visual perception is the process of interpreting and integrating visual information with theother parts of the brain. • it is the connections that are madefrom the visual cortex to the visual associationcortex. • This includes the two commonly definedstreams: • One is the dorsal stream aka ambient system, “where” pathway that is responsiblefor producing our sense of spatialorientation,binocular fusion/depth perception, and the location, movement, movement direction and velocity of objects in space. • The other is the ventralstream aka focal system, “what” pathway that isresponsible for recognizing objects and colors,reading text, and learning and rememberingvisual objects

32. DESCRIPTION OF THE VISUALPERCEPTUAL PROCESSING AREAS • visual perceptual processing may be considered to have three component areas: • Visual Spatial Skills • Visual Analysis Skills • Visual Integration Skills

33. Visual Spatial Skills • Laterality● This skill is an internal self-awareness of twobody sides, knowing they are different andappropriately naming them as left or right. • Directionality● This skill represents the ability to projectleft–right concepts into visual space, thatis, the ability to evaluate left–right in aprojected sense. • Bilateral integration● The ability to use the two sides of the bodyeither in unison or separately.

34. Visual Analysis Skills Figure–ground● This skill represents the ability to extracta particular piece of information whilesimultaneously ignoring or disregardingirrelevant information. Visual discrimination● This is the ability to identify the differencesin features and forms such as shape, size,orientation, color, or any other quality. Form constancy● This skill allows the individual to consistently recognize an object despite changesin some of its properties such as size andorientation. This ability may be considereda subset of visual discrimination. Visual spatial relations● This skill represents the ability to understand directional concepts that organizevisual space. These skills allow an individual to develop spatial concepts, such asright and left, front and back, and up anddown, as they relate to their body and toobjects in space.

35. Visual Analysis Skills Visual closure● Visual closure is the ability to identify anincomplete object. This skill allows an individual to use a limited amount of visualinformation to determine the identity of apartial hidden or obscured object. Visual spatial memory● Visual spatial memory involves recallingthe spatial location of a previously presented visual stimulus. Visual sequential memory● The ability to recall a sequence (objects,letters, numbers, or words etc.) in the orderin which they were first displayed. Processing speed● This represents how quickly information isabsorbed and utilized. It refers to both thespeed of acquisition and the rate at which asimple visual task may be performed. Visualization● A higher-level skill needed to create amental image of an object one has seen andthen manipulate the image in his mind. Inmany ways, this skill is the culminationof all of the previously described visualabilities.

37. Visual perception and academic learning • Without accurate visual perceptual processing, a student would have difficulty learning to read, give or follow directions, copy from the whiteboard, visualize objects or past experiences, have good eye-hand coordination, integrate visual information with other senses to do things like ride a bike, play catch, shoot baskets when playing basketball, or hear a sound and visualize where it is coming from (like the siren on a police car). • Writing skill.(visual motor praxis/ object recognition / motion perception) • Reading skill( coding visual stimuli to auditory code and reverse/ object recognition / motion perception) • Reasoning ! (how to improve reasoning?)leading to math ability • ADL • PLAY !

38. Dysgraphia Spatial • A person with spatial dysgraphia has a defect in the understanding of space. They will have illegible spontaneously written work, illegible copied work, and problems with drawing abilities. • They have normal spelling and normal finger tapping speed, suggesting that this subtype is not fine motor based. • they may be unable to figure out what direction to move the pencil to make the curves and angles that they can see (motor planning). • Understanding words such as under, over, sideways and behind. • “Reversals” of letters, like d and b • Writing letters on a line. • Spacing letters and words. • Starting to write at the correct place on a page.

39. Dyslexia • a brain-based type of learning disability that specifically impairs a person's ability to read. These individuals typically read at levels significantly lower than expected despite having normal intelligence • Dyslexia is a learning disability that manifests itself as a difficulty with word decoding and/or reading fluency. Comprehension may be affected as a result of difficulties with decoding, but is not a primary feature of dyslexia. Hyperlexia • Hyperlexic children are characterized by word-reading ability well above what would be expected given their ages and IQs. • Hyperlexia can be viewed as a superability in which word recognition ability goes far above expected levels of skill However, in spite of few problems with decoding, comprehension is poor. • Some hyperlexics also have trouble understanding speech. Most or perhaps all children with hyperlexia lie on the autism spectrum. Between 5–10% of autistic children have been estimated to be hyperlexic

40. Reading • Omitting letter or a word/ missing the line • Not Recognition word or letters • Poor SP • Poor visual discrimination • Poor visual memory • Poor visual closure • Poor eye movements • Poor form constancy • Integration of visual and auditory

41. Math and reasoning • Poor SP • Poor visual memory • Poor visual closure • Poor form constancy • Describe the shape (shape color orientation size) • Find the shape I describe! • Compare the shapes • What was happen? Describe it • Memorize!

42. Eye movements • We often have the impression that our eyes glide smoothly across the page as we read. • However, this impression is not quite accurate: the eyes alternate between periods when they are relatively stable (called fixations, which typically last about 200–250ms) • when they are moving (called saccades, which typically last only 20–40ms). • Vision is suppressed during the saccades, so visual information that is acquired from the text is obtained only during the fixations

43. skilled readers move their eyes backward in the text to look at previously processed words. These regressions, as they are called, make up about 10–15% of the fixations that skilled readers make. • generally assumed that they reflect comprehension difficulties • most of the regressions that readers make are actually quite short (often going back only a word or two in the text) and probably reflect oculomotor variability (i.e., overshooting the target word) or word recognition problems

44. The average saccade size in reading is about 7–8 letter spaces • Skilled readers make shorter fixations, longer saccades, and fewer regressions than less skilled readers • disabled readers make longer fixations, shorter saccades, more fixations, and more regressions than normal readers.

45. the fixation duration on the word would obviously be the best measure of the time to process a word. many words are skipped: • content words (nouns,verbs, adjectives, and adverbs) are fixated about 85% of the time • function words(prepositions, conjunctions, articles, and pronouns) are fixated about 35% of the time • One reason function words are skipped more than content words is that they tend to be short and there is clear relationship between the probability of fixating a word and its length • disabled readers make longer fixations, shorter saccades, more fixations, and more regressions than normal readers

47. Hand functions

48. Hand functions

49. In hand arcuate