Part 2

The Misunderstood Child: Understanding and Coping with Your Child's Learning Disabilities
by Larry B. Silver, M.D.

(Page 2 of 2)

If the area of the brain that is wired differently relates to the use of our muscles, we see what is called a motor disability. For some, the primary problems relate to the ability to coordinate and use teams of large muscles (gross motor skills); such kids have difficulty with running, jumping, or climbing. Others might have difficulty coordinating and using teams of small muscles (fine motor skills). They have difficulty learning to button, zip, tie, color within the line, use scissors, use eating utensils, and, later, use a pencil or pen to form letters and write. Still others might have a broader pattern of motor problems called sensory integration dysfunction. Now, in addition to gross and fine motor planning functions, they might have difficulty processing the information coming from nerve endings in the skin. They might be very sensitive to touch or misread temperature or pain. They also might have difficulty processing information from their inner ear (vestibular system), information the body uses to determine its relation to gravity. Thus, they have difficulty with movement in space or position in space. Which of these many possible motor problems are present will depend on the areas of the brain involved.

If the area of the brain that is wired differently relates to the processing of information for learning, we call it a learning disability. In some ways, this division of the cortex is artificial. If an individual has a learning disability, more than one area of the brain is involved.

In terms of human evolution, the most recent addition to the cortex is the sophisticated area of the brain that acts like the chief executive officer in a company. This area carries out what is called executive function. It orchestrates behaviors. This is the area that assesses a task or problem, decides how to tackle or solve the task, coordinates the necessary activities or functions, continually makes midcourse changes or corrections, and eventually reaches a successful and timely conclusion. If this area of the brain is wired differently, a person has difficulty with organizational planning and with carrying out tasks successfully.

This problem with wiring might extend beyond the cortex. There are connecting circuits within the brain that are often collectively referred to as the area of vigilance. This area of the brain is found in animals and primitive humans as well as in modern humans. It is the area that allows us to be a hunter. It controls the ability to sit very still so that you do not scare away your prey, the ability to track your prey and not be distracted by any background activity, and the ability to strike at just the right time. Picture, for example, a frog sitting on a lily pad. Not a muscle moves or the fly will go away. The eyes track the fly. At just the right moment, the tongue comes out and catches the fly. Some children have problems with the wiring of this area of vigilance. As a result, they might be hyperactive, distractible, or impulsive. We call this disorder attention-deficit/hyperactivity disorder (ADHD).

You can now see why some children have a learning disability. Others might have a language disability or a motor disability. Still others might have ADHD. Many might have one, two, three, or all four of these problems. They have multiple manifestations of the initial underlying problem that resulted in areas of the brain being wired differently.

Problems with Emotional Regulation

With the dramatic new methods for studying the brain, other problem areas are starting to make sense. Another group of circuits within the brain is referred to as the regulatory area. This is the area that maintains emotional balance or equilibrium, avoiding extremes. As we study this area, we find that there are many functions that need to be regulated. If any specific area is involved, we will find a problem with regulation of a specific emotion. Such problems usually become apparent in early childhood.

Some people have problems regulating anxiety. They have a history since early childhood of being high-strung or anxious. Over the years the focus of their anxiety may change, but the central theme is a high anxiety level. They might be afraid to go to sleep alone at night. Later they might have a fear of being in part of the house alone or a fear of bees or a fear of something else. Some of these children might develop a full-blown anxiety disorder. Some may have so much difficulty regulating anxiety that the level gets too high and triggers a physical (fight-or-flight) response. They have a panic disorder. They will break out into a sweat; their heart pounds; they feel weak.

Another regulating problem relates to the ability to control anger. These children have been irritable and angry since early childhood. They have always had tantrums. As they get older, they show a specific form of difficulty regulating anger called intermittent explosive disorder. When they get angry they don't just have a tantrum or pout or slam doors. Rather, they have a very short fuse. Sometimes they explode so fast you don't know for sure what caused it. Once they pass over their threshold, they lose control. They yell, scream, curse, hit, throw, threaten. They act in an irrational way and cannot be reasoned with. Sometimes they seem paranoid, saying people are trying to hurt them. This episode may last for fifteen minutes or more. Then it ends almost as abruptly as it began. Once it is over, the child may be tired and want to rest or sleep. They usually don't want to discuss what happened and seem confused about their behavior. Later they might feel remorse about their behavior. These are the "Dr. Jekyll-Mr. Hyde" children.

Some may have difficulty regulating their affect or mood. They seem to have been unhappy or sad much of their life. They are moody or depressed some of the time or all of the time. Some will go on to develop a disorder of depression. A very few children and adolescents may show difficulty regulating not just the down side (depression) but the up side (excitement or manic behavior). This might develop into bipolar disorder (formerly called manic-depressive disorder).

Another pattern of behavior that is part of these regulatory disorders relates to the ability to monitor thoughts and behaviors. Children may have difficulty controlling their thoughts and experience the need to rethink over and over a thought or thought pattern (obsessive behavior). Others feel they must do certain things in a certain way or they will get too anxious. They know "it is silly" but cannot stop. They might need to touch things a certain way or a number of times. They might need to check and recheck things (for example, if the front door is locked or the stove is off). They might need to perform certain patterns or rituals. This disorder is called obsessive-compulsive disorder.

There is one last area of difficulty with regulation that is not related to these regulatory problems but is found to be comorbid with learning disabilities. It is a condition that relates to difficulty regulating certain motor functions. Persons with this problem experience clusters of muscles contracting, causing what are called motor tics. Others may experience the need to say certain sounds or words, called oral tics. These individuals have a tic disorder. If this person has a chronic history of motor and vocal tics and there is a family history of such disorders, it is called Tourette's disorder.

What Does All Of This New Knowledge Mean?

Our brain is a beautifully functioning, fascinating part of our body. It has many functions. If something affects this brain early in development, this impact will cause areas of the brain to develop differently. Depending on which areas of the brain are involved, a person will develop a different problem. We have a name for each.

This road map will help you understand your son or daughter. Or, if you are a learning-disabled adult, it will help you understand yourself. As you read this road map, you will see many familiar trails or sites. It is not unusual for children, adolescents, or adults to have one or more of these disorders. The more one has, the more likely it is that they have even more. So it is not uncommon to find a child with learning disabilities and ADHD. This same child might have a tic disorder or an obsessive-compulsive disorder or be overly anxious or have trouble regulating anger.

The primary focus of this book is on learning disabilities. However, each of these related disorders will be discussed as well. I hope this road map helps you orient yourself as you travel from chapter to chapter.

Copyright © 2006 by Larry B. Silver, M.D.

About the Author

Larry B. Silver, M.D., a child and adolescent psychiatrist, is clinical professor of psychiatry at Georgetown University Medical Center in Washington, D.C. Prior to his current appointment, he was acting director and deputy director of the National Institute of Mental Health.