Specific Learning Disabilities

            At 8 years old, Linda is having problems in school.  In fact, her teachers have noticed her challenges soon after she entered Grade 1.  No matter how her teachers taught her to follow the model on her penmanship notebook, she frequently reversed certain letters.  Up to now, she still struggles in reading.  She tends to read the first two letters of the word and guesses the rest of the word.  Using this strategy, she sometimes pronounces the word correctly, but she is more often unsuccessful.  Her teachers have called her a “slow learner” and her parents believe that she will outgrow her problems.  After all, she is able to deal with the other challenges she faces in school, and has a healthy set of friends. 

            From this story, there is a strong likelihood that Linda might have a condition called a learning disability.  This condition is characterized by a difficulty to learn a particular skill set that is usually acquired through one’s school attendance.  It is often limited to a particular skill area, such as, reading words and texts, understanding what is read, speaking, understanding language, writing and spelling, and dealing with numbers and math concepts. 

            There are many names that specific learning disabilities are called.  Some people refer to them as “learning disorders,” and others call them “learning discrepancies.”  Still some use the words “learning problem.”  There are also specific names to certain learning difficulties.  Some of the more common names include the following:  “dyslexia” for a reading problem, “acalculia” for a math difficulty, and “dysgraphia” for a writing problem.      

            Of course, children learn many of the skills taught in school over time.  Many children typically fumble with language, reading, writing, and math and master the various levels of competency and fluency required over the years.  Nevertheless, teachers often have a sense of a particular student’s difficulties when most of the children in the same class have already mastered a skill that had been taught, and this one (or two) student(s) still struggle with past lessons.  This is often the time when a student may get referred to consult a specialist. 

            Children with specific learning disabilities are also quite intelligent, and they wonder how it is that their classmates are already able to master certain skills, whereas they are still struggling.  Although specific learning disabilities are fairly limited in scope to the lags in the particular learning area, this often has emotional and social repercussions for the child.  As children develop their sense of competence and self-concept, unaddressed lags can cause persistent feelings of frustration.  This can affect a child’s emotional life and peer relationships. 

            Specific learning discrepancies are said to be conditions rather than an illness.  That means that it is not something one develops.  It may really be caused by the way a child’s brain is wired.  Because of this, there are currently no medications or quick fixes that will address these problems.  Interventions are often long term, as it entails teaching the child habits that would help them cope and deal with their difficulties. 

            As such, there are many specialists who can help children with specific learning problems.  The primary interventions are educational, usually conducted by specialists trained in addressing each specific learning disorder.  A reading specialist might be one of these professionals.  Another is a teacher trained in special education.  Speech and language pathologists are also involved in language deficits (both listening and speaking).  Psychologists, counselors, psychiatrists and developmental pediatricians are often support professionals who help identify and address issues that may accompany the learning disability. 

            In time, Linda was referred to a psychologist, and is now undergoing daily educational interventions.  She is beginning to learn to read, and is coping better with the demands of her school. 

Selective Mutism

            James is a boy who kept quiet in school.  It’s not that he cannot talk.  At home, he talks to his parents and siblings.  It’s just that he did not talk in school and in public places.  The first few years he attended school, his teachers tolerated his silence.  As he got a bit older, however, this became a bigger problem.  As his teachers graded students for recitation and other oral requirements, he remained quiet and consequently was not given a grade. 

            This is an example of a child who has Selective Mutism.  This is a condition where a child or adult remains silent even in situations that require them to speak.  For many children who have this condition, they typically do not speak in school but have regular speaking voices at home.  Oftentimes, these children are also quite shy and demonstrate behaviors related to fear and anxiety, such as, standing still and having a blank expression on their faces.  They have a hard time saying what they need to say. 

            Selective Mutism is currently understood as a form of anxiety disorder.  That means, children who cannot speak have anxious feelings that they cannot manage well enough, so their capacity to speak is hampered.  This seems to be related to a basically shy temperament that these children inherently possess.  Whereas science still does not fully understand the real cause of such behaviors, we do know that the children are not intentionally doing this as a form of resistance or rebellion, and that these behaviors do not appear to be linked to trauma or experience of abuse. 

            Some people wonder if these behaviors are self limiting, and would resolve on its own when the child gets older.  While there are instances when children who had Selective Mutism when they were younger eventually learned to speak in places and with people they did not speak before, there is no certainty that this will happen to all children with Selective Mutism.  In fact, there are times when Selective Mutism carries over until one’s adulthood, and the individual learns to cope with not speaking in many public situations. 

            The impact of Selective Mutism on the development of an individual is great, as children often learn to make friends as they start to go to school.  The socialization that happens in school provides important life experiences for children to learn how to interact with peers and other adults.  When children are too shy, even anxious, to speak and interact with others, they are also excluding themselves from opportunities to initiate and sustain friendships. 

            One of the first things that help these children is when parents recognize the situation early enough and seek professional help for it.  With at least one parent’s assistance and the family’s involvement, treatment can proceed using various techniques.  Many of these techniques often begin with helping the child become comfortable in the situation where he/she is not speaking.  In small, incremental steps that do not significantly heighten the child’s anxiety, the child is encouraged to make a sound, to whisper a word, to whisper some more, until such time that the child is comfortable enough to speak.  Sometimes, humor is used to get the child to feel comfortable.  They might be rewarded for doing these incremental steps, but never in a way that puts them in a spotlight, as that might further heighten anxiety.  They might also be taught techniques in helping themselves feel more relaxed.  Many times, this journey takes a long time, but it is often worth the time and effort. 

            As James received help from his family, school, and psychologist, he eventually started to whisper, and then to speak; at first, to one classmate, and then later to a few others.  He is now a teenager who enjoys sports and the company of his friends. 

The Importance of Social Skills

            Edgar is already 21 years old and fresh out of college.  For most of his life, he had focused almost exclusively on his school work.  He did rather well, if grades were the only measure of success.  Edgar never made friends and mostly kept to himself.  All his hobbies were solitary activities, mostly involving the computer.  Even his conversations with the most important people in his life, his family, were limited to the day-to-day practical essentials.  He never really needed to connect with anyone.   As Edgar was growing up, his parents never really paid too much attention on his apparently lagging social skills.  They simply thought he would outgrow it.  After all, he appears reasonably intelligent anyway.  

            As Edgar enters the world of work, he finds himself in situations where he cannot avoid interacting with other people.  Some projects are even done in teams.  To cut the long story short, his ineptness in dealing with people quickly surface and he finds himself overwhelmed.  He does not quite understand what is going on when others interact with him.  Apart from the literal meaning of the words used, he does not quite understand much else.  And so, he finds himself being the brunt of other people’s impatience.  He then finds his social environment unpleasant.  Not long after, he quits work. 

            Social skills are among the most complex set of skills that everyone needs to learn, and basic intelligence (school smarts) is not enough to understand the complexities of even everyday human social interaction.  And so, parents really need to be watchful if their child is not behaving as expected in various social situations.  Of course, not everyone will be bubbly lives- of- the-party types, but everyone needs at least one friend with whom they can interact and connect.  In social situations, we like our children to behave appropriately. 

            Effectively interacting with people entails many sets of skills.  The most basic social skills entail understanding the usual conventions in social interaction.  This includes the following:  establishing and maintaining eye contact, using proper greetings, introducing oneself when necessary, using polite words, at least two strategies in starting and ending conversations, etc.  More sophisticated social skills entail more flexibility with the rules and adjusting to the nuances of situations.  These skills usually include the following:  understanding and responding to both verbal and nonverbal cues from other people, the use of humor, empathy and ensuring that others feel good about themselves in the interaction, etc. 

            Many people learn the nuances of social skills without them ever being taught these skills formally.  We pick them up in actual circumstances, sometimes from the example of others and other times when we reflect about our own behavior in a given situation.  Although many might think that social skills are learned in time and will naturally occur, not all children will learn social skills in this way.  There are some children who will only learn social skills adequately if they are taught these skills directly.  This is particularly true of people who are not very much attracted to being with people and interacting with others. 

            Children need to learn social skills very early.  In fact, as soon as they are three years old, interactions with peers become a good source for learning appropriate social skills.  This is the primary reason preschool is so important.  As the child gets older, social skills are further enhanced. 

            As for Edgar, learning social skills as an adult would be more difficult; not impossible, but difficult.  He will need a lot of perseverance and tolerance for making mistakes.  He also needs to be open in changing old habits and reaching out to others a bit more.  These are huge challenges as his habits and preferences become more set. 

On the morning of March 5, 2011 (Saturday), PsychConsult, Inc. will be sponsoring a FREE back-to-back talks.  I will be giving a talk on strategies in dealing with school bullying and my colleague Ms. Berny Go will be discussing teaching children social skills.  I will be explaining the systemic approach to addressing this phenomenon of bullying.  If you or anyone you know are interested to participate, please call PsychConsult, Inc. at (02)4212469 for reservations.  Do call as there are limited seats for this event. 

Play Therapy

Only in Grade IV, Andy is not doing well in school. For about two years now, he has not been getting good grades, and his parents are on his case. They want him to do better, and they are doing the best that they can to push him harder. Andy feels pressured and tries to escape his situation by playing video games. Apart from the low grades, he has also been involved in a few disciplinary cases in school. He is known as a class bully and he does not have too many friends. After many meetings in school, his guidance counselor recommended for his parents to bring him to a psychologist. Although unsure how a professional can help them, Andy’s parents accompany him to see a psychologist.


After conducting a thorough evaluation process, the psychologist recommends regular play therapy for Andy. Having explained to his parents how this may help Andy, his parents agreed to have him attend weekly hour-long sessions with the psychologist. Every so often, the parents were also involved in discussing the progress noted in Andy over the weeks and months.

Play is the most natural way that children relate to the world around them. At the same time, play is also the way that children are able to express themselves with little or no reservation. Using these givens, psychologists create a safe environment for children to be able to express themselves and find a resolution to the circumstances in which they find themselves. This is all done in the context of a natural play environment that puts the child at ease. In as much as they are given much control over how they will use the play therapy hour (e.g., what toys to use, how the toys will be played, what topics will be brought up and discussed, etc.) , limits are also set in terms of appropriate behaviors.

The most important element in play therapy is the relationship that is built between the child and the therapist. By far, this is cornerstone of this intervention. In the person of the therapist, the child is allowed to gain confidence in their own abilities and personal resources. The children are made to feel good about themselves, basing on the reality of their experiences. This context allows the child to freely express themselves, and in this process, discover a sensible way of dealing with their difficulties.

Although the toys and materials in play therapy are secondary only to the person of the therapist, they are also carefully chosen to evoke basic themes that portray the experience of the child. A doll house complete with various family members is a common fixture in play therapy rooms. Art materials and a sand box are also often seen.

In the years I have been doing play therapy, I have seen children magically blossom right before my eyes. Once affirmed and supported, the children naturally express themselves and find themselves. They are able to deal with the complexities of their situation in a way that words often cannot simply express. This is one clear advantage of using play as a medium for therapy—words are not the most integral elements in making sense of the world of the child, both outside and within.

So far, I have explained play therapy in a very generic sort of way. Please do not think that play therapy can only apply to specific emotional concerns of children. The truth is that this intervention can be quite versatile across various concerns that children may have. It has also been used with adolescents and adults as well. Trained play therapists are able to create the environment that best addresses the needs of a particular child.

Andy enjoyed his play therapy sessions. He found an ally in his play therapist, and after a number of sessions, was able to gain a better sense of himself. This newfound self-mastery allowed him to gradually do better in school. He also began to have friends in school as his reputation of being a bully faded. His parents also learned to discipline Andy in ways that enhanced Andy’s self-mastery. The progress noted became clear signs that Andy was ready to end his play therapy sessions.

Children Who Just Can't Sit Still

Arnold was 7-1/2 years old and already in Grade 2 when his teachers called his parents over to school for parent conferences soon after school began. This was a repetition of an old story in as far as Arnold’s parents are concerned. He was just rather disruptive in class. He blurted out answers whenever the teacher asked questions and interfered with his classmates’ work despite not doing his own. He walked around class and hardly stayed in his seat. In spite of these behaviors, he was often able to answer his teachers’ questions when he was asked. His parents admit that he had been this way from the time he was in preschool, but they never thought anything of it.


Whereas there is some truth that some children tend to be more active than others, we do expect that most, if not all, children will be able to settle down for at least 15 to 20 minutes when they reach the age six or seven. When a child is unable to do so by this age, we start to suspect that the child’s development is not going according to what is usually expected.

By the time children reach the age of 7 years, there is a general expectation among experts that children have settled and developed in the following areas: attention span, impulse control, and the need to keep on moving physically. First, children passed 7 are better able to manage their own affairs. They are able to sit still and attend to a task at hand, whether that is play or work. Notwithstanding their interest level in the task at hand, they are generally able to sit still and focus on what needs to be done. Second, they are able to control their impulses better that they are able to socialize in a way that is acceptable. They are able to transition from one thing to another, and do not switch tasks haphazardly. They are able to start some simple activities and stop with some resolution to what they started. They are also able to wait their turn and plan their behaviors reasonably well. Lastly, they are physically more settled and may not demand to move all the time.

When children reach the said age and still have significant difficulties behaving in the way described in the previous paragraph, seeking the consult of a professional might be in order. Consulting a professional who deals with children’s behavioral problems might be appropriate. Clinical Psychologists are among these professionals that parents can consult regarding their child.

What often comes to the mind of the professionals when the behaviors described are not met by a child is Attention-deficit/Hyperactivity Disorder or AD/HD. We do not really know the cause of this disorder, but the general belief about it is that it is a lifelong condition that children will need to cope with.

After identifying areas of growth of the child, appropriate treatment may proceed. Behavioral interventions are significant in helping a child deal with his/her difficulties. This can take the form of parent coaching, behavior modification techniques, and individual and/or group play therapy. Home-school coordination is also valuable in making sure that interventions are consistent across the places where the child spends most of his/her time. In some instances, medication can also help.

It has been a year since Arnold started attending weekly sessions with a psychologist. Although he still has difficulties in managing his focus and attention span, he has been able to do reasonably better in school, both in his studies and his behavior in school. He was also able to make friends with a few of his classmates and appear to be much happier.

What is Autism?

This week, I wanted to share 2 videos that I found on You Tube.  The first one outlines the basic features in identifying Autism, and the other one highlights some treatment modalities for children with Autism.  Although both are generally good videos, I must warn you that they express the opinion of the makers of the video, and do not necessarily reflect my professional opinion on all their points.

What is autism?  This question can be better understood in the context of the basic understanding that each person has five (5) aspects within him/herself.  These five aspects are the:  physical, intellectual/cognitive, emotional, social, and spiritual aspects.  As all these aspects overlap with each other and often intertwine, we started developing in each of the different aspects form the time we were conceived, and we continue to do so for the rest of our lives. 

Particularly in the first few years of life, development in these areas is crucial because many basic building blocks for later learning and being happen at this time.  And development in these basic areas is often sequential and fairly predictable.  Autism is one of the conditions where significant developmental delays in these aspects are observed. 

Autism is a condition where children do not develop in ways that are expected.  Essentially, there are three major areas of development that impact on the five (5) aspects of a person mentioned earlier.  These include the following: 

• Communication – Youngsters with Autism do not learn language at the time children are expected to learn it.  Because of this, many are suspected to have hearing impairments when they are young, but this suspicion is promptly disproved by appropriate hearing tests.  When they start speaking, their use of language is often unusual, even nonsensical.  For instance, they often repeat phrases incoherently, have a monotone when they are speaking, and say made-up words that do not exist. 
• Social interaction – Children with Autism have difficulty understanding and engaging in many everyday social interactions that many of us take for granted.  For starters, they often have difficulty establishing and maintaining eye contact.  As such, they have difficulty deciphering social cues and reacting appropriately to the situation. 
• Stereotypic interests and behaviors – Before age 3, children are expected to be able to play with objects in the way they are intended to be used.  They are also able to use their imagination to pretend-play (e.g., using a play telephone to simulate a conversation with another person; using a toy car to run a race with another toy car).  Children with autism often do not use things in ways that the things were intended to be used.  Instead, they typically enjoy watching spinning things and lining up objects repeatedly.  They also tend to be focused on a specific area of interest and hardly veer away from this (e.g., memorizing road maps or flags of countries).  They are rather inflexible, even rigid, in their area of interest and ways of conducting themselves. 

 

Currently, Autism is understood to be: 

• Biologically-based – It appears to have a genetic and neurologic (in the brain) component, although these are not yet fully understood.   
• Lifelong – As it is not a disease but a condition, it cannot be cured.  It is something a person has for the rest of his/her life. 
• A developmental disability – Signs of patterns of delay in development can be observed in the first few years of life, and these delays impact on later development of the person.    
• A spectrum disorder – Autism can be seen across any intellectual level (from the intellectually challenged to the very gifted), and the severity of impairment in language and social interaction is vast.  The development of different children as they get older also varies greatly from one individual to another. 

When Autism is diagnosed by a qualified professional (including, but not limited to any of the following:  Neurologist, Psychiatrist, Developmental Pediatrician, Neuropsychologist or a Clinical Psychologist), parents are often recommended to bring the child for various interventions.  It is important to note the goals of these intervention centers on minimizing the problems of autism and maximizing independence and quality of life.  The child and his/her family are also often helped to cope with the condition in more effective ways. 

Despite progress in the various modalities of treatment, many services in the Philippines are available only in the urbanized areas.  Many of the services required by children with Autism are also private with very limited government funding.  As such, a majority of our countrymen who have this condition are unable to access services they need.

The most effective interventions for children with Autism have been found to have three basic features.  First, they emphasize early intervention (the earlier, the better) and involve the parents and main caregiver.  Many exercises done in intervention sessions need to be reinforced at home, where the child spends most of his/her time.  Second, they are oriented to the particular developmental stage where the child is currently functioning.  Interventions need to have a clear underlying comprehension of developmental stages so that mastery of current skills is reinforced and subsequent incremental development is prompted and rehearsed.  Third, these methods are echoed in the educational techniques used for special needs populations.   

On the part of many parents, the diagnosis of Autism can be both a confirmation of a gut instinct and a devastating blow to their dreams and aspirations for their child.  They have to go through a long process of understanding their child and their role as parents of these children. 

In the years I have been working with such parents and their children, I noticed that the children who make very good progress in the goals of treatment over the years have parents with certain characteristics and habits.  I believe these practices often boil down to the following: 

• Openness – They are open to the reality of the situation, and wholeheartedly deal with their own reactions. 
• Motivation – They are motivated to learn about their child and his/her condition.  They read up, engage various professionals, join support groups, and ask relevant questions.  They apply what they have learned in understanding the specifics of their child and become a true expert when it comes to their child’s special needs.  This brings about a clear understanding of the goals they have for their child, and they engage professionals with this in mind. 
• Delay of Gratification – They realize that their child’s development will be gradual and incremental, and there are no quick fixes.  So, they learn to be happy with the small progress their child is making.  They persist in fostering the hope of achieving the goals of treatment, at least to some extent. 
• Administrative Skills – They manage the needs of the family within the context of the special needs of their child with Autism.  Similarly, they also facilitate the healthy collaboration among the various professionals working with their child. 

Having a child with Autism is both challenging and rewarding.  It is also a gift that we have to learn to appreciate over time, and I know many parents who, after many difficult years of taking care of their child with Autism, tell me that this is an experience they will never ever regret having gone through. 

The Path of Acceptance: the Journey of Parents with Children Who Have Special Needs

I have had my share of memorable incidents with parents whose children I have assessed to have certain special needs. I recall one parent who threatened to sue me if anything of what I just told her “got out to other people.” Maybe I was remiss in educating her about the strict adherence to confidentiality in our professional ethics. Perhaps I was not tactful enough in explaining what I thought her son needed. Whether these were factors that justified such threats, I will never know. What I do know is that parents go through a very rough time when they first hear from a professional, like me, that their child has special needs, particularly when these special needs are due to lifelong conditions/disabilities that have no known cure and also bear a stigma in society.


Some of these conditions I am talking about include the following: Mental Retardation (also known as Severe Learning Disabilities, Global Developmental Delay or Intellectual challenges); Pervasive Developmental Disorders (and its specific gradients of severity that are seen in Autism, Asperger’s Syndrome, and what may be termed as the Autism Spectrum Disorder); Attention Deficit Disorders (also referred to as ADD or AD/HD); Specific Learning Disorders (also known as LD’s or Learning Deficits). These conditions are often believed to be life-long and have an impact on various developmental stages of the person’s life. As these disabilities or conditions cannot be strictly classified as illnesses, they have no known cure. Most of the long-term interventions for these groups of young people aim at helping them become as self-sufficient and as well-rounded as they can be.

I know that parents go through the grieving process (as described in my post dated March 26, 2010) when they learn about their child’s condition/disability. I have seen parents spend years in denial, constantly finding potential miracle cures for their child’s condition. They desperately cling to the hope that some fad treatment might work despite scientific evidence that only certain kinds of time-tested interventions have been proven to be effective. Moving along, the threat I got from my story earlier appears to be a combination of this denial and anger, which is also part of the bereavement process. Bargaining is also often mistaken for hope when a cure for the condition is sought through some spiritual healer or novel cure-all food supplement. Over time and with much struggle, some parents begin to feel helpless and depressed after spending much time and energy trying to find a cure.

Only after going through the above-mentioned stages of grief, at least to some extent, can parents really come to terms with the reality that they are facing. Parents who have truly accepted their child’s condition are often at peace. I often observe the following among these parents:
• understanding the unique pace and personality of their child;
• appreciation of the unique gifts of their child;
• joy that come with the acknowledgement of the incremental (often slow) progress and change observed in their child;
• find meaning in having a child with special needs;
• feel at peace, find renewed hope, and enjoy life more; and
• sustain a “life-goes-on” attitude.

On this journey towards acceptance, these parents spend much time educating themselves about their child’s condition. They don’t limit their understanding of their child from the diagnostic and prognostic perspectives only, but also venture into getting to know their child as an individual who has unique qualities and gifts. They reach out to those who can help them understand the individual personality and strengths of their child, including those who share the same situation as they and professionals who help their children. Along the way, their perspectives of their children and themselves as parents make a shift. From the previously held ideas of how children “should” and “ought” to be, they start seeing the reality that all children are unique individuals who bear both inherent strengths and areas of improvement.

Acknowledging their need for self-care is also helpful for many of these parents. They may continue to pursue their personal goals amidst the demands of parenting a child with special needs. They can also benefit from having some alone time.

For some parents, finding a voice for their children through advocacy work gives them a sense of meaning and purpose. They become agents of change in society that work towards promoting the rights of people with these disabilities. In many instances, they even set up schools and organizations that promote the welfare of their own children as well as other children who are in a similar situation.

This path of acceptance is not an easy journey. It is riddled with struggles and self-searching. As the child with special needs grows up, old issues get resolved and new concerns emerge. At this juncture, a question begs to be asked: how is this similar to or different from the path of parenting any child?