PSY 316 Learning Disabilities Chapter Recap

Lecture 1 – Intro

- Important terms:
o IDEA
▪ Individuals with Disabilities Educational Act
▪ Purpose: Protects the right of students with special needs to obtain evaluation
and FAPE from schools
o FAPE
▪ Free appropriate program of education
▪ Purpose: Protects against discrimination, eg. Primary language difference; rights
of due process in procedures of assessment, placement, programming, and
appropriate education
• Appropriate: program designed to provide “educational benefits” and
related services (if necessary)
• Eg: is it appropriate to use color as a signal in class for blind students?
o IEP
▪ Individualised Educational Program
▪ Once an appropriate program is identified, it will be documented in an IEP
▪ Developed by multidisciplinary team (psychologist, special/general educators,
parents, the student, etc)
▪ Compulsory for special needs students
▪ For 16 years and above, Individualised Transition Program (ITP) must be in place
▪ Why it’s important: the school is legally bound to provide only the services,
accommodations (change in task/setting), and interventions listed in the IEP
• Case example: Doe vs Withers (teacher refused to do oral testing with
child as specified in IEP and was sued for $15k)
o Interventions
▪ Treatments used to change a child with disabilities (medication/skill training in
weak areas), eg. Remedial phonics training for reading
o Assistive Technology
▪ Low/high tech, non-electronic/electronic item/equipment used to increase,
maintain, or improve functional capability for an individual with a disability
▪ No tech ▪ Low tech ▪ High tech
▪ Pencil grip ▪ Buzzers ▪ E-Readers
▪ Post-it notes ▪ Portable word ▪ Touch screen devices
▪ Slanted surfaces processors ▪ Computerized testing
▪ Raised line paper ▪ Talking calculator ▪ Speech recognition
▪ Covered overlays ▪ MP3 players software
▪ Tactile letters ▪ Electronic organizers ▪ Word processors
▪ Magnifying bars ▪ Switches/buzzers ▪ Text-to-Speech (TTS)
▪ Weighted pencils ▪ Lights ▪ Progress monitoring
software
- Disability categories
o 14 as of 2014 according to IDEA
▪ Autism
▪ Deaf-blindness
▪ Deafness (more severe than hearing impairment)
▪ Developmental delay
▪ Emotional disturbance (ED)
▪ Mental retardation (AAMR prefers “intellectual disability)
▪ Multiple disabilities
▪ Orthopedic impairment
▪ Other health impairment (OHI)
▪ Specific learning disabilities (SLD/LD)
▪ Speech or language impairment
▪ Traumatic brain injury (TBI)
▪ Visual impairment including blindness
o Categories are updated periodically due to
▪ Identifying more disabilities
▪ Acknowledging co-morbidity
▪ Emphasizing functional behavior (according to settings, tasks, and interventions)
▪ Information by IDEA & DSM-V
- Section 504
o “No otherwise qualified individual with a disability in the United States, as defined in
section 706(8) of this title, shall, solely by reason of her or his disability, be excluded
from the participation in, be denied the benefits of, or be subjected to discrimination
under any program or activity receiving Federal financial assistance…”
o “An individual with a disability means any person who: (i) has a mental or physical
impairment that substantially limits one or more major life activity; (ii) has a record of
such an impairment; or (iii) is regarded as having such an impairment”
▪ walking, seeing, hearing, speaking, sleeping, breathing, working, caring for
oneself, performing manual tasks, & learning
▪ e.g. if labelled in high school, can be applied in college as well
▪ e.g. seen as disabled by parents
- Norms
o The most frequently occurring score in a setting or during the performance of a task
o Labels are derived from the extent of deviation from the norm
- Traits
o Habitual pattern of behavior
o Relatively enduring over time
o Usually associated with personality characteristics (extroversion)
o Can be physical (height, eye colour, hair colour)
- Disability/ disorder
o When a trait becomes extreme & leads to loss of social or academic functioning
o Inborn traits relevant to school functioning
▪ Sensory processes (seeing, hearing)
 ▪ Learning processes (intelligence, memory)
▪ Personality (introversion, adaptive ability)
- Normal distribution
o In a normal curve, children with disabilities would be at least 1 SD off the mean on a
particular trait
- States
o The task and setting variables
o Yerkes-Dodson law: Performance improves with arousal (increased alertness) to a
certain level
o Intellectually demanding task → higher arousal
▪ Best performed when relaxed (lower arousal)
o Repetitive, simple task → lower arousal
▪ Best performed when excited (higher arousal), eg. high-energy music
- Relation to Learning Disabilities
o Type of task must match type of child
▪ Higher initial trait arousal (eg. Anxiety, autism) → simple, boring task
▪ Lower initial trait arousal (eg. ADHD) → short, interesting task
- Points to Ponder
o Children who are not optimally aroused will seek stimulation through behavior
▪ Underaroused → will increase activity level
▪ Overaroused → will avoid task & self-calm through repetitive task

Lecture 2 – Intro to LD: Analysis of Characteristic Behavior

- Functional Analysis
o Antecedents, behavior, consequences, payoffs
o Understand misbehavior and poor performance within specific settings
o Teach substituting behavior to achieve the same purpose
o Normally, everyone behaves “abnormally” when placed in “abnormal” settings (eg.
Trouble adapting when moving to a new school in a different country)
o Children with disabilities behave “abnormally” even under “normal” settings
- Procedures in Functional Analysis
o 1. Observe Behavior
▪ Record positive and negative incidents
▪ Use objective descriptions (as close to the exact event as possible, without
personal interpretations)
o 2. Analyze Log
▪ Categorize the recorded observation as antecedent, behavior, consequence,
and payoff
• Antecedent – settings/tasks & activities/persons/time
• Behavior – objective descriptions of observable behavior
• Consequences – response to behavior/what happens as a result of
behavior
 • Payoffs – purpose – get/avoid
o 3. Summarize Data
▪ Allows a holistic view of the behavior pattern & the motivation
▪ Get payoffs (positive values); Avoid payoffs (negative values)
o 4. Select Target Payoffs
▪ Choose >= 2 goals that address high-frequency payoffs
▪ REMEMBER: Target payoffs, not behavior (behavior is only a means to achieve
payoffs)
▪ Eg: To decrease work-avoidance payoff, increase the fun/challenge OR decrease
task difficulty (whichever led to work-avoidance payoff in the first place)

Payoffs Coding Criteria

Get payoffs Avoid payoffs (some of which may be related to

future possible outcomes)
Children attempt to get competence (mastery of Children attempt to avoid possible social
achievement) by punishment or failure from specific
- Talking about or demonstrating - Subject areas (math)
accomplishments or interests in reading, - Response requirements (handwriting,
projects, after-school clubs, and the like. talking)
- Asking for help or making statements - Worksheets, listening, group contexts
such as “I don’t get this.” Alternatively,
any statement of “I know this…”
- Creating or collecting objects, stories, or
records of accomplishments.
- Reading by subvocalizing (whispering or
reading out loud) to help them perform
optimally.
Children attempt to get relatedness from Children attempt to avoid social experiences with
- Peer attention or interactions - Peers
- Adult attention, proximity, or interactions - Teacher attention or possible reprimands
(by blaming others, making excuses,
lying)
Children attempt to get self-determination or Children attempt to avoid possible lack of control
control by or predictability by
- Controlling (correcting, choosing, - Preferring familiar settings and resisting
bossing, leading) new social situations (e.g., during
- Continuing an activity or task that is transitions at the beginning and ending of
preferred class).
- Maintaining independent action, opinion, - Resisting specific tasks (e.g., difficult,
or feelings (arguing, debating) independent, non-preferred tasks).
Children attempt to get different types of Children attempt to avoid boredom by
stimulation: - Avoiding routine or basic tasks (e.g.,
- Emotional stimulation (intense or computations, phonics workbook
negative social reactions, e.g., shock, activities, handwriting)
anger, disgust).
 - Activity or kinesthetic stimulation - Avoiding repetitive activities such as
(physical contact) morning calendar time
- Sensory and tangible stimulation (sights,
objects, tastes/food, smells, sounds).
- Change (fun, excitement, play, risks,
unusual projects or activities).
- Cognitive stimulation (thinking, problem
solving, daydreaming, creating).

Lecture 3 – Verbal and Nonverbal LD: Disorders of spoken language

- Specific Learning Disability

o IDEA: A disorder in one or more of the basic psychological processes involved in
understanding or using language, spoken or written
▪ may manifest itself in an imperfect ability to listen, think, speak, read, write,
spell, or do mathematical calculations
▪ includes perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia,
and developmental aphasia
▪ does not include learning problems resulting from visual, hearing, or motor
disabilities, of mental retardation, of emotional disturbance, or of
environmental, cultural, or economic disadvantage
- Language Disorder
o IDEA: A communication disorder
▪ E.g. Stuttering, impaired articulation, language impairment, voice impairment
▪ Condition that adversely affects child academically
o DSM-IV-TR:
▪ Expressive language symptoms: limited vocab, errors in tense, difficulty recalling
words or producing complex sentence (age appropriate)
▪ Receptive language symptoms: difficulty understanding words, sentences, or
specific types of words, such as spatial terms
o DSM-V:
▪ Combines DSM IV Expressive Language Disorder & Mixed Receptive-Expressive
Language Disorder
- Specific Expressive Language Disorders:
o Anomia/dysnomia
▪ Poor verbal memory → poor word production
▪ Coping strategy: Use nonverbal sounds, pantomime, delayed response,
circumlocutions, written response, silent reading (recognize words but not
pronunciation)
o Aphasia
▪ Poor working memory → syntax & verb tenses confusion
o Cluttering
▪ Disturbance in fluency
▪ Abnormally rapid rate (may leave out syllables)
▪ Erratic rhythm of speech
 ▪ Disturbance in language structure
- Etiology (occurrence of language disorders can be categorized into):
o Biogenetic
▪ Family with histories of communication/learning disorder
o Environmental
▪ Acquired language disorder
▪ Exogenous factors, e.g. brain injury, environmental disadvantage (lack of
exposure)
o Functional
▪ Assessment of behavior function → way to avoid social contact
- Occurrence of Spoken Language Disorder
o Prevalence: Common for age 3 and below (10% - 15%)
o Gender: boys > girls (expressive language disorder)
o Age identified:
▪ Preschool: Mixed receptive-expressive (2-4 years)
▪ Elementary: Milder verbal language disorders
o Culture:
▪ Non-primary English speakers (not supposed to diagnose)
▪ Difficulties in primary language (difficult to diagnose – absence of assessment in
primary language)
- Informal Identification of Characteristics (tell-tale signs)
o Behavioral
▪ Inattentive, limited comprehension, irrelevant responses, appear withdrawn
▪ Acting out behavior, e.g. disruptive
o Social-emotional
▪ Displayed through:
• Depression & low self-esteem (past failures)
• Frustration & anger (current failures)
• Anxiety disorder (anticipated failures)
▪ Leads to negative social communications
• Less peer considerations
• More peer rejections
• Avoid appearing ignorant
• Appear unmotivated
o Cognitive
▪ Failure understanding abstract verbal language
▪ Performance in comparison with equivalent IQ peers (thinking tasks, eg
hypothesis testing, rule identification):
• No options to choose from → performs worse than peers
• Choice options available → performs as well as peers
• Conclusion: poor memory → lack verbal comprehension
o Communication
▪ Requires language (verbal/non-verbal)
▪ Two categories of verbal language:
 • Receptive language (listening & central auditory processing skills)
o Indicators
▪ Takes 5 – 10s more to process info
▪ Requires repetition
▪ Overly loud
o Difficulties
▪ Hearing words/questions incorrectly
▪ Insensitivity to rhyming words
▪ Failure following instructions
▪ Failure understanding word meanings/ complex logic
• Expressive language (speaking)
o Related to amount & quality of language produced compared to
peers
o Quantity
▪ Fewer words
▪ Fewer word variety
▪ Shorter sentences
o Quality
▪ Less complex syntax
▪ Less mature grammar
▪ Later speech
▪ Omission of sentence parts
▪ Unusual word order
▪ Semantics difficulty
▪ Pragmatics difficulty
▪ Confuse similar words
o Academic
▪ Can affect all subjects
▪ May evolve
• Age 5: spoken language problem
• Age 8: reading problems
• Age 14: composition problems (written language)
▪ Indicators
• Slower verbal response
• Longer completion of task
• Less complex storytelling
- Summary: Strengths & Needs
o Probable strengths:
▪ Non-verbal area (non-verbal math, science, art, computers)
o Probable needs:
▪ Alternative demonstration of competence
▪ non-language tasks
▪ assistance in group tasks (helps decrease need for understanding verbal
directions)
- What to do as an educator: Response to Intervention (RTI)
o Assess effects of research-based intervention on performance and behavior
o How?
▪ Tier 1: 80%
• Total Class Intervention
o How does the child perform compared to peers?
o What specific content does the child know/ not know?
o If performance doesn’t improve → Tier 2
▪ Tier 2: 15%
• Small Group Intervention
o At risk students who do not respond to Tier 1 interventions
o If performance doesn’t improve → tier 3
▪ Tier 3: 5%
• Individual Intervention
o Individualized instruction
o Formal diagnosis considered
o Special education considered
o Remember:
▪ RTI does not replace comprehensive evaluation
▪ Only part of evaluation
▪ Serves as eligibility procedure
▪ Underlying question: child/educator’s problem?
▪ Intervention increases in intensity (tier 3 > tier 2 > tier 1)
- Examples for RTI
o Tier 1: Accommodation in General Education: Receptive Language
▪ What to do [How to do]
• Decrease verbal instruction [rate, quantity]
• Use technology [digital recorders, ipad apps, graphic organizers,
flowcharts]
• Cuing/prompting [pictures/cue cards (especially multiple instructions)]
o Tier 1: Accommodation in General Education: Expressive language
▪ What to do [When to use]
• Picture cues [insufficient production]
• Story maps [poor organization]
• Self-questioning [poor goal structure]
o Tier 2 & 3: Intervention in Small Group & Individual: Receptive Language
▪ What to do [How to do]
• Teach single words, phrases, paragraphs, simple stories [concrete →
abstract (eg sleep (C) good (A); want milk (C) love you (A)]
o Tier 2 & 3: Intervention in Small Group & Individual: Expressive Language
▪ What to do [How to do]
• Increase vocab & abstract language use [Shared book reading
(parent/child or teacher/child)]
 • Use light-tech device [Gestures, necklace photos, communication
boards, eye-gazing objects, choice boards, props, voice output device]
• Record messages/use screen display device [High-tech augmentative
and alternative communication (AAC) device]
o Tier 2 & 3: Intervention in Small Group & Individual: Anomia/ Dysnomia
▪ Poor verbal memory → poor ability to speak/produce words
▪ What to do [How to do]
• Concrete experience, picture-object pairing [Named within categories,
pairs, associations]
• Increase vocabular [Sentence-completion task, timed naming drills]
o Tier 2 & 3: Intervention in Small Group & Individual: Syntactical Aphasia
▪ Poor working memory → Confuse word order in sentences
▪ What to do [How to do]
• Teach natural language within meaningful setting [Sentence-building
exercises (non-verb to more complex sentences; eg: “tell me about this
picture”)]
- Intervention for Pragmatics
o What to do [How to do]
▪ Teach functional language [Request needed objects in natural environment; eg:
“I want cookie”]
▪ Pretend play (improves comprehension and narrative skills) [Encourage child to
stick to a theme & narrate the plot; eg: “Pretend you are a crocodile and show
me what you would do”]
▪ Provide interaction opportunities [Dyadic interactions (multiple partners)]
- Long-term Outcomes
o Dropout rate for verbal LD = 40%
o 70% of Spoken Language Disorder (SLD) diagnosed in preschool will continue
experiencing difficulties at age 9
o Prevalence of SLD at school age → 3% - 7%
o SLD may be replaced by other verbal LD (e.g. reading disabilities)

Lecture 4 – Disorders of written language

- Written language disorders

o Reading disabilities
▪ Problems with decoding (translating visual symbols to sounds/words) and
encoding (understanding what is read)
▪ IDEA: a disorder in one or more of the basic psychological processes involved in
understanding or using language, spoken or written, which may manifest itself
in an imperfect ability to listen, think, speak, read, write, spell, or do
mathematical calculations
▪ DSM-V:
 • Inaccurate or slow and effortful word reading (e.g., reads single words
aloud incorrectly or slowly and hesitantly, frequently guesses words, has
difficulty sounding out words).
• Difficulty understanding the meaning of what is read (e.g., may read
text accurately but not understand the sequence, relationships,
inferences, or deeper meanings of what is read).
• Categorized under specific learning disorder
▪ Common subtypes
• Dyslexia
o Type of problem: decoding
o Language component: phonology
o Main problem: cannot read; can understand
o Milder form: can read; can’t spell
• Hyperlexia
o Type of problem: encoding
o Language component: comprehension
o Main problem: can read; cannot understand
▪ Common co-existing conditions
• RD + ADHD > RD/ADHD only
• 50% who have math disabilities have RD too
• Anxiety, depression, withdrawal, low self-esteem → more RD than non-
RD (girls > boys)
▪ Etiology
• Biogenetics
o Runs in the family
o Father’s occupation: Manual laborers (dyslexic > non-dyslexic)
• Environmental
o Pre-natal risk factors (loss of oxygen, poor nutrition)
o Educational and economic background of the family
▪ RD is more prevalent among poor families and schools,
small-town families, and families of low socio- economic
status (SES)
▪ poor teaching and miss important pre-reading
experiences
• Functional assessment
o (dyslexia) avoids reading assignment, especially reading aloud,
o do not avoid other areas (e.g. math calculations, physical
education, theater, or art)
o E.g. students with hyperlexia will volunteer to show off their
excellent decoding skills but avoid answering questions about
the meaning of what they have read
▪ Occurrence of written language
• Prevalence
 o common diagnoses in school- age children at about 18% of
students
• Gender
o 10–15-year-old boys underperform in reading achievement
more than do girls
o 3 boys : 1 girl
• Age
o Preschool and early elementary school: early language delay
predicts later reading failure
o Elementary school: Children with RD are diagnosed around age
7 after failing in response to initial reading instruction
o Secondary school: Difficulty with text-rich subjects & foreign
language learning
• Culture
o Higher among impoverished children (limited vocab exposure
upon entering kindergarten)
▪ Informal Identification of Characteristics
• Behavioral
o RD boys higher behavioural problem (44% clinical range) than
typical peers
o Appear insensitive and offensive
o Aggressive, clownish, difficult to control
• Social-emotional
o poor emotion recognition (Most & Greenbank, 2000; Nabuzoka
& Smith, 1995), poor academic self-concept (Settle & Milich,
1999), anxiety, depression, learned helplessness, and feelings of
self-dissatisfaction
o more shyness, anxiety, and depression esp. girls (due to past
failure)
o disruptive and antisocial to passive and withdrawn (attempt to
protect the child’s self-image)
o Peer responses to students with RD are typically negative: 75%
are teased or bullied and 60% are rejected in early elementary
school
• Cognitive
o Attention
▪ Poorer selective & sustained attention (compared to
typical peers)
▪ Due to lack of motivation (in reading)
o Intellectual
▪ Average to above average
▪ Weaker verbal intelligence (includes executive
functioning)  required in reading
o Auditory memory
 ▪ Remember sounds, syllables, words, and ideas
▪ Associate letter symbols with sounds (phonics)
▪ Weaker working memory → weaker LTM
o Visual memory
▪ Visual-spatial (eg: recalling object placement)
▪ Visual STM
▪ Visual perceptual speed (coding and matching symbols)
o Deficit in discriminating similar looking characters
• Communication
o Usually normal development
o Delay indicated by poor thought organization
• Motor, physical and somatic
o More severe compared to typical & ADHD
o Eg: gross motor, fine motor, visual-motor integration
• Academic
o Specific academic difficulties
▪ Poor fluency (speed reading)  guessing & context cues
(e.g. pics)
▪ Difficulty with new vocab
▪ Dislikes reading aloud
o Specific learning disabilities
▪ Visual errors
• Letter reversals, e.g. b & d, w & m, pit & tip, left
& felt
• Punctuation & capitalization errors
• Poor phonetic recall spelling
• Symbol inconsistencies with good sound
analysis, e.g. knight → nite
▪ Auditory errors (usually dyslexics)
• Misreading phonetically consistent non-words,
e.g. tat, fong, pip
• Poor syllable & phoneme counting
• Poor detection of rhyming words,
phoneme/syllable manipulation, e.g. read “pot”
without “o”
▪ Summary:
• Strengths
o Social skills & peer relationships
o Alternate strength, eg: math
o Strategies focusing on gestalt, e.g. reading headings only
o Develop meaning guessing ability (using verbal context cues,
pictures, etc.)
• Needs
o Assessment of RD effects on other areas, e.g. math
 o Less emphasis on speed & reading aloud
o Lower elementary – learn to read
o Upper elementary – read to learn
▪ Implications
• Tier 1
o Whole language approach
▪ Context enriched
o Basal/ sight approach
o Phonological code systems (phonological rules to print) (can be
peer-assisted)
▪ Phonological awareness
▪ Letter patterns
▪ Fluency
▪ Vocabulary
o Use of technology
▪ Low-tech
• Extend time to complete task
▪ High-tech
• Talking storybooks
• Books on tape
• Electronic books
• Reading-assistive technology
• Quicktionary Reading Pen II
• Tier 2
o Computers – spellcheck & reorganize writing
o Approach chosen is age-dependent
o Current practice
▪ Primary grades
• Sound-symbol correspondence
• Fluency
• Comprehension
• Vocabulary
▪ Older students
• Functional sight words (meaningful context)
• Functional curriculum (text-to-speech
accommodation)
• Motivational priming
o Research finding
▪ Functional interventions improve
• Prose literacy: Knowledge & skill to understand
and use info from text (e.g. editorials, news,
poems, fiction)
 • Document literacy: Knowledge & skill to locate
& use info in various formats (e.g. job
application, payroll forms, maps, tables)
• Tier 3
o One-to-one daily instruction
o Computerized training (focusing on working memory)
o Use “interesting” reading materials (novel, action-oriented,
surprising, scary)
o For hyperplexia, start with understanding spoken language
o Use cognitive maps → reduce cognitive load
o Use story mapping (characters, setting, events, etc.)  improve
recall & comprehension
▪ Long-term outcomes
• Early intervention reduces incidence of RD from 18% to 1.4-5.4%
• Without intervention, condition might worsen
• RD effects may spread into other areas (e.g. social studies, science)
• Literacy in first grade predicts long-term student achievement
regardless of IQ (Cunningham & Stanovich, 1997)
▪ RD depends on strength/weakness in skills required to read in respective
language
o Spelling disabilities and Composition disabilities
▪ DSM-V
• Difficulties with spelling (e.g. may add, omit, or substitute vowels or
consonants)
• Difficulties with written expression (e.g. makes multiple grammatical or
punctuation errors within sentences; employs poor paragraph
organization; written expression of ideas lacks clarity)
• Categorized under specific learning disorder
▪ Composition skills
• Complex activity → requires all skills in language production &
understanding
• Low level skills: Writing mechanics [e.g. logical sequence, translates idea
→ symbols (vocab + spelling)]
• High level skills: Generate content (gather knowledge, plan & organize
content, translate, revise, & improve writing)
▪ Spelling skills (subcomponent of writing)
• Translate: sounds + words (spoken) → visual symbols
• Spelling disorder:
o Weak sound-letter link
o Weak visual memory (inconsistent spelling, e.g. “knife”
pronounced “naif”, “plumber” pronounced “plamer”, etc.)
▪ Common subtypes
• Problems categorized by
o Content
 ▪ Generation of ideas
▪ Writing development
• 1st to 4th grade → knowledge telling
• By 6th grade → knowledge transforming
o Form
▪ Mechanical aspects
▪ Eg: grammar, punctuation, spelling, handwriting
▪ Best composition → dictation & writing speed are
synchronized
o Clarity
▪ Through process of revision (detection of errors of
consistency, organization, and form as well as errors of
perspective)
▪ Common co-existing conditions
• Co-morbidity • Problems
• Reading problems • ¾ of students with composition disability
• ADHD • Difficulty planning, organizing, revising materials
due to:
• Poor working memory
• Avoidance of repetitive editing
• Difficulty with handwriting (poor fine motor)
• Dysgraphia • Avoids composition task due to: poor quality
handwriting, poor visual-motor skills
• Possible strength: spoken narratives, typed
stories
▪ Etiology
• Biogenetic
o Heritability (spelling > reading difficulties)
• Environmental
o Poor living conditions
o Poor instruction (school)
o Lacking significant verbal interactions/reading experiences
• Functional assessment
o Avoid long assignments requiring planning (performs poorly)
o May develop “I can’t write” mindset
▪ Occurrence of written language
• Prevalence
o Estimated: 8- 15% of school population
o 2/5 LD students (IEP contains goals on written language)
• Gender
o Boys > girls
• Age
o Usually apparent by 2nd grade
 o By 10 – 12 years, fluency should increase (visual memory >
phonics)
o Otherwise, may suspect disorder
▪ Informal Identification of Characteristics
• Behavioral
o Off-task/disruptiveness (during writing)
• Social-emotional
o Low academic self-concept
o Passivity
• Cognitive
o Intellectual (lower IQ, less abstract writing)
o Memory & organization
▪ Written work – brief, incomplete, lacking development
& organization
▪ Poor time management
o Perception
▪ Auditory errors (Through process of revision (detection
of errors of consistency, organization, and form as well
as errors of perspective))
▪ Visual errors (spelling – punctuation & capitalization,
poor handwriting – lack eye-hand coordination)
• Communication
o 50% RD → spoken language difficulties
o Determine: any problem in oral language?
• Motor, physical and somatic
o Poor handwriting if poor fine motor
o Possible strength: spoken language
• Academic
o Writing (fewer sentences, fewer long words, more spelling &
capitalization errors)
▪ Summary
• Strengths
o Good oral language
o Good keyboarding skills
o Good gross motor skills
• Probable needs
o Focus on content (Alternative: verbal communication, audio
recordings, debate, etc.)
o Use verbal/pictorial presentation (express ideas)
o Assistance revising/organizing text
o Extend time & give breaks (written assignments)
▪ Implications
• Tier 1
o Problem o Strategy
 o Too little quantity o Extend time
o Reduce required length
o Verbal narrative presentation
o Use word processors
o Use mnemonics
o Use “think sheets”
o Organization o Concept maps
o “Connector” cards, e.g. “Similarly”, “on
the other hand”
o Draw & sequence pics before writing
o Cuing steps, e.g. 6WH questions
o Graphic organizer, e.g. mind map
o Teacher & peer feedback
o Self-monitoring checklist
o Computer-assisted composition (CAC)
o Speech feedback program
o Motivation o Meaningful tasks (novel, varied, diverse,
interesting)
o Challenging but reasonable tasks
o Present options
o Focus on mastery, not comparison
o Evaluate privately
o Recognize student effort
o Accept mistakes as learning opportunity
• Tier 2 & 3
o Strategy o Example
o Teach academic o Modeling
writing strategies o Use templates (different writing styles)
o Independent learners (self-instructions,
self reinforcement, goal-setting, self-monitoring)
o Teach editing o Peer editors (student-critic vs. student
writer)
o Teach cognitive o E.g. jokes, riddles, opinion essays, etc.
flexibility
o Spelling strategy
▪ Peer tutoring – oral spelling test
▪ Self-correction
▪ Finger spelling (using sign language)

Lecture 5 – Verbal and Non-verbal LD: Math Disability & Non-Verbal Communication Disability

- Math Learning
o Math requires
▪ Verbal skill (eg: math word problem, math vocab)
▪ Quantitative thinking (eg: numeric symbols, distance, time)
o Built-in ability in human & animals
 ▪ Numerosity (how many)
▪ Magnitude estimation (more/less than)
- Math Learning Disabilities
o IDEA: a disorder in one or more of the basic psychological processes involved in
understanding or using language, spoken or written, which may manifest itself in an
imperfect ability to listen, think, speak read, write, spell, or do mathematical
calculations.
o DSM-V:
▪ Difficulties mastering number sense, number facts, or calculation (e.g., has poor
understanding of numbers, their magnitude, and relationships; counts on
fingers to add single-digit numbers instead of recalling the math fact as peers
do; gets lost in the midst of arithmetic computation and may switch
procedures).
▪ Difficulties with mathematical reasoning (e.g., has severe difficulty applying
mathematical concepts, facts, or procedures to solve quantitative problems).
▪ Categorized under specific learning disorder
- Students with Math LD cannot grasp
o Meaningfulness of number
o Size
o Relative value of number
o Hence, heavily relies on finger counting
- Common subtypes (based on DSM-IV-TR)
o Number sense
o Memorization of arithmetic facts
o Accurate or fluent calculation
o Accurate math reasoning
- Alternative categorization
o Skill type o Concrete Skills o Abstract skills
o Example o Calculation o Problem solving
o Procedural (know sequence)
o Conceptual (understand principles)
o Utilization (right application)
o Emphasis o Memory-based o Strategy & concept selection
- Common Co-Existing Conditions
o Often with neurological disorders (eg: ADHD, epilepsy, fragile X syndrome)
o Higher rates of ADHD also have MLD (31%) vs. general population (6 – 7%)
o 32% MLD have attentional problem, hence often misdiagnosed as ADHD
- Etiology
o Biogenetic
▪ Brain-based disorder
▪ Prevalence of dyscalculia → within family: general population = 10 : 1
o Environmental
▪ Prematurity, low birth weight, poor teaching
o Functional Assessment
▪ Antecedent: math assignments
 ▪ Classroom disruption linked to poor basic math
- Occurrence of MLD
o Prevalence
▪ 5 – 8% general school population
▪ 25% LD receive math help
o Gender
▪ Dyscalculia affects both genders equally
o Age
▪ Diagnosed by end of 1st grade
▪ Math reasoning difficulties by 4th grade or later
o Culture
▪ Generally, Asians (eg: Korea, Japan) outperform western countries (eg: England,
Norway, Denmark, US)
- Informal Identification
o Behavioral
▪ Externalizing disruptive behavior
▪ Payoff: Avoid work
• Deflect attention from academic difficulties
o Social-Emotional
▪ Purpose: Cover up
• Eg: withdrawing effort, give up easily, criticize others, aggression
▪ Independent phenomenon: Math anxiety
• When fear interferes with number manipulation & solving math
problem
• Occurrence: 4% high school students (girls > boys)
• May exist without general anxiety
• Math anxiety
o Focuses on speed rather than accuracy
o Worsens when speed emphasized, work problem at board
(reading aloud), high demand for correctness
o Cognitive
▪ Intellectual
• Employ strategies used by normal younger students
• Eg: Finger counting vs mental calculation
▪ Memory/ perception
• Poor memory → less advanced strategy
▪ Visual perception
• Poor left/right orientation
• Confusing numbers
▪ Inattention
• Careless errors (eg: omitting numbers, overlook operation change)
- Summary
o Strengths
▪ Compensates in other academic areas (e.g. reading, writing, spelling, art)
 ▪ Good spoken language (may be talkative)
o Probable needs
▪ Verbal math deficits: Additional instructions in math language + reduced
problem verbiage
▪ Visual math deficits: verbal instruction + visual concepts
- Implications
o Tier 1
▪ Math problem solving
• Real-world problems
o Multiple solutions
o Description using text/graph/table
o Compare & contrast solutions
• Visual supports
• Guided practice with new items
• Application of new concepts
▪ Use technology
• FLYPen – audio feedback on solution accuracy
• Software – concrete/visual problem representation (e.g. sketching
software)
• Clicker system – answer betting
• Software for practicing computation
• Computer games/talking on-screen calculators – slowed calculation
▪ Teacher factor
• Questions students’ strategies & get explanation
▪ Problem ▪ Strategy
▪ Reading ▪ Reduce text amount
▪ Read problem to child
▪ Match reading level to materials
▪ Working memory ▪ Use checklists – problem solving procedure
▪ Use drawings
▪ Reduce information amount per question
▪ Use calculators
▪ Failure to attend ▪ Highlighting signs & steps
to important info
o Tier 2
▪ Weekly sessions (20-40 mins, 4-5 times/week), monthly monitoring
• Building math proficiencies
▪ Self-monitoring
▪ Goal-setting with graph
▪ Dyadic interactions
o Tier 3
▪ Lack of evidence-based approach
▪ Current practice
• Use concrete materials, eg: Cuisenaire rods, number cards
 • Conceptual model-based problem-solving instructions (COMPS)
o Represent math concepts in models
o Transition of math problem to equations
- Non-Verbal Learning Disabilities
o IDEA: same as RD and MLD
o DSM: no formal definition
o Distinctive characteristics
▪ Social & math disabilities (right-hemisphere)
▪ Compensatory strength, eg: high interest in reading, talkative
▪ Visual communication difficulties
o Common subtypes
▪ Motoric deficits
• Lack of or delayed coordination
• Balance problems
• Grapho-motor skills
▪ Visual-spatial-organizational difficulties
• Poor visual recall
• Faulty spatial perception
• Difficulty with spatial relations
▪ Social problems
• Poorer comprehension of nonverbal communication (facial expression
and gestures)
• Difficulty adjusting to transitions and novel situations
• Deficits in social judgements
o Common related conditions (often misdiagnosed as):
▪ Giftedness
• Overlap: Mature vocabulary, rote memory skills, and reading ability
• Contradictory: Visual deficits (NVLD)
▪ Asperger’s Syndrome (AS)
• Overlap: Odd behavior & routine preference
• Contradictory: Enjoys interaction (NVLD); repetitive behavior (AS)
▪ Dyspraxia and or/ dysgraphia
• Overlap: Coordination & motor control problem
▪ Communication disorder
• Overlap: Speech/articulation problem (preschool)
• Contradictory: Good language skills (NVLD)
▪ Intellectual disabilities
• Overlap: Low visual IQ
• Contradictory: Average/above average verbal IQ (NVLD)
▪ Narcissistic or borderline personality disorders
• Overlap: Appear self-centred
• Contradictory: Honest, nonaggressive, self-awareness (NVLD)
o Etiology
 ▪ Biogenetic
• Neuropsychological deficit (right hemisphere)
▪ Environmental
• Sarcastic response
▪ Functional Assessment
• Antecedent: New situations, transitions, math tasks, social interaction,
motor-coordination tasks
• Coping strategy: Use verbal interaction & questioning, avoid tasks,
disrupt lessons
o Occurrence of non-verbal LD
▪ Prevalence
• 0.1 – 1% of general population
• <10% of LD
• Underreported → failure to identify (strong verbal skills); misdiagnosed
(AS)
▪ Gender
• Girls > boys (left hemisphere matures faster)
▪ Age
• Hard to detect
• Early years academic (memory-based task, eg: reading, decoding) –
perform well
• Later years – compensate with excellent verbal memory skills
o Informal identification
▪ Behavioral
• Aggressive – confused & frustrated
• Typically: hardworking, persistent, goal-oriented, honest
▪ Social-emotional
• Difficulty making friends
• Appear rude/insensitive
• Difficulty responding to social-emotional signals (lacks social
understanding)
• Cannot “read between the lines”
• Lacks social boundaries
▪ Cognitive
• Attention/perception
o Visual perceptual skill deficits (spatial skills)
• Intellectual
o Difficulty getting the “big picture”
• Memory
o Verbal memory > visual memory
o Weak revisualization
o Engaging in confabulation
▪ Communication
 • Good auditory skill
o Content-focused rather than paralanguage (i.e. how it is said)
• Early speech development
• May be hyperverbal (compensate visual deficits)
o Quantity > quality (often asking “dumb” questions)
▪ Motor, physical, somatic
• Poor motor skills
o Clumsiness
o Difficulty with self-help (buttoning shirts)
o Rarely plays puzzles, blocks, construction toys
o Poor balancing
• However, some kids may have better skills
▪ Academic
• Poor handwriting (poor motor skills)
• Difficulty with numbers (counting, balancing checkbook)
• Difficulty with independence skills (complete homework, following non-
explicit directions)
• Lacks cause-and-effect knowledge
• May do well in language-based subjects
o Summary
▪ Probable strengths
• Verbal academic areas, e.g. reading, writing, spelling
• Good spoken language (may be talkative)
• Verbal memory
• Ability to adapt to difficulties (e.g., using a “talking” clock; using a
physical attribute, such as a scar, to tell left from right)
▪ Probable needs
• Math assistance (understanding symbols & problem meanings) •
• Scripted responses (social situations)
• Verbal explanation of new events/context
• Fine motor skill development/accommodations
• Spatial understanding assistance
• Help with paraphrasing
• Emphasis on strengths and developing reasonable bypass strategies
• Social interactions with peers (e.g., online peerbased book clubs) to
reduce their overreliance on adults
o Implications
▪ Tier 1
• Simultaneous verbalization: visual info + verbal explanation
• Encourage questioning
• Task analysis
• Give explicit feedback
• Utilize strength, e.g. reading & rote memory, to compensate visuals
 ▪ Tier 2 & 3
• Use direct verbal instructions
o Eg: scripted phone call
• Practice interpreting social cues (eg: facial expressions, voice tone, and
body language)
o Using gestures, charades, sequences of pictures and movies

Week 6 – Cognitive Disability: Mild Intellectual Disability

- Cognitive Exceptionalities
o Mild intellectual disabilities
o Mild traumatic brain injuries
o Gifted & talented
- Cognitive Disabilities
o Mild intellectual disabilities
o Mild traumatic brain injuries
- Intelligence (2 types that are assessed)
o Performance intelligence
▪ Using visual stimuli
• Eg: pictures, maze, blocks, objects
o Verbal intelligence
▪ Using auditory stimuli
• Eg: vocabulary, statement
- Mild Intellectual Disability (MID)
o IQ range below 70 – 75
o WISC – verbal & performance scale
o Typically, MID defined by IQ
o Now, includes application of intelligence to adapt
o IDEA: “significantly sub-average general intellectual functioning existing concurrently
with deficits in adaptive behavior and manifested during the developmental period that
adversely affects a child’s educational performance
o DSM-V criteria:
▪ Deficits in intellectual functions, such as reasoning, problem solving, planning,
abstract thinking, judgment, academic learning, and learning from experience,
confirmed by both clinical assessment and individualized, standardized
intelligence testing
▪ Deficits in adaptive functioning that result in failure to meet developmental and
sociocultural standards for personal independence and social responsibility.
Without ongoing support, the adaptive deficits limit functioning in one or more
activities of daily life, such as communication, social participation, and
independent living, across multiple environments, such as home, school, work,
and community.
▪ Onset of intellectual and adaptive deficits during the developmental period.
o Common sub-types
▪ Down syndrome
• Genetic condition characterized by presence of an extra 21st
chromosome
▪ Fragile X syndrome
• Associated with symptoms of autism
▪ Fetal Alcohol Syndrome (FAS)
• Medical condition characterized by physical and behavioral disabilities
• Result of mother’s heavy exposure to alcohol during pregnancy
o Common co-existing conditions
▪ LD and ADHD (only average – above average IQ), hence ID excluded
▪ ID compared to
• Emotional & behavioral disorders (EBD) – EBD scores higher, more
behavioral problem
• Specific Learning Disability – ID has broader area of dysfunction
o Etiology
▪ Biogenetic
• Genetic influence increases with age
• 25% ID case due to single-gene abnormalities
• As a result of chromosomal abnormality (down syndrome, fragile x
syndrome)
▪ Environmental
• Prenatal
o Infections (german measles)
o Severe maternal stress
o Malnutrition (fetal alcohol syndrome [FAS])
• Postnatal
o Premature birth
o Post-birth infections (meningitis, encephalitis)
o Toxin exposure (lead)
o Low SES → stimuli deprivation
• Functional Assessment
o Shows academic difficulties & behavioral abreactions for these
tasks
▪ Abstract, requires transference
▪ Fast responding
▪ Independent thinking
▪ Info application/generalization
▪ Incidental learning (informal learning)
▪ Problem solving
o Occurrence of MID
▪ Prevalence
• 1 in every 10 families (USA)
• 3rd largest disability
 ▪ Gender
• 3 Males : 1 Females
▪ Age
• Usually identifiable after preschool
▪ Culture
• Low SES → Lack of resources, understimulating, environment, lower
parental education
o Informal Identification
▪ Behavioral
• 3x greater than average students
• Factor – comorbidity
o Eg: higher ADHD symptoms among lower IQ
• Trigger
o Environmental change (setting, teacher)
o Difficult tasks
▪ Social-emotional
• Not necessarily low social skills
• Social functioning linked to cognitive functioning
o Poor social interpersonal problem solving
o Lower social competence (gullibility, easily manipulated,
stressful social exchange)
• Internalize difficulty (anxiety, depression, withdrawal)
▪ Cognitive
• Intellectual performance
o Generally delayed intellectual development
o Poor abstract thinking
o Poor executive functioning (incidental learning, transference,
generalization)
o Eg: unable to recognize words in text even after practicing
reading them individually (transference problem)
▪ Working memory & attention
• Deficits in selective & sustained attention
• Slow to identify relevant info
• BUT can learn rapidly once “catch on”
• Lacking short-term memory strategies
• Auditory STM span 2-4 numbers vs 5 numbers (typical children)
▪ Communication
• Delayed speech development
o Eg: babbling → speech (infancy)
o First word → around age 3
o First sentence → around age 5
• Slower processing speed → delayed response
▪ Motor, physical, somatic
• More prone to injury compared to non-MID
 • Several physical diagnostic characteristics, eg: FAS, Fragile X syndrome,
Down syndrome
• Other physical/ sensory characteristics
o Seizure disorders
o Hearing impairment
o Fine motor immaturity
o May have congenital heart defects
▪ Academic
• Delayed educational development rate
• Unlike LD, occur across subject areas especially comprehension and
application
• More reliant on extrinsic motivation
• Reading
o May develop basic decoding & comprehension
• Math
o May develop basic & functional math
o Lacks higher-level problem solving
o Summary
▪ Strengths
• Can improve reading by focusing on interest areas
• Learn rapidly once “catch on”
• May be socially skilled
▪ Needs
• Focus on strength & interest areas
• Highlighting relevant dimensions (task/setting)
• Transfer skills training
• Independence training using direct instruction
• Extend time
• Focus on functional curriculum (adaptive living)
• Simplify instruction (language & structure)
o Implications
▪ Tier 1
• Provide choices
o Encourage self-determination
• Encourage goal-setting
o Improve task performance rate & accuracy
o Improve social success & self-determination
• Peer tutoring
o Provides social opportunities → builds friendship
• Using computers (additional practice)
o Improve memory
• Compliance training/modeling/role play/positive feedback
o Reduce disruptive behavior
 ▪ Tier 2 (Skill/Area → Strategy/Method)
• Social Skills →
o Simple to demanding tasks progression
o Teach problem-solving based on interest
o Use meaningful materials
• Task performance →
o Simple to demanding tasks progression
o Discrimination learning & training
▪ Taught to identify relevant dimensions
▪ Eg: compare T&F (F has a cross in the middle)
• Sequential processing →
o Math problem: Each step prompts the next step
o Identify operations using verbs
o Translate problem info to equations
• Communication skills →
o Receptive before expressive
▪ Tier 3
• Provide structure lessons in real settings
o Community-based learning (eg: cooking, dressing, community
mobility)
o Higher success in learning & independent leaving
• Use functional curriculum
o Focus on functional skills (eg: money concepts, time concepts,
health & safety concepts)
o Long-term outcomes
▪ Less likely than non-MID peers to transition to adulthood & live independently
▪ By adulthood, achieve adequate self-care but still requires supervision
▪ Inclusion in general classroom results in achievement & adaptability

Lecture 6 part 2 – Cognitive Disability: Traumatic Brain Injuries (TBI)

- Definitions
o IDEA:
▪ an acquired injury to the brain caused by an external physical force, resulting in
total or partial functional disability or psychosocial impairment, or both, that
adversely affects a child’s educational performance.
▪ open or closed head injuries resulting in impairments in one or more areas, such
as cognition; language; memory; attention; reasoning; abstract thinking;
judgment; problem-solving; sensory, perceptual, and motor abilities; psycho-
social behavior; physical functions; information processing; and speech.
▪ does not apply to brain injuries that are congenital or degenerative, or to brain
injuries induced by birth trauma.
o DSM-V
 ▪ Categorized under Neurocognitive Disorder (NCD)
▪ “…brain trauma with specific characteristics that include at least one of the
following: loss of consciousness, posttraumatic amnesia, disorientation and
confusion, or, in more severe cases, neurological signs (e.g., positive
neuroimaging, a new onset of seizures or a marked worsening of a preexisting
seizure disorder, visual field cuts, anosmia, hemiparesis) (Criterion B). To be
attributable to TBI, the NCD must present either immediately after the brain
injury occurs or immediately after the individual recovers consciousness after
the injury and persist past the acute post-injury period (Criterion C).”
- Common sub-types
o Severity indicated by type of physical damage
▪ Concussion
• Focal effects that can be recovered
• No tissue damage (except in repeated concussions)
▪ Contusion
• Focal damage to brain cells
▪ Shearing
• Global damage to brain cells
o Types of causes
▪ External forces
• Commonly found below age 2
• Eg: shaken, tossed babies
▪ Opposing forces
• Usually sustained during accidents
• Eg: MVA, contact sport
▪ Lack of oxygen
• Eg: drowning, stroke
- Common co-existing conditions
o Children with disabilities often experience TBI
▪ E.g. 20-50% of TBI children have ADHD
▪ Depression is also common & persistent among TBI
▪ TBI + EBD (34%) vs. TBI + other physical disabilities (11%)
▪ TBI + other physical disabilities : TBI only = 2 : 1
o TBI may worsen prior condition
- Etiology
o Biogenetic
▪ Not direct cause BUT increases risk of TBI
o Environmental
▪ Primary cause by environmental conditions (eg: fall, accidents)
▪ Family behavior & attitude increases risk (eg: disorganized, careless)
- Occurrence of TBI
o Prevalence
▪ 25% of pediatric injuries each year (70 – 90% MTBI)
▪ >30% of self-reported brain injury by age 25
 ▪ 20% TBIs are results of sports injury
o Gender
▪ Children – 2 Males : 1 Female
▪ Adults – 3 Males : 1 Female
o Age
▪ Peak of TBI: 0-4 years (fall) & 15-19 years (sports)
▪ Signs & symptoms: Vomiting & fatigue (infant & young children); headache,
dizziness, & fatigue (older children)
o Culture
▪ Highest among lower SES
- Informal identification
o Behavioral
▪ Preschool / early elementary
• Unpredictable behavior – extreme or mild unexpected response
• E.g. increased hyperactivity/passivity, distractibility, impulsivity,
tantrums
▪ Older elementary / secondary
• Inappropriate comments, e.g. crude language
• Inappropriate actions, e.g. drug abuse, promiscuity, violence
o Socio-emotional
▪ Problem for families
• Behavior disturbance & personality change
• Difficulty adjusting expectations
▪ Problem for child
• Profound sense of loss (readjustment)
• May develop secondary internalizing disorder
• Earlier TBI (before schoolage), less readjustment
• Tendency for emotional overreactions
• Impulsivity (difficulty planning & organizing)
o Cognitive
▪ Uneven cognitive performance
▪ Executive functional difficulties
▪ Intellectual
• Decline in general intelligence (esp. nonverbal)
• Nonverbal IQ – processing speed, manipulating novel stimuli
▪ Attention, memory & organization
• Difficulty focusing & multitasking
• Poor memory (STM & LTM)
▪ Visual-spatial perception
• Depending on injured region
• Problem locating large objects → clumsiness
• Motor limitations & spatial deficits
o Communication
▪ Aspects – receptive, expressive, pragmatics
 ▪ Younger onset, problem area includes
• Vocabulary
• Memory (naming objects)
• Multiple-step instructions
• Inappropriate speech content
• Difficulty to empathize
• Dysarthria (unintelligible speech)
• Confused language
o Motor, physical, somatic
▪ Motor
• Spasticity (sudden muscular contraction)
• Partial/complete paralysis (one/both sides)
• Low stamina
• Poor balancing, inability walking straight
• Trouble throwing ball
• Assess by comparing dominant & non-dominant hand performance
▪ Somatic
• Dizziness, insomnia, nausea, headache, seizures, sensory loss
(smell/taste)
• Chronic pain
o Academic
▪ Difficult areas:
• Math problem solving
• Reading comprehension
• Writing composition
• Planning
• Understanding event sequences
▪ May face “plateauing”
- Summary
o Strengths
▪ Depends on preinjury personality & skills
▪ Positive indicators: higher IQ & fewer pretrauma psychological problem
o Needs
▪ Early identification of intracranial bleeding (Indicators: seizures, vomiting,
amnesia)
▪ Predictable daily life (e.g. routine, schedule)
▪ Skills handling change
▪ Planning & self-monitoring skills
▪ Buddy system (reintegration into classroom)
- Implications
o Tier 1
▪ Low tech accommodation
• Extend task completion time
 • Flexible expectation (increase success opportunity)
• One-step direction/written directions
• Physical environment adjustment, e.g. resting area, spacious area
• Establish routine
• Use advance organizer (planning/solve problem)
• Specific accommodations (depending on affected skill)
• Provide supervision
▪ High-tech accommodation
• Computer, voice recorder, smartphones, etc.
o Function: Prompting, alarm, schedule, etc.
o Tier 2 & 3
▪ Special education (43-73% TBI students)
▪ Involvement of multidisciplinary professionals (e.g. speech therapist, clinical
psychologist, educators)
▪ Self-monitoring training
• E.g. using assignment books & daily schedules
- Long-Term Outcomes
o Infancy – kindergarten
▪ Brain plasticity helps in recovering function
▪ May be more responsive to treatment
▪ May adapt socially/emotionally
▪ May resemble LD
o Elementary & secondary levels
▪ Grief of loss skills & ability
▪ Less adaptive socially & emotionally
▪ Increased negative emotions & awareness of injury impact
▪ Has “old learning” advantage

Lecture 7 - Social Disorder: Externalizing Behavior Disorder

- Social disorders
o Behavioral Disorders
▪ ODD
▪ CD
▪ NPD
o Emotional Disorders
o Autism Spectrum Disorders
- Behavioral Disorders
o IDEA: Emotional Behavioural Disorder exhibits one or more of the following
characteristics over a long period of time and to a marked degree that adversely affects
a child’s educational performance:
▪ An inability to learn that cannot be explained by intellectual, sensory, or health
factors.
 ▪ An inability to build or maintain satisfactory interpersonal relationships with
peers and teachers.
▪ . Inappropriate types of behavior or feelings under normal circumstances.
o Types of Aggression
▪ Offensive (Proactive)
• To advance own interest at any cost
• Little to no guilt
• Eg: CD & NPD justify behavior as response towards provocation
▪ Defensive (Reactive)
• To protect child against:
o Excessive demands (eg: noise, crowding)
o Difficult task demands
o Threats to “image”
• Higher physiological arousal when facing threats
o Eg: ODD thinks he/she is “put upon”
• Conclusion:
o The best defense is a good offense
o Oppositional Defiant Disorder (ODD)
▪ IDEA: categorized under externalizing behavior disorder (EBD)
▪ DSM-V
• A pattern of angry/irritable mood, argumentative/defiant behavior, or
vindictiveness lasting at least 6 months as evidenced by at least four
symptoms from any of the following categories, and exhibited during
interaction with at least one individual who is not a sibling.
• Angry/irritable mood
o Often loses temper
o Is often touchy or easily annoyed
o Is often angry and resentful
• Argumentative/ defiant behavior
o Often argues with authority figures or, for children and
adolescents, with adults.
o Often actively defies or refuses to comply with requests from
authority figures or with rules.
o Often deliberately annoys others.
o Often blames others for his or her mistakes or misbehavior.
• Vindictiveness
o Has been spiteful or vindictive at least twice within the past 6
months
• Context: The disturbance in behavior is associated with distress in the
individual or others in his or her immediate social context (e.g., family,
peer group, work colleagues), or it impacts negatively on social,
educational, occupational, or other important areas of functioning.
 • Exclusion: The behaviors do not occur exclusively during the course of a
psychotic, substance use, depressive, or bipolar disorder. Also, the
criteria are not met for disruptive mood dysregulation disorder.
• Categorization
o Mild Confined to 1 setting:
o Home
o School
o Work
o With peers
o Moderate o >= 2 settings
o Severe o >= 3 settings
▪ Common subtypes
• Active
o Argues/always says no
o Gives excuses for finally doing the exact opposite
o Provocative (stir up controversy)
• Passive
o Ignores/delays response
o Passive resistance (not really doing exactly as told)
• Passive-aggressive
o Combines passive + aggressive (not alternately):
▪ Quarrelsome + submissive
▪ Manipulative + charming
▪ Conforming + irritating
o Identifying characteristics
▪ Ongoing whining & grumbling
▪ Complaints of being misunderstood
▪ Anti-authority critical comments
▪ Comorbidity
• Rarely appear as a single disorder
• Related: depression, anxiety, ADHD, LD, CD
• Might indicate: depressive & bipolar
• ODD/CD + depressed: ODD/CD only = 4 to 10 : 1
• 40% ODD have anxiety disorder
• 80 – 93% ODD have ADHD
▪ Etiology
• Biological
o Evidence of disorders in parents
o More rigid, demanding, active (compared to peers)
o Males more prevalent (esp problematic temperaments/ high
motor activity in preschool years)
• Environmental
o Dysfunctional family
▪ Marital problem, abusive
 o Inconsistent parenting
▪ Irritable, explosive, inflexible
o Inadequate parental models
▪ Insular, less involved, low SES
• Functional Assessment
o Normal for 2 y/o or adolescents
▪ Need for self-detemination/ independence
o Other age:
▪ Probable antecedents
• Commands
• Demands
• Requests
▪ Probable payoff
• Avoid possible failure / loss of control
• Gain control, competence, access preferred
activity
▪ Occurrence of ODD
• Prevalence
o Sample population: 3-16% children
o Clinical population: 33-65% diagnosed
• Gender
o 1 girl : 4 boys
o Different ODD exhibition
• Age
o Before 8 to adolescence (not indicator of CD)
• Culture
o Annual household income < $20,000
o Punitive disciplinary practices
o Lower maternal support
▪ Informal identification
• Behavioral
o More confrontational than peers
o Poor adaptive skills
o Resistant/actively defiant
o Easily provoked & provocative
o High risk-taking behavior
• Socio-emotional
o Few friends unless similar tendency
o Challenging authority (esp. parents)
o Lack empathy
o Unable identify own emotion
o Low/overly inflated self-esteem
o Mood swings
o Low frustration tolerance
 • Cognitive & Academic
o Problem solving deficits
o Working memory deficits
o Lower academic confidence
o Lower school adjustment
▪ Implications
• Tier 1
o Choice & routines + advance warnings & organizers
o Specific feedback
o Alpha commands + sustain eye contacts (20-30s after request)
o Reinforce appropriate behavior
• Tier 2
o Carried out by support team (eg: special educator, therapist,
counsellor)
o Behavioral
▪ Differentiate aggressive & assertive
▪ Training use of positive words, e.g. “You have different
opinion – that’s ok.”
o Cognitive
▪ Cognitive-behavioural model therapy, e.g. Collaborative
Problem Solving (CPS)
▪ Repeated verbal prompts, e.g. “What is fair to you
might not be fair for others”
▪ Self-monitoring of behaviour
▪ Emotion identification intervention
• Tier 3
o Medication
o Parent education on:
▪ Behavioral management → build students’ positivity
▪ Alpha commands
o Conduct Disorder (CD)
▪ Violates someone’s rights/property
▪ Setting: family, school, society
▪ IDEA: Categorized under EBD
▪ DSM-V: Repetitive & persistent behaviour whereby basic rights or major societal
norms(age-appropriate) are violated
• >=3 criteria present (past 12 months)
• >=1 criterion present (past 6 months)
▪ Aggression to people & animals
• Often bullies, threatens, or intimidates others
• Often initiates physical fights
• Has used a weapon that can cause serious physical harm to others (e.g.,
a bat, brick, broken bottle, knife, gun)
• Has been physically cruel to people
 • Has been physically cruel to animals
• Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery)
• Has forced someone into sexual activity
▪ Destruction of property
• Has deliberately engaged in fire setting with the intention of causing
serious damage
• Has deliberately destroyed others’ property (other than by fire setting)
▪ Serious violations of rules
• Often stays out at night despite parental prohibitions, beginning before
age 13 years
• Has run away from home overnight >=2 while living in parental or
parental surrogate home (or once without returning for a lengthy
period)
• Is often truant from school, beginning before age 13 years
▪ Common subtypes
• Intermittent explosive disorder
o Behavioral earthquakes
▪ Not reacting to specific provocations (not truly CD)
o Tension → aggressive acts → relief
▪ Comorbidity
• Depression
o CD + depression > CD only
o Predicts suicide
• Anxiety disorder
o Less aggression
• Narcissism
• Addictions
• ADHD
o 45 – 70% learn aggression
o Greater disturbance & poorer outcome
o Self-report goals
▪ Being fair (less)
▪ Get into trouble (more) → have fun
▪ Etiology
• Biogenetic
o Common among parents
▪ Alcohol dependence
▪ Mood disorder
▪ Schizophrenia
▪ ADHD
▪ CD
o Lower physical arousal reduces
▪ Reactivity to punishment
 ▪ Capacity receiving emotional info
• Environmental
o Prenatal
▪ Smoking >10 cigarettes/day
▪ Alcohol exposure (1st trimester)
o Family factor
▪ Parents behaviour, i.e. neglectful parenting, antisocial
behaviour, harsh discipline
▪ Parental low education
▪ Large family size
▪ Traumatic life events, e.g. abuse
▪ Frequently switching caregivers
• Functional Assessment
o Payoff o Antecedents
o Avoid demands o Unskilled children
o Self-protect o Settings condition
(overcrowded, unstructured)
o Nature of task (difficult,
inflexible responses)
o Gain power/ o Peer rejection, “weak” victims
control (eg: cry, whine, give in to demands)
▪ Occurrence of CD
• Prevalence
o Boys
▪ Parents behaviour, i.e. neglectful parenting, antisocial
behaviour, harsh discipline
▪ Parental low education
▪ Large family size
▪ Traumatic life events, e.g. abuse
▪ Frequently switching caregivers
o Girls
▪ Negative verbal behaviour
▪ Relational aggression
▪ Covert aggression
• Age
o Identified from middle childhood → middle adolescence
o Early CD symptoms predict later CD symptoms
o Progression of CD o Examples of Behavior
symptoms
o 1st – less severe o Lying, shoplifting, physical
fighting
o 2nd – more extreme o Burglary
o rd
3 – most severe o Rape, mugging
• Culture
o Urban > rural
 o Higher in Western culture
▪ Informal identification
• Behavioral
o Early substance abuse & antisocial behavior predict CD
o Deceitfulness or theft
▪ Has broken into someone else’s house, building, or car
▪ Often lies to obtain goods or favors or to avoid
obligations (i.e., “cons” others)
▪ Has stolen items of nontrivial value without confronting
a victim (e.g., shoplifting, but without breaking and
entering; forgery)
• Social-emotional
o Exhibits proactive & reactive aggression
o Reactive due to impulsivity & poor frustration tolerance
o Proactive gain higher social competence
o Fail to identify emotions (self & others)
• Cognitive
o Poor attention, planning, & verbal memory
o Misinterpreting social events/cues
• Communication
o CD, delinquents, criminals – Higher rates of verbal deficits
o Poor language performance – more verbal aggression
• Academic
o Reading & other verbal skills – not at par with age & intelligence
o Skipping school/expelled → poor academic
▪ Implications
• Tier 1
o Provide warning
▪ Eg: routines, prompting (difficult setting)
o Catch them being good
▪ Increase emotional response to prosocial behaviour;
teach peers proper response
o Restate prior events verbally
▪ Effective for conflict interaction
• Tier 2
o CBT
▪ Train social & problem solving skills
o Use “hassle log”
▪ Record aggressive reactions  understand trigger to
anger
o Self-monitoring notebook
▪ Tally negative & positive behaviour – get teacher
feedback
o Teach appropriate social behavior
 ▪ E.g. Ask questions, NOT make demands when making
friends
o Personality disorder: Narcissism (NPD)
▪ Obsession with one’s own gratification & dominance over others
▪ IDEA: Categorized under EBD
▪ DSM-V:
• Pervasive pattern of grandiosity (fantasy/behaviour) need for
admiration and lack of empathy (beginning early adulthood in various
contexts)
• >= 5 criteria present
o Grandiose sense of self-importance
o Preoccupied with fantasies (unlimited success, power, beauty,
etc.)
o Believes he/she is special & can only be understood by other
special/high-status people
o Requires excessive admiration
o Sense of entitlement (unreasonably)
o Interpersonally exploitative
o Lacks empathy
o Often envious/believes that others are envious of him/her
o Shows arrogant, haughty behaviour/attitudes
▪ Common subtypes
• Narcissistic vulnerability
o Diminished self-image
o Shameful
o Depressed
o Socially withdrawn
• Narcissistic grandiosity
o Repress negative aspects of self
o Inflated self-image
o Fantasize power & wealth
o Envies others & show aggression
▪ Difference between narcissism vs giftedness
• Narcissism
o Positive entitlement – Views self as only positive & entitled to
rights
o Negative entitlement – Views self as protected from wrong
• Giftedness
o Arrogance is not a cover
o Is truly competent
o Able to empathize
▪ Occurrence of NPD
• Prevalence
o 1% of general population
 o 2-16% of clinical population
• Gender
o 75% diagnosed are males
• Age
o Characteristics commonly found among adolescents
o Hence, instead of diagnosing NPD, note the degree of
manifestation
• Culture
o Coddled & wealthy
o Divorced family
o Narcissistic parents
o Adopted children
o Successful parents
▪ Informal identification
• Behavioral
o Deliquency
▪ 72% drugs
▪ 69% alcohol
▪ 88% sexually provocative
o Response when thwarted
▪ Rage
▪ Vindictive
o Protect false self
▪ Act charming
▪ Simulated emotions
▪ Attend to others’ superficial needs
▪ Lying
▪ Bossy
• Social-emotional
o Social impairment
▪ Apathy except anger
▪ Instant gratification
▪ Keeps physical distance
▪ Very sensitive to criticism
• Cognitive & communication
o Cognitive distortion
▪ Entitlement about self, world, & future
▪ Communicate to get something out of someone
• Academic
o Ambitious & high need for success
o Gain admiration
o Considerable academic self-confidence
o Performs well under pressure
o Sensitivity to criticism → negative implication
 ▪ Implications
• Tier 1
o Give spotlight
▪ NPD perform well under pressure
o Contract for R+
▪ Eg: no praise until homework is done
o Motivate through competition
▪ NPD always needs to be the best
• Tier 2 & 3
o CBT
▪ Reduce cognitive distortion “I am special”
o Learn empathy
▪ Differentiate between friendship & manipulating others
o Important: Role of support team (e.g. counsellor, special
educator, behavioural consultant, etc.)

Lecture 8 – Social Disorder Internalizing Emotional Disorder

- Anxiety
o Cognitive responses, i.e. worry & thoughts about future danger
o Physiological responses that accompany fear, e.g. increased heart rate
o Behavioural responses that are typically avoidant
- Anxiety vs Depression
o Anxiety
▪ Anticipates danger/difficulties
▪ Worrying forward
▪ Future-oriented emotion
▪ Worry about self & others’ reactions
o Depression
▪ Avoids possible pain related to past actions/events/person
▪ Worrying backward
▪ Past-oriented emotion
▪ Negative self-concept is already formed
- Generalized Anxiety Disorder
o High levels of anxiety across situations. Shows distressing internal symptoms &
avoidance behavior
o IDEA: Emotional Behavioural Disorder exhibits one or more of the following
characteristics over a long period of time and to a marked degree that adversely affects
a child’s educational performance:
▪ A general pervasive mood of unhappiness or depression.
▪ A tendency to develop physical symptoms or fears associated with personal or
school problems. . . . Emotional disturbance includes schizophrenia. The term
does not apply to children who are socially maladjusted.
o DSM-V
 ▪ Excessive anxiety and worry (apprehensive expectation), occurring more days
than not for ≥6 months, about a number of events or activities (such as work or
school performance
▪ Difficult to control worry
▪ Anxiety associated with >=3 following symptoms (for kids, >=1 symptom)
• Restlessness or feeling keyed up or on edge.
• Being easily fatigued.
• Difficulty concentrating or mind going blank.
• Irritability.
• Muscle tension.
• Sleep disturbance (difficulty falling or staying asleep, or restless,
unsatisfying sleep).
▪ The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
▪ The disturbance is not attributable to the physiological effects of a substance
(e.g. drug, medication) or another medical condition (e.g. hyperthyroidism).
▪ The disturbance is not better explained by another mental disorder (e.g.,
anxiety or worry about having panic attacks in panic disorder, negative
evaluation in social anxiety disorder [social phobia], contamination or other
obsessions in obsessive-compulsive disorder, separation from attachment
figures in separation anxiety disorder, reminders of traumatic events in
posttraumatic stress disorder, gaining weight in anorexia nervosa, physical
complaints in somatic symptom disorder, perceived appearance flaws in body
dysmorphic disorder, having a serious illness in illness anxiety disorder, or the
content of delusional beliefs in schizophrenia or delusional disorder)
- Common subtypes
o Specific anxiety disorder
o Post-traumatic stress disorder (PTSD)
▪ Less children
▪ Experienced/witnessed/confronted with events involving actual/threatened
serious injury/death → creates fear/helplessness/horror
▪ Trigger: Sounds/smells/visual details
▪ Behaviour: Hypervigilant & easily startled by unexpected sight/sound
o Panic disorder
▪ Abrupt episodes of intense fear/discomfort
▪ Peaks in approx. 10 mins
▪ Feels imminent danger & need to escape
▪ Somatic symptoms: Palpitations, sweating, shortness of breath, choking, chest
pain, nausea, abdominal discomfort, dizziness, tingling sensations, chills/hot
flushes, trembling, feeling surreal, fear of “going crazy”/dying (with or without
agoraphobia)
- Comorbidity
o 33% children with anxiety disorders (have ≥2 anxiety subtypes)
o 92% children with LD history
- Etiology
o Biogenetic
▪ All individuals undergo normal developmental stages of anxiety
▪ Inherited abnormality: Inhibited/shy, avoidant of novelty/change
▪ 1/3 anxiety disorders is inherited
▪ Neurologically, left hemisphere responds to negative emotions (e.g. sadness,
anxiety), right hemisphere responds to positive emotions (including body
language & paralanguage)
o Environmental
▪ Based on own life experience
▪ Observation learning (vicarious reinforcement)
▪ Known as conditioned fears
o Functional Assessment
▪ Tends to worsen under stress
▪ Source of stress varies: Family problems, abuse, bullying, academic difficulties,
etc.
▪ Coping strategy (Fight/flight): Stomachache, headache, anger, aggression,
regression, etc.
- Occurrence of Generalized Anxiety Disorder
o Prevalence
▪ 10-21% school-age populations (more among older)
▪ 45% clinic populations
▪ Clearer by middle childhood & older
o Gender
▪ By age 6, girls twice as likely as boys (difference increases over age levels)
o Age
▪ Normal development of anxiety
• Moro reflex (infancy) → fear of separation → fear of imaginary
creatures/animals/dark
▪ Abnormality
• More inhibited, physiologically aroused, & anxious (new
situation/people/unpredictable events)
▪ As children age, fear may change/spread, e.g. fear of new situation 
agoraphobia
▪ Common specific fears according to age
• Young children • Fear of spiders
• School age children • School-related fears
• Adolescence • Fears related to social &
evaluative settings
o Culture
▪ Possible factors: Race, culture, ethnicity
▪ E.g. African Americans experience more phobias, panic disorders, sleep
problems
▪ Asian culture tends to express in somatic form (e.g. muscle tension)
- Informal identification
o Behavioral
▪ Usually introverted & avoidant
▪ Younger children tend to respond with emotional outbursts
▪ Older children show repetitive behaviour (e.g. tics, rituals)
o Social-emotional
▪ 10-21% children reported clinical levels (impacts academic, social, peer
relations, future emotional health)
▪ E.g. Loves occasional attention but when feeling “incompetent” (own standard),
might want to be invisible
o Cognitive
▪ Normal basic intelligence & memory
▪ High anxiety might impair cognitive functioning
▪ E.g. misinterpret ambiguous situation → overestimating danger,
underestimating self
▪ Tendency to selectively focus on threatening experience
o Communication
▪ Tends to sound negative towards self/overall
▪ E.g. “I thought I would fail”, “Nothing ever turns out well”
▪ Some sub-vocal negative self-statements/warnings, e.g. don’t talk too loud, be
careful of pronunciations, etc.
o Academic
▪ Anxiety improves performance of simple tasks but worsens it for complex tasks
▪ High rates impaired academic functioning
▪ Anxiety preoccupies child’s attention; hence less is devoted to learning
▪ School refusal
• A.k.a. school phobia, separation anxiety
• Avoids school chronically due to fear of:
o Separation from parents/caregivers
o School-related persons/events
o Other unknown elements
• DSM-V
o Developmentally inappropriate and excessive fear or anxiety
concerning separation from those to whom the individual is
attached, as evidenced by ≥ 3 of the following:
▪ Recurrent excessive distress when anticipating or
experiencing separation from home or from major
attachment figures.
▪ Persistent and excessive worry about losing major
attachment figures or about possible harm to them,
such as illness, injury, disasters, or death.
▪ Persistent and excessive worry about experiencing an
untoward event (e.g., getting lost, being kidnapped,
 having an accident, becoming ill) that causes separation
from a major attachment figure.
▪ Persistent reluctance or refusal to go out, away from
home, to school, to work, or elsewhere because of fear
of separation
▪ Persistent and excessive fear of or reluctance about
being alone or without major attachment figures at
home or in other settings.
▪ Persistent reluctance or refusal to sleep away from
home or to go to sleep without being near a major
attachment figure.
▪ Repeated nightmares involving the theme of
separation.
▪ Repeated complaints of physical symptoms (e.g.,
headaches, stomachaches, nausea, vomiting) when
separation from major attachment figures occurs or is
anticipated.
o The fear, anxiety, or avoidance is persistent, lasting ≥ 4 weeks in
children and adolescents and typically 6 months or more in
adults.
o The disturbance causes clinically significant distress or
impairment in social, academic, occupational, or other
important areas of functioning.
o The disturbance is not better explained by another mental
disorder, such as refusing to leave home because of excessive
resistance to change in autism spectrum disorder; delusions or
hallucinations concerning separation in psychotic disorders;
refusal to go outside without a trusted companion in
agoraphobia; worries about ill health or other harm befalling
significant others in generalized anxiety disorder; or concerns
about having an illness in illness anxiety disorder.
• Comorbidity
o Social anxiety, oppositionality, depressive symptoms
o Often confused with truancy
• Etiology
o Environmental
▪ Fear of school
▪ Reinforcement by parents, siblings, counselor’s
attention
▪ Family contributors: Unrealistic academic expectation;
mothers with anxiety disorders (discourage autonomy)
▪ Other factors: Life-changing event at home (e.g. death,
divorce, birth, move, etc.)
▪ School factors: Bullying; failure-oriented classrooms
 o Functional Assessment
▪ Function: Avoid negative school situation
(socially/academically)
▪ Esp. transition period, e.g. starting kindergarten, middle
school, etc.
▪ Seeks positive attention/special activities
• Occurrence of school refusals
o Prevalence
▪ 10% school refusals have school phobia
▪ 1-8% school-age children have school phobia
o Gender & age
▪ More common in boys
▪ In girls, occur at younger age
▪ Girls are more emotionally disturbed, and might have
separation anxiety
▪ Found in 5-15 year olds
o Culture
▪ More common in single-parent/divorced families
▪ For boys, typically from higher SES
• Informal Identification
o Behavioral
▪ Young children – physically clingy to parents
▪ Older children – cry/hide before school OR
aggression/noncompliance to get expelled
▪ Psychosomatic symptoms worsen as school day draws
near, e.g. Sunday evenings, Monday mornings
o Socio-emotional
▪ Negative self-images & low self-esteem
▪ Hypersensitive to criticism
▪ Typical emotional reactions: acute panic, terror,
depression, shame
▪ Social problems: Social withdrawal, interpersonal
relationship difficulty
▪ People-pleaser & conscientious conformers (to adults)
▪ Might wield too much power with adults → manipulate
parents to avoid school
o Cognitive
▪ Average/above-average intelligence
▪ Recognize fears as unreasonable
▪ However, cognitive distortions:
• Expects negative outcomes (If I go to school,
everyone will make fun of me)
• Negative evaluation of personal abilities (I am
not able to go to school)
 • Needs to escape (If I can’t leave school right
now, I will go crazy)
• Hopelessness (I will be a failure in life, I can’t
even go to school)
o Motor, physical, somatic
▪ Intense anxiety causes nightmares/somatic complaints
(nonexistent)
▪ Physical reactions: diarrhea, dizziness, nausea, etc.
(similar to stage fright)
▪ Illness are NOT faked – feeling loss of control over
terror or physiological reactions
o Academic
▪ About 50% underachieve → poor concentration, high
absenteeism (incomplete assignment, missed
instructions)
- Social Phobia
o Often described as “shy”, “timid”, “lonely”, “isolated”
o Rarely recognized in school
o Across social settings (e.g. meeting new people; performance related: writing, reading
aloud; eating/drinking in public; using public restroom)
o DSM-V
▪ Marked fear or anxiety about one or more social situations in which the
individual is exposed to possible scrutiny by others. Examples include social
interactions (e.g., having a conversation, meeting unfamiliar people), being
observed (e.g., eating or drinking), and performing in front of others (e.g., giving
a speech). (Note: In children, the anxiety must occur in peer settings and not
just during interactions with adults.)
▪ The individual fears that he or she will act in a way or show anxiety symptoms
that will be negatively evaluated (i.e., will be humiliating or embarrassing: will
lead to rejection or offend others).
▪ The social situations almost always provoke fear or anxiety. (Note: In children,
the fear or anxiety may be expressed by crying, tantrums, freezing, clinging,
shrinking, or failing to speak in social situations.)
▪ The social situations are avoided or endured with intense fear or anxiety.
▪ The fear or anxiety is out of proportion to the actual threat posed by the social
situation and to the sociocultural context.
▪ The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or
more.
▪ The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
▪ The fear, anxiety, or avoidance is not attributable to the physiological effects of
a substance (e.g., a drug of abuse, a medication) or another medical condition.
 ▪ The fear, anxiety, or avoidance is not better explained by the symptoms of
another mental disorder, such as panic disorder, body dysmorphic disorder, or
autism spectrum disorder
▪ If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement
from bums or injury) is present, the fear, anxiety, or avoidance is clearly
unrelated or is excessive
o Subtypes
▪ Performance anxiety
• Fear of being evaluated in public settings
▪ Elective/selective mutism (SM)
• Persistent (>= 1 month) failure to speak in certain settings
o Do not speak in large social situation despite desire to do so
(shy, fear, anxiety)
o May communicate nonverbally
o Speaks to a few selected people
o 37% 1st degree relatives with SM have SM
o 70% SM have social phobia
o Usually late identification → habitual & teased
o Comorbidity
▪ 90% other anxiety disorders
▪ 10% depression
▪ Substance abuse, speech & language LD, ADHD
▪ Gifted – fears external criticism (early success), perfectionist
▪ Often confused with shyness
• Shyness may be outgrown
• Initial discomfort interfering with pursuit of goals
• May be chronic (not outgrown) or context-specific
o Etiology
▪ Biogenetic
• >50% has ≥1 shy parent
• High rate of psychiatric disturbance in families  communication
difficulties at home
▪ Environmental
• Usually close with one overprotective parent (esp. mother)
• Home atmosphere not warmth (not free to express feelings)
• Fathers communicate little, often react with anger
▪ Functional Assessment
• For SM, identify type of communication, settings, persons (speak/not
speak)
• For social phobia, identify antecedents & payoffs – e.g. one-to-one
interaction, opposite-gender interaction, intimacy, groupwork, etc.
o Occurrence of social phobia
▪ Prevalence
• Identified in late childhood/early adolescence
 • ≈1-2% elementary level
• 6% adolescents in community
• 27-32% clinical population (children)
• May evolve into avoidant personality disorder in adulthood
▪ Culture
• Immigrant children/non-native speakers might refuse to speak in host
country’s language → may not be diagnosed as SM/social phobia
o Informal identification
▪ Behavioral (various expressions)
• Avoidant
o Crying, tantrums, freezing, pulling away from social situation
• Off-putting
o Growling, grumbling, negative comments, speak in foreign
language when spoken to, poor hygiene
• Oppositional & manipulative
o Refusing to participate in activities
▪ Socio-emotional
• Low self-esteem, fewer interpersonal relationships, fear seen as
“awkward”, difficulty being assertive
• Lack social skills due to lack of practice
• Overly sensitive to evaluation
• Responds to attention/criticism emotionally
• Prefers to be “invisible”
▪ Cognitive
• Normal IQ
• Occasionally in children with ID
• Some evidence of lower-than average verbal memory span
▪ Communication & Somatic
• Avoid communication & eye contact
• Structured & low-demand settings – normal language production
• Somatic side effects:
o Sweating
o Blushing
o Trembling
o Dizziness
o Increased heart rates
▪ Academic
• School = social situation
• Impairment in academic performance
• High dropout rate
o Implications
▪ Overall goal = increase attendance, decrease school-related stress
▪ Avoid using punishment → reinforces avoidance
▪ Avoid forceful “desensitization” & overprotectiveness
▪ Good teacher-student relationship
▪ Give practice tests → reduce pressure
▪ Tier 1
• Encourage extracurricular involvement → reduce peer isolation
• Use music
• Teach anxiety-reduction techniques
o Technique o Description
o Relaxation technique o Slow breathing
o Positive self- o “This will last only 10
statements mins,” “I have done this
before successfully”
o Sit by the door in o Leave room when
class anxiety attacks
▪ Tier 2 & 3
• Involve support team (special educator, therapist, counselor, etc.)
• Give immediate treatment (regardless of when)
• Major interventions:
o Reconditioning
▪ Role play, i.e. simulate situation & script response
▪ Desensitization, i.e. reinforce when face fears
▪ Matter-of-fact statements, e.g. the child “will go back to
school”
▪ Removal of avoidant behaviour reinforcers, e.g. no TV if
child does not attend school
o Guided participation
▪ Practice through modeling
▪ E.g. videotape person with object of fear & gradually
expose the real object with supervision
o Systematic desensitization
▪ Gradual & repeated exposure to fearproducing stimuli
▪ Use different stimuli (e.g. real life, pictures, books,
guided fantasy, etc.) + activity that is incompatible with
anxiety
o Self-control training
▪ Relaxation techniques
▪ Self-reinforcement
▪ Self-instruction
▪ Visual imagery
▪ Problem-solving strategies
▪ Recognize anxiety & physical reactions → modify
cognitions (I can do this) → make change & self-
reinforce
o Expressive therapies
 ▪ Art
▪ Music
▪ Drama
▪ Dance
▪ Bibliotherapy
o Cognitive behaviour modification
▪ Gradual school reintroduction:
• Provide escort
• (Family contract) Increase incentive for
attendance
▪ May be slow, hence focus on full-time attendance NOT
academic concerns
▪ E.g. Reinforce attendance, discourage crying/complaints
▪ For adolescents, teach social skills, realistic thinking,
relapse training

Week 9 – Social Disorders: Internalizing Emotional Disorders (Part 2)

- Obsessive-Compulsive Disorder
o Obsessions
▪ Repetitive thoughts that are intrusive & unwanted
o Compulsions
▪ Repetitive behavior/mental acts to ease obsessions
o DSM-V
▪ Presence of obsessions, compulsions, or both: Obsessions (i) Recurrent and
persistent thoughts, urges, or images that are experienced, at sometime during
the disturbance, as intrusive and unwanted, and that in most individuals cause
marked anxiety or distress.
▪ Presence of obsessions, compulsions, or both: Obsessions (ii) The individual
attempts to ignore or suppress such thoughts, urges, or images, or to neutralize
them with some other thought or action (i.e., by performing a compulsion)
▪ Presence of obsessions, compulsions, or both: Compulsions (i) Repetitive
behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the individual feels driven to perform in
response to an obsession or according to rules that must be applied rigidly.
▪ Presence of obsessions, compulsions, or both: Compulsions (ii) The behaviors or
mental acts are aimed at preventing or reducing anxiety or distress, or
preventing some dreaded event or situation; however, these behaviors or
mental acts are not connected in a realistic way with what they are designed to
neutralize or prevent, or are clearly excessive.
▪ The obsessions or compulsions are time-consuming (e.g., take more than 1 hour
per day) or cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
 ▪ The obsessive-compulsive symptoms are not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or another medical
condition.
▪ The disturbance is not better explained by the symptoms of another mental
disorder (e.g., excessive worries, as in generalized anxiety disorder;
preoccupation with appearance, as in body dysmorphic disorder; … or repetitive
patterns of behavior, as in autism spectrum disorder)
▪ Specify if:
• With good or fair insight: The individual recognizes that obsessive-
compulsive disorder beliefs are definitely or probably not true or that
they may or may not be true.
• With poor insight: The individual thinks obsessive-compulsive disorder
beliefs are probably true.
• With absent insight/delusional beliefs: The individual is completely
convinced that obsessive-compulsive disorder beliefs are true.
• Tic-related: The individual has a current or past history of a tic disorder.
o Common subtypes
▪ Perfectionism
• Compulsive redoing of work to get it “just right”
• Believes self-worth = performance
• Afraid of doing unless success is guaranteed
• Overly self-critical
• Symptoms:
o Procrastination
o Repeated starting over
o Inflexibility
o Preoccupation with details, rules, lists
• Positive outcomes: adaptive perfectionism
o Common comorbidity
▪ Cuts across different disabilities including other anxiety disorders:
• generalized anxiety disorder, panic disorder, Tourette’s syndrome,
ADHD
• 20-50% OCD have depression
• OCD + eating disorders frequently in girls
• Diagnosed in high-functioning autism (previously Asperger’s) – exhibit
different responses
o Etiology
▪ Biogenetic
• Strong genetic evidence:
o 52% have OCD in firstdegree relatives
o (PET scan) Brain pattern difference between OCD (< serotonin)
& non-OCD
• Serotonin: neurotransmitter in the brain that affects mood & its
regulation
▪ Functional assessment
• Stress-related
o Not caused by stress itself, rather a stressful event
o Function of OCD behaviour:
▪ maintain a sense of control to reduce stress
▪ avoid failure/possible criticism (perfectionists)
▪ Occurrence of OCD
• Culture
o Most often in high SES
• Prevalence
o 4 th most common (students): 2-5 in every 1000
o Often undiagnosed (attempt to hide)
• Gender & Age
o Boys > girls (2-3x)
o Hard to identify → normal developmental rituals (outgrown
@8)
o OCD onset @7 (gradual/abrupt)
o Children: Compulsion w/o obsession (40% deny linkage)
o Adult: Obsession w/o compulsion
▪ Informal identification
• Behavioral
o Form Rituals common in children:
▪ Washing/cleaning
▪ Checking
▪ Repeating
▪ Ordering
▪ Touching
▪ Counting
▪ Nail biting
▪ Pulling out hair/eyelashes
o 4 categories
▪ Symmetry/ order
▪ Contamination/ washing
▪ Hoarding
▪ Checking
• Socio-emotional
o 15% committed suicide
o Teased for odd behavior
o Fear ridicule → withdrawn
o Oblivious to annoyance due to unnecessary delays
o Shame & denials of obsession & compulsions
o Inflated sense of responsibility
o Upset over lack of control
• Cognitive
 o Cognitive distortions
▪ Black & white thinking
▪ “Hairsplitting”
▪ Indecisiveness
▪ Magical thinking
o Normal IQ & executive functioning
o Higher frequency of intrusive negative thoughts, behavior, &
emotional reactions → impairs functioning
• Communication & Somatic
o Some repeat words or sounds (e.g., “um”), ≈ verbal tics
(Tourette’s syndrome)
o Lethargy due to rituals
• Academic
o Fears interfere with task completion/decision making
(constantly weighing pros & cons)
o Procrastinates or not start task at all
o Distressing self-imposed high standards
o Mistaken for lazy, oppositional, poorly motivated
▪ Implications
• Tier 1
o Lower stress level → capitalize strength → establish
communication signals
o Educator’s job: Provide acceptance & reduce inappropriate
behavior to acceptable levels
o Strategy o Description
o Bibliotherapy o Stories about
characters with similar
fears/problems
o Extended time o E.g. Provide extra
time for tests
o Physical movement o Exercise (Evidence
indicates reduction of
anxiety in adults)
o Peer education o Intervention when
teased by peers; get parental
consent to educate class
about the child’s need to get
things “perfect”
• Tier 2
o Success redefined: Not black & white
o How? Reinforce times when performance is less than perfect
o Give specific feedback: E.g. “Your spelling has improved
tremendously. There are only 3 spelling errors in this whole
page! Excellent!”
• Tier 3
 o Anti-OCD drugs, e.g. serotonin reuptake inhibitors, SSRI →
effective with 50% children
o SSRI + CBT/behavioural therapy (with support personnel):
▪ i. Expose to anxiety conditions
▪ ii. Learn to tolerate anxiety
▪ iii. Response prevention
▪ Long-term outcomes
• Only 10% complete recovery (adults)
• 40-60% improve with intervention
• Presence of secondary symptoms predicts outcome
- Depressive Disorders
o Affected activity: eat, sleep, feel, think
o Duration: week, months, years
o DSM-V: Major Depressive Disorder
▪ ≥ 5 of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning: ≥ 1 of the symptoms
is either (1) depressed mood or (2) loss of interest or pleasure.
• Depressed mood most of the day nearly every day, as indicated by
either subjective report (e.g., feels sad, empty, hopeless) or observation
made by others (e.g., appears tearful).
• Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day (as indicated by either subjective
account or observation)
• Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in
appetite nearly every day
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed
down)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt (which may
be delusional) nearly every day (not merely self-reproach or guilt about
being sick)
• Diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others)
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan
for committing suicide
▪ The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
▪ The episode is not attributable to the physiological effects of a substance or to
another medical condition.
 ▪ The occurrence of the major depressive episode is not better explained by
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional
disorder, or other specified and unspecified schizophrenia spectrum and other
psychotic disorders.
▪ There has never been a manic episode or a hypomanic episode. Note: This
exclusion does not apply if all of the manic-like or hypomanic-like episodes are
substance-induced or are attributable to the physiological effects of another
medical condition.
o Common subtypes
▪ Unipolar depressive disorders
• Major depressive disorder
• Dysthymic disorder (symptoms ≥2 years) – onset childhood/adolescence
• Depression NOS
▪ Bipolar disorder (manic depression)
• Cycling between mania and depression
• More anxiety, worry, grief, remorse
o Possible comorbidity
▪ 90-95% coexists with anxiety disorder, behavioural disorder, ID, LD
▪ 20-25% general illness (e.g. diabetes, stroke) develop Major Depressive Disorder
▪ Bipolar often misdiagnosed as ADHD (during “up” state) & as depressed (during
“down” state)
▪ WARNING: Psychostimulant med (ADHD) increases irritability (bipolar);
antidepressants (depression) increases mania (bipolar)
▪ Differential diagnosis: ADHD more consistent, noncyclical, pattern of
overactivity
▪ However adolescent ADHD girls tend to overreact to any events
▪ Similarity with gifted: verbal fluency, racing thoughts, emotional intensity
▪ Differential diagnosis: Gifted sensitive & responsive to life events
▪ Difference with CD & ODD: Bipolar show excessive guilt, flight of ideas, cluttered
speech
o Etiology
▪ Biogenetic
• Overall heritability: 37- 45%
• Child with depressed parents → 3x risks
• First degree biological relatives → 1.5-3x more common
▪ Environmental
• Having depressed parent doubles the risk
• Behaviour of depressed parent:
o less positively involved
o less affectionate
o more negative
o unavailable
o unresponsive
o unsupportive
 • Traumatic life experiences (e.g. abuse) predate depression in
adolescents
• Depression-related ongoing life stressors
o LD
o Family loss
o Parental pathology/family conflict
o Disaster, abuse, illness, pregnancy, gay/lesbian, alcohol/cocaine
dependency
▪ Functional assessment
• Avoid future pain associated with loss, disappointment, or punishment
that has already occurred.
• “Flight” response to threat/stress
▪ Occurrence of Depressive Disorder
• Prevalence
o Increasing among adolescents
o US (general population) – 1% children (age 4); 2.5% children
(older); 8% adolescents
o Clinical population – Up 1% 2.5% 8% to 57% children
• Gender
o Childhood, boys = girls
o Adolescene, girls (2x) > boys
o Gender diff in depressive disorder
▪ Male ▪ Female
▪ Denial ▪ Repetitive
▪ More likely to thinking/rumination
use illicit substances ▪ Attempts suicide
▪ Complete ▪ Vulnerable,
suicide (error proof anxious, overly concerned
method) about somatic functioning
▪ Indulgent, & adequacy
antagonistic, aggressive,
antisocial, deceitful, &
mistrustful
• Age
o Getting younger
o Increases in magnitude with age & each prior depressive
episodes
o Symptoms differ by age:
▪ Preschool – regressive behavior
▪ School-aged – disobedience, tantrum, truancy, lethargy
▪ Adolescence – irritable, asocial/antisocial, low
selfesteem, substance abuse, school problems
• Culture
o Higher in low SES
o Higher in Mexican-American (SES controlled)
 ▪ Mothers’ individual coping style – repetitive thinking &
external locus of control
o Higher suicide rates among white male
▪ Informal identification
• Behavioral
o More negative & aggressive than peers
o More responsive compared to adults (may be cheered
periodically)
o Show less play & more non-play behavior
• Social-emotional
o Adolescent: Ill-tempered, touchy, & overreactive
o Boys: Externalized behaviour, e.g. aggression, delinquency
o Excessive partying
o Extreme thrill seeking
• Cognitive
o Self -renewing negative bias → increased depression
o E.g. self -devaluation, social devaluation, uncontrollable
depressive thoughts
o Cognitive distortion:
▪ Negatively biased
• Self-perception
• Past recall
▪ Poorer concentration
• Communication & somatic
o Speaks less, slower, longer pauses, softer, etc. → difficult to
understand
o Language content – resigned & resentful
o Able to withhold negativity with strangers
o Younger children - somatic & sleep problems
o Adolescents – substance abuse
• Academic
o Loss of interest
o Poor cooperative skills
o Often skip school
o Poor attention resulting in specific problems, e.g. math

Week 10 – Social Disorders: Autism Spectrum Disorder (ASD)

- Autism
o derived from the Greek word autos meaning “self,” connotes isolation within the self
o Characterized by deficits in 2 core domains
▪ Social communication & social interaction
▪ Restricted repetitive patterns of behaviour, interests, & activities
o IDEA:
▪ Developmental disability significantly affecting communication (verbal and
nonverbal) & social interaction
▪ Generally evident before age 3
▪ Adversely affects educational performance (not caused by emotional
disturbance)
▪ Typical characteristics: Repetitive activities, stereotyped movements, resistance
to change, unusual responses to sensory experience
o DSM-V
▪ Persistent deficits in social communication and social interaction across multiple
contexts, as manifested by the following, currently or by history:
• Deficits in social-emotional reciprocity, ranging, for example, from
abnormal social approach and failure of normal back-and-forth
conversation; to reduced sharing of interests, emotions, or affect; to
failure to initiate or respond to social interactions.
• Deficits in nonverbal communicative behaviors used for social
interaction, ranging, for example, from poorly integrated verbal and
nonverbal communication; to abnormalities in eye contact and body
language or deficits in understanding and use of gestures: to a total lack
of facial expressions and nonverbal communication.
• Deficits in developing, maintaining, and understanding relationships,
ranging, for example, from difficulties adjusting behavior to suit various
social contexts; to difficulties in sharing imaginative play or in making
friends; to absence of interest in peers.
• Specify current severity: Severity is based on social communication
impairments and restricted, repetitive patterns of behavior
▪ Restricted, repetitive patterns of behavior, interests, or activities, as manifested
by ≥ 2 of the following, currently or by history (examples are illustrative, not
exhaustive; see text):
• Stereotyped or repetitive motor movements, use of objects, or speech
(e.g., simple motor stereotypies, lining up toys or flipping objects,
echolalia, idiosyncratic phrases)
• Insistence on sameness, inflexible adherence to routines, or ritualized
patterns of verbal or nonverbal behavior (e.g., extreme distress at small
changes, difficulties with transitions, rigid thinking patterns, greeting
rituals, need to take same route or eat same food every day)
• Highly restricted, fixated interests that are abnormal in intensity or
focus (e.g., strong attachment to or preoccupation with unusual objects,
excessively circumscribed or perseverative interests)
• Hyper- or hypo-reactivity to sensory input or unusual interest in sensory
aspects of the environment (e.g., apparent indifference to
pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with lights
or movement)
 • Specify current severity: Severity is based on social communication
impairments and restricted, repetitive patterns of behavior
▪ Symptoms “ must be present in the early developmental period (but may not
become fully manifest until social demands exceed limited capacities, or may be
masked by learned strategies in later life).
▪ Symptoms cause clinically significant impairment in social, occupational, or
other important areas of current functioning.
▪ These disturbances are not better explained by intellectual disability
(intellectual developmental disorder) or global developmental delay
o Common subtypes
▪ Rett syndrome
• Characterized by marked degrees of impairment in intelligence,
language, & communication
• Loss in head growth from 5 -48 months
• Loss of previously acquired socialization skills, fine motor, & gross motor
skills
• Occurs in young females
▪ Childhood disintegrative disorder
• Characterized by marked degrees of intellectual disability
• Loss of previously acquired skills (language, social skills, & adaptive
behaviour lost more gradually)
o Comorbidity
▪ Depressive Disorders
▪ NVLD – may be mistaken for high functioning ASD (Difference: Math concept are
difficult for NVLD but not necessarily for ASD)
▪ ID (depending on spectrum)
o Differential diagnosis: Repetitive Behaviors
▪ Tourette ▪ ASD ▪ OCD
syndrome
▪ Non-functional ▪ Non-functional ▪ Functional
▪ Multiform ▪ Stereotyped & ▪ Serve an
repetitive apparent purpose
▪ Frequently ▪ High functioning ▪ Purpose:
changing motor & vocal – routines/ rituals; Cleanliness,
tics (eg: head tossing) Severe ASD – motor orderliness, safety
mannerisms (hand
flapping)
o Differential diagnosis: High functioning ASD vs ADHD
▪ High-functioning ASD ▪ ADHD
▪ More self-directed, ▪ Higher tendency to seek
responsible, purposeful, harm attachments, impulsive, seek novelty,
avoidant, fearful of change, shy disorderly, reward dependent
▪ Insist on sameness & ▪ Seeks change & frequently
predictability change topic in conversations
 ▪ Repetitive activity; self- ▪ Hyperactivity varies – more
report passiveness assertive & aggressive compared to
peers
▪ Attentive towards restricted, ▪ Attentive towards novelty
personal interests & familiar
individuals/activities
o Differential diagnosis: Related disorders
▪ Schizophrenia
• Develops after years of normal development
• Characteristics: Hallucinations, delusions, & disorganized speech
▪ SM
• Shows appropriate communication & interaction in specific settings
▪ OCD
• Obsessions are sources of anxiety, whereas for ASD, sources of pleasure
▪ Social phobia & other anxiety disorders
• Does not exhibit restricted interests
▪ Giftedness
• Concerned with broad issues, socially aware, empathetic, understand
metaphors, etc.
o Etiology
▪ Biogenetic
• Increased frequency among family members
• 25% higher among siblings
• Higher risk for older fathers to pass genetic mutations
• Larger brain volume/weight (white matter) → more efficient
connections (hence, sensory overload)
▪ Functional Assessment
• Possible triggers for abnormal responses
o Change of routine
o Loss of predictability/order
o Stress/anxiety
o Failure
o Change/transitions
o Noise
o Neophobia – fear of new persons/situations/tasks
o Occurrence
▪ Prevalence
• 1 in 88 individuals (US)
▪ Gender
• 15 males : 1 female
• Males show more emotional deficits
• Exhibit more skills, eg: math, engineering
▪ Age
 • Late identification (for HF-ASD) – may be masked by knowledge
accumulation (early age)
o Informal identification
▪ Behavioral
• Verbal & behavioural routines; described as OCD
• Restricted, repetitive patterns of behaviour, interests, activities
(pursued with intensity)
• “Stimming” behavior
▪ Socio-emotional
• Greater anxiety especially in interpersonal setting (crowding, noise,
perceived social threat)
• Reaction: Avoidance or aggression
• Inappropriate social behaviour:
o Clumsy social approach
o Self-centeredness
o Lacking empathy
o Poor emotion identification (lower functioning ASD)
• Tends to isolate self: solitary play, reading/writing, video games, etc.
• Friendship
o Naïve, inappropriate, onesided interaction
o Usually victims of bully
o May form friendship with similar restricted interest peers (older
ASD)
▪ Cognitive
• Ignore big picture; detailed-oriented
• Repetitive interest + focus on details contribute to “savant” abilities
• Learning mostly through memorization, esp. verbal ability
• Difficulty with abstractions, planning/organizing, transference,
generalization (change in setting)
▪ Communication
• Obsessed about topic of interest (talks repetitively)
• HF-ASD may have normal language skills except pragmatics
• Exhibits echolalia
• Literal interpretation
• Lacks joint attention
▪ Motor, physical, somatic, sensory
• 42-88% older children show heightened “responsiveness” to sensations
(sight, sound, touch)
• Fine motor may be less developed
• HF-ASD more sleep disturbances
▪ Academic
• Relatively strong for HF-ASD, esp. in area of interests
• Poor fine motor skills
 • LF-ASD have difficulties with composition, reading comprehension,
math prob-solving
o Summary
▪ Strengths
• General info in specific interest areas
• Concrete memory tasks
• Good calculation skills
• Good decoding skills
• Able to complete procedural tasks
• Can succeed in careers that focuses on special interests & strengths
▪ Needs
• Writing assessment (gauge skills: handwriting, comprehension, info
application)
• Reduce tasks requiring pencil skills
• Social stories on knowledge application
• Adaptive response in social settings, e.g. scripted response

Week 11: Attentional Disorder: Attention-Deficit Hyperactivity Disorder (Inattention subtype)

- ADHD (inattentive & combined subtypes)

o IDEA
▪ If co-occurs with LD, then receive services under LD
▪ If no co-occurrence, categorized as other health impairment (OHI)
 ▪ Limited strength, vitality, or alertnesss (including heightened alertness to
environmental stimuli), that results in limited alertness with respect to
educational environment
▪ Due to chronic/acute health problem, e.g. asthma, “ ADD, ADHD, diabetes,
epilepsy, heart condition, hemophilia, lead poisoning, leukemia, nephritis,
rheumatic fever, sickle cell anemia, Tourette syndrome
▪ Adversely affects child’s educational performance
▪ Excludes: (For ADHD-HI) low IQ, gifted, LD, transient emotional disorder (e.g.
child with parents divorcing)
▪ Placement: General education under Section 504
o DSM-V
▪ A persistent pattern of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development
▪ Inattention
• Often fails to give close attention to details or makes careless mistakes
in schoolwork, at work, or during other activities (e.g., overlooks or
misses details, work is inaccurate).
• Often has difficulty sustaining attention in tasks or play activities (e.g.,
has difficulty remaining focused during lectures, conversations, or
lengthy reading).
• Often does not seem to listen when spoken to directly (e.g., mind seems
elsewhere, even in the absence of any obvious distraction).
• Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks but
quickly loses focus and is easily sidetracked).
• Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and belongings
in order; messy, disorganized work; has poor time management; fails to
meet deadlines).
• Is often easily distracted by extraneous stimuli (for older adolescents
and adults, may include unrelated thoughts).
• Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports, completing forms, reviewing
lengthy papers).
• Often loses things necessary for tasks or activities (e.g., school
materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses,
mobile telephones).
• Is often forgetful in daily activities (e.g., doing chores, running errands;
for older adolescents and adults, returning calls, paying bills, keeping
appointments).
• ≥ 6 of the symptoms have persisted for “ ≥ 6 months to a degree that is
inconsistent with developmental level and that negatively impacts
directly on social and academic/occupational activities.
 ▪ Several inattentive or hyperactive-impulsive symptoms were present prior to
age 12.
▪ Several inattentive or hyperactive-impulsive symptoms are present in ≥ 2
settings (e.g., at home, school, or work; with friends or relatives; in other
activities).
▪ There is clear evidence that the symptoms interfere with, or reduce the quality
of, social, academic, or occupational functioning.
▪ The symptoms do not occur exclusively during the course of schizophrenia or
another psychotic disorder and are not better explained by another mental
disorder (e.g., mood disorder, anxiety disorder, dissociative disorder,
personality disorder, substance intoxication or withdrawal).
▪ Specify current severity
• Mild: Few, if any, symptoms in excess of those required to make the
diagnosis are present, and symptoms result in no more than minor
impairments in social or occupational functioning.
• Moderate: Symptoms or functional impairment between “mild” and
“severe” are present.
• Severe: Many symptoms in excess of those required to make the
diagnosis, or several symptoms that are particularly severe, are present,
or the symptoms result in marked impairment in social or occupational
functioning.
▪ Specify if
• In partial remission: When full criteria were previously met, fewer than
the full criteria have been met for the past 6 months, and the symptoms
still result in impairment in social, academic, or occupational functioning
o Common subtypes
▪ Combined presentation: If both inattention and hyperactivity-impulsivity are
met for the past 6 months.
▪ Predominantly inattentive presentation: If inattention is present but
hyperactivity-impulsivity is not present for the past 6 months.
▪ Predominantly hyperactive/impulsive presentation: If hyperactivity-impulsivity
is present and inattention is not present for the past 6 months
o Etiology
▪ Biogenetic
• Combined subtype – higher heritability than ADHD-HI/ADHD-IN
• Genetic stronger than environmental → identical twins (.91) vs.
fraternal twins (.75)
• D4 receptor gene
• Dopamine & norepinephrine deficiency (transmission of information
among nerve cells)
• Psychostimulants (e.g. Ritalin/methylphenidate) → increase dopamine
• Brain structure (not a factor but is associated):
o 3-4% reduced total brain size
o 8% smaller prefrontal cortex
 o Lower activity in frontal lobes
• ADHD lacks executive function (however, cannot be used to explain
ADHD characteristics)
▪ Environmental
• 1 in 5 children – Prenatal: maternal smoking, Postnatal: brain injury,
toxin ingestions (e.g. lead)
• 3-5% ADHD preschoolers are sensitive to food dyes, sugar
• 40% ADHD have essential fatty acids deficiency
▪ Functional Assessment
• “Distraction” creates novelty/change
• Inattention indicates a mismatch between child’s arousal state
(biogenetic) & arousal state required to perform task (environmental)
• Behavior • Inattention • Attentive
• Antecedents • Non- • Novel tasks
meaningful, (e.g. involving
nonstimulating, rote colour/light, sound,
task, long delay-time movement,
between responses emotion,
(e.g. listening task) meaningfulness,
interest)
o Occurrence of ADHD
▪ Prevalence
• ADHD most common disorder in school (overdiagnosis)
• Only 3-7% show dysfunctions in multiple areas
▪ Age
• ADHD-IN – usually identified during elementary level
▪ Cultural
• ADHD characteristics correlate with family stressors (e.g. low parental
education, singleparent & stepparent families, low SES)
▪ Gender
• ADHD-IN equivalent between boys and girls
• ADHD combined – 4 males : 1 female
o Informal identification
▪ Behavioral
• ADHD-IN are less disruptive
• Less likely ODD/CD than ADHD-HI
• Handwriting
o Visual-motor deficits (less developed for ADHD-IN) → illegible
handwriting
o Poor fine motor (ADHD-HI worse than ADHD-IN) → slower &
less accurate typing
▪ Socio-emotional
• More internalizing emotional problems (e.g. anxiety, depression, social
passivity) esp. girls
 • Older ADHD combined tends to have cognitive distortions
▪ Cognitive
• Intellectual
o ADHD + LD: Lower verbal IQ
o Intellectual impairments – girls > boys (due to inattention)
o As age ↑, IQ score ↓ (probably due to nature of IQ test)
o Higher score on creative thinking
o Tells more creative stories (novel themes & plots)
o Uses more non-verbal info & strategies in problem solving
involving videos/games
o Higher % correct solutions in cooperative groups
o Higher tolerance for ambiguity
• Attention
o Have selective attention → difficult to focus on neutral cues
(failure to “get on track”)
o Consequently, get lost in beginnings/transitions/complex task
o Have sustained inattention → difficult to stay focused on long,
boring tasks (failure to “stay on track”)
o Consequently, reduces work speed & production
o Attending to “distractions” can help ADHD-IN perform
o Mild distractions provide doses of arousal that child needs to
complete long tasks
o Assessment of child’s performance:
▪ With/without distractions
▪ Tasks of varying engagement
• Memory
o Depends on length of material
o Difficulty attending to repetitive info leads to difficulty recalling
info
o Insufficient arousal (lack of dopamine) results in WM
deficiencies
o Fun tasks → dopamine release → temporary improvement of
WM
o Lower recall for STM tasks
o Precategorized info/sorting practice → recall as much as peers
o Verbal LTM → primary impairment related to objects’/colour’s
name
o Perceptual skills – attend less time, respond faster
o Perceptual speed – Slower than average (depends on stimuli)
▪ Communication
• Listening skills
o Appear distracted
o Able to get gist of conversation/stories if:
▪ Interesting material
 ▪ Not too much info
▪ Shorter task
• Expressive skills
o Combined ADHD shows verbal hyperactivity
o Language impairment:
▪ 35-50% of at-risk
▪ About 90% ADHD
• Pragmatics Deficits
o More off-task comments, interruptions, ambiguous referents,
topic change, poorer language organization
o When given specific topic:
▪ Fewer ideas
▪ Insufficient info
▪ Less info request
o Weaker WM – less info held while waiting for turn to talk
▪ Academic
• Lower in ADHD-IN (esp girls)
• Inattention → poor academic
• Academic difficulties:
o Starting task
o Organizing task
o Accuracy (grades)
o Persisting
o Producing sufficient work
• 80% academically delayed
• 25% comorbid with LD
• Difficulty with detailed cues & maintaining attention
• Verbal language
o Includes composition, reading, & spelling
o Difficulty writing composition > reading/math/spelling
o For ADHD+RD, symptoms same as RD but more problems
o Problem with if-then causality (keep info)
• Math
o 31-60% ADHD have MLD
o Generally, ADHD have problem holding info in mind (e.g.
borrowing, multiplication facts, multiple steps), shifting
operations (e.g. mixed operations), nonverbal concepts (e.g.
time, distance, sets)
o Strategy: Finger counting
o Results:
▪ Slower speed
▪ Attempt fewer problems
o Summary
▪ Strengths
 • Attention to gestalt cues
• Attention to novelty/interests
• Good memory when provided visual cues + pre-categorized information
• Greater performance & persistence on problem solving, divergent
thinking, creative storytelling (compared to peers)
• More competitive goals academically
• More intrinsically motivated learning than RD
▪ Needs
• Highlighting neutral cues/details
• Reduce anxiety & emotional overreaction (esp. adolescent girls)
• Chunking strategy (for easier recall)
• Using visual cues/pics for planning
• Breaks between tasks
• Alternative response to writing, e.g. verbal response, typing
• Establish rules & structured environment
• Vary teaching methods, materials, & provide response opportunity
• Studying strategies, note-taking, & time management
• Provide expectations & consequences
• Break tasks into smaller units & accommodate grading accordingly

Week 12: Attentional Disorders: ADHD (hyperactive/ impulsive subtype)

- ADHD (hyperactive/impulsive subtype)

o IDEA
▪ Same as inattention subtype
o DSM-V
▪ A persistent pattern of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development
• Often fidgets with or taps hands or feet or squirms in seat.
• Often leaves seat in situations when remaining seated is expected (e.g.,
leaves his or her place in the classroom, in the office or other
workplace, or in other situations that require remaining in place).
• Often runs about or climbs in situations where it is inappropriate. (Note:
In adolescents or adults, may be limited to feeling restless.)
• Often unable to play or engage in leisure activities quietly.
• Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to
be or uncomfortable being still for extended time, as in restaurants,
meetings; may be experienced by others as being restless or difficult to
keep up with).
• Often talks excessively.
• Often blurts out an answer before a question has been completed (e.g.,
completes people’s sentences; cannot wait for turn in conversation).
• Often has difficulty waiting his or her turn (e.g., while waiting in line).
 • Often interrupts or intrudes on others (e.g., butts into conversations,
games, or activities; may start using other people’s things without
asking or receiving permission; for adolescents and adults, may intrude
into or take over what others are doing).
▪ ≥ 6 of the symptoms have persisted for ≥ 6 months to a degree that is
inconsistent with developmental level and that negatively impacts directly on
social and academic/occupational activities.
▪ Note: The symptoms are not solely a manifestation of oppositional behavior,
defiance, hostility, or failure to understand tasks or instructions. For older
adolescents and adults (age 17 and older), ≥ 5 symptoms are required.
o Comorbidity
▪ Co-occurs with >30 disorders (e.g. sensory, academic, social, etc.)
▪ 54-67% ADHD + ODD (clinical samples: young children)
▪ 44-50% of these, may have CD by adolescents
▪ High possibility of RD
o Differential diagnosis
▪ Chronic nature of activity to a marked degree (not typically seen in peers)
▪ Higher impulsivity & aggressiveness → higher rejection & negative peer
feedback/ teasing/ abuse
▪ Highly competitive & less eager to please teachers compared to ADHD-IN
▪ Exhibits sensation-seeking behaviour
▪ Pursue stimulation through inappropriate ways
▪ ADHD-IN ▪ ADHD-HI ▪ Combined
subtype
▪ Passivity ▪ Hyperactivity ▪ Combination
▪ Cooperativeness (various activity) of social & academic
▪ Socially ▪ Spontaneous talk problems faced by IN
neglected ▪ Aggression & HI subtypes
▪ Learning ▪ Emotional
problems & LD intensity
comorbidity ▪ Competitiveness
▪ Fine motor ▪ Peer-rejection
problems ▪ Worse fine
▪ Inattention motor problems
▪ Weak working ▪ Gross motor
memory problems (50%)
o Etiology
▪ Biogenetic
• Heritability of activity level is higher than IQ
• Shares genetic heritability of 37% with CD & 42% with ODD
• Lower correlations of shared heritability for combined & ADHD-IN
• Differences observed in frontal regions of ADHD brains
• For adults, there is evidence of reduced dopamine in hippocampus &
amygdala
▪ Environmental
 • Hyperactivity & impulsivity NOT the result of parenting style
• However, environment influences the EXTENT of impairments &
comorbidity
• Research finds correlation between hyperactive + aggressive
preschoolers and:
o i. Fathers who are more restrictive with preschoolers BUT
permissive with school-age children
o ii. Siblings who retaliated aggressively
o iii. Mothers who show physical aggression to partners
o iv. Mothers who receive verbal aggression from partners
o v. Mothers who are less protective of their children
▪ Functional assessment
• Possible antecedents
o Activities/tasks requiring delayed response
o Sitting & listening (lacking active response opportunity)
o Repetition or overfamiliarity d. Reduced novelty of
task/materials e. Familiarity of person
o Few interaction opportunities
o Occurrence of ADHD-HI
▪ Prevalence
• More common in younger children
• 15 – 18% of ADHD
▪ Age
• Often identified in school setting (when developmental tasks are
required)
• Social impairment identified later
▪ Culture
• Overrepresetation of African-American in school/community
• Underrepresentation of African-American in clinical samples
• Factors: rater bias, lack of access to clinical resources (low SES)
▪ Gender
• 4 males : 1 female
• 12% boys vs. 2.4% girls with ADHD-HI
• Often missed in girls
• Diff manifestation: Male – more gross motor behaviour; Female – more
fine motor (e.g. doodling), emotional, verbal impulsivity (e.g.
interrupting, swearing, changing topics, etc.)
o Informal identification
▪ Behavioral
• Primary characteristics
o Hyperactivity
o Attention disordered
o Impulsivity
• More often out of seat
 • 3x more body movement (compared to peers)
• 2x more head movement
• 4x area of movement covered
• Middle-school: restless
• High rate of sensation seeking verbal & motor activity
• Impulsive (35-50% of ADHD) → higher rate of accidents
▪ Socio-emotional
• Normal needs for social stimulation, e.g. attention, participation,
recognition
• HOWEVER, does not know appropriate ways to achieve goals
• During elementary, equally desirable play partners; less desirable
schoolwork partners
• Behaviour: > aggressive, < considerate/friendly (not relationship
enhancing)
• ADHD-HI girls have no problem initiating friendships, but have difficulty
sustaining friendship
▪ Cognitive
• Lacks adaptive intelligence
• May attempt to adapt but unsuccessfully
• No difficulty with problem solving
▪ Communication
• Appears to have difficulty listening (esp. to lectures)
• Receptive language may be adequate
• Expressive language is more problematic (more talkative – esp. girls,
noisier, louder, more intense)
• Not focused on topic (spontaneously strayed by associational memory
or visual stimuli)
• Speech contains more dsyfluencies (substitution errors, revisions)
▪ Motor, physical, somatic
• Difficulty performing fine motor sequences
• Hence, slower performance in classroom tasks
• About 50% ADHD have gross motor-coordination dysfunction
▪ Academic
• Combined subtype (more LD) – academic problems masked by
disruption
• ADHD-HI learns well while being active
• Avoids repetition
• Impulsivity affects academic more negatively than activity
• Having difficulties in
o Passively listening
o Asking for help
o Choosing among alternative responses (e.g. MCQ)
o Planning within time frame
 o Summary
▪ Strengths
• Productive, busy, enthusiastic
• Sociable (unless experienced social punishment)
• Helpful
• Spontaneous & funny
• Creative (contributes in group problem solving)
▪ Needs
• Reinforcement for good manners
• Frequent breaks during long tasks
• Strategy to handle own emotional intensity
• Strategy to plan without requiring delay
• Strategy to stay on topic
• Social interactive stimulation (train to follow instructions)
• Schoolwide discipline policies ( serious offense vs. minor offense)

Week 13 – Motor Disabilities

- Motor Disorders
o Motor skill deficits that prevent individuals to respond adequately in speaking/writing or
difficulty inhibiting motor responses
o Inadequate control
▪ Motor programming
• Gross motor
o Developmental coordination disorder (DCD)
• Fine motor
o Dyspraxia
o Dysgraphia
▪ Motor disinhibition
• Tourette’s syndrome
- Developmental Coordination Disorder & Dyspraxia
o DCD is a failure to acquire both gross & fine motor
o A communication disorder that adversely affects educational performance due to:
▪ Stuttering, OR
▪ Impaired articulation, OR
▪ Language impairment, OR
▪ Voice impairment
o DSM-V
▪ The acquisition and execution of coordinated motor skills is substantially below
that expected given the individual’s chronological age and opportunity for skill
learning and use
▪ Difficulties are manifested as
• Clumsiness (e.g., dropping or bumping into objects)
 • Slowness and inaccuracy of motor performance (e.g., catching an
object, using scissors or cutlery, handwriting, riding a bike, or
participating in sports).
▪ The motor skills deficit in Criterion A “ significantly and persistently interferes
with
• Daily living (e.g., self-care and self-maintenance)
• Academic/school productivity
• Prevocational & vocational activities
• Leisure & play
▪ Onset of symptoms is in the “ early developmental period.
▪ The motor skills deficits are not better explained by intellectual disability
(Intellectual developmental disorder) or visual impairment and are not
attributable to a neurological condition affecting movement (e.g., cerebral
palsy, muscular dystrophy, degenerative disorder)
o Differential diagnosis
▪ Dyspraxia
• Fine motor programming failure of articulatory muscle
• Might comorbid with dysgraphia
• Similar disorders: Stuttering, stammering
▪ Apraxia
• Failure to produce any speech
• Often confused with selective/elective mutism & hearing impairment
o Etiology
▪ Biogenetic
• Apraxia/dyspraxia & DCD involve problem with motor programming in
the cerebellum
• Signal sent by the brain to the muscle is disrupted
▪ Functional Assessment
• Antecedents: PE lesson, playground activities, sports, classroom
discussion
• May get angry/frustrated or clown around
o Occurrence
▪ Prevalence
• 6% in the population aged 5- 11 years
• Higher rates in SEN (36%) than general education (4-5%)
• Higher among boys
▪ Age
• Typically not diagnosed before age 5 (motor skills acquisition vary)
• May improve motor skills through practice/experience
• Difficulty occurs when learning new motor skills
o Informal Identification
▪ Behavioral & communication
 • Primary characteristics: Unsequenced sounds/syllables, inconsistent
speech, loss of sounds/words during articulation
• Examples: “shif” vs. “fish”, “miskate” vs. “mistake”, “gate” (today) vs.
“kate”/ “date” (next day)
▪ Socio-emotional
• Lower self-esteem in tasks involving motor skills (might be socially
excluded)
• Mostly isolates self during playground time
• More likely socially deviant & poorer socialization due to teasing by
others
▪ Motor, physical, somatic
• Might have difficulties writing (dysgraphia), using scissors, buttoning,
etc. if poor in balancing & gross motor
• DCD might have speech difficulty (dyspraxia)
▪ Cognitive & academic
• Typically average/above average IQ
• However, motor difficulties might negatively affect cognitive in the long
run (failure to do → failure to experience → failure to know)
- Handwriting Disabilities (Dysgraphia)
o Involves motor control of hand, guided by the eyes following planning of the brain
o Subtypes
▪ Memory dysgraphia – cannot recall letter shapes but can copy
▪ Motor dysgraphia – poor ability to form letters due to poor fine motor skills
▪ Perceptual-spatial Dysgraphia – poor handwriting but unable to recognize their
bad forms
o Etiology
▪ Biogenetic
• Parents/close relatives are often also dysgraphic
▪ Environmental
• Results of stroke or TBI
▪ Functional Assessment
• Antecedents: Written response tasks, fine motor tasks
o Occurrence
▪ Prevalence & age
• 10-34% general population
• Diagnosed between age 7-10 (after learning to write)
▪ Behavioral & socio-emotional
• Often misunderstood as lazy, careless, impulsive
• Tends to be punished
• Takes home lots of unfinished homework
• Avoids writing tasks, prefers verbal tasks
o Informal identification
▪ Perceptual/ motor, physical, somatic
 • Awkward writing mechanics, e.g. odd wrist placement, finger positions,
etc.
• May experience pain while writing – worsens during stress
• Needs to “watch” own hand writing
• Writes slower
▪ Cognitive & academic
• Typically, average/ above average IQ
• Grade affected by writing difficulties (e.g. spelling, punctuation, math
column alignment, neatness, etc.)
• Specific handwriting problems:
o Inconsistent spacing
o Inconsistent forms/slant
o Irregular letter shapes/sizes
o On-the-line & margin errors
o Poor organization on page
o Summary
▪ Strengths
• Intelligent
• Adequate response in verbal tasks OR nonvocal, motor responses
▪ Needs
• Extended time & alternative response method
• Support in activities requiring organization
• Separate grading of content & form
- Tourette Syndrome
o Characterized by tics/involuntary repetitive movement either motor/vocal or both
o IDEA
▪ Categorized under OHI: Limited strength, vitality, or alertnesss (including
heightened alertness to environmental stimuli), that results in limited alertness
with respect to educational environment
▪ Due to chronic/acute health problem, e.g. asthma, ADD, ADHD, diabetes,
epilepsy, heart condition, hemophilia, lead poisoning, leukemia, nephritis,
rheumatic fever, sickle cell anemia, Tourette syndrome
▪ Adversely affects child’s educational performance
o DSM-V
▪ Both multiple motor and “ one or more vocal tics have been present at some
time during the illness, although not necessarily concurrently.
▪ The tics may wax and wane in frequency but have persisted for more than 1
year since first tic onset.
▪ Onset is before age 18 years.
▪ Not attributable to the physiological effects of a substance (e.g., cocaine) or
another medical condition (e.g., Huntington’s disease, post-viral encephalitis).
o Comorbidity
▪ Tourette’s plus (TS+) – comorbidity with other disorder
▪ May prefer to appear disruptive than lack of control
 ▪ Hence, often misdiagnosed as ADHD
o Etiology
▪ Biogenetic
• Inherited brain disorder with biochemical differences
▪ Environmental
• Identical twins who inherit TS might differ in intensity & frequency
• Not all who inherits the genetic vulnerability manifest TS
• Prenatal factors
o Drug exposure
o Maternal stress
▪ Functional Assessment
• Tics increase with stress/anxiety
• May function to reduce stress
• Worsens when given attention to, ingestion of caffeine, cough syrup,
drugs, etc
o Occurrence
▪ Prevalence, Gender, Age
• Between 31-157 in every 1000 (age 13-14)
• M:F=3:1
• Symptoms are visible by age 7 (may decrease during adolescence)
o Informal identification
▪ Behavioral
• Sequence of development:
o i. Eye tics
o ii. Facial tics/vocal tics
o iii. Others (within weeks/months), e.g. head jerks, grimaces,
hand - to -face movement
• Frequency/ intensity may vary & change type
▪ Socio-emotional
• Embarrassed & teased which may increase tics
• Adolescence: Most difficult period with strong emphasis on physical
attractiveness
• May withdraw/ aggressive
▪ Cognitive & academic
• Typically normal IQ
• May have visual perceptual problems & visual-motor problems
• May interfere task involving writing
• Might experience disability fatigue in social setting
▪ Communication: verbal/ vocal
• Simple vocal tics: throat clearing, sniffing, coughing, grunting, spitting,
stuttering, etc
• Complex vocal tics: Animal sounds, repeating words/phrases out of
context, coprolalia, palilalia, echolalia
 ▪ Motor/ physical & somatic
• Simple motor tics: Blinking, neck-jerking, shrugging, flipping head,
kicking, swinging, tapping feet, etc.
• Complex motor tics: Facial gestures (e.g. eye rolling), grooming
behaviour, smelling things, squatting, hitting, biting, echopraxia,
copropraxia
o Summary
▪ Strengths
• Intelligent
• Usually free of tics when engaging in activities of interest
• Severity usually decreases in adolescence
▪ Needs
• Coping strategy for stressful situation (esp. disability fatigue), e.g. leave
situation briefly
• Prohibition of teasing
• Evaluation of academic difficulties
• Alternative response method
• Scripted response for unstructured situations