My child forgets what he learns in school & he is not able to follow instructions often. What could be the reason?

Forgetting what is taught in the classroom, difficulty in following the teacher’s instructions and difficulty in attending to a specific task can suggest a diagnosis of Intellectual Developmental Disorder (IDD), formerly known as Mental Retardation. It is a disorder in which the child’s intellectual/mental functioning is impaired (along with other symptoms).

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How is IDD defined?

Intellectual Developmental Disorder (IDD) is a neuro-developmental disorder originating during an individual’s developmental phase. It is characterized by significant limitations in:

  • Intellectual functioning (general mental capacity such as learning, reasoning, problem solving, judgment, academic learning, and abstract thinking)

  • Adaptive behavior (social and practical adaptive skills). For instance, the individual may have difficulty in learning a new skill, planning future tasks, or judging appropriate social behavior. Deficits in these abilities lead to impairment in social functioning such as interpersonal communication, social engagement. It also leads to impairment in activities of daily living such as dressing oneself, cooking, and money management.

IDD is classified under the Neuro-developmental Disorders section of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (Johns Hopkins Psychiatry Guide http://www.hopkinsguides.com/hopkins). The DSM-5 classifies IDD according to varying degrees (mild, moderate, severe, profound) in the following domains:

  • Conceptual (academic skills involving reading, writing, mathematics, time, money; executive function involving planning, strategizing, priority setting; short-term memory; and functional use of academic skills for instance, reading, telling the time).

  • Social (understanding social cues, social interaction, social judgment, social communication).

  • Practical (ability to perform daily living tasks, household tasks, vocational skills).

The term ‘Intellectual Disability’ is an equivalent for the diagnosis of ‘Intellectual Developmental Disorder’ and is more commonly used (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition)

What does it mean?

Children with IDD have below-average intelligence. Children with IDD learn more slowly than typically developing children. This learning deficit applies to learning across developmental phases and across many skills. For instance, children with IDD may learn to sit up, crawl, walk, and talk later than typically developing children. Most children with IDD also face deficits in their communication skills, and their ability to interpret and apply new information – they find it difficult to communicate their wants and needs. As a result, such children often find it hard to keep up with their peers in school (Child Mind Institute http://childmind.org/guide/intellectual-development-disorder/).

Older children with IDD may show deficits in memory, social and problem-solving skills. Some children may also show a lack of social inhibitions – that is, he/she may act inappropriately or say socially inappropriate things in public. They are not able to understand what behaviors are socially appropriate/acceptable in a given situation and hence might say or do things that come across as inappropriate, rude, or rebellious (Child Mind Institute http://childmind.org/guide/intellectual-development-disorder/).

Children with IDD also often have difficulty with adaptive skills – they are unable to perform tasks necessary for day-to-day living (activities of daily living) independently. They struggle with taking care of themselves. In most cases, individuals with IDD require assistance with activities of daily living.

Standardized tests such as an IQ test can be used to determine a child’s intellectual development. A score below 70 on a standardized IQ test would indicate that the child may have IDD. A key area to be observed before officially diagnosing a child is his/her adaptive behavior such as his/her interpersonal skills, communication skills, and daily living skills such as grooming, using the bathroom independently (Child Mind Institute http://childmind.org/guide/intellectual-development-disorder/)

IDD is not a disease and hence cannot be ‘cured’ but early diagnosis and intervention can improve adaptive functioning (Millcreek Behavioral Health Treatment Center http://www.millcreekofmagee.com/). IDD can be tackled through the intervention programs including Special Education, Speech Therapy, Occupational Therapy, and family counseling aimed specifically at helping children learn adaptive skills so that they can live independent lives.

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My child has just been diagnosed with autism, Will he ever be able to speak?

Many parents of children with autism have been told that if their child has not started speaking by the age of 5, he/she is unlikely to ever speak. However, some researchers have opposed this view. There have been cases of children who developed language during primary school or even adolescence. These are children who were diagnosed with autism and severe language delay at age 4. However, they have gone on to learn language. Researchers have also found that who go on to speak at a later age had higher IQs and lower social impairment (Wodka, Mathy, and Kalb, 2013). This shows that language rarely develops in isolation, but developing cognitive and social skills (such as joint attention, understanding and usage of gestures, eye contact) promotes language development. Therefore, early intervention programs must also target cognition and social interaction.

Each individual with autism is unique & even with tremendous effort, a strategy that works well with one child may not work with another. Therefore, though language development is a good objective, establishing communication is the broader goal. Non-verbal children with autism have plenty of alternatives to help them communicate like visual support or assistive technology.

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What types of intervention help children to speak?

Interventions which use Augmentative and Alternative Communication (AAC) show optimum outcomes (Kasari, 2013). The AAC approach uses techniques like sign language, speech generating devices and PECS.

Picture Exchange Communication System (PECS)

This is designed to help children communicate their wants and needs in a variety of settings and contexts (home/ school/ community). PECS does not require complex or expensive materials as it mainly uses picture symbols to communicate. The goal is to make the child initiate spontaneous and functional communication. That is, first the child is taught to approach the person they would like to communicate with, with a picture of a desired object or food item and place the picture in the person’s hand. The understanding is that the child would like this object/item and is communicating his desire for it. The next goal in the PECS system is to generalise this skill by using it in different places with different people and across distances. After this step, children are trained to select from two or more pictures to ask for their desired/preferred item. These are usually placed in a “communication booklet” – a ring binder with Velcro strips where pictures are stored for easy retrieval.

More advanced phases of this system include training to construct simple sentences on a detachable sentence strip using an “I want” picture followed by a picture of the item requested.

Children then learn to expand their sentences by using adjectives, verbs, and prepositions. Finally, children learn to answer questions using PECs, for instance, “What do you want?”; and comment in response to questions such as, “What do you see?”, “What do you hear?”, and “What is it?”.

Although you might be worried that such a system of communicating might replace speech, research has shown that there is no evidence of such an effect. On the other hand, PECS has been found to facilitate speech in some children.

Speech-generating Device

Another method to facilitate communication is a speech-generating device. Studies have shown that minimally verbal children with autism do gain spoken language faster when play-based therapy included speech-generating devices (Kasari, 2013) including iPads with special apps. Such therapy encourages engagement with the therapist and the use of spoken language. Children are shown to use words more often and engage in social communication with others more spontaneously.

Interactive Play & Social Communication

Other effective strategies to help children communicate include: encouraging play and social interaction. Children learn through play. Interactive play provides the opportunity for you and your child to communicate. You can try playful activities that promote social interaction like singing nursery rhymes. Imitating your child’s sounds and play behaviour has been shown to encourage more vocalizing and interaction. This in turn encourages your child to imitate you and take turns (Dawson and Elder, 2013).

Also, do pay attention to nonverbal communication. Gestures and eye contact build a foundation for further communication. Encourage your child by performing such actions, try and exaggerate your gestures. Use both your body and voice when communicating, for example extend your hand to point when you say “look”; nod your head when you say “yes”. Respond to your child’s gestures, for instance, when your child looks at or points to a toy, hand it to him/her. Similarly, point to a toy you want before picking it up (Dawson and Elder, 2013).

Simplify your language. Doing this helps your child follow what you are saying. Use single words (for instance, if you and your child are playing with a ball, say “roll ball” or “catch”). If your child is speaking using single words, progress to the next level: start speaking in short phrases (for instance, “catch the ball” or “throw it to me”) (Dawson and Elder, 2013).

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To summarize, developing communication with or without language should be an important goal of all interventions.