DOWNS SYNDROME

Definition
- also called trisomy 21 because of a chromosomal
mutation resulting in a 3rd chromosome 21
- a chromosomal disorder resulting in 47 chromosomes
instead of 46
- results from faulty cell division affecting the 21st pair of
chromosomes

Etiology
- Increases in the frequency of thyroid autoantibodies
- Most translocations consist of centric fusions between
No. 21 and a D chromosome; ~1/2 of these are inherited.
- Viral infection that disturbs chromosome segregation for
infants following epidemics of infectious hepatitis.
- Advanced maternal age

Epidemiology
- Approximately 4000 infants with Down syndrome are
born annually in the United States with an incidence of 1
in 800 to 1000 live births.

Pathophysiology & Clinical Manifestations

The extra chromosome 21 affects almost every organ

system and results in a wide spectrum of phenotypic
consequences.

Two hypotheses to explain the mechanism of gene action

in Down Syndrome
Developmental instability (loss of chromosomal
balance)
1. Neuropathology
a) Brain weight is 76% of normal
b) Micrrocephaly
c) Brain is abnormally rounded and short with a
decreased
anterior
=-posterior
diameter
(mircorbrachycephaly)
d) Number of secondary sucli is decreased
e) Paucity of small neurons
f) Migrational defect involving small neurons
g) Decresed synaptogenesis owing to altered
synaptoc morphology
h) Structural abnormalities in the dendritic spines in
the pyramidal tracts of the motor cortex
i) Lack of myelination
j) 8% of children with down syndrome also have
some form of seizure diorder

2. Sensory Deficits
a) Visual and hearing deficits
b) Hearing speech
c) Can have cataracts, farsightedness, strabismus,
and nystagmus
3. Musculoskeletal Differences
a) Lineaar growtth deficits
b) Decrease in normal velocity of growth in stature
c) Led length reduction
d) 10-30% reduction in metacarpal and pahalangeal
length
e) Absent palmaris longus and supernumerary
forearm flexors
f) Lack of differentiation of distinct mm bellies for
the zygomaticus major and minor and the levatr
labii superioris
g) Hypotonia and ligamentous laxity
h) Hip subluxation is common
i) Deficiency in grip strength, isometric strength and
ankle strength
4. Cardiopulmonary pathologies
a) 40% are born with congenital heart defecrs, most
commonly atrioventricular canal defects and
ventriculoseptal defects
5. Physical Characteristics
a) Brachycephaly
b) Fontanesl are frequently larger than normal and
take longer to close
c) Aeas of hair loss
d) Skin is often dry and mottled in infancy and gets
rough when child gets older
e) Face has flat contour
f) Underdeveloped facial bones and mm and a small
nose
g) Eyes are characterized by narrow, slightly slanted
eyelids, with the corners marked by epicanthal
folds
h) Mouth is small, palate is narrow and tongue if
furrowed shape in later childhood
i) Dentition is often delayed and may be spotty
j) Abdomen may be slightly protuberant
k) Chest may have an abnormal shape
l) 90% have umbilical hernia
m) Hands and feet tend to be small and 5th finger is
curved inward
n) 50 % have a single crease across the aplm in one

or both hands
o) Toes are unusually short
p) Majority has a wide space between the 1st and 2nd
toes with a crease running between them on the
sole
Table 299-1. Some Complications of Down Syndrome*
SYSTEM
DEFICIT
Congenital heart disease, most often VSD and AV canal
Cardiac
Increased risk of mitral valve prolapse and aortic
regurgitation
Cognitive impairment (mild to severe)
Gross motor and language delay
CNS
Autistic behavior
Alzheimer's disease
Duodenal atresia or stenosis
GI
Hirschsprung's disease
Celiac sprue
Hypothyroidism
Endocrine
Diabetes
Ophthalmic disorders (eg, congenital cataracts, glaucoma,
strabismus, refractive errors)
EENT
Hearing loss
Increased incidence of otitis media
Short stature
Growth
Obesity
Hematologic disorders (eg, neonatal polycythemia,
Hematologic
transient leukemia, acute megakaryoblastic leukemia,
acute lymphoblastic leukemia)
Musculoskeletal
Atlantoaxial and atlanto-occipital instability
*Not all are present in a given patient, but incidence is increased compared with
unaffected population.
AV = atrioventricular; EENT = eyes, ears, nose, and throat; VSD = ventricular
septal defect.

Diagnosis
A doctor can make an initial diagnosis at birth based on
the looks of the baby. The baby may hear a
heart murmur when listening to the babys chest with a
stethoscope.
- X-rays
- CT Scan
- Amniocentesis
- Chorionic villus sampling
- Blood test
- Echocardiogram
- ECG
- Prenatal amniocentesis with karyotype analysis

- Sometimes neonatal karyotype analysis (if prenatal

diagnosis not done)

Differential Diagnosis

a. Trisomy 18 (Edward syndrome)

an extra copy of chromosome 18
usually severe mental retardation and heart problems
sometimes stomach, digestive tract, reproductive
organ & urological tract problems
fatal in infancy and childhood
b. 47XXY (Kleinfelter syndrome)
most common chromosomal disorder with an extra
X chromosome
mild mental deficiency, infertility, small testis,
gynecomastia, antisocial behaviour
c. XXX (Trisomy X)
chromosomal disorder with an extra X chromosome
female, mild mental deficiencies, psychosis, menstrual
abnormalities
Multiple X chromosomes
male infants born with one or more additional X
chromosome in each cell
no. of chromosome beyond normal total of 46
mental IQ and distinct facial appearance and speech,
skeletal, and coordination
Problems

Prognosis

In most cases, prognosis for Downs syndrome has

been favorable.\
Life expectancy has increased substantially, reaching
the age of 50 or over 50 years
80% survive to the age of 5years
Risk for other medical conditions that affects nearly
every system of the body.
underlying disorder cannot be treated
Treatment depends on specific manifestations
Later in life, approximately 75% of adults over 60
years with Down Syndrome show signs & symptoms of
Alzheimers disease

PT Management
a. Objectives of care
General Goal: Anticipate gross and fine motor delay and
provide interventions and weight
Bearing

b. Appropriate interventions and its rationale

1. Utilize positioning and handling activities throughout
early infancy and childhood
to promote anti-gravity control and weight bearing
2. Facilitate anti-gravity extension in prone and weight
shifting within and as transition
from prone.
3. In supine and supported sitting, encourage midline
orientation, anti-gravity
bimanual activities including eye-hand coordination, and
anterior neck and trunk
anti-gravity activities to promote anti-gravity muscle
strength
4. Emphasize trunk extension and extremity loading to
increase axial muscle
strength
5. Encourage emergence of righting and postural
reactions through use of rotation
within and during movement.
6. Allow for dynamic rather than static exploration of
movement.
7.
Introduce
developmental
milestones
when
chronologically appropriate, including
supported sitting and standing, when trunk control and
alignment are able to be
established.
8. Anticipate delay in postural control responses and
provide functional opportunities
to enhance development in areas of cognition, language,
and socialization.
9. Teach parents and other team members activities and
position choices that will
enhance the childs overall development.
c. Relevant health teaching(s) to patient & family
Support group that would help the individual with Downs
syndrome be comfortable with
his/her life. Behavioral training can also help people with
Downs syndrome and their families deal with the
frustrations, anger and compulsive behavior that often
occur. Parents or caregivers should learn to help a person
with Downs syndrome deal with frustration. At the same
time, it is also important to encourage independence
References
Tecklin, Jan S., Pediatric Physical Therapy, 4th ed,
pp. 368, 370

 Behram, Kliegman, Jenson , Nelson Textbook of

Pediatrics, 17th ed
THE MERCK MANUAL OF DIAGNOSIS AND THERAPY - 19th
Ed. (2011)
Crepeau, Elizabeth B. , Cohn Ellen, Schell, Barbara A. , Occupational
Therapy Willard & Spackmans

MENTAL RETARDATION or INTELLECTUAL

DISABILITY
Definition (TECKLIN)
- is a disability characterized by significant limitations in
both intellectual functoning and adaptive behavior
expressed in conceptual, social, and practical adaptive
skills.
-In order to be classified as mental retardation,
onset of this disability occurs before age 18
- According to DSM- IV -TR 4 th ed, essential feature of
mental retardation is significantly subaverage general
intellectual functioning, accompanied by significant
limitations in adaptive functioning in at least two of the
following applicable adaptive skill areas: communication,
self-care, home living, social/ interpersonal skills, use
community resources, self-direction, health and safety,
functional academic skills, leisure, and work
- a condition existing in an individual that is described by
the specific performance of the individual not due to a
specific trait
- performance state in which functioning is impaired
DEFINITION (MERCK)
- Intellectual disability (ID, previously called mental
retardation) is characterized by significantly sub-average
intellectual functioning (often expressed as an intelligence
quotient < 70 to 75) combined with limitations of > 2 of
the following: communication, self-direction, social skills,
self-care, use of community resources, and maintenance
of personal safety. Management consists of education,
family counseling, and social support.
CLASSIFICATION
LEVELS OF RETARDATION (Merck Manuals)
LEVEL
IQ
Ability
at Ability
at Ability at Adult
RAN
Preschool Age School Age (6- Age (21 years
GE
(Birth
6 20 years)
and older)
years)

Mild

5268

Can develop
social
and
communicatio
n
skills,
muscle
coordination is
slightly
impaired,
often
not
diagnosed til
later age

Can learn up
to about the
6th-grade level
by late teens,
can be guided
toward social
conformity,
can
be
educated

Can
usually
achieve enough
social
and
vocational skills
for self support,
but may need
guidance
and
assistance
during times of
unusual social
or
economic
crisis

Moderate

3651

Can talk or
learn
to
communicate;
social
awareness is
poor; muscle
coordination is
fair;
profit
from
selftraining
in
self-help

Can
learn
some
skills
and
occupational
skills;
progression
beyond
2ndgrade level in
schoolwork is
unlikely; may
learn to travel
alone
in
familiar
training

May
achieve
self-support by
performing
unskilled
or
semiskilled
work
under
sheltered
conditions;
need
supervision and
guidance when
under
mild
social
or
economic
stress

Severe

2035

Can say a few

words; able to
learn
some
self-help skills;
have few or
no expressive
skills; muscle
coordination is
poor

Can talk or
learn
to
communicate;
can
learn
simple health
habits; benefit
from
habit
training

May
continue
partially to selfcare
under
complete
supervision,
can
develop
some
useful
self-protection
skills
in
controlled
environment

Profound

19 or Extremely
Some muscle
belo
retarded; little coordination;
w
muscle
unlikely
to
coordination;
walk or talk
may
need
nursing care

Some
muscle
coordination
and
speech;
may
achieve
very
limited
self-care, need
nursing care

TECKLIN CLASSIFICATION
- key elements in the definition of MR are :
capabilities, environment and function
- previously used terms of mildly, moderate severely,
or profoundly retarded are no longer wildly
used
- Current classification carries with it an application of
new diagnostic criteria directly correlated to
need for support
-Four intensities of support: intermittent, limited,
extensive, and pervasive
-Support services may come to child with MR from 4
sources:
the individual child, other people, technology,
or habilitation services

IQ

50-55 to 70

Presch
ool

Often
appears
unimpaired;
develops
functional
social and
communicati
on skill

35-40 to
50-55

20-25 to
35-40

Impaired
social skills;
can
communicat
e; may need
supervision

Severely
impaired
communica
tion;
impared
motor skills

<20-25
Requires fullsupport;
dependent
for care;
limited
sensorimotor
development

Schoolaged

Academic
skills of 6th
grade are
possible;
special
education
support is
needed for
secondary
school

Adult

Can learn
social skills
and
vocational
skills

Can develop
up to 4th
grad
academic
skills with
special
traiming/
modification

Unskilled or
semiskilled
vocation

May learn
to
communica
te; basic
personal
health
habits,
limited
academic
skills
Needs
complete
support
and
supervision
for any selfsupport
activity

Some motor
development
contines to
be
dependdent
for
care;limited
success with
trainin
Limited
motor ability
and
communicati
on; continued
dependency
for care

ETIOLOGY

- Most cases of mental retardation the cause is unknown

-several conditions during a womans pregnancy can
cause or contribute to mental retardation in her child
Use of certain drugs
Excessive consumption of alcohol
Radiation therapy
Poor nutrition
and certain viral conditions (German measles
or rubella)
Chromosomal abnormalities: Down Syndrome

ETIOLOGIC CLASSIFICATION OF MR
ETIOLOGY
Prenatal Onset
1. Chromosomal Disorder

EXAMPLES
Examples
Downturner or Klinefelters syndrome

2. Syndrome disorders

Neurofibromatosis, myotonic muscular

dystrophy.
Prader-Willi,
Tuberous
sclerosis
Phenylketonuria
carbohydraate
disorders, Lesch - Nyhan syndrome
Anencephaly,
hydrocephalus,
porencephaly, microcephaly
Intrauterine malnutrition, drugs, toxins,
alcohol, narcotics, maternal dss

3. Inborn errors of metabolism

4. Developmental disordeers
brain formation
5. Environmental influences

of

Perinatal Causes
6. Intrauterine disorders
7. Neonatal disorders
Postnatal Causes
8. Head injuries
9. Infections
10. Demyelinating disorders
11.Degenerative disorders
12.Seizure disorders
13. Toxic-metabolic disorders
14. Malnutrition
15.Environmental deprivation

Examples
Placental insufficiency, maternal sepsis,
abnormal labor or delivery
Intraventricular hemorrhage, maternal
sepsis, abnormal labor or delivery
Examples
Intracranial
hemorrhage, contusion,
concussion
Encephalitis, meningitis, viral infections
Post-infections and post-immunization
disorders
Syndromic disorders, poliodystrophies,
basal ganglia
disorders, leukodystrophies
Infantile spasms, myoclonic epilepsy
Reyes syndrome, lead intoxication,
metabolic disorders
Protein-calorie,
prolonged
IV
alimentation
Psychosocial disadvantage, child abuse/
neglect

Prenatal drug and toxin exposure cause ID. Fetal alcohol

syndrome is the most common of these conditions.
Anticonvulsants
,
chemotherapy
drugs,
radiation
exposure, lead, and methylmercury are also causes.
Severe undernutrition during pregnancy may affect fetal
brain development, resulting in ID.
Perinatal: Complications related to prematurity, CNS
bleeding, periventricular leukomalacia, breech or high
forceps delivery, multiple births, placenta previa,
preeclampsia, and perinatal asphyxia may increase the
risk of ID. The risk is increased in small-forgestational-age
infants; intellectual impairment and decreased weight
share the same cause. Very low- and extremely low-birthweight infants have variably increased chances of having
ID, depending on gestational age, perinatal events, and
quality of care.
Postnatal: Undernutrition and environmental deprivation
(lack of physical, emotional, and cognitive support
required for growth, development, and social adaptation)
during infancy and early childhood may be the most
common causes of ID worldwide. Viral and bacterial
encephalitides
(including
AIDS-associated
neuroencephalopathy) and meningitides, poisoning (eg,
lead, mercury), and accidents that cause severe head
injuries or asphyxia may result in ID.

INCIDENCE
3% of population of US is assumed to have mental
retardation, only 1% to 1.5% are actually
diagnosed.
80% of cases , the cause is unknown
(4x) M.> W
75%- mild form
20%- moderate form
5%- severe or profound form
Down Syndrome - one fo the most prevalent form (
1 in 800 to 1000 in live births

PATHOPHYSIOLOGY
1. Depending on the cause; early diagnosis and prompt
treatment may be particularly important in cases
involving an identifiable and possibly correctable cause,
such as phenylketonuria, malnutrition, or child abuse.
2. Diagnosis usually is made after a period of suspicion.
Diagnosis may be made at birth from recognition of a
specific syndrome, such as Down syndrome. Diagnosis
and classification are based on standard IQ test scores.

CLINICAL MANIFESTATION
COMMON MANIFESTATIONS OF MENTAL RETARDATION by
AGE
Age
Newborn
Early infancy (2-4mo)

Later infancy (6-8mo)

Toddlers (2-3yr)
Preschool (3-5yr)

School age (over 5yr)

COMPLICATIONS (TECKLIN)
1. Neuromotor Impairments

Area of Concern
Dysmorphisms
major organ system dysfunction
(feeding & breathing)
Failure
to
interact
with
the
environment
Concerns about vision and hearing
impairments
Gross motor delay
Language delays or difficulties
Language difficulties or delays
Behavior difficulties, including play
Delays in fine motor skills: cutting,
coloring, drawing
Academic underachievement
Behavior difficulties

- most neuromuscular impairments are present as

a result of primary pahtology in the CNS
- secondary impairments then include deficits in
motor control, coordination, postural control,
force production, flexibility, and balance
2. Learning Impairment
- Impaired ability to utilize advanced cognitive
processes,
manage
simultaneous
or
multiple
demands,
and
successfully
organize
complex
information, with subsequent effects on task
performance as well as task mastery

Diagnosis
Table 304-5. Tests for Some Causes of Intellectual Disability (MERCK)
SUSPECTED CAUSE

INDICATED TESTS

Single major anomaly or multiple Chromosome analysis

minor anomalies
Chromosomal microarray analysis
Family history of cognitive disability Cranial CT and/or MRI*

Failure to thrive
Idiopathic hypotonia
Genetic metabolic disorders

HIV screening in high-risk infants

Nutritional and psychosocial history
Urine and/or blood amino acid and enzyme
studies for storage diseases or peroxisomal
disorders
Muscle enzymes
SMA
12
(includes
albumin,
alkaline
phosphatase, AST, total bilirubin, BUN, Ca,
cholesterol, creatinine, glucose, P, total
protein, and uric acid)
Bone age, skeletal x-rays

Seizures

EEG
Cranial CT, MRI*, or both
Blood Ca, P, Mg, amino acids, glucose, and
lead levels

Cranial
abnormalities
(eg,
premature closure of the sutures,
microcephaly,
macrocephaly,
craniostenosis, hydrocephalus)
Cerebral atrophy
Cerebral malformations
CNS hemorrhage
Tumor
Intracranial calcifications due to
toxoplasmosis,
cytomegalovirus
infection, or tuberous sclerosis

Cranial CT, MRI*, or both

TORCH screening
Urine culture for virus
Chromosome analysis
Chromosomal microarray analysis

*After neurologic consultation.

SMA = sequential multiple
cytomegalovirus, herpes.

analyzer;

TORCH

Diagnosis of MR is based on the criteria

embodied within the definition reflecting
intellectual functioning level and adaptive skill
level (TECKLIN)

Assessment of Intellectual Functioning

Standardized intelligence test
- administered by a psychologist

toxoplasmosis,

rubella,

-determine
a
childs
inteelectual
functioning on the basis of an IQ of 70 or
75 below
- Instruments commonly used:
Stanford-Binet Intelligence Scale, 5th ed,
One of tthe Wechsler Scales, such as
Wechsler Intelligence Scale for ChildrenIV or Wechsler Preschool and Primary
Scale of Intelligence II, and the Kaufman
Assessment Battery for Children
Assessment of Adapive Skill level
Impairments in adaptive function are usuallt
the presenting symptoms in individuals with MR.
Adaptive skills are those skills considered to be central
to successful life functioning and are frequently
related to the need for supports for persons with
mental retardation

DIFFERENTIAL DIAGNOSIS
Autism
Borderline intellectual functioning
Child Abuse &amp; Neglect, Posttraumatic Stress
Disorder
Childhood Disintegrative Disorder
Cognitive Deficits
Learning Disorder, Reading
Learning Disorder, Written Expression
Mathematics Learning Disorder
Pediatric Depression
Pervasive Developmental Disorder
Rett Syndrome
Severe communication/language disorders

Prognosis
Many people with mild to moderate ID can support
themselves, live independently, and be successful at jobs
that require basic intellectual skills. Life expectancy may
be shortened, depending on the etiology of the disability,
but health care is improving long-term health outcomes
for people with all types of developmental disabilities.
People with severe ID are likely to require life-long
support. The more severe the cognitive disability and the
greater the immobility, the higher the mortality risk.

PT MANAGEMENT
A. Objectives of care

Analyze not only what the child can do, but also the
process underlying the observed skills and behaviors
Perform an evaluation with as many functional
aspects as is reasonable
Identify not only the disability, but also the childs
abilites, however minimal
Understand by what means, or even whether, the
child is perceiving the world, including yo, before
continuing with the evaluation

B. Appropriate interventions and its rationae

Assess all children for all signs of developmental delays
1. Sensory examination and intervention
VISUAL: Stimulation and practice in both focusing and
tracking
AUDITORY: Vesitubular stimulation to enhance
auditory integration
TACTILE : Heavy touch and pressure or weightbearing Decrease tactile hypersensitivity and
promoting proximal joint stability
VESTIBULAR: vestibular activities- improve balance ,
stimulate experience of movement, activate mm
contraction, promote awareness and eye contact , and
increase spatial awareness and perception
2. Intervention to limit cognitive impairment
Present concepts using meaningful and concrete
directions
Repetition of activities (long term memory use)
Meaningful tasks using the thrapeutic tools to
improve transfer of learning
3. Intervention to limit physical impairments and
functional limitations
Activities deesigned to limit musculoskeletal,
neuromuscular and cardiopulmonary impairments;
reduce functional limitations; prevent secondary
impairment
C. Relevant health teaching(s) to patient and family
Encourage the prevention of mental retardation
References
Tecklin, Jan S., Pediatric Physical Therapy, 4th ed, pp.
368, 370,
Muscari, M.E. (2005). Pediatric nursing, 4th edition,
Lippincott William & Wilkins.

Behram, Kliegman, Jenson , Nelson Textbook of

Pediatrics, 17th ed, pp. 140-142
THE MERCK MANUAL OF DIAGNOSIS AND THERAPY - 19th Ed.
(2011)

LEARNING DISABILITIES
(MERCK)
Learning disabilities are conditions that cause a
discrepancy between potential and actual levels of
academic performance as predicted by the person's
intellectual abilities.
Learning disabilities involve impairments or difficulties in
concentration or attention, language development, or
visual and aural information processing.

Etiology

Usually present from birth, although it may go

undetected until later in life.
Genetic predisposition
Chromosomal abnormalities
Single abnormal gene
Multi-factorial
Perinatal injury
Other medical conditions
Infection, trauma, environmental toxins

Epidemiology

The number of children with learning disabilities is

unknown, about 5% of the school-age population in the
US receives special educational services for learning
disabilities. Among affected children, boys outnumber
girls 5:1.

Pathophysiology

Learning disabilities may be congenital or acquired. No

single cause has been defined, but neurologic deficits are
evident or presumed. Genetic influences are often
implicated. Other possible causes include
Maternal illness or use of toxic drugs during pregnancy
Complications during pregnancy or delivery (eg,
spotting, toxemia, prolonged labor, precipitous delivery)
Neonatal problems (eg, prematurity, low birth weight,
severe jaundice, perinatal asphyxia, postmaturity,
respiratory distress)
Potential
postnatal
factors
include
exposure
to
environmental toxins (eg, lead), CNS infections, cancers
and their treatments, trauma, undernutrition, and severe
social isolation or deprivation.
- Structural changes involving frontal/striatal system and
intra- and interhemispheric white matter
Projections

Clinical Manifestations

Children with learning disabilities typically have at

least average intelligence, although such disabilities
can occur in children with lower cognitive function as
well.
Symptoms and signs of severe disabilities tend to
manifest at an early age.
Mild to moderate learning disabilities are usually not
recognized until school age, when
the
rigors
of
academic learning are encountered.
Affected children may have trouble learning the
alphabet and may be delayed in paired associative
learning (eg, color naming, labeling, counting, letter
naming).
Speech perception may be limited, language may be
learned at a slower rate, and vocabulary may be
decreased.
Affected children may not understand what is read,
have very messy handwriting or hold a pencil
awkwardly, have trouble organizing or beginning tasks
or retelling a story in sequential order, or confuse
math symbols and misread numbers.
Disturbances or delays in expressive language or
listening comprehension are predictors of academic
problems beyond the preschool years.

 Memory may be defective, including short-term and

long-term memory, memory use (eg, rehearsal), and
verbal recall or retrieval
Some children with learning disabilities have difficulty
following social conventions (eg, taking turns,
standing too close to the listener, not understanding
jokes); these difficulties are often components of mild
autism
Difficulties with impulse control, non-goal-directed
behavior and overactivity, discipline problems,
aggressiveness, withdrawal and avoidance behavior,
excessive shyness, and excessive fear may occur.
Learning disabilities and attention-deficit/hyperactivity
disorder (ADHD) often occur together.

Diagnosis
Cognitive evaluation typically includes verbal and
nonverbal intelligence testing and is usually done by
school personnel. Psychoeducational testing may be
helpful in describing the child's preferred manner of
processing information (eg, holistically or analytically,
visually or aurally). Neuropsychologic assessment is
particularly useful in children with known CNS injury or
illness to map the areas of the brain that correspond to
specific functional strengths and weaknesses. Speech and
language evaluations establish integrity of comprehension
and language use, phonologic processing, and verbal
memory.
Behavioral assessment and performance evaluation by
teachers' observations of classroom behavior and
determination of academic performance are essential.
Reading evaluations measure abilities in word decoding
and recognition, comprehension, and fluency. Writing
samples should be obtained to evaluate spelling, syntax,
and fluency of ideas. Mathematical ability should be
assessed in terms of computation skills, knowledge of
operations, and understanding of concepts.
Medical evaluation includes a detailed family history,
the child's medical history, a physical examination, and a
neurologic or neurodevelopmental examination to look for
underlying disorders. Although infrequent, physical
abnormalities and neurologic signs may indicate medically
treatable causes of learning disabilities. Gross motor
coordination problems may indicate neurologic deficits or
neurodevelopmental delays. Developmental level is

evaluated according to standardized criteria.

Psychologic evaluation helps identify ADHD, conduct
disorder, anxiety disorders, depression, and poor selfesteem, which frequently accompany and must be
differentiated from learning disabilities. Attitude toward
school, motivation, peer relationships, and self-confidence
are assessed.

Prognosis

A learning disability cant be cured or fixed

A lifelong issue
No treatment available
with the right support and intervention, however,
children with learning disabilities can succeed in
school and go on to successful, often distinguished
careers later in life.
Without proper support,
people with learning
disabilities adapting and coping up with psychological
and social adjustments in both working and nonworking environments

Complications
a. Learning disabilities in reading (dyslexia)
Signs of reading difficulty include problems with:
Letter and word recognition
Understanding words and ideas
Reading of speed and fluency
General vocabulary skills
b. Learning disabilities in math (dyscalculia)
A child with a math-based learning disorder may
struggle with memorization and
organization of numbers, operation signs, and number
Children with math learning disorders might also have
trouble with counting principles (such as counting by 2s
or counting by 5s) or have difficulty telling time.
c. Learning disabilities in writing (dysgraphia)
Symptoms of a written language learning disability
revolve around the act of writing. They
include problems with:
Neatness and consistency of writing
Accurately copying letters and words
Spelling consistency
Writing organization and coherence
Table 304-3.

Common Learning Disabilities

DISABILITY
Dyslexia
Phonologic
dyslexia
Surface
dyslexia
Dysgraphia
Dyscalculia
Ageometria
Anarithmia
Dysnomia

MANIFESTATION
Problems with reading
Problems with sound analysis and memory
Problems with visual recognition of forms and structures of words
Problems with spelling, written expression, or handwriting
Problems with mathematics and difficulties with problem-solving
Problems due to disturbances in mathematical reasoning
Disturbances in basic concept formation and inability to acquire
computational skills
Difficulty recalling words and information from memory on
demand

PT Management
a. Objectives of care
Improve the quality of life and ability through learning
Improve functional abilities
Improve health
b. Appropriate interventions and its rationale
Exercises should address these three and should be
meaningful and relevant for the
patient
1. Cognitive show them pictures of storytelling then
make them recall the
sequence of the pictures shown or remember parts of the
story
2. Perceptual speed flash cards to an individual with a
learning disability for
him/her to recognize things
3. Psychomotor imagery
c. Rationale of intervention
1. To improve their cognitive functioning like for memory
and processing.
2. To be able to know objects or people in the pictures as
fast as they can to
test the individuals speed
3. For the individual to sychronize ones action with ones
imagination that the
physical therapist shall visually cue
d. Relevant health teaching(s) to patient & family
- Teach family to be supportive, kind and patient. They
should understand the situation of their
child and they should be show him/her love and care.
References

Keltner, N. L., Schwecke, L.H., & Bostrom, C.E. (2007).

Psychiatric nursing, 5th edition, p. 637. Singapore:
Mosby Elsevier
Behram, Kliegman, Jenson , Nelson Textbook of
Pediatrics, 17th ed, pp. 100-106
Rose, Nicholas D., Essential Psychiatry2nd ed, 168,
170-181.
Tecklin Jan, Pediatric Physical therapy 4th ed pp. 367381
Molnar, Grabriella, Pediatric rehabilitation 3rd ed p. 61
Rennie J. Learning Diability, Physical therapy,,
Treatment and Management, 2nd ed.
THE MERCK MANUAL OF DIAGNOSIS AND THERAPY - 19th Ed.
(2011)