eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Cognitive Deficits

W Douglas Tynan, PhD, Chief Psychologist, Nemours Health and Prevention Division Programs; Director, Primary Care Mental Health Program, A I duPont Hospital for Children; Consulting Psychologist, Nemours Clinical Management
Daniel Earl, DO, Clinical Associate Professor, Department of Family and Community Medicine, University of Arizona College of Medicine, Chino Valley Medical Center

Updated: Jun 6, 2006

Introduction

Background

Cognitive deficits in children range from profound mental retardation with minimal functioning to mild impairment in specific operations. To understand the concept of cognitive deficit, some primary issues in the measurement of cognitive function must be understood.

Cognitive deficit is an inclusive term used to describe deficits in intellectual functioning in global disorders (eg, mental retardation) or specific deficits in cognitive abilities (eg, certain learning disabilities such as dyslexia).

Of the global disorders, mental retardation is defined by Wolraich and Schor as "below-average abilities in cognitive and adaptive functioning." Thus, mental retardation is only defined when both cognitive deficits and poor adaptive behavior skills are present in the same individual. Many individuals have reduced cognitive capacity as evidenced by low scores on a specific test of intellectual ability (eg, an IQ test) but who have appropriate adaptive and social behavior and can function quite well in society. These individuals are not diagnosed as being mentally retarded. Indeed, impairments in social and adaptive behavior usually comprise presenting symptoms in children with mental retardation.

Evaluation of mental retardation almost always involves gathering of information by a number of professionals, including education, mental health, and health care providers. Assessment of adaptive and social behavior is performed with a structured interview of the caregiver using the Vineland Adaptive Behavior Scale or similar social adaptation measure, usually performed by a mental health or education professional.

Mental retardation is classified into 4 degrees of severity in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association and the American Association of Mental Deficiency.

These classifications are primarily based on estimates of cognitive functioning from standardized IQ tests administered by psychologists. These categories are mild mental retardation (IQ levels of approximately 55-70), which affects 85% of the cognitively deficient population; moderate retardation (IQ levels of 40-55), which affects approximately 10% of those with retardation diagnoses; severe mental retardation (IQ levels of 25-40); and profound mental retardation (IQ levels <25). With young children or with very severely impaired or noncooperative individuals, completing intellectual evaluations may not be possible. Consequently, trained professionals develop estimates by observation of daily functioning.

The generic term learning disabilities, used when children are classified for education purposes, encompasses 7 categories. Under the guidelines for special education, these 7 categories are listening, speaking, basic reading skills, reading comprehension, written expression, mathematics calculation, and mathematic reasoning. School guidelines do not include other learning problems, but such problems certainly affect academic functioning. These would include problems of concentration, attention, memory, and executive function. Executive function is the ability to monitor and modify one's own behavior and shift learning strategies when working on problem-solving tasks as needed.

When a learning disability is suspected, a complete multidisciplinary evaluation can be requested at the child's local public school (even if the child attends a private school or is home-schooled), or the child can be referred to the appropriate psychology, speech and language, or education professionals for discipline-specific evaluation.

Developmental speech and language disorders

Speech and language problems are often the earliest indicators of a learning disability. People with developmental speech and language disorders have difficulty producing speech sounds, using spoken language for communication, or understanding the verbal content of other people. The diagnosis depends on the specific communication problem. Specific problems in listening or speaking are defined as learning disabilities for education purposes.

• Developmental articulation disorder: Children may have trouble controlling their rate of speech, or they may lag behind playmates in learning to make specific speech sounds. For example, 6-year-old Wallace still said wabbit instead of rabbit and thwim instead of swim. Developmental articulation disorders are common. They appear in at least 10% of children younger than 8 years. Fortunately, children often outgrow articulation disorders. Alternatively, treatment with speech therapy can also resolve articulation disorders. Of themselves, articulation disorders do not indicate problems in language functioning and are not predictive of other academic difficulties.
• Developmental expressive language disorder
  • Some children with language impairments have problems expressing themselves in speech. Child language follows a predictable course of development, starting with expressive babbling of a variety of sounds, which quickly develops into babbling of the sounds of the language used at home. It then develops into single words that are used with inflection and gesture to convey meaning and then into 2- and 3-word phrases in which the child combines and changes the order of words to express ideas and meaning.
  • Delay in the acquisition of single words or any language is of concern. Also problematic is a delay in the acquisition of 2 and 3-word syntactical language and the use of correct pronouns, plurals, and simple prepositions (by age 3 y). Language delay is serious, particularly when combined with poor socialization, including lack of eye contact and not engaging with adults (see Pervasive Developmental Disorder). Delays in the development of full language in correctly constructed sentences, describing things, asking intelligible questions, and engaging others socially usually predict other academic problems, particularly reading difficulties.
• Developmental receptive language disorder
  • Some people have trouble understanding certain sounds of speech or particular structures, such as longer sentences or combinations of words. They seem to lack the capacity to listen to different frequencies, or they become overwhelmed by too much information and the reception is poor. Examples include a toddler who does not respond to his name, a preschooler who hands you a bell when you asked for a ball, and a worker who consistently is unable to follow simple directions. Their hearing is fine, but they cannot make sense of certain sounds, words, or sentences. They may appear inattentive.
  • Because using and understanding speech are strongly related, many people with receptive language disorders also have an expressive language disability. In preschool-aged children, some misuse of sounds, words, or grammar is a normal part of learning to speak. When these problems persist, concern is warranted. Consistent problems in discriminating sounds or in segmenting words into sounds often are predictive of reading difficulty.

Academic skills disorders

Students with academic skills disorders are often years behind their classmates in developing reading, writing, or arithmetic skills. Diagnoses in this category include basic reading of words, reading comprehension, writing, arithmetic calculation problems, or arithmetic reasoning (problem solving) disorders.

• Developmental reading disorder
  • This disorder, formerly known as dyslexia, is the most widespread learning disability. Reading disabilities affect 8-15% of elementary school–aged children.
  • Reading is a remarkable process that links the highly developed visual perception system to the highly developed language system. The specific skills required include the following abilities:
    • Recognizing specific visual symbols as letters
    • Focusing and scanning across the page
    • Recognizing sounds associated with letters and making that connection (demonstrated by research to be the usual area of deficit in poor readers)
    • Understanding words and grammar (ie, language skills)
    • Building ideas and images
    • Comparing new ideas to what one already knows
    • Storing ideas in memory
  • Such mental juggling requires a rich intact network of nerve cells that connects the brain's centers of vision, language, and memory. The most recent research on individuals who have severe reading problems demonstrates that their brains process information quite differently from fluent readers. In some individuals, the central nervous system appears to be wired differently; as a result, they may have difficulty reading.
  • A person can have problems in any of the tasks involved in reading. Scientists report that a significant number of people with dyslexia share an inability to distinguish or separate the sounds in spoken words. For example, Dennis cannot identify the word bat by sounding out, by using phonics, the individual letters b-a-t. Other children with dyslexia may have trouble with rhyming games, such as rhyming cat with bat. Other children cannot recall seeing a specific word previously and have poor "word confrontation" memory recognition. Scientists indicate that these skills are fundamental to the process of learning to read. Remedial reading specialists developed techniques that can help many children with dyslexia to acquire these skills. To date, the most successful techniques are those that emphasize phoneme recognition (identification of sounds) and phonologic processing (combining sounds into words).
  • Reading involves more than simply recognizing words. If the brain is unable to form images or relate new ideas to those stored in memory, the reader cannot remember or integrate the new concepts and thus cannot use reading to further greater understanding and comprehension. Therefore, other types of reading disabilities can appear in older children in upper grades, when the focus of reading shifts from word identification to comprehension.
• Developmental writing disorder: Writing also involves several brain areas and functions. The brain networks for vocabulary, grammar, hand movement, and memory must be in good working order. A developmental writing disorder may result from problems in any of these areas. For example, Dennis, who was unable to distinguish the sequence of sounds in a word, had problems with spelling. A child with a writing disability, particularly when based on an expressive language disorder, may be unable to compose complete grammatically correct sentences. Many children with disorders of impulse control, such as attention-deficit/hyperactivity disorder (ADHD), have problems with printing and cursive writing. They also have problems in the sustained effort that is required to complete a written assignment.
• Developmental arithmetic disorder
  • Arithmetic is a complex process, and deficits in this area can include those of calculation or problem solving. If in doubt, consider the steps required to solve this simple problem: 25 divided by 3. Arithmetic involves recognizing numbers and symbols, memorizing facts (eg, multiplication table), aligning numbers, and understanding abstract concepts (eg, place value, fractions). Any of these tasks may be difficult for children with developmental arithmetic disorders. Problems with numbers or basic concepts are likely to appear early. Problems in mathematic reasoning or problem solving are somewhat different. This type of work can be disrupted if the child has difficulty with language skills required to understand the problem or if the child lacks the ability to understand how to apply the arithmetic needed to solve problems. Hindrance may also occur if memory deficits in the visual or auditory spheres create poor recall of previously learned concepts or skills.
  • Many aspects of speaking, listening, reading, writing, and arithmetic overlap and build on the same brain capabilities, particularly those of complex language. Language is used internally to help mentally talk through problems. Not surprisingly, people can have multiple learning disabilities. For example, the ability to understand language underlies learning to speak; therefore, any disorder that hinders the ability to understand language also interferes with the speech development. This, in turn, hinders learning to read and write. A single gap in brain operation can disrupt many types of cognitive activity.

Other learning disabilities

The DSM-IV lists other learning disability categories, including motor skills disorders and developmental disorders not otherwise specified. These categories include delays in acquiring language, academic, and motor skills that can affect the ability to learn but that do not meet the criteria for a specific learning disability. Also included are coordination disorders that can lead to poor penmanship, certain spelling and memory disorders, and attention disorders.

• Nearly 4 million school-aged children have some type of disability or difficulty in the process of learning. Of these, research indicates that at least 15% have a disorder that leaves them unable to focus (attention-deficit disorder with or without hyperactivity).
• Some children and adults with attention disorders appear to daydream excessively; once they begin to pay attention, they are often distracted easily. In a large proportion of children (mostly boys) affected, the attention deficit is accompanied by restlessness and hyperactivity. These children also act impulsively (eg, running into traffic, toppling desks), blurt out answers, and interrupt others. When playing games, they cannot wait for their turn. These children's problems usually are easy to detect and, because of their constant motion and explosive energy, hyperactive children often encounter disciplinary problems with their parents, teachers, and peers (see Attention-Deficit/Hyperactivity Disorder). Hyperactivity leading to difficulty in learning may have other etiologies. Careful assessment regarding cause is indicated.
• Physical hyperactivity, over time, may subside into fidgeting and restlessness. Most hyperactive children, but not all, decrease their level of activity in adolescence; however, the problems with attention and concentration may continue into adulthood. Adults with ADHD often have trouble organizing tasks or completing their work. They seem unable to listen to or follow directions. Their work may be messy and may appear careless. Approximately one third of adults with ADHD who demonstrated problems since childhood require medication.
• Attention disorders, with or without hyperactivity, are not considered specific learning disabilities. Because attention problems can seriously interfere with school performance, they often accompany academic skills disorders and resultant difficulties in learning.

Frequency

• Providing an exact number of cases is difficult; doing so implies that the reporting of children with nominal decreases in cognitive function is possible. From a statistical standpoint, clearly children in the lower 10% of the IQ range, for the most part, experience difficulty in school achievement. Thus, compared to peers of average-to-normal ability in all functioning, at least 10-15% of all children can be considered as having some cognitive deficits that raise concerns in parents or teachers.
• In 1988, Jones reported that the prevalence of severe-to-profound mental retardation is approximately 3-4 cases per 1000 population and the rate of mild retardation is approximately 25-30 cases per 1000 population. Learning disabilities and dyslexia are more common. Some estimates indicate that as many as 4 million school-aged children in the United States have some type of learning disability.

Diagnosis

In the clinical setting, diagnosis of a cognitive deficit depends on several factors. Parental concerns about lack of development or schoolteachers' reports on lack of achievement usually raise red flags. Clinicians can use various tools to assist in the diagnosis. For example, anthropometric data offer concrete measurements of a child's development. As a first step in raising awareness of potential cognitive deficits, developmental tools, such as the Denver Developmental Scale, may help to screen for children who are lower on the curve.

A multidisciplinary approach is of great value. Under current school guidelines issued by the US Department of Education, all children suspected of having a disability must be screened by the local public school. A parent request, in writing, is one effective way to start this process. Screening is usually performed by at least 2 staff members; if they concur that a problem may be present, then the school performs a multidisciplinary evaluation. This includes the pediatrician (or behavioral-developmental pediatrician), schoolteachers, education specialists, school psychologists, speech therapists, occupational therapists, and the school social workers. An alternative would be to have private evaluations; however, often these services are only partially covered, if at all, by health insurance.

The assimilation and integration of numerous pieces of data by all specialists in a conference setting offers the most specific and accurate diagnosis. While this can initially be time consuming, an accurate diagnosis and plan is necessary to develop appropriate intervention strategies.

The differential diagnosis is lengthy for children with cognitive deficits and includes the following:

• Metabolic derangements
• Adrenal disease
• Ingestions (eg, lead)
• Other phenomena that impair cognitive function: Seizure disorders, which may be subtle (eg, Kleffner-Landau syndrome) or even subictal and infectious causes (eg, chronic lyme disease) may also be implicated as causes for cognitive deficits in children (Tager, 2001).
• Physical causes, including visual and hearing defects that may impair cognitive development
• Genetic causes and congenital causes: Determining etiology depends a great deal on presentation. If the child has never met cognitive or developmental milestones, consider a congenital cause such as a perinatal infection or prenatal toxin. If a child develops an abrupt deviation in cognitive function, consider de novo medical, emotional, or social phenomena. Careful examination of the social environment of the child may yield clues that are related to psychosocial deprivation. This may also allow for a review of possible genetic causes by performing a genogram and obtaining a chromosome analysis. Neurofibromatosis type 1, for example, is associated strongly with cognitive deficits in children (Hyman, 2005).

Metabolic disease and toxins can be identified through laboratory evaluation, including the following:

• Thyroid function
• Lead levels
• Hemoglobin electrophoresis blood tests (to screen for hemoglobinopathies may be warranted because of associated cognitive deficits in persons born with HbSS) (Steen, 2005)
• Evaluation of adrenal function

An EEG may be included in cases with seizure disorders. Thorough visual and hearing evaluations are also very important. Some children, remarkably, are able to adapt with minimal hearing or visual function.

Measurement of cognitive function

The descriptions of number of screening tests, appropriate for pediatric office use are available at Developmental-Behavioral Pediatrics Online Community. For screening for children aged 3-72 months, the Child Development Inventories has 3 forms for children of different ages. The parent completes 60 yes-no questions; the inventory only takes 10 minutes even if the physician must go over the items with the parents, and less time is required if parents complete it independently. Forms are available from Behavior Science Systems, Minneapolis, MN (612) 929 6220.

Infants

• Bayley Scales of Infant Development II (BSID-II)
  • First designed in 1969 and adapted and modified since then, this is probably the most commonly used measure of infant development. It is divided into 3 assessment sections: the mental, motor, and behavior rating scales.
  • The scale has excellent validity and is based on 1988 US census data. It is extremely helpful as a predictor of future intellectual abilities in very young children with abilities below or significantly below intelligence norms.

Children

• Cognitive function is measured with several tools. They are selected according to the child's age and the aspects to be examined. The most commonly used overall measures of cognitive function in children include the following:
  • Stanford-Binet Intelligence Scale, 4th edition (SB:FE): First designed in 1905 and redesigned a number of times, the SB:FE is based on 1980 US census data. The SB:FE has both excellent validity and reliability.
  • Wechsler Intelligence Scale for Children, 3rd edition, 1990 (WISC-III): First published in 1939, the WISC-III is the most commonly used measure of verbal and performance intelligence in North America.
  • Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R): A lengthy test for preschool children (approximately 75 min), the WPPSI-R has good validity and is helpful as a tool for evaluating preschool-aged children. It is very sensitive to detecting problems in language.
• Other less commonly used measuring techniques include the following:
  • The Differential Abilities Scale, a test developed in the United Kingdom, has lengthy, untimed, problem-solving portions and several different test batteries, ranging from brief to lengthy, that can be administered. It provides a good measure for children who have language impairment and is also becoming commonly used to assess children with autism or other pervasive developmental disabilities. A general score including language can be produced, or a nonverbal composite score that assesses other types of problem-solving can be produced. The test is appropriate for children aged 2.5-18 years.
  • The Wide Range Intelligence Test is a 20-minute test with excellent validity and reliability, which correlate highly with both the WISC-III and Stanford-Binet. In a practice setting, this may be the preferred test to determine IQ in those aged 4-85 years.
  • The Columbia Mental Maturity Scale (CMMS) is appropriate for children aged 4-10 years.
  • The Detroit Tests of Learning Aptitude-P is appropriate for children aged 3-9 years.
  • The Goodenough-Harris Drawing test (Draw-a-man) is used for children aged 3-16 years.
  • The Kaufman Assessment Battery for Children (K-ABC) is appropriate for children aged 2.5-12.5 years.

Management

Poor cognitive functioning and the subsequent skills deficits that evolve require a multidisciplinary educationally based approach. Cooperation with schools and other agencies involved is essential. Obtaining signed releases of information and regularly scheduled (perhaps annually or more often if needed) routine conferences are most helpful. In the medical setting, the identification and management of concurrent illness, seizure disorders, or physical etiology of cognitive impairment are of paramount importance, allowing children to develop at their own pace. Children may find an easier path for cognitive development if obstacles are removed.

For mental retardation (see Mental Retardation and Mental Retardation), a combination of appropriate school placement with a high level of slowly paced appropriate material working toward specific goals, good behavioral management, and strategies at home is the most helpful intervention. Depending on the age of the child with mental retardation, parental concerns vary as their child falls farther behind age peers cognitively, academically, and socially. Parents' greatest concerns often arise in adolescence because these children do not achieve the same degree of independence as their peers.

Parents frequently have concerns about these issues. Guidance is often necessary for setting appropriate and attainable educational and vocational goals for these children. Helping parents access educational and social service resources is critical and can often be achieved within the school setting. Common behavioral problems, including oppositional behavior or social skills deficits, can be referred to a mental health professional skilled in working with these patients.

Children who have speech and language delays and other learning disabilities generally do not have a very optimistic prognosis from an educational standpoint (see specific types of learning disabilities Learning Disorder: Mathematics, Learning Disorder: Reading, Learning Disorder: Written Expression). A very high risk of dropping out of school exists, and these children have subsequent poor levels of independent employment and social functioning. Essential to their success is an educational plan that not only sets goals each year, but also meets these goals. By middle school, if the fully implemented and supportive academic approach clearly continues to be problematic, then serious consideration should be given to prevocational and vocational training in high school.

Delivering a diagnosis of childhood learning disability may be traumatic for the child and the parents. Images of profound dysfunction may be evoked; therefore, the professional must succinctly address fears and concerns. Numerous excellent resources are available, and parent groups and Internet sites may provide helpful information (see Resources).

Prognosis

Physicians have few options to directly affect most cases of cognitive dysfunction; however, proficient medical management of concomitant medical conditions may assist the individual to achieve optimal function. Judicious use of anticonvulsant therapy and careful management of these medications, for example, may have a positive effect on a child's cognitive skills. In addition, for children who have attention problems, appropriate diagnosis of children with attention-deficit disorder or ADHD and treatment with stimulants or other appropriate psychopharmaceutical medications may improve behavior and daily school performance. During the child's development from birth to late adolescence, the primary care physician is frequently the individual who has the long-term perspective because the child changes schools, teachers, and other professionals.

Referral to other trained professionals must occur as early as feasible to "child find" and to correctly diagnose cognitive handicaps and then begin appropriate remediation as quickly as feasible and appropriate. Counseling to help parents to recognize and accept their child's skills and deficits and guiding the parents to educators and mental health professionals who can help the child meet achievable goals are necessary and important roles for the physician.

Summary

Cognitive deficits in children may be considered a symptom of something larger, perhaps a physical deficit (eg, metabolic, neurologic, visual, hearing) or a psychosocial issue (eg, deprivation). A critical role for the physician is to rule out possible physical etiology and genetic factors. The clinician must refer to appropriate professionals in other disciplines for assistance in fully delineating the diagnosis and possible remediation. However, most cognitive deficit problems are idiopathic.

Clinicians have few options to directly improve cognitive function other than identification of potentially reversible or treatable causes of impairment. Careful attention to possible metabolic derangements and neurologic causes is important. However, the primary care provider plays a critically important role in guiding the parent to seek educational and therapeutic interventions to help the child achieve higher functioning levels in areas of cognitive functioning, adaptive behavior, and long-term independent life skills.

Resources

Support groups and organizations

American Speech-Language-Hearing Association: This organization provides information on speech and language disorders and referrals to certified speech-language therapists.
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, MD 20852
(800) 638-8255

Attention Deficit Information Network: This organization provides up-to-date information on current research and regional meetings. They also offer aid in finding solutions to practical problems faced by adults and children with an attention disorder.
Attention Deficit Information Network
475 Hillside Avenue
Needham, MA 02194
(781) 455-9895

Candlelighters Childhood Cancer Foundation: This organization provides information and support for children who are treated for cancer and later experience learning disabilities.
Candlelighters Childhood Cancer Foundation
7910 Woodmont Avenue, Suite 460
Bethesda, MD 20814
(800) 366-2223

Center for Mental Health Services Office of Consumer, Family, and Public Information: This new national center, a component of the US Public Health Service, provides a range of information on mental health, treatment, and support services.
Center for Mental Health Services Office of Consumer, Family, and Public Information
5600 Fishers Lane, Room 15-81
Rockville, MD 20857
(301) 443-2792

Children with Attention Deficit Disorders (CHADD): CHADD runs support groups and publishes 2 newsletters on attention disorders for parents and professionals.
Children with Attention Deficit Disorders (CHADD)
8181 Professional Place, Suite 201
Landover, MD 20785
(800) 233-4050

Council for Exceptional Children: This organization provides publications for educators. They can also provide referral to ERIC Clearinghouse for Handicapped and Gifted Children.
Council for Exceptional Children
11920 Association Drive
Reston, VA 22091
(888) 232-7733

Federation of Families for Children's Mental Health: This organization provides information, support, and referrals through federation chapters nationwide. This national parent-run organization focuses on the needs of children with broad mental health problems.
Federation of Families for Children's Mental Health
1021 Prince Street
Alexandria, VA 22314
(703) 684-7710

HEATH Resource Center: This is a national clearinghouse on post–high school education for people with disabilities.
HEATH Resource Center
American Council on Education
1 Dupont Circle, Suite 800
Washington, DC 20036
(800) 544-3284

Learning Disabilities Association of America: This organization provides information and referral to state chapters, parent resources, and local support groups. They also publish news briefs and a professional journal.
Learning Disabilities Association of America
4156 Library Road
Pittsburgh, PA 15234
(412) 341-1515

Library of Congress National Library Service for the Blind and Physically Handicapped: This organization publishes Talking Books and Reading Disabilities, a fact sheet outlining eligibility requirements for borrowing talking books.
Library of Congress National Library Service for the Blind and Physically Handicapped
1291 Taylor Street NW
Washington, DC 20542
(800) 424-8567

National Alliance for the Mentally Ill Children and Adolescents Network (NAMICAN): This organization provides support to families through personal contact and support meetings. They also provide education regarding coping strategies, reading material, and information about effective and ineffective practices.
National Alliance for the Mentally Ill Children and Adolescents Network
2101 Wilson Boulevard, Suite 302
Arlington, VA 22201
(800) 950-NAMI

National Association of Private Schools for Exceptional Children: This organization provides referrals to private special education programs.
National Association of Private Schools for Exceptional Children
1522 K Street NW, Suite 1032
Washington, DC 20005
(202) 408-3338

National Center for Learning Disabilities: This organization provides referrals and resources. It publishes Their World, a magazine describing true stories on ways children and adults cope with learning disabilities.
National Center for Learning Disabilities
381 Park Avenue South, Suite 1420
New York, NY 10016
(888) 575-7373

National Information Center for Children and Youth with Disabilities: This organization publishes a newsletter and arranges workshops. It also advises parents regarding the laws that entitle children with disabilities to special education and other services.
National Information Center for Children and Youth with Disabilities
PO Box 1492
Washington, DC 20013
(800) 695-0285

International Dyslexia Association: This organization answers individual questions on reading disability. They provide information and referrals to local resources.
International Dyslexia Association
Chester Building, Suite 382
8600 LaSalle Road
Baltimore, MD 21286-2044
(410) 296-0232

Other resources

Facts About Dyslexia
National Institute of Child Health and Human Development
Building 31, Room 2A32
9000 Rockville Pike
Bethesda, MD 20892
(800) 370-2943

Developmental Speech and Language Disorders—Hope through Research
National Institute on Deafness and Other Communicative Disorders
PO Box 37777
Washington, DC 20013
(800) 241-1044

References

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2. Hyman SL, Shores A, North KN. The nature and frequency of cognitive deficits in children with neurofibromatosis type 1. Neurology. Oct 11 2005;65(7):1037-44. [Medline].

3. Jones KL. Recognizable Patterns of Human Malformations. Philadelphia, Pa:. WB Saunders;1988.

4. Lyon GR, Cutting LE. Learning Disabilities. In: Mash E, Barkley RA, eds. Treatment of Childhood Disorders. 2nd ed. New York, NY:. Guilford Press;1998:468-500.

5. Sattler JM. Assessment of Children: Cognitive Applications. 4th ed. San Diego, Calif:. Jerome Sattler Publisher, Inc;2001.

6. Steen RG, Fineberg-Buchner C, Hankins G, et al. Cognitive deficits in children with sickle cell disease. J Child Neurol. Feb 2005;20(2):102-7. [Medline].

7. Tager FA, Fallon BA, Keilp J, et al. A controlled study of cognitive deficits in children with chronic Lyme disease. J Neuropsychiatry Clin Neurosci. 2001;13(4):500-7. [Medline].

8. Volmar F, Klin A, Cohen DJ. Diagnosis and classification of autism and related conditions: Consensus and issues. In: Cohen DJ, Volkmar FR, eds. Handbook of autism and pervasive developmental disorders. 2nd ed. New York, NY:. John Wiley & Sons;1997:5-40.

9. Wolraich ML, Schor D. Disorders of mental development. In: Wolraich M, ed. Disorders of Development and Learning: A Practical Guide to Assessment and Management. 2nd ed. St. Louis, Mo:. Mosby;1996.

Keywords

cognitive deficits, learning disability, learning disabilities, mental retardation, poor adaptive behavior skills, speech disorder, language disorder, speech and language disorders, cognitive function, adaptive function

Contributor Information and Disclosures

Author

W Douglas Tynan, PhD, Chief Psychologist, Nemours Health and Prevention Division Programs; Director, Primary Care Mental Health Program, A I duPont Hospital for Children; Consulting Psychologist, Nemours Clinical Management
W Douglas Tynan, PhD is a member of the following medical societies: American Academy of Pediatrics, American Psychological Association, Society for Developmental and Behavioral Pediatrics, and Society for Research In Child Development
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Earl, DO, Clinical Associate Professor, Department of Family and Community Medicine, University of Arizona College of Medicine, Chino Valley Medical Center
Daniel Earl, DO is a member of the following medical societies: American Academy of Family Physicians, American Osteopathic Association, and Society for Adolescent Medicine
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

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CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

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