DOWN’S SYNDROMEDefinition- 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. Neuropathologya) Brain weight is 76% of normal b) Micrrocephalyc) Brain is abnormally rounded and short with a

decreased anterior =-posterior diameter (mircorbrachycephaly)

d) Number of secondary sucli is decreasede) Paucity of small neuronsf) Migrational defect involving small neuronsg) Decresed synaptogenesis owing to altered

synaptoc morphologyh) Structural abnormalities in the dendritic spines in

the pyramidal tracts of the motor cortexi) Lack of myelinationj) 8% of children with down syndrome also have

some form of seizure diorder

2. Sensory Deficitsa) Visual and hearing deficitsb) Hearing speechc) Can have cataracts, farsightedness, strabismus,

and nystagmus

3. Musculoskeletal Differencesa) Lineaar growtth deficitsb) Decrease in normal velocity of growth in staturec) Led length reductiond) 10-30% reduction in metacarpal and pahalangeal

lengthe) Absent palmaris longus and supernumerary

forearm flexorsf) Lack of differentiation of distinct mm bellies for

the zygomaticus major and minor and the levatr labii superioris

g) Hypotonia and ligamentous laxityh) Hip subluxation is commoni) Deficiency in grip strength, isometric strength and

ankle strength

4. Cardiopulmonary pathologiesa) 40% are born with congenital heart defecrs, most

commonly atrioventricular canal defects and ventriculoseptal defects

5. Physical Characteristicsa) Brachycephalyb) Fontanesl are frequently larger than normal and

take longer to closec) Aeas of hair lossd) Skin is often dry and mottled in infancy and gets

rough when child gets oldere) Face has flat contourf) Underdeveloped facial bones and mm and a small

noseg) 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 spottyj) Abdomen may be slightly protuberantk) Chest may have an abnormal shapel) 90% have umbilical herniam) Hands and feet tend to be small and 5th finger is

curved inwardn) 50 % have a single crease across the aplm in one

or both hands

o) Toes are unusually shortp) 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

CardiacCongenital heart disease, most often VSD and AV canal Increased risk of mitral valve prolapse and aortic regurgitation

CNS

Cognitive impairment (mild to severe) Gross motor and language delay Autistic behavior Alzheimer's disease

GIDuodenal atresia or stenosis Hirschsprung's disease Celiac sprue

EndocrineHypothyroidism Diabetes

EENT

Ophthalmic disorders (eg, congenital cataracts, glaucoma, strabismus, refractive errors) Hearing loss Increased incidence of otitis media

GrowthShort stature Obesity

HematologicHematologic disorders (eg, neonatal polycythemia, 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.

DiagnosisA doctor can make an initial diagnosis at birth based on the looks of the baby. The baby may hear aheart murmur when listening to the baby‘s 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 Diagnosisa. 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 Down‘s 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 Alzheimer’s disease

PT Managementa. Objectives of careGeneral Goal: Anticipate gross and fine motor delay and provide interventions and weightBearing

b. Appropriate interventions and its rationale1. Utilize positioning and handling activities throughout early infancy and childhood –to promote anti-gravity control and weight bearing2. Facilitate anti-gravity extension in prone and weight shifting within and as transitionfrom prone.3. In supine and supported sitting, encourage midline orientation, anti-gravitybimanual activities including eye-hand coordination, and anterior neck and trunkanti-gravity activities – to promote anti-gravity muscle strength4. Emphasize trunk extension and extremity loading – to increase axial musclestrength5. Encourage emergence of righting and postural reactions through use of rotationwithin and during movement.6. Allow for dynamic rather than static exploration of movement.7. Introduce developmental milestones when chronologically appropriate, includingsupported sitting and standing, when trunk control and alignment are able to beestablished.8. Anticipate delay in postural control responses and provide functional opportunitiesto enhance development in areas of cognition, language, and socialization.9. Teach parents and other team members activities and position choices that willenhance the child‘s overall development.

c. Relevant health teaching(s) to patient & familySupport group that would help the individual with Down‘s syndrome be comfortable withhis/her life. Behavioral training can also help people with Down‘s 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 Down‘s 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 & Spackman’s

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 4th 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.

CLASSIFICATIONLEVELS OF RETARDATION (Merck Manuals)

LEVEL IQ RANGE

Ability at Preschool Age (Birth - 6 years)

Ability at School Age (6-20 years)

Ability at Adult Age (21 years and older)

Mild 52-68

Can develop social and communication 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 36-51

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

Can learn some skills and occupational skills; progression beyond 2nd-grade 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 20-35

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 self-care under complete supervision, can develop some useful self-protection skills in controlled environment

Profound 19 or below

Extremely retarded; little muscle coordination; may need nursing care

Some muscle coordination; unlikely to walk or talk

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 7035-40 to

50-5520-25 to

35-40<20-25

Preschool

Often appears

unimpaired; develops functional social and

communication skill

Impaired social skills;

can communicate; may need supervision

Severely impaired

communication;

impared motor skills

Requires full-support;

dependent for care; limited

sensorimotor development

School-aged

Academic skills of 6th

grade are possible; special

education support is needed for

Can develop up to 4th

grad academic skills with

special traiming/

modification

May learn to

communicate; basic personal health habits, limited

Some motor development contines to

be dependdent

for care;limited success with

trainin

secondary school

academic skills

AdultCan learn

social skills and

vocational skills

Unskilled or semiskilled

vocation

Needs complete support

and supervision for any self-

support activity

Limited motor ability

and communication; continued dependency

for care

ETIOLOGY- Most cases of mental retardation the cause is unknown-several conditions during a woman’s 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 MRETIOLOGY EXAMPLES

Prenatal Onset Examples1. Chromosomal Disorder Downturner or Klinefelter’s syndrome

2. Syndrome disorders Neurofibromatosis, myotonic muscular dystrophy. Prader-Willi, Tuberous sclerosis

3. Inborn errors of metabolism Phenylketonuria carbohydraate disorders, Lesch - Nyhan syndrome

4. Developmental disordeers of brain formation

Anencephaly, hydrocephalus, porencephaly, microcephaly

5. Environmental influences Intrauterine malnutrition, drugs, toxins, alcohol, narcotics, maternal dss

Perinatal Causes Examples6. Intrauterine disorders Placental insufficiency, maternal sepsis,

abnormal labor or delivery7. Neonatal disorders Intraventricular hemorrhage, maternal

sepsis, abnormal labor or deliveryPostnatal Causes Examples8. Head injuries Intracranial hemorrhage, contusion,

concussion9. Infections Encephalitis, meningitis, viral infections10. Demyelinating disorders Post-infections and post-immunization

disorders

11.Degenerative disorders Syndromic disorders, poliodystrophies, basal gangliadisorders, leukodystrophies

12.Seizure disorders Infantile spasms, myoclonic epilepsy13. Toxic-metabolic disorders Reye‘s syndrome, lead intoxication,

metabolic disorders14. Malnutrition Protein-calorie, prolonged IV

alimentation15.Environmental deprivation 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-birth-weight 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 form5%- severe or profound form

Down Syndrome - one fo the most prevalent form ( 1 in 800 to 1000 in live births

PATHOPHYSIOLOGY1. 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 Area of ConcernNewborn Dysmorphisms

major organ system dysfunction (feeding & breathing)

Early infancy (2-4mo) Failure to interact with the environmentConcerns about vision and hearing impairments

Later infancy (6-8mo) Gross motor delayToddlers (2-3yr) Language delays or difficultiesPreschool (3-5yr) Language difficulties or delays

Behavior difficulties, including playDelays in fine motor skills: cutting, coloring, drawing

School age (over 5yr) Academic underachievementBehavior difficulties

COMPLICATIONS (TECKLIN)1. Neuromotor Impairments

- 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 minor anomalies Family history of cognitive disability

Chromosome analysis Chromosomal microarray analysis 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 analyzer; TORCH = toxoplasmosis, rubella, cytomegalovirus, herpes.

Diagnosis of MR is based on the criteria embodied within the definition reflecting intellectual functioning level and adaptive skill level (TECKLIN)

Assessment of Intellectual FunctioningStandardized intelligence test

- administered by a psychologist-determine a child’s 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 Children-IV or Wechsler Preschool and Primary Scale of Intelligence II, and the Kaufman Assessment Battery for Children

Assessment of Adapive Skill levelImpairments 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

AutismBorderline intellectual functioningChild Abuse &amp; Neglect, Posttraumatic Stress DisorderChildhood Disintegrative DisorderCognitive DeficitsLearning Disorder, ReadingLearning Disorder, Written ExpressionMathematics Learning DisorderPediatric DepressionPervasive Developmental DisorderRett SyndromeSevere 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 child’s

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 rationaeAssess all children for all signs of developmental delays1. 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 weight-

bearing-

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 familyEncourage the prevention of mental retardation

ReferencesTecklin, 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. 140-142THE 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

EpidemiologyThe 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.

PathophysiologyLearning 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 matterProjections

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 self-esteem, 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 can‘t 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 non-working environments

Complicationsa. 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 andorganization 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. Theyinclude problems with: Neatness and consistency of writing Accurately copying letters and words Spelling consistency Writing organization and coherence

Table 304-3. Common Learning DisabilitiesDISABILITY MANIFESTATIONDyslexia Problems with readingPhonologic dyslexia

Problems with sound analysis and memory

Surface dyslexia

Problems with visual recognition of forms and structures of words

Dysgraphia Problems with spelling, written expression, or handwritingDyscalculia Problems with mathematics and difficulties with problem-solvingAgeometria Problems due to disturbances in mathematical reasoning

AnarithmiaDisturbances in basic concept formation and inability to acquire computational skills

DysnomiaDifficulty recalling words and information from memory on demand

PT Managementa. Objectives of care Improve the quality of life and ability through learning Improve functional abilities Improve health

b. Appropriate interventions and its rationaleExercises should address these three and should be meaningful and relevant for the

patient1. Cognitive – show them pictures of storytelling then make them recall thesequence of the pictures shown or remember parts of the story2. Perceptual speed – flash cards to an individual with a learning disability forhim/her to recognize things3. Psychomotor – imagery

c. Rationale of intervention1. 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 totest the individual‘s speed3. For the individual to sychronize one‘s action with one‘s imagination that thephysical 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 theirchild and they should be show him/her love and care.

ReferencesKeltner, N. L., Schwecke, L.H., & Bostrom, C.E. (2007). Psychiatric nursing, 5th edition, p. 637. Singapore: Mosby ElsevierBehram, Kliegman, Jenson , Nelson Textbook of Pediatrics, 17th ed, pp. 100-106Rose, Nicholas D., Essential Psychiatry¸2nd ed, 168, 170-181.Tecklin Jan, Pediatric Physical therapy 4th ed pp. 367-381Molnar, Grabriella, Pediatric rehabilitation 3rd ed p. 61Rennie J. Learning Diability, Physical therapy,, Treatment and Management, 2nd ed. THE MERCK MANUAL OF DIAGNOSIS AND THERAPY - 19th Ed. (2011)