LEARNING DISABILITIES, HABIT DISORDER, SPEECH DISORDER.pptx

learning disabilities, habit and speech disorder- by Colleen Karaila

1. LEARNING DISABILITIES, HABIT DISORDER, SPEECH DISORDER.

2. LEARNING DISABILITIES DEFINITION: According to DSM-IV : Learning disabilities are diagnosed when the individuals achievement on individually administered , standardized test in reading, mathematics or written expression is substantially below the expected age, schooling and level of intelligence. The learning problems significantly interfere with academia achievement or activities of daily living. According ICD-10, 1999: Learning disabilities refer to a significant deficit in learning due to person’s inability to interpret what is seen and heard or to link information from different parts of the brain.

3. EPIDEMIOLOGY: Global Incidence Dyslexia: Affects about 5-10% of the global population. It is the most common learning disability. Dyscalculia: Affects approximately 3-6% of the global population. Dysgraphia: The prevalence is less clear but is estimated to affect about 5-20% of school-aged children, often overlapping with other learning disabilities.

4. Contd… Incidence in India A study conducted in various parts of India indicates that the prevalence of learning disabilities among school-aged children ranges from 5-15%. Specific learning disabilities like dyslexia are reported to affect about 10-12% of school-aged children in India.

5. Contd… Diagnosis and Reporting: In high-income countries, the identification and diagnosis rates are higher due to better awareness, screening programs, and access to educational and healthcare services. In low and middle-income countries, the prevalence rates might appear lower due to underdiagnosis, lack of awareness, and limited resources for screening and intervention.

6. TYPES:

7. DYSLEXIA: Dyslexia (also known as reading disability) a specific learning disability that affects reading and related language-based processing skills is the most common learning disability accounting for at least 80 per cent of all LDs The word “dyslexia” is of Greek origin, meaning “impaired”. Lyon et.al defined dyslexia as a SLD that is neurobiological in origin and characterized by difficulties with inaccurate word recognition and poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language”

8. Dyslexia symptoms in preschoolers Delayed speech, problems with pronunciation. Problems with rhyming words and learning rhymes. Difficulty with learning shapes, colors and how to write their own name. Difficulty with retelling a story in the right order of events. Lack of interest in playing games with language sounds (e.g., repetition, rhyming) Failure to recognize letters in their own name Trouble remembering names of letters, numbers, or days of the week.

9. Symptoms of dyslexia in school going kids Reading well below the expected level for age Problems remembering the sequences Difficulty in seeing similarities and differences in letters and words Difficulty in spelling words Receives reports of “not doing well in school” Unable to read one-syllable words, such as “mat” or “top” Problems in connecting sounds and letters (e.g., “big” for “got”) Difficulty in sequencing numbers and letters.

10. Assessment tools The reading subtests useful are • Woodcock-Johnson Psycho-Educational Battery- Revised, and • The Peabody Individual Achievement Test-Revised • Test of Word Reading Efficiency (TOWRE)

11. DYSGRAPHIA Dysgraphia is a specific learning disability diagnosed in childhood that affects a person’s handwriting ability and fine motor skills. It is characterized by poor writing skills that are significantly below for the child’s age, intelligence, and education, and cause problems with the child’s academic success or other important areas of life. Dysgraphia is also sometimes referred as spelling disorder and spelling dyslexia. Problems may include illegible handwriting, inconsistent spacing, and poor spatial.

12. Dysgraphia symptoms in children Avoiding written work Producing only a few words or sentences at a time when other pupils are completing many paragraphs Excessive difficulties in composing a text (output failure) Numerous technical faults of punctuation, grammar, word usage, sentence structure, and paragraph structure is observed Omitting words frequently in sentences or unfinished sentences Failure to capitalize the first letter of the first word in a sentence

13. Poorly organized written work (e.g., weak paragraph organization; poor sentence cohesiveness) Illegible handwriting; incorrect use of upper- and lower-case letters, inverted characters; mixing of printing and cursive writing Basic written activities, such as taking notes, are challenging as they require simultaneous listening. Letters or sounds that are too similar are confused (e.g., “ jumpt ” for “jumped”; “ caterpault ” for “catapult”) Inability to choose the correct spelling from two reasonable options (e.g., successful/ succesfull ; conscious/ consious ; necessary/ necessery ) Use of non-permissible letter strings consistently (e.g., “ egszakt ” for “exact”; discuss/ diskus ; “ freeeqwnt ” for “frequent”)

14. Inconsistent page positioning in terms of lines and margins Uneven spacing between words and letters Cramped or odd grip; holds the writing instrument very near to the paper, or holds thumb over two fingers and writes from the wrist .

15. Standardized tests for assessing written expression Wechsler Individual Achievement test (WIAT-II). Test of Written Language (TOWL; 3rd edition). Test of Early Written Language (TEWL; 2nd edition). Test of Written Spelling (TOWS; 4th edition). Test of Written Expression (TOWE).

16. DYSCALCULIA It refers to a type of specific learning disability that affects a person’s ability to understand numbers and learn math facts and difficulty in learning arithmetic. Individuals with this type of LD may also have poor comprehension of math symbols, may struggle with memorizing and organizing numbers, have difficulty telling time, or have trouble with counting. Various psychological, neurological, genetic, environmental and emotional factors are responsible for dyscalculia. Inferior parietal sulcus plays a dominant role MRI studies have shown decreased gray matter in the left parietal lobe of children suffering from Dyscalculia.

17. Dyscalculia symptoms A child with inadequate arithmetic skills may just rely on rote memorization for the first 2 or 3 years of primary school. As mathematics problems include discrimination and manipulation of spatial and numerical relationships, a youngster with math challenges will be impacted negatively sooner or later.

18. Individuals might have difficulty reading clocks to tell time, counting money, identifying patterns, remembering math facts, and solving mental math. Counts with fingers because of difficulty with counting Problems with differentiating between left and right No alignment of digits and completing the arithmetic procedure in the wrong direction (e.g., left to right; top to bottom). Poor comprehension of fractional concepts (1/2) In older children (i.e., third grade and above), major impairments are evident in solving more complex arithmetic problems. And rapid retrieval of number facts (e.g., 4 × 9) and Difficulty keeping scores or remembering score procedures in games, like bowling, etc. Often loses track of whose turn it is during games, like cards and board games. Has limited strategic planning ability for games, like chess.

19. Assessment tools The Key math Diagnostic Arithmetic Test assesses understanding of mathematical content, function, and calculation, among other things. It is used to assess students in grades one through six. Woodcock–Johnson Achievement Battery-III Test of Early Mathematical Abilities Teacher Academic Attainment Scale (TAAS) Child self- reported math anxiety scales. [11 items] Mathematics Anxiety Scale for Children

20. AUDITORY PROCESSING DISORDER (APD) APD is a deficit in neural processing of auditory stimuli that is not a problem with understanding meaning but it means the brain of the affected child does not “hear” sounds in the usual way. It’s also known as Central Auditory Processing Disorder, and it’s a disorder that makes it difficult for sound to pass freely through the ear and be processed or interpreted by the brain. Even when the sounds are loud and clear enough to be heard, people with APD are unable to distinguish minor variations between sounds in words. They may be unable to filter distinct noises or mistake the order of sounds. In APD, the brain misinterprets the information received and processed from the ear.

21. Symptoms The child may find it hard to, Understand speech in the presence of competing background noise or in resonating acoustic environments Inability to localize the source of a signal Issues with hearing on the phone Inconsistent or inappropriate responses to requests for information Difficulty following rapid speech

22. Frequent requests for repetition and/or rephrasing of information Unable to follow directions Difficulty or inability to detect the humor and sarcasm made by subtle changes in intonation. Difficulty learning a foreign language or novel speech materials, especially technical language Difficulty maintaining attention.

23. Causes Although the actual causes of APD are unknown, it is thought to be associated to illness like chronic ear infections, meningitis, or lead poisoning. APD can develop in patients who have neurological system illnesses such multiple sclerosis and also be caused by premature delivery, low weight, head injury, and genes (APD can run in families).

24. Assessment An audiologist can diagnose APD by conducting a series of advanced listening tests in which the child will listen to different sounds and respond when they hear them. However, children usually aren’t tested for APD until age 7 because their responses to the listening test may not be accurate when they are younger .

25. NONVERBAL LEARNING DISABILITIES (NLD OR NVLD) Almost 65% of all communication is conveyed nonverbally. NLD is a disorder which is usually characterized by a significant discrepancy between higher verbal skills, weaker motor, visual–spatial and social skills. While it may sound like nonverbal learning disabilities (NVLD) relate to an individual’s inability to speak, it actually refers to difficulties in decoding nonverbal behaviors or social cues. Children with NVLD are often well-spoken and can write well, but struggle with subtle social cues and comprehension of abstract concepts or the nonverbal aspects of communication.

26. SIGN AND SYMPTOMS The typical characteristic of an individual with NLD (or NVLD) is having trouble interpreting nonverbal cues like facial expressions or body language, tone of voice and poor coordination. Hence they will have difficulty to make and keep friends Struggle with life skills that require an understanding of spatial relationships, such as recognizing how parts fit together into a whole, completing jigsaw puzzles and building with blocks, learning routes for travel, and manipulating objects in space. Difficulty in developing fine-motor skills those results in poor handwriting, difficulty learning to tie their shoelaces, and problems using small tools and utensils.

27. Are weak in executive functions or will find hard to sustain attention. They may have trouble handling new tasks, solving problems and remaining flexible in their thinking. They may also have difficulty staying focused, completing multistep instructions, organizing tasks and materials and controlling their impulses. •Exhibit difficulty with reading comprehension or mathematical problem solving •Physically clumsy, often bumps into objects or people •Struggles with metaphors or abstract concepts and thinks of things in literal terms

28. VISUAL PERCEPTUAL OR VISUAL MOTOR DEFICIT It impairs a person’s ability to grasp information that they see, as well as their ability to draw or copy and understand information collected by visual means. Visual discrimination : An individual with issues in this area may have difficulty distinguishing between two similar letters, objects, or patterns. Visual figure-ground discrimination: A person who struggles in this category may have trouble finding a specific piece of information on a page full of words or numbers. They may also struggle to notice an image if there is distracting background.

29. Visual sequencing: Individuals with problems in this category may be unable to stay in the correct spot while reading (skipping lines or re-reading the same line over and over), struggle with using a separate answer sheet, reversing or misreading letters and words, and have difficulty understanding mathematical equations. Visual motor processing : Individuals may struggle to stay between the lines while writing (or coloring ), copying from a board onto paper, moving about without tripping over things, and playing sports that involve timed and exact space motions. Visual memory: A person may have trouble remembering and spelling common words, remembering phone numbers, reading comprehension, and typing on a keyboard or pad.

30. Visual closure: Refers to the ability to determine what an object is while only a portion of it is visible. An individual may have difficulty recognizing an object in a picture that is not presented in its entirety (for example, portraying an elephant without a trunk), identifying a word with a letter missing, and recognizing a face with only one feature missing (such as the ears). Spatial relationships : It refers to the skill to identify an object in space and relate it to oneself. According to National Center for Learning Disabilities, 2003, an individual child with this difficulty will have trouble going from one place to another, spacing of words and letters on a page, judging time, and reading maps.

31. Signs and symptoms of visual perceptual motor deficit Difficulty with activities such as printing or copying, or learning to tie shoelaces. Find hard to write, may put more pressure on a pencil or pen to control the motor movements, and may take much longer to write and experience fatigue with writing. Have trouble orienting their body in space and may need more help to learn dressing or may confuse left and right. Reversing superficially similar letters such as ‘p’ and ‘q’ or ‘m’ and ‘w’ Difficulty navigating around school or campus

32. Turns head while reading or hold paper at odd angles and closes one eye while reading Often loses place while reading Unable to recognize a word if only part of it is shown Struggles with cut and paste Shows poor organization on the page, messy words, irregular spacing, and misaligned letters

33. PATHOPHYSIOLOGY Differences in the structure and function of certain brain areas are associated with learning disabilities. For instance: Dyslexia: Abnormalities in the left hemisphere, particularly in areas associated with language processing (such as the left temporal-parietal region). Dyscalculia: Differences in the parietal lobe, which is involved in numerical processing. ADHD: Dysfunctional activity in the prefrontal cortex, which affects attention and executive function.

34. Contd… Neurotransmitters: Imbalances in neurotransmitters such as dopamine, norepinephrine, and glutamate can affect learning and attention processes. Cognitive Processes: Deficits in working memory, processing speed, auditory and visual processing, and executive functions contribute to learning disabilities.

35. TREATMENT 1.Dyslexia: Orton-Gillingham Approach: A multisensory, phonics-based technique for teaching reading and spelling. Reading Programs: Structured literacy programs like Wilson Reading System or Barton Reading and Spelling System. Assistive Technology: Text-to-speech software and audiobooks.

36. Dyscalculia: Multisensory Math Instruction: Using visual aids, manipulatives, and practical examples. Specialized Math Programs: Programs like Math-U-See or TouchMath . Accommodations: Extra time for math tests, use of calculators, and math software.

37. 3.Dysgraphia: Occupational Therapy: Improving fine motor skills and handwriting. Assistive Technology: Typing programs and speech-to-text software. Writing Programs: Structured writing instruction like Handwriting Without Tears. Auditory Training Programs: Programs like Fast ForWord or Earobics . Classroom Accommodations: Preferential seating, use of visual aids, and repeating instructions. Speech and Language Therapy: Improving listening skills and auditory memory.

38. 4. Visual Processing Disorder: Vision Therapy: Exercises to improve visual skills. Classroom Accommodations: Use of large print materials, color-coded information, and graphic organizers. Occupational Therapy: To address visual-motor integration.

39. 5.Nonverbal Learning Disorder (NLD): Social Skills Training: Teaching appropriate social interactions and understanding nonverbal cues. Occupational Therapy: Improving motor coordination and spatial awareness. Academic Support: Focused help with math and reading comprehension.

40. COMPLICATIONS Academic Complications Poor Academic Performance Repeated Grades Inadequate Skill Development Social and Emotional Complications Low Self-Esteem Social Isolation Behavioral Issues Mental Health Issues

41. Long-Term Complications Limited Educational Attainment Employment Challenges Lower Income Dependence: Greater likelihood of relying on family or social services for support. Other Complications Executive Function Deficits: Problems with planning, organization, time management, and problem-solving. Adaptive Functioning: Difficulty with everyday tasks and independence, impacting daily living skills. Physical Health Issues: Stress and anxiety can contribute to physical health problems, such as headaches, stomach aches, and fatigue.

42. Impact on Family Parental Stress Siblings may feel neglected or take on more responsibilities, leading to resentment or behavioral issues. Financial Strain: Costs associated with tutoring, therapy, and specialized programs can strain family finances. Social Perception Stigmatization: Negative perceptions and stigma associated with learning disabilities can lead to discrimination and exclusion. Bullying.

43. PROGNOSIS DEPENDS on: 1.Early Identification and Intervention 2.Individualized Education and Support 3.Family and Social Support 4.Access to Resources 5. Developing self-advocacy skills and effective coping mechanisms enables individuals to manage challenges more independently and confidently.

44. Common outcomes with adequate support: 1.Academic Achievement 2.Employment 3.Social and Emotional Well-being 4.Independence

45. NURSING MANAGEMENT Dyslexia Assessment: Monitor reading, writing, and spelling abilities. Assess for signs of frustration or low self-esteem. Interventions: Educational Support: Collaborate with educators to implement reading programs that use multisensory approaches (e.g., Orton-Gillingham). Assistive Technology: Recommend and help integrate tools such as audiobooks and text-to-speech software. Parental Support: Educate parents about dyslexia and encourage reading activities at home.

46. Dyscalculia Assessment: Evaluate math skills, number sense, and ability to perform calculations. Observe for signs of anxiety related to math tasks. Interventions: Math Instruction: Advocate for specialized math instruction using visual aids and manipulatives. Accommodations: Suggest extra time for math tests and the use of calculators. Parental Guidance: Provide strategies for parents to support math learning at home.

47. Dysgraphia Assessment: Assess handwriting, spelling, and ability to organize thoughts in writing. Check for fine motor skill difficulties. Interventions: Occupational Therapy: Refer to occupational therapy to improve fine motor skills and handwriting. Assistive Technology: Promote the use of typing programs and speech-to-text software. Classroom Accommodations: Advocate for modified assignments and alternative assessment methods.

48. Auditory Processing Disorder (APD) Assessment: Evaluate listening skills, ability to follow verbal instructions, and auditory memory. Identify environmental factors that may affect hearing. Interventions: Environmental Modifications: Recommend seating arrangements that reduce background noise and enhance the child’s ability to hear the teacher. Auditory Training: Support programs that improve auditory processing skills. Communication Strategies: Teach parents and teachers to use clear, concise instructions and visual aids.

49. Visual Processing Disorder Assessment: Assess visual perception, reading skills, and spatial awareness. Identify difficulties in interpreting visual information. Interventions: Vision Therapy: Refer to specialists for vision therapy if needed. Classroom Modifications: Recommend large print materials, color-coded information, and graphic organizers. Assistive Devices: Promote the use of tools like magnifiers or computer software designed for visual processing issues.

50. Nonverbal Learning Disorder (NLD) Assessment: Evaluate social skills, motor coordination, and visual-spatial abilities. Observe for signs of anxiety or social isolation. Interventions: Social Skills Training: Support programs that teach appropriate social interactions and nonverbal communication. Occupational Therapy: Refer to occupational therapy to improve motor coordination and spatial skills. Academic Support: Advocate for individualized instruction in subjects that present challenges, such as math.

51. HABIT DISORDERS DEFINITION: Habit disorder is a nonfunctional, Repetitive behavior present for at least 4 weeks that interfere with child’s normal activities or cause physical harm to the child on the basis of history and observation. Habit disorder also known as stereotypic movement disorder, it is a childhood onset neurodevelopment disorder that cause various types of non productive movement disorder

52. CAUSES AND RISK FACTORS Underlying causes for the development of habit disorders are not well understood. However, as with many psychological disorders, the evidence suggests that numerous factors, such as genetic vulnerability, learning and environment, may contribute to the development and maintenance of these disorders.

53. COMMON HABIT DISORDERS

54. THUMB SUCKING It is non nutritive thumb sucking behaviour. Repeated forceful sucking of the thumb associated with strong buccal and lip contraction. If thumb sucking continues about five years or above it indicates emotional problems. Majority of the children give up thumb sucking by the age of 2 years.

55. Causes Thumb sucking provides comfort and security, helping children to calm down, fall asleep, or deal with stress. Children may suck their thumbs when they are bored or need stimulation. Hunger Children may turn to thumb sucking as a coping mechanism during times of stress, such as changes in the family environment, starting school, or the arrival of a new sibling.

56. Contd… Habit Developmental Delays Oral Fixation If a child observes peers or siblings sucking their thumbs and receives positive reinforcement for the behavior , they might be more likely to continue the habit.

57. MANAGEMENT Positive Reinforcement : Reward System: and Offer praise and encouragement when the child refrains from thumb sucking. Distraction and Substitution : Engage in Activities, Comfort Items Behavioral Techniques : Use gentle reminders to help the child become aware of when they are sucking their thumb. Consider using a thumb guard or bandage to discourage thumb sucking, especially at night.

58. Contd… Address Underlying Causes : Stress Reduction : Identify and address sources of stress or anxiety in the child’s life. Create a calm and supportive environment. Seek help from a child psychologist or counselor if the thumb sucking is related to emotional or psychological issues. Habit Reversal Training : Teach the child to replace thumb sucking with another behavior , such as squeezing a stress ball or clenching their fist. Dental Interventions : In cases where thumb sucking has led to dental issues, consult a pediatric dentist. They may recommend dental ppliances to discourage the habit.

59. Contd… Consistency and Patience : Be consistent in applying the chosen strategies and ensure all caregivers are on the same page. Understand that breaking the habit takes time. Be patient and supportive throughout the process. Education and Understanding : Educate the Child Empowerment

60. ADVERSE EFFECTS Dental and Oral Health Issues Malocclusion Palatal Changes Teeth Misalignment Skin Problems Speech and Feeding Issues Speech Impediments Difficulty with Feeding Social and Psychological Issues Social Stigma Dependency Additional Health Concerns Infection Risk Speech Development

61. NAIL BITTING Nail biting, known medically as onychophagia, is a common behavioral disorder that affects many individuals, particularly children and adolescents. It is usually an onset of anxiety in older children. Nail cutting can occur with tension.

62. Incidence Children and Adolescents: Nail biting is particularly prevalent among children and adolescents. Studies suggest that approximately 20-30% of children aged 7-10 years and 45% of teenagers engage in nail biting. Adults: While less common in adults, nail biting can persist into adulthood, with estimates suggesting that about 20-30% of adults bite their nails. The behavior typically peaks during adolescence, a period often associated with increased stress and anxiety. Some studies suggest that nail biting is slightly more common in boys than in girls, particularly during adolescence.

63. Etiology Out of curiousity Stress Successor of thumb sucking Feeling of insecurity

64. Management Give suggestions to the parents to decrease stress and tension. Do not scold or punish the child. Give positive reinforcement to stop biting the nails. Do not restrain the child. If the child chooses mitten or gloves, wearing at night may act as a reminder. Toe nails can be enclosed by pyjamas with attached feet.

65. Management Use bitter substance like nail polish applied on the nail as a deterrent only if the child agrees. School age girls can be helped to develop interest in proper manicuring. Keep the child hand s and toes softened with lotion or warm oil, may decrease nail picking because dryness add to the desire to pull and cut the cuticles. Teachers and nurse should encourage the child to carry nail file so that jagged nails can be cut off. Parents should take care of child’s hand cleanliness.

66. ADVERSE EFFECTS Dental Issues : Tooth Damage Malocclusion Nail and Finger Damage : Infections Nail Deformities Bleeding and Soreness

67. Oral Health Problems : Gum Injuries : Biting nails can cause damage to the gums, potentially leading to gum infections or injuries. Temporomandibular Joint (TMJ) Disorders : Excessive nail biting can strain the jaw muscles and joints, leading to TMJ disorders and associated pain. Digestive Issues :Bits of nail and skin swallowed during nail biting can cause gastrointestinal issues and expose the digestive system to harmful pathogens.

68. TICS Tics are sudden, repetitive, non-rhythmic movements or sounds that individuals make, often without realizing it. Onset: 2-15 years

69. Types of tics 1. Motor Tics: Simple Motor Tics : Involve a single muscle group, such as blinking, grimacing, shoulder shrugging, or head jerking. Complex Motor Tics : Involve multiple muscle groups and more coordinated movements, such as touching objects, hopping, or making obscene gestures (copropraxia). 2. Vocal (Phonic) Tics : Simple Vocal Tics : Involve simple sounds, such as throat clearing, grunting, sniffing, or coughing. Complex Vocal Tics : Involve more complex sounds or phrases, such as repeating words or phrases, using inappropriate language (coprolalia), or echoing others’ speech (echolalia).

70. Common Tic Disorders Transient Tic Disorder : Characterized by tics that last for less than a year. Common in children and often resolves without treatment. Chronic Tic Disorder : Involves motor or vocal tics (but not both) that persist for more than a year. Tics may come and go but are present for more than a year. Tourette Syndrome : A more severe tic disorder involving both motor and vocal tics. Tics must be present for more than a year, and onset is typically before age 18. Often associated with other conditions such as ADHD, OCD, and anxiety disorders.

71. Causes and Risk Factors Tics tend to run in families, indicating a genetic component. Imbalances in neurotransmitters like dopamine and serotonin may contribute to tic disorders. Stress, fatigue, illness, and certain medications can exacerbate tics. Structural and functional abnormalities in specific brain regions may be involved.

72. Management and Treatment Behavioral Interventions : Involves increasing awareness of tics and developing competing responses to reduce tic behavior . Combines HRT with relaxation techniques and strategies to manage tic triggers. Medications : Antipsychotics : Medications like risperidone and aripiprazole can help reduce tics. Alpha-2 Adrenergic Agonists : Medications like clonidine and guanfacine are sometimes used, especially if ADHD is also present. Other Medications : SSRIs may be prescribed if the individual has co-occurring anxiety or OCD.

73. Education and Support : Educating the individual and their family about tics and how to manage them. Support Groups : Joining support groups can provide emotional support and practical advice. Lifestyle Modifications : Stress Management : Techniques such as mindfulness, meditation, and exercise can help reduce stress-related tics. Adequate Sleep : Ensuring sufficient rest can help minimize tics. School and Work Accommodations : Individualized Education Plans (IEPs) : For children with tic disorders, IEPs can provide accommodations to support their learning. Workplace Adjustments : Adults with tic disorders may benefit from flexible work environments and supportive colleagues.

74. Adverse effects Physical Health Effects Muscle Pain and Fatigue Injury Dental and Oral Issues Skin Damage Psychological and Emotional Effects Anxiety and Stress Depression Obsessive-Compulsive Behaviors Social and Interpersonal Effects Social Stigma and Bullying Social Isolation Impact on Family Dynamics Interference with Learning :

75. ENURESIS The term "enuresis" is derived from the Greek word " enourein ," which means "to urinate in." The prefix " en -" means "in," and " ourein " means "to urinate." The term has been used in medical literature to describe involuntary urination, particularly bedwetting, that is inappropriate for the individual’s age. Definition: According to DSM-V, Enuresis is the repeated voiding of urine into bed or clothes, whether involuntary or intentional. It is a condition observed in individuals who have reached an age at which continence is expected.

76. EPIDEMIOLOGY More common in boys than in girls with an incidence rate of 2:1 Prevalence decreases with age: 15-20% in aged 5 years; 10% in 7 years; 5 % inn 10 years; 2-3 % in 12-14 years.

77. CLASSIFICATION Primary Enuresis : Definition : The child has never achieved consistent nighttime dryness. Common Age : Common in young children and typically resolves with age. Secondary Enuresis : Definition : The child or adult begins wetting the bed after having achieved at least six months of dryness. Possible Causes : Often linked to stress, infections, or other medical conditions.

78. Contd… Nocturnal Enuresis : Definition : Bedwetting that occurs during sleep. Prevalence : The most common form of enuresis. Diurnal Enuresis : Definition : Involuntary urination during waking hours. Prevalence : Less common and often associated with urinary tract issues or psychological factors.

79. Causes and Risk Factors Genetics : Family history of enuresis increases the likelihood of a child experiencing it. Bladder Issues : Bladder Size : Small bladder capacity may lead to enuresis. Bladder Dysfunction : Poor bladder control can result in involuntary urination. Hormonal Factors : Antidiuretic Hormone (ADH) : Low levels of ADH, which reduces urine production at night, can contribute to bedwetting.

80. Contd… Sleep Patterns : Deep Sleep : Children who are deep sleepers may not wake up when their bladder is full. Sleep Disorders : Conditions like sleep apnea can be linked to enuresis. Medical Conditions : Urinary Tract Infections (UTIs) : Can cause both nocturnal and diurnal enuresis. Diabetes : Excessive urine production due to high blood sugar levels. Neurological Disorders : Affect bladder control. Psychological Factors : Stress and Anxiety : Major life changes, family issues, or trauma can trigger secondary enuresis. Attention-Deficit/Hyperactivity Disorder (ADHD) : Higher incidence of enuresis in children with ADHD.

81. DIAGNOSIS Detail interview of child with parents. Complete physical examination and investigation X-ray of lumbo-sacral spine. Intravenous urogram Urine analysis and culture. Voiding chart. Others: KUB, MCUG, Uroflowmetry.

82. DIAGNOSTIC CRITERIA ACCORDING TO DSM-V: Frequency and Duration : Age Requirement : Chronological age is at least 5 years (or the equivalent developmental level). Exclusion of Medical Conditions

83. Management Behavioral Interventions : Bladder Training : Encouraging the child to hold urine for longer periods to increase bladder capacity. Scheduled Voiding : Regular bathroom breaks, particularly before bedtime. Positive Reinforcement : Rewarding dry nights to encourage behavior change. Lifestyle and Home Remedies : Fluid Management : Reducing fluid intake in the evening, especially caffeinated or sugary drinks. Bathroom Routine : Encouraging the child to urinate before going to bed. Enuresis Alarms : Devices that detect moisture and wake the child to use the bathroom.

84. Medical Treatment : Anticholinergic Drugs : Desmopressin spray ( Synthetic ADH to reduce nighttime urine production), Oxybutynin. Imipramine HCL . 25-75 mg at bedtime for 6 weeks Amitrytylline and nitroxazepine HCl also give good response . Addressing Underlying Conditions : Treating any infections, diabetes, or other medical issues contributing to enuresis.

85. Psychological Support : Counseling : For stress, anxiety, or other psychological factors. Family Therapy : To address family dynamics or stressors impacting the child. Environmental Adjustments : Protective Bedding : Using waterproof mattress covers and absorbent underwear. Easy Access to Bathroom : Ensuring the child can easily reach the bathroom at night.

86. NURSING CONSIDERATIONS Have child void in a measuring cup after after holding urine for a s long as possible. Normal bladder capacity ion a child is child’s age + 2. Educate parents on bladder training, schedule voiding, positive reinforcement. Counselling for stress anxiety or other psychological factors. Environmental adjustments.

87. ENCOPRESIS Definition: According to DSM-V & ICD-10, Encopresis is defined as both voluntary and involuntary passage of faeces in inappropriate places in a child aged four years or older after organic cause has been ruled out. Epidemiology: It is more common in boys than in girls, with boys being affected approximately 3-6 times more frequently. Prevalence is 4-6 years: 1-3% ; 7-10 years: 1-2% and adolescents <1 %

88. CLASSIFICATION Primary (continuous): child has never completed toilet training for stool. Secondary ( discontinuous): toilet trained child regresses to incontinence Retentive Encopresis : Associated with chronic constipation and stool retention. The child holds in stool, leading to hard, dry stool that is difficult to pass. Overflow incontinence occurs when liquid stool leaks around the retained stool. 4.Non-retentive Encopresis : Not associated with constipation often manifestation of emotional disturbance. The child soils without evidence of underlying constipation or stool retention.

89. Diagnostic Criteria (DSM-5) According to the DSM-5, the diagnostic criteria for encopresis are: Repeated Passage of Feces : Inappropriate places such as clothing or on the floor, whether involuntary or intentional. Frequency and Duration : At least one such event occurs each month for at least three months. Age Requirement : Chronological age of at least four years (or equivalent developmental level). 4. Exclusion of Medical Conditions The behavior is not due exclusively to the direct physiological effect of a substance (e.g., laxatives)

90. Causes and Risk Factors Chronic Constipation : Painful Bowel Movements : Pain associated with defecation can lead to withholding behavior , exacerbating constipation. Stool Retention : Prolonged retention leads to the accumulation of large, hard stools, causing rectal stretching and reducing sensitivity to the urge to defecate. Dietary Factors : Low fiber intake and insufficient fluid consumption can contribute to constipation.

91. Psychological Factors : Stressful life events, emotional disturbances, and family dynamics can contribute to the development or exacerbation of encopresis. Children with attention deficit hyperactivity disorder (ADHD) and other behavioral disorders are at increased risk. Toilet Training Issues : Inconsistent or negative toilet training experiences can contribute to withholding behavior and subsequent encopresis. Medical Conditions : Conditions such as Hirschsprung’s disease, spinal cord abnormalities, or other gastrointestinal disorders can cause or contribute to encopresis.

92. Physical Examination And Investigation Abdominal distension Palpable fecal mass Poor perianal hygiene Patulous sphincter stool in rectum

93. Contd… Abdominal X-ray: faecal impaction Barium enema: dilated rectum Rectal biopsy Anorectal manometry.

94. Treatment Education and support Colonic decompaction: enemas, polyethylene glycol, magnesium citrate. Routine laxative therapy : lactulose, bisacodryl Behavioural intervention: schedule toileting and positive reinforcement. Dietary changes: increase fiber intake and adequate hydration. Assess for underlying conditions and regular follow up.

95. STEALING When a child takes something that belongs to others without permission is called stealing. ETIOLOGY: Poor impulse control, to be cool and impress others and stress. Management : use disapproval, talk with child, talk about ethics and values, restitution and behaviour watching.

96. TELLING LIES To make an untrue statement with an intent to deceive. Occurs in4-6 years of age. Aetiology: to cover something, experiment, attention, to get something they want and avoid to hurt someones feeling

97. Management: Make conversation about lying. Help children to avoid situation where they have to lie. Own upon doing wrong Praise for the good Be a role model for telling the truth.

98. BRUXISM It is characterised by non-functional repeated grinding of teeth with high pitched sound usually during sleep. Etiology : Abnormal sleep activity. Familial behavioural pattern Pinworm infestation Psychiatric disorders.

99. Management Awareness and Habit Modification Stress Management : Relaxation Techniques Cognitive Behavioural Therapy (CBT). Sleep Hygiene : Good Sleep Practices : Establish a regular sleep schedule, create a relaxing bedtime routine, and ensure a comfortable sleep environment. Avoid Stimulants .

100. Dental Approaches Mouthguards or Splints : Night Guards : Custom-fitted plastic mouthpieces worn over teeth at night to prevent grinding and protect teeth from damage. Splints : Dental appliances that help reposition the jaw to alleviate muscle tension and reduce grinding. Dental Correction : Orthodontic Treatment : Correcting tooth alignment may help reduce grinding in some cases. Equilibration : Adjusting the biting surfaces of teeth to improve alignment and reduce stress on the jaw. Medical Treatment: Muscle Relaxants : Prescribed to relax jaw muscles and reduce grinding(diazepam). Botox Injections : Injections into the jaw muscles to temporarily paralyze them and reduce grinding activity.

101. SPEECH DISORDER Definition: A speech disorder is characterized by difficulty with articulation (speech sound production), voice or fluency (the flow of speech). Types: Articulation Disorders Fluency Disorders Voice Disorders

102. SPEECH SOUND DISORDER/ ARTICULATION DISORDER A significant deficiency in the ability to produce sounds in conversational speech not consistent with chronological age. Substitutions – replacing one sound with another sound Example: “wed”/red; “tat”/cat; “tun”/sun. Omissions – omit a sound in a word. Example: – “to-“top; “uh-/up; “- nake ”/snake. Additions – insert an extra sound within a word. “ balluh ”/ball; “ doguh ”/dog. Distortions – produce a sound in an unfamiliar manner imprecise sounds (“slushy” sounds, such as a lisp* - “ thip ”/sip)

103. A frontal lips is an error pattern in which the child produces the “S” and “Z” sounds .(sometimes “SH,” “CH,” and “J” as well) with their tongue between their teeth, instead Of behind their teeth, making the “S” sound more like a “TH” (“think”/sink). Phonological disorders have phonemic errors. No difficulty executing movements for speech, but difficulties understanding the rules of language, which are primarily disorders of the morphology (word structure), syntax (grammar), semantics (meaning) and pragmatic (usage) of language rather than the sound system.

104. Apraxia of speech Apraxia of speech, or verbal apraxia, is a motor speech disorder caused by damage to the parts of the brain related to speaking. The severity can range from mild to severe. Apraxia of speech has two types - Developmental Apraxia of Speech (DAS) - DAS (also sometimes called CAS for childhood apraxia Of speech) occurs in children, is present from birth, and generally affects more boys than girls. Acquired Apraxia – Acquired apraxia of speech can affect a person of any age but typically occurs in adults and results in the loss or impairment of a person’s existing ability to speak.

105. Dysarthria is a group of neurologically related speech disorders. Known as motor speech disorders, dysarthria’s are caused by lesions on the brain in areas responsible for planning, executing, and controlling the movements necessary for speech. This damage can cause speech muscles to become weak or paralyzed. Dysarthria is most common in people born with cerebral palsy or muscular dystrophy and adults who have experienced a stroke, tumor , or degenerative disease such as Parkinson’s disease.

106. Speech affected by cleft lip or palate: Cleft palate produces speech that is nasal in quality and Can be hard to understand. Forming sounds for letters such As “t,” “k,” “s,” “ sh ,” “d,” and “x” is difficult because these and other consonants require contact between the palate and tongue. Speech affected by Deaf and Hard hearing: As might be expected, the inability to hear the sounds of speech makes it particularly difficult to learn to produce them

107. 2 . Voice disorders Speech voice–deficiency in pitch, intensity, resonance, or quality resulting from pathological conditions or inappropriate use of the vocal mechanism, which reduces the speaker’s ability to communicate within the learning environment. Voice disorders are caused by damage, disease, or deformity of the larynx, or voice box. Pitch: high, typical, or low, Loudness: loud, typical, or soft, Quality: may include descriptive terms such as hoarse, harsh, breathy, strained, or weak, Resonance: hyper-nasal (too much nasality) or hyponasal (not enough nasality).

108. 3. Fluency disorders Fluency disorders are related to the smoothness or rhythm of Speech. A person with a fluency disorder may hesitate, repeat words, or prolong certain sounds, syllables, words, or phrases. Stuttering and cluttering are types of fluency disorders.

109. Stuttering “Stuttering occurs when the forward flow of speech is interrupted abnormally by repetition or prolongation of sound,syllable or articulatory posture or by avoidance and struggle behavior .” Most common and easily recognized speech disorder. Most stuttering began between the ages of 2 to 6 years. Characteristic of stuttering is divided into three critical groups- 1.core behavior 2.accessory behavior 3.emotional reactions

110. Core Behaviors -The key feature of stuttering is the presence of involuntary discontinuities in the flow of speech. Accessory Behaviors - As disfluencies persist, the person who stutters begins to develop an awareness of his or her difficulties. Emotional Reaction - Ongoing struggle in the production of speech gradually results in deep- rooted feelings of shame, frustration, anger, anxiety, fear, negative self- perceptions, and, eventually, habitual avoidance of speaking situations.

111. Cluttering Cluttered speech is another type of disfluent speech pattern. It is characterized primarily by a rapid sounding rate of speech articulation, intermittent bursts of rapid and/or unintelligible speech (particularly in conjunction with multisyllabic words), excessive production of certain disfluency types (particularly revision of previously spoken words), and interjection of meaningless filler.

112. CAUSES OF SPEECH DISORDER Developmental Factors : Genetics and Premature Birth Neurological Conditions : Stroke, Traumatic Brain Injury , Degenerative Diseases : Conditions like Parkinson's disease or ALS (amyotrophic lateral sclerosis) can lead to speech difficulties. Structural Abnormalities : Cleft Lip or Palate, Anatomical Variations : Abnormalities in the mouth, throat, or vocal cords can contribute to voice disorders. Psychological and Environmental Factors .

113. DIAGNOSIS AND TREATMENT Assessment : Speech-language pathologists (SLPs) conduct assessments to evaluate speech production, fluency, and voice quality. Intervention : Speech Therapy : Individualized therapy sessions to improve speech production, articulation, fluency, or voice quality. Behavioral Techniques : Strategies to manage stuttering or improve vocal hygiene. Augmentative and Alternative Communication (AAC) : Devices or systems used to supplement or replace speech, such as communication boards or electronic devices. Medical Interventions : Surgery or medical treatments may be recommended for structural abnormalities or neurological conditions affecting speech. Multidisciplinary Approach