7.5 Children with Special Needs

Many children have learning patterns that respond best to targeted education. Although some differences among children are harmless, others indicate disorders that need to be recognized to help children learn. Before leaping from diagnosis to special education, however, we need to understand three concepts: comorbidity, multifinality, and equifinality (Cicchetti & Toth, 2009).

Many disorders are comorbid, which means that at least two problems occur in the same person. A child may need special help to overcome one problem, but that help needs to take into account other problems that the child might have.

Multifinality means that one cause can have many (multiple) final manifestations. The same genes or past trauma may produce a child who is easily angered (conduct disorder) or quick to cry (major depression).

Equifinality (equal in final form) means that one symptom can have many causes. For instance, a 6-year-old who does not talk may be autistic, hard of hearing, developmentally disabled, or electively mute. Comorbidity, multifinality, and equifinality are reasons to be cautious before leaping from symptom to cure.

To illustrate all three concepts, we focus here only on attention deficit and bipolar disorders, learning disabilities, and autism spectrum disorders.

Attention Deficit Hyperactivity, Bipolar, and Disruptive Mood Dysregulation Disorders

Attention deficit hyperactivity disorder and bipolar disorder are discussed together because they are often comorbid and confused with one other (Miklowitz & Cicchetti, 2010). Disruptive mood dysregulation disorder is a new diagnosis that helps resolve this confusion.

Attention Deficit Hyperactivity DisorderPerhaps 10 percent of all young children have attention deficit hyperactivity disorder (ADHD), which means they have difficulty paying attention and may also be filled with uncontrollable urges to be active or to act out impulsively. A typical child with ADHD, when made to sit down to do homework, might look up, ask questions, think about playing, get a drink, fidget, squirm, tap the table, jiggle his or her legs, and go to the bath-room—and then start the whole sequence again. Not surprisingly, such children tend to have academic difficulties; they are less likely to graduate from high school and college (Loe & Feldman, 2007).

The number of children diagnosed with ADHD has increased in recent decades. For instance, the rate of diagnosis in the United States has increased from 5 percent in 1980 to about 10 percent currently. The rate has doubled in Europe as well (e.g., Hsia & Maclennan, 2009; van den Ban et al., 2010). About twice as many boys as girls have ADHD (National Center for Health Statistics, 2011).

Diagnosis is a problem, since some adults are quick to blame children’s (especially boys’) behaviour on a disorder. Experts say that ADHD should be diagnosed only when it is apparent in at least two places (e.g., home and school) and when it does not improve with consistent structure and guidance. A first step is for parents and teachers to learn how to provide that guidance (Subcommittee on ADHD, 2011).

Almost Impossible The concentration needed to do homework is almost beyond Clint, age 11, who takes medication for attention deficit hyperactivity disorder (ADHD). Note his furrowed brow, resting head, and sad face.

SACRAMENTO BEE/LEZLIE STERLING/ZUMA PRESS

Bipolar DisorderBipolar disorder is characterized by extreme mood swings, from euphoria to deep depression, that are not linked to external circumstances. Children with bipolar disorder experience at least one episode of grandiosity. They might believe, for instance, that they are the smartest person in the school, a genius destined to save the entire world. At other times, the same child might be severely depressed, unwilling or unable to read, play, or go to school (Miklowitz & Cicchetti, 2010).

One U.S. study reported that medical visits for youth under age 18 with a primary diagnosis of bipolar disorder increased 40-fold between 1995 and 2003, a period when adult diagnoses of bipolar merely doubled (Moreno et al, 2007). Such a rapid increase suggested to critics that childhood bipolar disorder was a diagnosis in the mind of the observer, not in the moods of the child. Others suggested that the rapid increase in diagnosis was the result of earlier misdiagnosis, not current overdiagnosis (Miklowitz & Cicchetti, 2010; Santosh & Canagaratnam, 2008).

Disruptive Mood Dysregulation DisorderAlthough professionals agreed that the rapid increase in the rates of childhood bipolar disorder were a result of misdiagnoses, they could not ignore the fact that many children were being brought to pediatricians and psychologists by parents (or referred by teachers) because they were too often rageful and irritable, even on their best days. These weren’t just children going through a difficult phase, but children who were chronically angry, and whose behaviour was occurring at home, at school, and for months on end. The new edition of the DSM-5 includes a new type of depressive disorder, disruptive mood dysregulation disorder (DMDD), to describe the behaviour of these children. These are children who may scream over a dropped ice cream cone, or throw a remote control across the room rather than share it—and who look sad or angry when they are not losing their temper. These behaviours may not be precursors of adult bipolar disorder, but may instead predict later anxiety and depressive disorders, now apparent in a storm of unregulated feeling.

Distinguishing Between DisordersBipolar disorder is extremely difficult to differentiate from other psychiatric illnesses in youth (Phillips, 2010). Many children diagnosed with either ADHD or bipolar disorder may be more accurately diagnosed with the other. It is hoped that the new DMDD diagnosis will result in more accurate diagnosis and effective treatment.

Go Team Remember that abnormality is normal. Which of these boys has been diagnosed with a serious disability? Michael, second from the right, has bipolar disorder.

MARC ASNIN/REDUX

Both ADHD and bipolar disorder are more common in children whose parents have a disorder, sometimes the same disorder as the child. Parents of children with ADHD often have learning disabilities, whereas parents of children with bipolar disorder are likely to have mood disturbances. This suggests a genetic link as well as multifinality.

Both disorders are related to unusual brain patterns. Children with either disorder are less able than the average child to distinguish emotions when looking at faces. That much is true for both disorders, but activation of distinct parts of the amygdala differs between the two (Brotman et al., 2008, 2010).

Treatment involves (1) counselling and training for the family and the child; (2) showing teachers how to direct attention and increase structure to help the children learn; and, if that does not help, (3) medication to stabilize moods for bipolar children and to calm children with ADHD. Ongoing monitoring is crucial because some drugs help children with ADHD but harm those with bipolar disorder. In addition, each child responds differently to each drug, and responses change with time.

Specific Learning Disorders

The DSM-5 diagnosis of specific learning disorder now combines diagnoses of deficits in the perception or processing of information; such difficulty is commonly referred to as a learning disability. Many children have a specific learning disorder that leads to difficulty in mastering a particular skill that other people acquire easily. Indeed, according to Gardner’s view of multiple intelligences, almost everyone has a specific inadequacy or two. Perhaps one person is clumsy (low in kinesthetic intelligence), while another sings loudly but off key (low in musical intelligence). Most such learning disabilities are not debilitating (the off-key singer learns to be quiet in chorus), but every schoolchild is expected to learn reading and math. Disabilities in either of these two subjects often undercut academic achievement and make a child feel inadequate, ashamed, and stupid.

Data from the 2002/2003 National Longitudinal Survey of Children and Youth (NLSCY) reported that about 4 percent of Canadian children from 8 to 11 years of age were diagnosed with a learning disability in 2002 (Milan et al., 2006). The most commonly diagnosed learning disability is dyslexia, unusual difficulty with reading. No single test accurately diagnoses dyslexia (or any learning disability) (Riccio & Rodriguez, 2007).

Learning to Make Sounds Most children teach themselves to talk clearly, but some need special help—as this 5-year-old does. Mirrors, mentoring, and manipulation may all be part of speech therapy.

©LAURENT/GLUCK/AGE FOTOSTOCK

Early theories hypothesized that visual difficulties—for example, reversals of letters (reading was instead of saw) and mirror writing (b instead of d)—were the cause of dyslexia. We now know that more often dyslexia originates with speech and hearing difficulties (Gabrieli, 2009).

A decade ago, dyslexia was diagnosed when a child’s reading achievement was far below that child’s intellectual potential—that is, scores on achievement tests were lower than IQ. Now fMRI brain scans reveal that children of all intellectual levels (from genius to disabled) can have neurological problems that make reading difficult (Tanaka et al., 2011). It is no longer necessary to wait until tests reveal low achievement.

Dyscalculia is unusual difficulty with math. The root cause is neurological, and although dyslexia and dyscalculia can be comorbid, each is a separate disorder originating from a different part of the brain, and each requires targeted education (Butterworth et al., 2011). Often computer programs as well as various auditory and visual treatments help. One strategy that is not effective and that can, in effect, be dangerous is simply waiting for a child to outgrow a learning disability. Many children who have learning problems develop behaviour problems as well.

Autism Spectrum Disorder

Of all special needs children, those with autism spectrum disorder (ASD) are perhaps the most troubling, not only because their problems are severe, but also because the causes of and treatments for ASD are hotly disputed. Most children with ASD can be identified in the first year of life, but some seem quite typical at first and then display signs of the disorder later on.

The Centers for Disease Control and Prevention (CDCP) report that ASD affects about 1 in every 88 children in the United States (three times as many boys as girls and more European-Americans than Latino-, Asian-, or African-Americans) (CDCP, 2013). In Canada, there is no national system in place to provide accurate data about the prevalence of autism spectrum disorder. However, a 2012 report from the National Epidemiological Database for the Study of Autism in Canada discovered increased rates of ASD diagnoses among children in Prince Edward Island, Newfoundland and Labrador, and southeastern Ontario. Depending on the age group and region, these increases varied from 39 to 204 percent (NEDSAC, 2012).

SymptomsThe two signs of autism spectrum disorder are (1) problems in social interaction and the social use of language, and (2) restricted, repetitive patterns of behaviour. Children with any form of ASD find it difficult to understand the emotions of others, which makes them feel alien, like “an anthropologist on Mars,” as Temple Grandin, an educator and writer with ASD, expressed it (quoted in Sacks, 1995). Consequently, they do not want to talk, play, or otherwise interact with anyone, and they are especially delayed in developing a theory of mind (Senju et al., 2010).

Some children with autism spectrum disorder never speak, rarely smile, and often play for hours with one object (such as a spinning top or a toy train). Others are called “high-functioning” and are extremely talented in some specialized area, such as drawing or geometry. Such high-functioning children are still said by some to have Asperger syndrome, but most clinicians and the DSM-5 consider this a part of the autism spectrum. Many are brilliant in unusual ways (Dawson et al., 2007), including Grandin, a well-respected expert on animal care (Grandin & Johnson, 2009).

Far more children have ASD now than in 1990, either because the incidence has increased or because more children receive the diagnosis. You read that currently in the United States about 1 child in 88 has ASD. Some other estimates put the number even higher—perhaps 1 child in 40. Underlying that estimate is the reality that no measure diagnoses ASD definitively: Many people are socially inept and poor at communication—do they all have ASD? No; for a diagnosis of autism spectrum disorder, a person’s symptoms must be severe enough to significantly impact their ability to function.

TreatmentSome children with ASD are on special diets, take vitamin supplements, or are on medication. One drug in particular, risperidone, relieves some symptoms (although research finds side effects, including weight gain), but no biochemical treatment has proven successful at relieving the disorder itself. As you already know, medication use is controversial: Whether a child takes risperidone depends on many factors other than symptoms (Arnold et al., 2010; Rosenberg et al., 2010).

Precious Gifts Many children with ASD are gifted artists. This boy attends a school in Montmoreau, France, that features workshops in which children with ASD develop social, play, and learning skills.

PHANIE/SCIENCE SOURCE

Some parents of children with ASD reported that they first noticed their infant’s lack of social responses after vaccinations and believe thimerosal, an antiseptic containing mercury that was once used in immunizations, was the cause. No scientist who examines the evidence agrees: Extensive research has disproven this hypothesis many times (Offit, 2008). Thimerosal was removed from vaccines a decade ago, but the rate of ASD is still rising.

Doctors fear that parents who cling to this hypothesis and forgo routine vaccinations for their children are not only wrong, but are also harming millions of other children. Indeed, in North America, the 2012 rate of whooping cough was higher than in any year since 1960. Babies younger than 2 months have died of whooping cough because they are too young to be immunized and because older children whose parents do not vaccinate them spread contagious diseases.

One popular treatment for ASD is putting the child in a hyperbaric chamber to breathe more concentrated oxygen than is found in everyday air. Two studies of hyperbaric treatments—both with randomized participant selection and with control groups—reported contradictory results, either benefits (Rossignol et al., 2009) or no effect (Granpeesheh et al., 2010). Part of the problem may be multifinality and equifinality. Children with ASD share core symptoms (equifinality), but they differ in causes, from genes to birth trauma, from prenatal toxic substances to postnatal chemicals, and those same causes sometimes have other outcomes (multifinality).

Many behavioural methods to improve talking and socialization have been tried, with mixed results (Granpeesheh et al., 2009; Hayward et al., 2009; Howlin et al., 2009). Many clinicians use a mix of behaviour analysis, sensory play, and communication therapy to help children with ASD develop imaginative play, cognitive flexibility, and an understanding of the feelings of others. Early and individualized education of the child and parents sometimes succeeds, although special education is not a panacea, as you will now see.

Special Education in Canada

Developmentalists are well aware that physical, cognitive, and psychosocial development interact to affect each child’s behaviour. That means doctors, parents, teachers, and policy-makers need to work collaboratively for each child. However, this does not necessarily occur. Special education is one example.

Changing PoliciesIn the past in North America, children with disabilities were educated in separate schools or classrooms, if at all. Starting in the 1960s, in Canada and the United States, school administrators and government officials began to recognize that all students had the right to be educated in a common environment. One groundbreaking piece of legislation was the 1975 Education of All Handicapped Children Act in the United States, which stipulated that children with special needs must be educated in the least restrictive environment (LRE) (Edmunds & Edmunds, 2008). This national law meant that every state in the country had to adjust its educational practices in regard to children with disabilities.

In Canada, even though there is no federal department of education, every province and territory has adopted policies that to a large extent mirror those of the U.S. law when it comes to instructing children with special needs in an LRE. Most of the time, this has meant placing these children with other children in a regular class, also called “mainstreaming,” rather than in a special classroom or school. Sometimes children are sent to a resource room, with a teacher who provides targeted tutoring. Other times, students attend an inclusion class, which means that children with special needs are included in the general classroom, with appropriate aids and services (Kalambouka et al., 2007). TABLE 7.4 describes how provincial and territorial departments of education define the concept of an LRE in their respective statements of philosophy regarding the education of students with special needs.

A recent strategy in both Canada and the United States is called response to intervention (RTI) (Fletcher & Vaughan, 2009; Shapiro et al., 2011). All children who demonstrate below average achievement are given some special intervention. Most of them improve. For those who do not, more intervention occurs. Only if repeated intervention fails is the child referred for testing.

Professionals use a battery of tests (not just IQ or achievement tests) to decide whether a child needs special education. If so, they discuss an individual education plan (IEP) with the parents to specify educational goals for the child. The IEP goes by different names in different parts of Canada: individual program plan (IPP) in Alberta and Nova Scotia; personal program plan (PPP) in Saskatchewan; and individual services support plan (ISSP) in Newfoundland and Labrador. However, the intent and format of the document is similar from province to province. According to the Ontario Ministry of Education, an IEP is

Teaching strategies to assist students with disabilities may include using special resources such as videos, audiotapes, and simplified reading materials. Accommodating students includes giving them extra time for their tests or assignments, or assigning them scribes to take notes for them in class (Ontario Ministry of Education, 2000).

Prevalence and AccessSince there is no federal department of education in Canada, this country lacks statistics on the overall number of students with disabilities. However, reports from the United States have revealed two important statistics:

• The number of students receiving special education services has increased every year since 1976–1977.
• In 2010, the number of 3- to 21-year-olds being served by special education was about 13 percent of the student population.

All Together Now Kiemel Lamb (top centre) leads children with ASD in song, a major accomplishment. For many of them, music is soothing, but words are difficult and hand-holding in a group is almost impossible.

AP PHOTO/THE TUSCALOOSA NEWS, DUSTY COMPTON

Most experts think that similar trends and statistics apply in Canada (Edmunds & Edmunds, 2008). According to a 2006 Statistics Canada Survey, learning disabilities, which include ADHD and dyslexia/dyscalculia, are by far (81 percent) the most frequently reported condition requiring special education services (Kohen et al., 2006). In specific populations, rates of learning disabilities can be higher. For example, a report on students with special needs in First Nations schools in British Columbia concluded that almost one-third of the First Nations student population have been identified with moderate to severe special needs (Auerbach, 2007).

Cultural DifferencesDevelopmentalists consider a child’s biological and brain development as the starting point for whatever special assistance will allow each child to reach full potential. Then home and school practices are crucial. In regard to access to special education services, almost one-third of Canadian children with disabilities experience some sort of difficulty in getting the help they require. Problems range from insufficient staffing levels, to difficulties with assessment, to communication problems between parents and teachers and school administrators (Kohen et al., 2006).

At times, the problems parents experience in getting what they consider necessary services for their children have erupted into national controversies. Consider the case of Jeffrey Moore, a child with dyslexia attending a British Columbia grade school in the early 1990s. Every week in Grade 1, Jeffrey received two 40-minute sessions with a tutor and three 30-minute sessions with a learning-assistance teacher in addition to his regular class time. A psychologist said it would benefit Jeffrey to receive additional assistance at a reading-assistance centre in North Vancouver. During a financial crisis, the North Vancouver school district closed the centre. Several years later the Supreme Court of Canada ruled that this closing effectively discriminated against Jeffrey as a student with special needs. Reacting to the ruling, the Globe and Mail accused the court of opening a “Pandora’s box” that would force public schools to “bleed” funds from other programs to support those for children with special needs. Where do we draw the line between what is merely “beneficial” and what is “required” (Globe and Mail, 2012)?

These are North American controversies. Other countries have quite different policies and approaches toward special education. For instance, in Finland almost every child is recognized as having some special educational needs, but almost no child is labelled or removed from the class for that reason. Instead, every teacher works to help each child with his or her special needs (Sahlberg, 2011).

Gifted and TalentedQuestions surrounding access and funding are also apparent for the 2 percent of school-age children who are unusually gifted. In Canada, most provinces and territories have systems in place for identifying and educating gifted children. How they do it varies tremendously. Should such children be accelerated, skipped, segregated, enriched, or left alone?

In the past, such children were simply put ahead a grade or more, but that left them socially isolated. One gifted student remembers:

Lifelong problems occurred for this girl partly because she skipped two grades. She still thinks it might have been her fault that she was a weed, not a flower.

Currently, the most common solution for gifted children is to teach them all together, either in a separate classroom within a school or in a separate school, such as the Westmount Charter School in Calgary, Alberta, which caters exclusively to the gifted. Ideally, the children are neither bored nor lonely because each is challenged and appreciated. Their brains develop as well. A child’s brain is quite plastic, and all children learn whatever their context teaches.

Some parents, however, experience problems in trying to place their children in gifted programs, even when the children have been assessed as gifted. Access problems are especially evident in times of financial restraint. During economic recessions, governments often cut education funding, and school boards in turn look for staff and programs to cut. Gifted programs, like special education programs, often suffer from these financial cuts.

Another issue that has repeatedly dogged gifted programs is their perceived tendency to favour students from higher-SES families and more privileged ethnic groups. One mother expressed her frustration in trying to find a diversified environment for her gifted middle-school child in this way: “I looked at every program in town and, frankly, they were all little white boys. We live in [ethnically diverse] Toronto. I don’t see the point of that” (Pearce, 2012).

Such concerns are not abstract. One Canadian report indicated that in the Ottawa-Carleton area, 4 percent of schoolchildren have been assessed as gifted (which surpasses the North American average by 2 percentage points), while in neighbouring Renfrew County, the average was only 0.2 percent (Mendleson, 2009). No one really believes that living in the nation’s capital makes kids smarter than their peers in other areas. Instead, the question may be whether coming from politically well-connected families gives them better access to special services.

Difference as the RuleScholars all find “much heterogeneity and diversity of high human potential in terms of varied developmental niches, trajectories, and pathways” (Dai, 2010). With so many complexities, some nations and school systems avoid special education of the gifted, or of any child with special needs, at least until high school or post-secondary education.

China insists that effort, not innate ability, leads to excellence, and thus all children are educated together. In many nations of Asia and Africa, every child is expected to help his or her classmates, so separating out gifted students or those with disabilities would undercut education. This sometimes occurs in North America as well. For instance, Fern Hill School, a private school with campuses in Oakville and Burlington, Ontario, no longer assigns the gifted designation to any of its students. When asked why, one school administrator stressed that all children have talents (Pearce, 2012). A leading U.S. educator suggests that we

Considering development in body and mind during middle childhood, differences abound—in size, health, skill, logic, intelligence, language, and more. The next chapter describes other major differences in family structures and social contexts. What are the implications? Answers are suggested at the end of Chapter 8.