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Until the Arizona state government declares a significant reduction in the social distancing requirements due the the COVID-19 pandemic CHADD of Tucson will not have any support group meetings. Please check this website and out Facebook page (http://www.facebook.com/chaddoftucson) for update about when we will begin to meet again. In the meantime, please be safe and healthy!

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COVID-19 CHADD of Tucson Blog

COVID-19 AND HOME SCHOOLING

A mentor and colleague of Kevin’s, C. Wilson Anderson, Jr., MAT, a master teacher, taught him homework is intended to give the student practice in refining a new skill recently learned in school. It is the teacher’s job to teach the skill and the parent’s job to provide an environment to practice it. The parent should not be expected to “teach” the child the skill; that is the teacher’s job. Due to our new reality of life during this pandemic these roles have been skewed. The teacher cannot ensure your child has totally learned the concepts covered due to the brevity of time allowed to have internet bandwidth, etc. As a result, the parent must take on more of a teaching role.

For better than a month many parents have been occupying a new roll, school teacher. This is one of the new realities of the effects of social distancing due to COVID-19. Few parents have training and experience with school curriculum and teaching methods that are appropriate for their children given their age and development. Yet, innumerable parents and children have recently found themselves in front of screens watching a classroom teacher demonstrate a math problem, or discuss a new concept, and then the teacher will give the child and by proxy the parent an assignment related to what has just been covered. Often the parent is lost about how to proceed if the child does not completely understand the task. This is especially so for the parent with a child with AD/HD.

Please be aware it is quite common for any parent of a school-aged child without AD/HD to have great difficulty with their new role in on-line learning. In many ways, on-line learning for a child is similar to having a mechanic tell you by Skype or Zoom how to fix your car’s transmission when you have no experience doing such things. No one would blame you for having trouble performing in such a situation. You must also know that although most elementary school teachers have training and expertise in curriculum and instruction, they rarely know how to impart those skills to others. Again, this is particularly true for the skills needed to teach children with AD/HD.

Additionally, it is not uncommon, for the standard elementary school teacher to have little knowledge about how to adapt the curriculum of a mainstream classroom to meet the needs of a child with AD/HD. So do not feel lacking in parental skills and abilities if you feel overwhelmed by your new role. All of this is new to you and your feelings of inadequacy are expected but unfounded.

Over the course of this pandemic I will be offering some hints on how to help your child with AD/HD learn and practice their school work under such conditions.

The first thing you should know is you can always ask the teacher questions as needs arise as well as ask other school staff (i.e., special education teacher, music teacher, PE teacher, etc.). Feel free to send them an e-mail, text or call them.

The following are things to be aware of:

• Below is a list of the attention spans of typically developing children without AD/HD by chronological age:

o Two years old – 5 minutes

o Four year old - 10 minutes

o Six year olds - 14 minutes

o Eight year olds - 20 minutes

o Ten year olds - 25 minutes

o Twelve year olds - 30 minutes

o Fourteen year olds - 35 minutes

o Sixteen year olds - 40 minutes

o

➢ The above means that you should work on a school subject with your non-AD/HD child for the amount of time listed above that most closely matches their age. Once the age appropriate time is reached stop teaching that subject and teach another subject for the same amount of time.

➢ For the child with AD/HD you take the average amount of time that closely matches the age of your child and subtract 1/3 from it to best estimate how much time you should spend on one topic. For example, your child with AD/HD who is 10 years old would typically have an attention span that was 1/3 less than their non-AD/HD age peers, or 20 minutes (1/3 X 30 minutes = 10 minutes; 30 minutes – 10 minutes = 20 minutes.)

➢ When changing activities from one subject to another it can be helpful to inform the child you are about to change, for example it is typically best to tell your child, in five minutes we are going to stop working on math. Then we will work on reading. Some parents find it helpful to actually put a clock where the child can see it. This helps the child transition as many children, adolescents and even adults with AH/HD have difficulty changing from one activity to another. At the end of the five minutes, ask them to put away their math book and those materials needed for math and if needed allow them a short break.

➢ Exercise is good for all children, but it can be especially helpful with AD/HD children. Having the child every 20 to 30 minutes stand up, stretch, run in place, take the dog out to do it’s business, etc. provides a break and gives the child some exercise which has been shown to help with the symptoms of AD/HD.

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➢ When ending a break to return to study, you once again want to give the child some time to transition. It may be particularly difficult to redirect your child back to study if they are engaging in an activity they prefer. So once again it may be useful to tell your child that in five minutes we will stop playing, running, etc. and go back to study. It is useful to add what you are going to go back to study for example it may be reading or science. Letting them know in advance gives then time to make that transition more smoothly. Such simple activities can help with the transition of activities from one activity to another, which can be especially hard for a child with AD/HD and it also helps establish a routine which helps immensely with attention and learning a new skill.

➢ But it is important to realize they may still ask for more time for their favored activity and this is when just repeating the directions comes in useful and eliminates arguing. Don’t fall into arguing with your child or negotiating, simply stick to repeating that it is time now to go in and work on your reading etc and you can have another break soon after reading.

➢ Once you return from the break use the same guidelines as to how much time to expect your child to be able to maintain focus, use transitions wisely and always be aware of your child’s ability to focus. The above timelines are a general guide and you can use them as such but remember children do vary in their ability to focus based on numerous factors. Just a few of these factors are how well they slept the night before as a child who is sleepy will have less ability to focus, concentrate, comprehend and retain information. Also, how interested they are in the task at hand can make a difference in their ability to concentrate on that task. Often parents tell me their child can focus on tasks they enjoy and this is especially true of those with AD/HD. Remember if they are engaged with the task they naturally can focus on it for a longer period of time. Another factor that can influence concentration is the difficulty level of the task. We all enjoy working on tasks we can master more easily than the ones we struggle to master. There are more factors that affect concentration which we will be addressing in future articles. Pease stay tuned for more information.

➢ If you have questions please contact us at kblake@drkevintblake.com, or 520-327-7002 and we will happily respond. I hope the above is helpful and you and your family stay safe and healthy!

Kevin T. Blake, Ph.D., P.L.C., ADHD-CCSP

Freda Harper Blake, Psy.D.

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COVID-19 AND HOMESCHOOLING

ESTABLISH A ROUTINE

Routines are extremely valuable to everyone. This is particularly true of the school age child, whether or not they have AD/HD. When in their typical “brick and mortar” schoolhouse teachers quickly establish a daily routine for their students. Every day begins with the ring of the school bell, the principal making announcements over the PA, and the students reciting the Pledge of Allegiance. Typically, certain subjects are taught the same time during the day. This is true of activities, too, such as recess and lunchtime.

In fact, one of the best things you can do for your child is to keep a daily routine that in some way approximates their typical day at brick and mortar school. Keeping them in a routine is one of the best ways to help them tolerate these scary times. It gives them some feeling of control and the predictability of what to expect as well as keeps their minds occupied and off scary thoughts. It will also be beneficial to you as parents who may be working from home now and have lost the routine of your own work environment.

TIPS FOR ESTABLISHING AND MAINTAINING A ROUTINE

1. In order to create a structure and a routine that actually works, you have to work together. Establish a short, weekly family meeting to figure out a daily schedule that includes the needs of everyone. The day could be divided into blocks for studying, doing chores, exercise, fun activities and chilling out (with and without screens). You child may need more frequent breaks than you expect because kids with ADHD and LD often struggle to concentrate on one thing for long periods of time.

2. Use the suggestions from yesterday’s post to know how long you can reasonably expect your child to attend to one subject/activity. There is some evidence that children with

AD/HD have better attention and cognitive function around 2:00 PM.so you may want to

consider presenting their most difficult subject to them around this time. In addition, there should be at least one hour of time between the completion of eating lunch and commencing study of the subject they find most difficult.

3. Once you have developed your family’s plan, post it in the kitchen and bedrooms so everyone can easily refer to it. This helps everyone know what to expect. Especially initially expect to make adjustments along the way at a weekly family chat or more frequently as needed. Remember you are all in this together and you are all new to this so communication is essential.

4. Set up formal study periods. Break assignments into do-able chunks based on how long your child or teen can actually focus. If your child can focus for 20 minutes and then needs a quick break, set up three of these consecutive periods before a longer snack or movement break. Offer incentives (like bonus screen time) for the completion of work. You most likely will want to work yourself at the table alongside your child to be available for any questions. Your presence can also help them stay on task. Just don’t anxiously hover over them as this increases their anxiety and thereby reduces their ability to focus and ultimately to retain information.

5. Asking a child to honestly tell you how many math problems they can complete or pages they can read within a time period appropriate given their age appropriate attention span (see yesterday’s post) can give the child some feeling of control over learning and give them a goal to meet. It can also encourage them to meet the goal they set for themselves. People are more apt to do something if they tell another person they will do it.

STARTING THE DAY

Brick and mortar school typically start the day between 8:00 and 9:00 AM. In this new world of homeschooling you may want to relax that a bit to say 10:00 AM. You may want to extend wake-up and bedtime routines. It Is harder to get up and get moving or go to bed when there’s nothing compelling you to do so. For kids with AD/HD who often lack motivation for things they don’t want to do or dislike, it’s even more difficult. Cut your kids and yourself some slack and think about starting anywhere from a half hour to two hours later than their normal school day. This is particularly true for adolescents, whose sleep cycle is altered as part of their normal biological development. They naturally stay awake later and wake up later in the morning. Plenty of research has suggested that high school students’ performance is greatly enhanced when classes start closer to 10:00 AM instead of 8:00 AM. However it is difficult for large systems such as high schools to change their routines but you may have that option during this crisis. By starting homeschooling later it also allows your family to make sure things that need to be done at home are accomplished and there is some quality time.

TIPS FOR STARTING THE DAY

1. It may be helpful at the appointed time when school is to start in your home to ring a bell, honk the car horn, make your cell phone ring, etc. to ritually start the school day. I have seen videos of families with school children begin the day by reciting the Pledge of Allegiance at home during the pandemic. It might also be helpful to make certain announcements at the start of the day. This may include when subjects will be studied, what will be provided for lunch and what time lunch will be taken and when fun activities are scheduled during the day. The point is to have the child’s school day at home follow a schedule much like that at school but which can be tailored to your family’s individual needs and your particular home life during this time.

2. Expect your new school ritual to take about a month to become established as you and your adjusts to and learns the new routine. Give your self permission to make adjustments along the way, remember this is new to all of us and there is always a learning curve with any new undertaking.

SOCIALIZATION

Given the current pandemic lockdown it is hard to socialize and your children and adolescents are missing out on an important element of development, that of socialization. We often forget that socialization is an important part of a regular school day. Some experts have estimated as much as one half of the school day involves learning and practicing socialization skills. This also includes after school activities. With schools and parks and recreational facilities closed you child may be feeling a great loss. They may be missing out on attending a friend or relative’s birthday party and/or play dates and other activities with friends and extended family. In order to address this, first allow your children an opportunity to express these feeling and reassure them this is normal but also temporary and that you will work with them to make sure they stay connected with the important people in their lives.

TIPS FOR SOCIALIZATION

1. Gaming and social media are now lifelines for connection with others. Everyday allow your child to contact their friends, connect with family via, FaceTime, Zoom, Skype, etc. On-line gaming with friends and family members is another way to relax, have fun and connect with friends and family. Texting and telephone calls are also ways of staying connected but they do not offer the socialization needed to practice the skills of reading facial and body language. As much as 70 to 93 percent of social interaction is visual and these other modalities offer the opportunity to connect visually as well verbally. I think we all may have had the experience of feeling more connected when we can see the person we are talking too.

2. Plan for a certain amount of daily automatic screen time with bonus time. Here’s how this works: If you want your kids to have three hours of daily time on their devices outside of schoolwork, try giving them a baseline of 90 minutes. They can then earn bonus time based on completing schoolwork and chores. If they can’t get off the devices as planned, they don’t earn the privileged bonus time. If you are working from home, use your kids’ automatic screen time to your advantage and schedule it for times that will help you.

That is enough for today but stay tuned for more! Remember, if you have questions feel free to contact us at kblake@drkevintblake.com and/or 520-327-7002.

Be well and stay safe!

Kevin T. Blake, Ph.D., P.L.C., CCSP-ADHD

Freda Harper Blake, Psy.D.

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HOW TO KNOW THERE IS A GOOD CHANCE THE “RESEARCH” YOU READ ON THE WEB IS LEGITIMATE

During these uncertain times, when many of us are confined to our homes, where do we turn to get answers to our questions? Physicians and other medical professionals are often unavailable because they are on front lines fighting COVID-19. Teachers have their hands full attempting to teach their students online. Those who work in other essential businesses are too swamped to answer our questions. Then there are those who work for non-essential businesses that might have the answers we need, but the businesses are shuttered and they are unavailable.

This is even more true for the parent of a child with a disability or an adult with a disability. Often the places they need to go to have their questions answered are those with highly specialized professionals who are unavailable now. Where can they go to have their questions answered?

The internet, of course is the answer; however; that can be a very dangerous place. All of us have heard of maliciously false information placed on a website that “looks legitimate,” but offers dangerous/life threatening information. How can one know what is legitimate, or not?

To begin, do not believe anything you see on Wikipedia, unless you can verify it with at least three other resources. Wikipedia has been created by the general population of the world, not experts. Those of us who are old enough to remember printed encyclopedias were told they were created and updated by experts in their fields and they should, for the most part, be trusted. When we were in school our teachers, as we became older, told us to use other sources in our book reports, etc., because the information in encyclopedias was often outdated and not as good as proctored scientific journals, etc.

At best, Wikipedia should be used as a place to start to answer a question you may have. Look at the citations given at the end of the page and check on them. Look at other articles that may arise in your search engine that are not connected to Wikipedia. Read those articles.

If an article says, “I have used this treatment with thousands of patients and I know it works,” be careful and very skeptical. Be wary of statements such as, “Many physicians/scientists lie about this technique for political reasons,” or “Prove me wrong that this technique does not work,” and assume the entire article is false. Additionally, if there is no research about the technique in a proctored, peer-reviewed scientific professional journal, or what is in such journals indicated it is not useful assume the method will not work.

You may ask what does a good research article look like?

For one, people in the study were randomly assigned to groups and there is a control group where people get no treatment, a placebo or “sham” treatment. Those in the study should not know what group they are in (placebo or treatment) and the researcher conducting the study should not have this information either as it can bias the way they interact with or interpret the study. This type of research is called blinding.

Additionally, the larger the number of people in the study the better. If there is one person in the study, there is an overwhelming chance that not much was found that is useful. Although this type of study sometimes precedes additional research with a much larger number of subjects. If there were 1000 in the study there is a better chance that something useful was found.

Also the study should have been replicated by other scientists. If you find that only one study showed a particular treatment works that means little. Other researchers must recreate, or replicate the first study to make sure there really was something of use found. If ten follow-up studies found the same thing, then there may be something of use there. But if no other study yielded the same results then there may be something wrong with the first study. In such a case, don’t follow the suggestions of the first study.

A classic example of this was back in the early 1990’s when two researchers in Utah announced they had developed an inexhaustible clean energy source called cold fusion. If this was the case, everyone on Earth would have all the power they needed and that power was completely clean, completely safe, with no waste. At first, the press went wild over this “discovery.” However, other researchers were not able to recreate the first study. Today, you do not hear of cold fusion, because we now know it doesn’t work.

Finally, find out who paid for the study. There was a classic study that showed having one drink of alcohol a day was much better health wise than never drinking. That study was funded by an alcohol lobbying association. Further research found those who never drank had significantly better health than those who had one drink per day. The study conducted by the alcohol lobbying association included former alcoholics in the group reported they did not drink. The former alcoholics health was significantly worse than those that never drank. By having the former alcoholics as part of the group that never drank it appeared those that never drank had worse health than those who had one drink per day. Follow-up researchers conducted similar studies to the first one but did not put reformed alcoholics in the group that never dank. This resulted in the group that never drank having significantly better health than those who had one drink per day. Most people are not aware of this more recent research result because the results of the first study were so widely touted by the alcohol trade association. So if say a pharmaceutical company says it’s research shows a certain medication works, wait until someone not associated with the manufacturer has research showing it works before you think it is time to use it.

In summary what do you need to know if a study is “good?”

1. Random assignment of the people in the groups in the study.

2. A control/placebo/sham treatment group was used.

3. The people in the study and the researchers were blind to which treatment a person is getting.

4. A very large pool of people were tested in the study.

5. Other researchers around the world found similar results.

6. Those touting a treatment did not pay for the study.

I hope this information is helpful. Please stay safe and healthy during the pandemic!

Kevin T. Blake, Ph.D. P.L.C. ADHD-CCSP

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This article originally appeared in the May/June 2000 issue of Attention!® magazine, copyright CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder). For information, please visit www.chadd.org.

Two Common Reading Problems Experienced

By Many AD/HD Adults, 2013 Edition

Kevin T. Blake, Ph.D. P.L.C.

Opening note:

On Saturday, May 19, 2013 the American Psychiatric Association (APA) released the much anticipated and argued Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) with great fanfare in San Francisco, California during the organization’s 166^th Annual Meeting. In May of last year APA indicated on its DSM-5 website what was called “Reading Disorder” in the Fourth Edition of the manual would be called “Dyslexia (Author, May 1, 2012)”. Shortly thereafter the DSM-5 Task Force met with the heads of the US Department of Health and Human Services (HSS) and the major health insurance companies (Barkley, November 9, 2012). The DSM-5 Task force was told the DSM-5 would not be accepted by HSS and health insurance companies as a guide to the diagnosis of mental diseases if it significantly raised prevalence rates of disorders (Barkley, November 9, 2012) . Reading Disorder’s prevalence rate in DSM-4, TR (Text Revision, 2000, p. 52) was around 4 percent of the general population. Over forty years of research into reading problems conducted by the National Institute of Child Health and Development (NICHD) of the National Institutes of Health indicated that percentage was about 15 percent (Fletcher, Lyon, Fucks and Barnes (2007). Every scientific indication was that Dyslexia exists and it afflicts 15 percent of the population. However, due to the prevalence increase concerns of HSS and the insurance companies the DSM-5 Task Force decided to drop Dyslexia from the manual and after a discussion with Larry Silver adopted his (Larry Silver’s) nomenclature for learning problems of reading: Specific Learning Disorder-Reading (Author, July, 2012). This was done in large part to keep the prevalence of reading problems to 4 percent of the population.

For the purposes of this article and to follow the over forty years of research Specific Learning Disorder-Reading will be called “ Reading Disorder/Dyslexia” (RDD) and a unique reading difficulty that afflicts many with AD/HD will be called “Reading Disorder of Recall/Comprehension”(RDR/C).

Only in the past few decades has adult AD/HD been recognized. The same is true of adult learning disorders. The most common of the learning disorders, Reading Disorder, has been researched in children for over 100 years (Shaywitz 1994, 2003), but only relatively recently in adults. Even more recently still, scientists have begun to study individuals who have both AD/HD and Reading Disorder. The following will discuss the diagnosis and Treatment of two types of Reading Disorders that can afflict adults with AD/HD.

Reading Disorder-Dyslexia

The first of these is Reading Disorder-Dyslexia (RDD). Since the 1960s, the National Institute of Child Health and Development (NICHD) has been conducting the Research Program in Reading Development, Reading Disorders and Reading Instruction.This research has included tens of thousands of adults and children with RDD and has been conducted at 42 sites in the United States and Europe. Similar research projects have been conducted in Russia, China, England, Sweden and Turkey (Lyon, 1999). For a good synopsis of this research check Fletcher, Lyon, Fucks and Barnes (2007).

Although the percentages fluctuate from study to study, about 25 to 30 percent of AD/HD adults have RDD. The NICHD research, as well as other studies, has demonstrated AD/HD and RDD are separate and distinct disorders. However, when they both exist at the same time, these disorders can have a negative effect on each other. Additionally, many adults with RDD and/or AD/HD have a history of language disorders in childhood.

The NICHD found RDD to be an inherited disorder that causes significant anatomical differences in the brain resulting in reading difficulties (Sherman, 1999). Additionally, it was discovered RDD is a lifelong disability that afflicts one in five Americans (Lyon, 1999). Equal numbers of men and women have RDD and it is not connected to intelligence (Young, 1999). In other words, you can have low or high I.Q., be male or female and still have RDD.

Perhaps the most important discoveries the NICHD has made about RDD is what Nancy Mather (Mather, 2000) calls the triple deficit hypothesis. This includes weaknesses in phonological awareness, rapid automatized naming and orthographic processing. Of these three deficits, the research indicates phonological awareness is the key difficulty in RDD. Phonological awareness allows a person to manipulate or study the individual sounds in words. People with RDD have great difficulty connecting sounds to symbols in words and pronouncing words phonetically. The second deficit, weak rapid automatized naming, means those with RDD are impaired in their ability to rapidly name objects they see. This dysnomia appears to be connected to slowness in overall sensory processing speed that makes reading even slower for those with RDD and makes remembering names of objects and people difficult. Reading is not an automatic process for those with RDD; it tends to be quite labored. The third deficit, weak orthographic processing, is remembering how words look when correctly spelled and how the letters relate to the phonics of the word. Thus, the adult with RDD will have difficulty spelling due to his/her poor ability to connect sounds to letters (phonological awareness) and poor memory of how the word looks when spelled correctly. For a good summary of the genetics and neurology of the above see Nicolson and Fawcett (2008).

The NICHD and International Dyslexia Association in light of the above defines RDD as:

“Dyslexia is a specific learning disability that is neurological in origin. It is characterized by difficulties with accurate and/or fluent word recognition as well as by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the lack of provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge.” (International Dyslexia Association, April 20, 2005, p. 1 of 2).

The most common manifestation of RDD in adults is slow and labored reading and very poor spelling. RDD adults can also have disorders of depression and anxiety, as well as suffer from low self-esteem.

How is RDD diagnosed? The Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition,Text Revision provided a bare bones diagnostic criteria. Essentially, administering a standardized I.Q. test and test of reading achievement to determine if the person’s I.Q. is substantially higher than their reading achievement is adequate to diagnose RDD. However, the NICHD research indicates such a technique does not differentiate those with RDD from those with a poor educational background, low intellect or other reasons for reading difficulties. A standardized I.Q. test and test of reading achievement can be helpful to determine if an adult suspected of RDD has sufficient intellect for particular work or educational settings and may point out academic skill weaknesses. However, the NICHD research indicates tests of phonological awareness (i.e., phonemically regular nonsense word reading – “noil”, etc.), rapid automatized naming (i.e., Boston Naming Test, etc.), and orthographic processing (i.e., a standardized spelling test) are necessary to diagnose RDD. Such an evaluation should include an in-depth historical interview to determine if other disorders accompany RDD, like AD/HD and emotional disorders, are present. As a result of the NICHD research and other similar research the new Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (2013) has dropped the requirement of administering an I.Q. test as part of the diagnostic process for RDD. The Individuals with Disabilities Education Act of 2004 (IDEA) (US Department of Education, 2004) also dropped the requirement nationally for public schools across the country. Psychologists, in conjunction with educational therapist/clinical learning specialists, can conduct such evaluations. An excellent guide for such diagnostic evaluations was written by Mapou (2009).

Treatment Options and Accommodations

How is RDD treated in an AD/HD adult? First it is recommended the AD/HD is properly treated. This includes management of their AD/HD with medication as well as learning strategies to compensate for the AD/HD by working with an AD/HD coach. If needed, a mental health professional can address emotional concerns such as depression, anxiety or family problems. Will this cure their RDD? No, however their chances of being able to respond to the RDD training are greatly improved because the AD/HD symptoms of impulsivity, hyperactivity and inattentiveness are better controlled.

Once the RDD symptomatology has been addressed, the RDD issues can be overcome. Although the NICHD research indicates that there is no cure for RDD, many RDD adults can improve their reading skills by being taught to read with a systematic synthetic-multisensory-phonics technique. For example, the adult with RDD is asked tolook at a printed phoneme (one of the 44 sounds of the English language in written form), make the sound of the phoneme (i.e., B – “b”, etc.) and then with their fingers trace the letter as they look at it and say the sound. This “see it - say it – trace it” technique has been quite successful in teaching those with RDD to read. Perhaps the best known of these teaching methods is Orton-Gillingham. However, there are 12 other systematic–synthetic-multisensory-phonics techniques that are equally helpful as determined by the International Dyslexia Association (Henry, No Date)

More advanced readers are given multisensory training in prefixes, root words and suffixes. For example, the adult is presented a card with a printed prefix and they see it, say it and trace it. Although these techniques require substantial drill, many adults with RDD and AD/HD combined will find substantial improvement in their reading. Such training can often be obtained from educational therapists/clinical learning specialists, some adult literacy volunteers and some speech language pathologists.

Recent brain imaging research has shown such training can lead to significantly improved neuroconnectivity and neuroanatomical changes as well as somewhat normalized reading process for those with dyslexia. In 2011 Krafnick and colleagues reported the results of a study where 11 children with RDD were given eight weeks of training in the Lindamood-Bell technique (one of the 13 multi-sensory methods recommended by the International Dyslexia Association). Prior to the training the children’s brains were pre-imaged with MRI grey matter volume voxel-based morphology. Their reading skills were also assessed using reading subtests of the Woodcock-Johnson III. The training was followed by eight weeks of no training. Following the no training period the children were reassessed neurologically and academically. They were found to have made significant improvement in their reading skills and significant neurological changes were found in their brains. In fact, the volume of grey matter in their brains increased significantly in the following areas, all of which have been shown to be the areas non-dyslexics use when engaged in reading: the left anterior fusiform gyrus/hippocampus, left precuneus, right hippocampus and right anterior cerebellum. Non-habilitated RDD children have been found to use other areas of their brains for reading (Dehaene, 2009, p. 235-262).

In addition to training in multisensory-synthetic-multisensory-phonics, there are several work and educational accommodations that can be helpful to eligible adults with RDD. Some of these include LearningAlly, Learning Through Listening (formerly known as: Recordings for the Blind and Dyslexic), Kurzweil reading machines, KNFB Reading (Kurzweil reading phones), Intel Readers, voice activated computers, hand held spell checkers, Quicktionary Reading Pen, Livescribe pen, speech to text computer programs such as Dragon NaturallySpeaking and readers for exams and others.

Many AD/HD adults with RDD are offered protection under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act, Amendment Act of 2008 against discrimination in employment and/or educational settings and many receive accommodations for their disabilities if they qualify. Professionals who diagnosereading/learning disorders need to familiarize themselves with the Association for Higher Education and Disability (AHEAD) (2012): Supporting Accommodation Requests: Guidance on Documentation Practices. It is important that professionals who write reports documenting RDD/learning disorders of their clients follow these guidelines. By doing so, they can help ensure their clients who qualify can receive the work and educational accommodations they need.

Reading Disorder of Recall/Comprehension

Gregg (2009) gave an excellent description of reading comprehension as follows,“To sum up the research findings across theoretical perspectives, it is clear that many different cognitive and linguistic factors may influence an individual’s reading comprehension performance. These include (but are not limited to) word recognition and sublexical processes influencing decoding (phonemic, orthographic and morphemic awareness); fluency; long-term memory; working memory; oral language comprehension; executive strategies; prior knowledge and motivation…” (p. 154).

Unfortunately, the second Reading Disorder many adults with AD/HD tend to experience has not been researched as much. Currently, it is not known what percentage of AD/HD adults suffer from it or the ratio of women to men. However, many clinicians describe AD/HD adults who state they can read fluidly both silently and orally, pronounce all the words, read at an adequate rate and are good spellers, but they cannot remember what they read. This reading problem has not had a consistent name associated with it in the scientific literature. Some have called it “Word Calling” or nonspecificreading disability (Aaron and Baker, 1991, p. 46-47). The term, word calling, can be confused with another disorder, Hyperlexia, which is found in many people with autism spectrum disorders such as Autism Spectrum Disorder. Hyperalexia is a differnt type of reading disorder from what this article will cover. For this article, the type of reading disorder previously described in which AD/HD adults do not remember what they read will be called Reading Disorder of Recall Comprehension (RDR/C).

Most AD/HD adults with RDR/C have adequate phonological awareness, orthographic processing and rapid automatized naming. In fact, they have no symptoms of RDD at all. They just do not remember what they read. Some complain of this after reading a sentence and others after reading a few page. Scientists are not absolutely certain what causes this disorder, but there is accumulating evidence that it could be due to a weakness in working memory. Working memory allows us to keep an idea in mind long enough to manipulate it for a few seconds. The two types of working memory involved appear to be verbal and non-verbal. Russell Barkley, Ph.D. (1998, 2006) describes verbal working memory as internal speech. He states weaknesses in this area are key of his theory of AD/HD. Non-verbal working memory aids us in planning, remembering the spatial location of objects and gives us a sense of time. Deficits in these two working memory systems often come together in AD/HD adults to create difficulties in remembering what they read, thus resulting in a reading comprehension problem. Often adults with RDR/C will have other subtle language comprehension problems. As Barkley (2006) wrote:

“…Because ADHD interferes with working memory (both verbal and nonverbal), those with the disorder should have greater difficulty holding in mind the content of what is read and therefore should be less proficient in understanding what is read. As many clinical patients with ADHD will describe, when reading they often forget what was read at the top portion of the page by the time they have reached the middle or lower portion of the page and therefore must return to the top and read it once again…Given that this is a working memory problem, it should affect not just reading, but listening to story narratives and even viewing televised content…” (p. 322)

People with RDD may also have difficulty with reading comprehension, but this is due to weaknesses in phonological awareness and orthographic processing, as well as rapid automatized naming. AD/HD adults with RDR/C do not tend to have these difficulties; their weaknesses stem from the above mentioned memory deficits. Additionally, AD/HD adults with RDR/C can also have RDD.

Diagnosis and Treatment

How does one diagnose RDR/C? Again, the Diagnostic and Statistical Manual (DSM-IV) offers a bare bones assessment suggestion. An evaluation that includes I.Q. testing and a thorough examination of all reading skills, especially reading comprehension, is suggested. This should include both sentence and paragraph comprehension. It is also suggested additional evaluation of working memory, listening comprehension and a thorough historical interview be conducted. Often a psychologist and/or educational therapist/clinical learning specialist can do the reading evaluation. Apsychologist should conduct the intellectual testing. Sometimes AD/HD adults with RDR/C will also have problems with listening comprehension and other language processing problems. In such cases, a thorough evaluation by a speech language pathologist is urged. Like those with AD/HD and RDD, AD/HD-RDR/C adults can have co-morbid conditions such as depression and anxiety. These should be evaluated by a mental health professional. It is recommended that written reports of the evaluation for such a disability follow the AHEAD Guidelines. Again, Mapou’s (2009) book on assessment is an excellent guide for conducting such assessments.

Treatment for RDR/C is multifaceted. Often those with RDR/C find significant reduction in their problems with recall and comprehension when they are placed on stimulant medication. Those who do not respond sufficiently to this may need to work with an educational therapist/clinical learning specialist to learn methods of actively monitoring what they are reading. This would involve learning ways to survey material prior to reading it—taking note of the bold print, italicized words, pictures, headings, footnotes, etc. in the text in order to construct questions to answer while reading. Once they have written down questions, they actively read the text with the idea of answering them. When they come to an answer to a question, they write it down. These questions and answers can be used for review. The above technique is often called SQ4R, but there are many similar techniques that are just as appropriate. Most educational therapists/special education teachers and clinical learning specialists are familiar with such techniques and can provide the appropriate instruction.

Nanci Bell (1991) believes people with RDR/C do not adequately use visual or mental imaging as they read. She has developed a program to teach adults with RDR/C how to image while they read. She believes learning how to image what is read will allow them to generalize and grasp the global concepts of the material. The program is also said to help those with difficulty in oral expression, oral language comprehension and some written language skills. It is said to help those with RDR/C create entire images that include color and movement. Initial results of the use of this technique have been promising. Often speech language pathologists are trained in the use of this program.

Recently a new technology, COGMED-RM, has been developed that may aid in habilitating RDR/C. This is a computer program developed to teach visual-spatial working memory to those who are weak in this ability. Klingberg (2008) a Swedish neurologist as well as neuropsychologist and his colleagues discovered in the early part of the 21^st Century that children, adolescents and adults with combined type AD/HD have seriously debilitating weaknesses in visual-spatial memory. His program has been shown to be helpful in teaching some with Combined Type AD/HD to read and simultaneously visualize what they read. Dahlin (2011) reported the COGMED-RM program significantly improved reading comprehension in 57 Swedish elementary students with special needs. However, two resent literature reviews of COGMED-RM and similar computer programs indicate that although they may teach students to become more efficient in using such programs, this improvement does not generalize to academic skills and other life areas (Melby-Lervag, and Hulme, May 12, 2012; Shipstead, Redick, and Randall, 2012).. Hence, COGMED may not be ready to be considered a first line treatment for RDR/C, but it may be worth a try if other options are not successful.

For the most severe cases of RDR/C, it is suggested treatment be sought from a speech language pathologist.

Accommodations

“Read-alouds or extended time alone do not always effectively meet the learning needs of individuals with LD who are struggling with the meaning of oral or written language. For adolescents and adults with ADHD whose executive processing deficits limits their strategic thinking, organization and revision skills, such accommodations may be limited in their effectiveness.” (Gregg, 2009, p. 157)

Gregg (2009) suggested using text-to-speech (TTS) software, like Dragon Naturally Speaking, to give students with RDR/C multisensory input (visual and auditory) of what they are reading. In this vain it makes sense to use the aforementioned Kurzweil technologies, Intel Readers, electronic pens and reading/listening services for this population as well.

Many RDR/C adults qualify for protection under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act, Amendment Act of 2008. Several of the above mentioned workplace and educational accommodations useful for those with RDD are also helpful with RDR/C. However, the specific accommodations must be assigned according to the specific disability profile of the individual. It is recommended the reports of evaluations of such reading problems follow the AHEAD (2012) guidelines.

AD/HD adults can have both RDD and RDR/C and these two reading problems can cause great frustration. Therefore, it is important adults receive thorough evaluations of their reading problems, as well as appropriate treatment and accommodations. By doing so they can be more successful in school and work and possibly have a better quality of life.

Postscript: Thirteen years ago when I wrote the first version of this article I could not envision the advances we have made in our understanding of RDD, AD/HD and RDR/C. The knowledge continues to advance at a breakneck pace. Today I read a brain imagery research article that found the neuroanatomy of girls with RDD differs significantly from that of boys with RDD (Evans, Flowers, Napoliello and Eden, April, 2013). The authors concluded if their findings are replicated we may eventually have gender specific methods of habilitating RDD.

Thirteen years ago I thanked Freda Harper, Psy.D. for her help in editing this article. Now Dr. Harper is Dr. Blake, my wife, and again I thank her for her help in re-editing this article.

*****This article by Dr. Blake appeared in the May/June, 2000 edition of Attention!, 6, (5), pp. 30-33.

References

Aaron, P.G., and Baker, C. (1991). Reading Disabilities in College and High School:

Diagnosis and Management. Parkton, MD: York.

Association for Higher Education and Disability (AHEAD) (2012) Supporting

Accommodation Requests: Guidance on Documentation Practices. From website: http://www.ahead.org/uploads/docs/resources/Final_AHEAD_Supporting%20Accommodation%20Requests%20with%20Q&A%2009_12.pdf.

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition. Washington, DC: American Psychiatric Association.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition-Text Revision. Washington, DC: American Psychiatric Association.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition. Washington, DC: American Psychiatric Association.

Author (July, 2012). An Insightful Q&A with Dr. Larry Silver: An Inside Look At DSM-5. Pittsburg, PA: Learning Disabilities Association of America. From Website: http://www.ldanatl.org/legislative/pubs/120820_DSM-5_Q-A_with-Larry-Silver.pdf.

Author (May 1, 2012) Attention Deficit/Hyperactivity Disorder-Rationale: Rationale for Changes in ADHD in DSM-5 From the ADHD and Disruptive Behavior Disorders Workgroup. From website: http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383#.

Barkley, R. A. (November 9, 2012) The Other Attention Disorder: Sluggish Cognitive Tempo (ADD/SCT) Vs. ADHD– Impairment, and Management. Paper presented at the 24^th Annual CHADD International Conference on ADHD, Burlingame, CA, November 8 – 10, 2012.

Barkley, R.A. (2006). Attention Deficit Hyperactivity Disorder, Third Edition. New

York, NY: Guilford.

Bell, N. (1991). Visualizing and Verbalizing for Language Comprehension and Thinking.

San Luis Obispo, CA: Grander Educational Publishing.

Dehaene, S. (2009). Reading In The Brain: The Science Of How We Read. New York, NY: Penguin.

Dahlin, K.I. (2011). Effects of Working Memory Training On Reading in Children with Special Needs. Reading and Writing, 24(4), 479-491. From website: http://link.springer.com/article/10.1007%2Fs11145-010-9238-y.

Evans, T.M., Flowers, D.L., Napoliello, E.M. and Eden, G.F. (April, 2013). Sex-specific gray matter volume differences in females with developmental dyslexia. Brain Structure and Function, DOI 10.1007/s00429-013-0552-4. From website: http://link.springer.com/article/10.1007%2Fs00429-013-0552-4#.

Henry, M. (No Date). Framework for Informed Reading and Language Instruction: Matrix of Multisensory Structured Language Programs. Baltimore, MD: International Dyslexia Association.

International Dyslexia Association (April 20, 2005). IDA/NIH Adopts A New Definition of Dyslexia. From website: www.interdys.org/serlet/compose?section_id=8&page_id=69, Page 1 of 2.

Klingberg, T. (2008). The Overflow Brain: Information Overload and The limits of Working Memory. New York, NY: Oxford.

Lyon, G.R. (November 4, 1999) . In Celebration of Science in the Study of Reading Development, Reading Disorders and Reading Instruction. Paper presented at the International Dyslexia Association, 50th Anniversary Conference.

Mather, N. (February 16, 2000). So What’s Up with Dyslexia? Paper presented at the 37^th Annual Conference of the Learning Disability Association, Reno, NV.

Mapou, R.L. (2009). Adult Learning Disabilities and ADHD: Research-Informed Assessment. NewYork, NY: Oxford University Press.

Melby-Lervag, M., and Hulme, C. (May 12, 2012). Is Working Memory Training Effective? A Meta-Analytic Review. Developmental Psychology. From website: http://www.ncbi.nlm.nih.gov/pubmed/22612437 .

Nicolson, R.I. and Fawcett, A.J. (2008). Dyslexia, Learning, and The Brain. London, England: MIT Press.

Shaywitz, S.E. (November, 1996). Dyslexia. Scientific America, 275 (5), 98-104.

Shaywitz, S. (2003). Overcoming Dyslexia: A New and Complete Science-Based program for Reading Problems at Any Level. New York, NY: Alfred Knopf.

Sherman, G. (November 4, 1999). Anatomical and Cognitive Variability in

Developmental Dyslexia. Paper presented at the International Dyslexia

Association, 50th Anniversary Conference, Chicago, IL.

US Department of Education (No Date). On the legacy IDEA 2004. http://idea.ed.gov/Building.

Young, G. (October 25, 1999). Ten Years of Progress. Paper Presented at the Learning

Disabilities Association of Arizona, 29th Annual Conference, Phoenix, AZ.

Professional Books Related to Adult Reading Problems

Aaron, P.C., and Baker, C. (1991). Reading Disabilities in College and High School:

Diagnosis and Treatment. Parkton, MD: York.

Bell, N., (1991). Visualizing and Verbalizing for Language Comprehension and

Thinking. San Luis Obispo, CA: Grander Educational Publishing.

Clark, D.B. (1988). Dyslexia: Theory and Practice of Remedial Instruction. Parkton,

MD: York.

Cramer, S.C., and Ellis, W. (1996). Learning Disabilities: Lifelong Issues. Baltimore,

MD: Paul H. Brooks.

Duane, D.D. (1999). Reading and Attention Disorders: Neurobiological Correlates.

Parkton, MD: York.

Dehaene, S. (2009). Reading In The Brain: The Science Of How We Read. New York, NY: Penguin.

Fletcher, J.M., Lyon, G.R., Fuchs, L.S. and Barnes, M.A. (2007). Learning Disabilities: From Identification to Intervention. New York, NY: Guilford.

Goldstein, S. (1997). Managing Attention and Learning Disorders in Late Adolescence

and Adulthood: A Guide for Practitioners. New York, NY: John Wiley and Sons.

Gregg, N. (2009). Adolescents and Adults With Learning Disabilities and ADHD: Assessment and Accommodation. New York, NY: Guilford.

Klingberg, T. (2008). The Overflow Brain: Information Overload and The limits of Working Memory. New York, NY: Oxford.

Nicolson, R.I. and Fawcett, A.J. (2008). Dyslexia, Learning, and The Brain. London, England: MIT Press.

Pennington, B.F. (2009). Diagnosing Learning Disorders: A Neuropsychological Framework, Second Edition. New York, NY: Guilford.

Shaywitz, S.E. (November, 1996). Dyslexia. Scientific America, 275 (5), 98-104.

Shaywitz, S. (2003). Overcoming Dyslexia: A New and Complete Science-Based program for Reading Problems at Any Level. New York, NY: Alfred Knopf.

Shipstead, Z., Redick, T.S. and Randall, W.E. (2012). Is Working Memory Training Effective? Psychological Bulletin, DOI: 10.1037/a0027473.

Tridas, E.Q. (2007). From ABC TO ADHD: What Parents Should Know About Dyslexia and Attention Problems. Baltimore, MD: International Dyslexia Association.

US Department of Education (No Date). On the legacy IDEA 2004. http://idea.ed.gov/Building.

Helpful Websites

Children and Adults with Attention Deficit Disorders (CHADD): www.chadd.org

National Resource Center on ADHD: A Program of CHADD: www.help4adhd.org

Attention Deficit Disorder Association: www.add.org

International Dyslexia Association: www.interdys.org

Learning Disabilities Association of America: www.ldanatl.org

National Center for Learning Disabilities: www.ncld.org

LD On Line: www.ldonline.org

What Works Clearinghouse: www.whatworks.ed.gov

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