EVERYTHING YOU NEED TO KNOW ABOUT
By the US National Institute of Mental Health
Imagine having important needs and ideas to communicate, but being unable
to express them. Perhaps feeling bombarded by sights and sounds, unable
to focus your attention. Or trying to read or add but not being able to
make sense of the letters or numbers.
You may not need to imagine. You may be the parent or teacher of a child
experiencing academic problems, or have someone in your family diagnosed
as learning disabled. Or possibly as a child you were told you had a reading
problem called dyslexia or some other learning handicap.
Although different from person to person, these difficulties make up the
common daily experiences of many learning disabled children, adolescents,
and adults. A person with a learning disability may experience a cycle
of academic failure and lowered self-esteem. Having these handicaps--or
living with someone who has them--can bring overwhelming frustration.
But the prospects are hopeful. It is important to remember that a person
with a learning disability can learn. The disability usually only
affects certain limited areas of a child's development. In fact, rarely
are learning disabilities severe enough to impair a person's potential
to live a happy, normal life.
This booklet is provided by the National Institute of Mental Health (NIMH),
the Federal agency that supports research nationwide on the brain, mental
illnesses, and mental health. Scientists supported by NIMH are dedicated
to understanding the workings and interrelationships of the various regions
of the brain, and to finding preventions and treatments to overcome brain
dysfunctions that handicap people in school, work, and play.
The booklet provides up--to-date information on learning disabilities and
the role of NIMH-sponsored research in discovering underlying causes and
effective treatments. It describes treatment options, strategies for coping,
and sources of information and support. Among these sources are doctors,
special education teachers, and mental health professionals who can help
identify learning disabilities and recommend the right combination of medical,
psychosocial, and educational treatment.
In this booklet, you'll also read the stories of Susan, Wallace, and Dennis,
three people who have learning disabilities. Although each had a rough
start, with help they learned to cope with their handicaps. You'll see
their early frustrations, their steps toward getting help, and their hopes
for the future.
The stories of Susan, Wallace, and Dennis are representative of people
with learning disabilities, but the characters are not real. Of course,
people with learning disabilities are not all alike, so these stories may
not fit any particular individual.
UNDERSTANDING THE PROBLEM
At age 14, Susan still tends to be quiet. Ever since she was a child,
she was so withdrawn that people sometimes forgot she was there. She seemed
to drift into a world of her own. When she did talk, she often called objects
by the wrong names. She had few friends and mostly played with dolls or
her little sister. In school, Susan hated reading and math because none
of the letters, numbers or "+" and "-" signs made any sense. She felt awful
about herself. She'd been told--and was convinced--that she was retarded.
Wallace has lived 46 years, and still has trouble understanding what
people say. Even as a boy, many words sounded alike. His father patiently
said things over and over. But whenever his mother was drunk, she flew
into a rage and spanked him for not listening. Wallace's speech also came
out funny. He had such problems saying words that in school his teacher
sometimes couldn't understand him. When classmates called him a "dummy,"
his fists just seemed to take over.
Dennis is 23 years old and still seems to have too much energy. But
he had always been an overactive boy, sometimes jumping on the sofa for
hours until he collapsed with exhaustion. In grade school, he never sat
still. He interrupted lessons. But he was a friendly, well-meaning kid,
so adults didn't get too angry. His academic problems became evident in
third grade, when his teacher realized that Dennis could only recognize
a few words and wrote like a first grader. She recommended that Dennis
repeat third grade, to give him time to "catch up." After another full
year, his behavior was still out of control, and his reading and writing
had not improved.
What Is a Learning Disability?
Unlike other disabilities, such as paralysis or blindness, a learning disability
(LD) is a hidden handicap. A learning disability doesn't disfigure or leave
visible signs that would invite others to be understanding or offer support.
A woman once blurted to Wallace, "You seem so intelligent--you don't look
LD is a disorder that affects people's ability to either interpret what
they see and hear or to link information from different parts of the brain.
These limitations can show up in many ways--as specific difficulties with
spoken and written language, coordination, self-control, or attention.
Such difficulties extend to schoolwork and can impede learning to read
or write, or to do math.
Learning disabilities can be lifelong conditions that, in some cases, affect
many parts of a person's life: school or work, daily routines, family life,
and sometimes even friendships and lay. In some people, many overlapping
learning disabilities may be apparent. Other people may have a single,
isolated learning problem that has little impact on other areas of their
What Are the Types of Learning Disabilities?
"Learning disability" is not a diagnosis in the same sense as "chickenpox"
or "mumps." Chickenpox and mumps imply a single, known cause with a predictable
set of symptoms. Rather, LD is a broad term that covers a pool of possible
causes, symptoms, treatments, and outcomes. Partly because learning disabilities
can show up in so many forms, it is difficult to diagnose or to pinpoint
the causes. And no one knows of a pill or remedy that will cure them.
Not all learning problems are necessarily learning disabilities. Many children
are simply slower in developing certain skills. Because children show natural
differences in their rate of development, sometimes what seems to be a
learning disability may simply be a delay in maturation. To be diagnosed
as a learning disability, specific criteria must be met.
The criteria and characteristics for diagnosing learning disabilities appear
in a reference book called the DSM (short for the Diagnostic and Statistical
Manual of Mental Disorders). The DSM diagnosis is commonly used when
applying for health insurance coverage of diagnostic and treatment services.
Learning disabilities can be divided into three broad categories:
Developmental speech and language disorders
Academic skills disorders
"Other," a catch-all that includes certain coordination disorders and learning
handicaps not covered by the other terms
Each of these categories includes a number of more specific disorders.
Developmental Speech and Language Disorders
Speech and language problems are often the earliest indicators of a
learning disability. People with developmental speech and language disorders
have difficulty producing speech sounds, using spoken language to communicate,
or understanding what other people say. Depending on the problem, the specific
diagnosis may be:
Developmental articulation disorder
Developmental expressive language disorder
Developmental receptive language disorder
Developmental Articulation Disorder -- Children with this
disorder may have trouble controlling their rate of speech. Or they may
lag behind playmates in learning to make speech sounds. For example, Wallace
at age 6 still said "wabbit" instead of "rabbit" and "thwim" for "swim."
Developmental articulation disorders are common. They appear in at least
10 percent of children younger than age 8. Fortunately, articulation disorders
can often be outgrown or successfully treated with speech therapy.
Developmental Expressive Language Disorder -- Some children
with language impairments have problems expressing themselves in speech.
Their disorder is called, therefore, a developmental expressive language
disorder. Susan, who often calls objects by the wrong names, has an expressive
language disorder. Of course, an expressive language disorder can take
other forms. A 4-year-old who speaks only in two-word phrases and a 6-year-old
who can't answer simple questions also have an expressive language disability.
Developmental Receptive Language Disorder -- Some people
have trouble understanding certain aspects of speech. It's as if their
brains are set to a different frequency and the reception is poor. There's
the toddler who doesn't respond to his name, a preschooler who hands you
a bell when you asked for a ball, or the worker who consistently can't
follow simple directions. Their hearing is fine, but they can't make sense
of certain sounds, words, or sentences they hear. They may even seem inattentive.
These people have a receptive language disorder. Because using and understanding
speech are strongly related, many people with receptive language disorders
also have an expressive language disability.
Of course, in preschoolers, some misuse of sounds, words, or grammar is
a normal part of learning to speak. It's only when these problems persist
that there is any cause for concern.
Academic Skills Disorders
Students with academic skills disorders are often years behind their
classmates in developing reading, writing, or arithmetic skills. The diagnoses
in this category include:
Developmental reading disorder
Developmental writing disorder
Developmental arithmetic disorder
Developmental Reading Disorder -- This type of disorder,
also known as dyslexia, is quite widespread. In fact, reading disabilities
affect 2 to 8 percent of elementary school children.
When you think of what is involved in the "three R's"--reading, 'riting,
and 'rithmetic--it's astounding that most of us do learn them. Consider
that to read, you must simultaneously:
Focus attention on the printed marks and control eye movements across the
Recognize the sounds associated with letters
Understand words and grammar
Build ideas and images
Compare new ideas to what you already know
Store ideas in memory
Such mental juggling requires a rich, intact network of nerve cells that
connect the brain's centers of vision, language, and memory.
A person can have problems in any of the tasks involved in reading. However,
scientists found that a significant number of people with dyslexia share
an inability to distinguish or separate the sounds in spoken words. Dennis,
for example, can't identify the word "bat" by sounding out the individual
letters, b-a-t. Other children with dyslexia may have trouble with rhyming
games, such as rhyming "cat" with "bat." Yet scientists have found these
skills fundamental to learning to read. Fortunately, remedial reading specialists
have developed techniques that can help many children with dyslexia acquire
However, there is more to reading than recognizing words. If the brain
is unable to form images or relate new ideas to those stored in memory,
the reader can't understand or remember the new concepts. So other types
of reading disabilities can appear in the upper grades when the focus of
reading shifts from word identification to comprehension.
Developmental Writing Disorder -- Writing, too, involves
several brain areas and functions. The brain networks for vocabulary, grammar,
hand movement, and memory must all be in good working order. So a developmental
writing disorder may result from problems in any of these areas. For example,
Dennis, who was unable to distinguish the sequence of sounds in a word,
had problems with spelling. A child with a writing disability, particularly
an expressive language disorder, might be unable to compose complete, grammatical
Developmental Arithmetic Disorder -- If you doubt that arithmetic
is a complex process, think of the steps you take to solve this simple
problem: 25 divided by 3 equals ?
Arithmetic involves recognizing numbers and symbols, memorizing facts such
as the multiplication table, aligning numbers, and understanding abstract
concepts like place value and fractions. Any of these may be difficult
for children with developmental arithmetic disorders. Problems with numbers
or basic concepts are likely to show up early. Disabilities that appear
in the later grades are more often tied to problems in reasoning.
Many aspects of speaking, listening, reading, writing, and arithmetic overlap
and build on the same brain capabilities. So it's not surprising that people
can be diagnosed as having more than one area of learning disability. For
example, the ability to understand language underlies learning speak. Therefore,
any disorder that hinders the ability to understand language will also
interfere with the development of speech, which in turn hinders learning
to read and write. A single gap in the brain's operation can disrupt many
types of activity.
"Other" Learning Disabilities
The DSM also lists additional categories, such as "motor skills disorders"
and "specific developmental disorders not otherwise specified." These diagnoses
include delays in acquiring language, academic, and motor skills that can
affect the ability to learn, but do not meet the criteria for a specific
learning disability. Also included are coordination disorders that can
lead to poor penmanship, as well as certain spelling and memory disorders.
Nearly 4 million school-age children have learning disabilities. Of
these, at least 20 percent have a type of disorder that leaves them unable
to focus their attention.
Some children and adults who have attention disorders appear to daydream
excessively. And once you get their attention, they're often easily distracted.
Susan, for example, tends to mentally drift off into a world of her own.
Children like Susan may have a number of learning difficulties. If, like
Susan, they are quiet and don't cause problems, their problems may go unnoticed.
They may be passed along from grade to grade, without getting the special
assistance they need.
In a large proportion of affected children--mostly boys--the attention
deficit is accompanied by hyperactivity. Dennis is an example of a person
with attention deficit hyperactivity disorder--ADHD. They act impulsively,
running into traffic or toppling desks. Like young Dennis, who jumped on
the sofa to exhaustion, hyperactive children can't sit still. They blurt
out answers and interrupt. In games, they can't wait their turn. These
children's problems are usually hard to miss. Because of their constant
motion and explosive energy, hyperactive children often get into trouble
with parents, teachers, and peers.
By adolescence, physical hyperactivity usually subsides into fidgeting
and restlessness. But the problems with attention and concentration often
continue into adulthood. At work, adults with ADHD often have trouble organizing
tasks or completing their work. They don't seem to listen to or follow
directions. Their work may be messy and appear careless.
Attention disorders, with or without hyperactivity, are not considered
learning disabilities in themselves. However, because attention problems
can seriously interfere with school performance, they often accompany academic
What Causes Learning Disabilities
Understandably, one of the first questions parents ask when they learn
their child has a learning disorder is "Why? What went wrong?"
Mental health professionals stress that since no one knows what causes
learning disabilities, it doesn't help parents to look backward to search
for possible reasons. There are too many possibilities to pin down the
cause of the disability with certainty. It is far more important for the
family to move forward in finding ways to get the fight help.
Scientists, however, do need to study causes in an effort to identify ways
to prevent learning disabilities.
Once, scientists thought that all learning disabilities were caused by
a single neurological problem. But research supported by NIMH has helped
us see that the causes are more diverse and complex. New evidence seems
to show that most learning disabilities do not stem from a single, specific
area of the brain, but from difficulties in bringing together information
from various brain regions.
Today, a leading theory is that learning disabilities stem from subtle
disturbances in brain structures and functions. Some scientists believe
that, in many cases, the disturbance begins before birth.
Errors in Fetal Brain Development
Throughout pregnancy, the fetal brain develops from a few all-purpose
cells into a complex organ made of billions of specialized, interconnected
nerve cells called neurons. During this amazing evolution, things can go
wrong that may alter how the neurons form or interconnect.
In the early stages of pregnancy, the brain stem forms. It controls basic
life functions such as breathing and digestion. Later, a deep ridge divides
the cerebrum--the thinking part of the brain--into two halves, a right
and left hemisphere. Finally, the areas involved with processing sight,
sound, and other senses develop, as well as the areas associated with attention,
thinking, and emotion.
As new cells form, they move into place to create various brain structures.
Nerve cells rapidly grow to form networks with other parts of the brain.
These networks are what allow information to be shared among various regions
of the brain.
Throughout pregnancy, this brain development is vulnerable to disruptions.
If the disruption occurs early, the fetus may die, or the infant may be
born with widespread disabilities and possibly mental retardation. If the
disruption occurs later, when the cells are becoming specialized and moving
into place, it may leave errors in the cell makeup, location, or connections.
Some scientists believe that these errors may later show up as learning
(Graphic Omitted. Shows brain development for stages 4-, 6-, and
8-month-old fetus; birth; and adult.)
Other Factors That Affect Brain Development
Through experiments with animals, scientists at NIMH and other research
facilities are tracking clues to determine what disrupts brain development.
By studying the normal processes of brain development, scientists can better
understand what can go wrong. Some of these studies are examining how genes,
substance abuse, pregnancy problems, and toxins may affect the developing
Genetic Factors -- The fact that learning disabilities tend
to run in families indicates that there may be a genetic link. For example,
children who lack some of the skills needed for reading, such as hearing
the separate sounds of words, are likely to have a parent with a related
problem. However, a parent's learning disability may take a slightly different
form in the child. A parent who has a writing disorder may have a child
with an expressive language disorder. For this reason, it seems unlikely
that specific learning disorders are inherited directly. Possibly, what
is inherited is a subtle brain dysfunction that can in turn lead to a learning
There may be an alternative explanation for why LD might seem to run in
families. Some learning difficulties may actually stem from the family
environment. For example, parents who have expressive language disorders
might talk less to their children, or the language they use may be distorted.
In such cases, the child lacks a good model for acquiring language and
therefore, may seem to be learning disabled.
Tobacco, Alcohol, and Other Drug Use -- Many drugs taken
by the mother pass directly to the fetus. Research shows that a mother's
use of cigarettes, alcohol, or other drugs during pregnancy may have damaging
effects on the unborn child. Therefore, to prevent potential harm to developing
babies, the U.S. Public Health Service supports efforts to make people
aware of the possible dangers of smoking, drinking, and using drugs.
Scientists have found that mothers who smoke during pregnancy may be more
likely to bear smaller babies. This is a concern because small newborns,
usually those weighing less than 5 pounds, tend to be at risk for a variety
of problems, including learning disorders.
Alcohol also may be dangerous to the fetus' developing brain. It appears
that alcohol may distort the developing neurons. Heavy alcohol use during
pregnancy has been linked to fetal alcohol syndrome, a condition that can
lead to low birth weigh, intellectual impairment, hyperactivity, and certain
physical defects. Any alcohol use during pregnancy, however, may influence
the child's development and lead to problems with learning, attention,
memory, or problem solving. Because scientists have not yet identified
"safe" levels, alcohol should be used cautiously by women who are pregnant
or who may soon become pregnant.
Drugs such as cocaine--especially in its smokable form known as crack--seem
to affect the normal development of brain receptors. These brain cell parts
help to transmit incoming signals from our skin, eyes, and ears, and help
regulate our physical response to the environment. Because children with
certain learning disabilities have difficulty understanding speech sounds
or letters, some researchers believe that learning disabilities, as well
as ADHD, may be related to faulty receptors. Current research points to
drug abuse as a possible cause of receptor damage.
Problems During Pregnancy or Delivery -- Other possible causes
of learning disabilities involve complications during pregnancy. In some
cases, the mother's immune system reacts to the ferns and attacks it as
if it were an infection. This type of disruption seems to cause newly formed
brain cells to settle in the wrong part of the brain. Or during delivery,
the umbilical cord may become twisted and temporarily cut off oxygen to
the fetus. This, too, can impair brain functions and lead to LD.
Toxins in the Child's Environment -- New brain cells and
neural networks continue to be produced for a year or so after the child
is born. These cells are vulnerable to certain disruptions, also.
Researchers are looking into environmental toxins that may lead to learning
disabilities, possibly by disrupting childhood brain development or brain
processes. Cadmium and lead, both prevalent in the environment, are becoming
a leading focus of neurological research. Cadmium, used in making some
steel products, can get into the soil, then into the foods we eat. Lead
was once common in paint and gasoline, and is still present in some water
pipes. A study of animals sponsored by the National Institutes of Health
showed a connection between exposure to lead and learning difficulties.
In the study, rats exposed to lead experienced changes in their brainwaves,
slowing their ability to learn. The learning problems lasted for weeks,
long after the rats were no longer exposed to lead.
In addition, there is growing evidence that learning problems may develop
in children with cancer who had been treated with chemotherapy or radiation
at an early age. This seems particularly true of children with brain tumors
who received radiation to the skull.
Are Learning Disabilities Related to Differences
in the Brain?
In comparing people with and without learning disabilities, scientists
have observed certain differences in the structure and functioning of the
brain. For example, new research indicates that there may be variations
in the brain structure called the planum temporale, a language-related
area found in both sides of the brain. In people with dyslexia, the two
structures were found to be equal in size. In people who are not dyslexic,
however, the left planum temporale was noticeably larger. Some scientists
believe reading problems may be related to such differences.
With more research, scientists hope to learn precisely how differences
in the structures and processes of the brain contribute to learning disabilities,
and how these differences might be treated or prevented.
Susan was promoted to the sixth grade but still couldn't do basic math.
So, her mother brought her to a private clinic for testing. The clinician
observed that Susan had trouble associating symbols with their meaning,
and this was holding back her language, reading, and math development.
Susan called objects by the wrong words and she could not associate sounds
with letters or recognize math symbols. However, an IQ of 128 meant that
Susan was quite bright. In addition to developing an Individualized Education
Plan, the clinician recommended that Susan receive counseling for her low
self-esteem and depression.
In the early 1960s, at the request of his ninth grade teacher, Wallace
was examined by a doctor to see why he didn't speak or listen well. The
doctor tested his vocal cords, vision, and hearing. They were all fine.
The teacher concluded that Wallace must have "brain damage," so not much
could be done. Wallace kept failing in school and was suspended several
times for fighting. He finally dropped out after tenth grade. He spent
the next 25 years working as a janitor. Because LD frequently went undiagnosed
at the time when Wallace was young, the needed help was not available to
In fifth grade, Dennis' teacher sent him to the school psychologist
for testing. Dennis was diagnosed as having developmental reading and developmental
writing disorders. He was also identified as having an attention disorder
with hyperactivity. He was placed in an all-day special education program,
where he could work on his particular deficits and get individual attention.
His family doctor prescribed the medication Ritalin to reduce his hyperactivity
and distractibility. Along with working to improve his reading, the special
education teacher helped him improve his listening skills. Since his handwriting
was still poor, he learned to type homework and reports on a computer.
At age 19, Dennis graduated from high school and was accepted by a college
that gives special assistance to students with learning disabilities.
How Are Learning Disabilities First Identified?
The first step in solving any problem is realizing there is one. Wallace,
sadly, was a product of his time, when learning disabilities were more
of a mystery and often went unrecognized. Today, professionals would know
how to help Wallace. Dennis and Susan were able to get help because someone
saw the problem and referred them for help.
When a baby is born, the parents eagerly wait for the baby's first step,
first word, a myriad of other "firsts." During routine checkups, the pediatrician,
too, watches for more subtle signs of development. The parents and doctor
are watching for the child to achieve developmental milestones. The developmental
milestones chart (omitted here; see page 18 of brochure) lists a few of
these markers and the ages and grades that they typically appear.
Parents are usually the first to notice obvious delays in their child reaching
early milestones. The pediatrician may observe more subtle signs of minor
neurological damage, such as a lack of coordination. But the classroom
teacher, in fact, may be the first to notice the child's persistent difficulties
in reading, writing, or arithmetic. As school tasks become more complex,
a child with a learning disability may have problems mentally juggling
The learning problems of children who are quiet and polite in school may
go unnoticed. Children with above average intelligence, who manage to maintain
passing grades despite their disability, are even less likely to be identified.
Children with hyperactivity, on the other hand, will be identified quickly
by their impulsive behavior and excessive movement. Hyperactivity usually
begins before age 4 but may not be recognized until the child enters school.
What should parents, doctors, and teachers do if critical developmental
milestones haven't appeared by the usual age? Sometimes it's best to allow
a little more time, simply for the brain to mature a bit. But if a milestone
is already long delayed, if there's a history of learning disabilities
in the family, or if there are several delayed kills, the child should
be professionally evaluated as soon as possible. An educator or a doctor
who treats children can suggest where to go for help.
How Are Learning Disabilities Formally Diagnosed?
By law, learning disability is defined as a significant gap between a person's
intelligence and the skills the person has achieved at each age. This means
that a severely retarded 10-year-old who speaks like a 6-year-old probably
doesn't have a language or speech disability. He has mastered language
up to the limits of his intelligence. On the other hand, a fifth grader
with an IQ of 100 who can't write a simple sentence probably does have
Learning disorders may be informally flagged by observing significant
delays in the child's skill development. A 2-year delay in the primary
grades is usually considered significant. For older students, such a delay
is not as debilitating, so learning disabilities aren't usually suspected
unless there is more than a 2-year delay. Actual diagnosis of learning
disabilities, however, is made using standardized tests that compare the
child's level of ability to what is considered normal development for a
person of that age and intelligence.
For example, as late as fifth grade, Susan couldn't add two numbers, even
though she rarely missed school and was good in other subjects. Her mother
took her to a clinician, who observed Susan's behavior and administered
standardized math and intelligence tests. The test results showed that
Susan's math skills were several years behind, given her mental capacity
for learning. Once other possible causes like lack of motivation and vision
problems were ruled out, Susan's math problem was formally diagnosed as
a specific learning disability.
Test outcomes depend not only on the child's actual abilities, but on the
reliability of the test and the child's ability to pay attention and understand
the questions. Children like Dennis, with poor attention or hyperactivity,
may score several points below their true level of ability. Testing a child
in an isolated room can sometimes help the child concentrate and score
Each type of LD is diagnosed in slightly different ways. To diagnose speech
and language disorders, a speech therapist tests the child's pronunciation,
vocabulary, and grammar and compares them to the developmental abilities
seen in most children that age. A psychologist tests the child's intelligence.
A physician checks for any ear infections, and an audiologist may be consulted
to rule out auditory problems. If the problem involves articulation, a
doctor examines the child's vocal cords and throat.
In the case of academic skills disorders, academic development in reading,
writing, and math is evaluated using standardized tests. In addition, vision
and hearing are tested to be sure the student can see words clearly and
can hear adequately. The specialist also checks if the child has missed
much school. It's important to rule out these other possible factors. After
all, treatment for a learning disability is very different from the remedy
for poor vision or missing school.
ADHD is diagnosed by checking for the long-term presence of specific behaviors,
such as considerable fidgeting, losing things, interrupting, and talking
excessively. Other signs include an inability to remain seated, stay on
task, or take turns. A diagnosis of ADHD is made only if the child shows
such behaviors substantially more than other children of the same age.
If the school fails to notice a learning delay, parents can request an
outside evaluation. In Susan's case, her mother chose to bring Susan to
a clinic for testing. She then brought documentation of the disability
back to the school. After confirming the diagnosis, the public school was
obligated to provide the kind of instructional program that Susan needed.
Parents should stay abreast of each step of the school's evaluation. Parents
also need to know that they may appeal the school's decision if they disagree
with the findings of the diagnostic team. And like Susan's mother, who
brought Susan to a clinic, parents always have the option of getting a
Some parents feel alone and confused when talking to learning specialists.
Such parents may find it helpful to ask someone they like and trust to
go with them to school meetings. The person may be the child's clinician
or caseworker, or even a neighbor. It can help to have someone along who
knows the child and can help understand the child's test scores or learning
What Are the Education Options?
Although obtaining a diagnosis is important, even more important is creating
a plan for getting the right help. Because LD can affect the child and
family in so many ways, help may be needed on a variety of fronts: educational,
medical, emotional, and practical.
In most ways, children with learning disabilities are no different from
children without these disabilities. At school, they eat together and share
sports, games, and after-school activities. But since children with learning
disabilities do have specific learning needs, most public schools provide
Schools typically provide special education programs either in a separate
all-day classroom or as a special education class that the student attends
for several hours each week. Some parents hire trained tutors to work with
their child after school. If the problems are severe, some parents choose
to place their child in a special school for the learning disabled.
If parents choose to get help outside the public schools, they should select
a learning specialist carefully. The specialist should be able to explain
things in terms that the parents can understand. Whenever possible, the
specialist should have professional certification and experience with the
learner's specific age group and type of disability. Some of the support
groups listed at the end of this booklet can provide references to qualified
special education programs.
Planning a special education program begins with systematically identifying
what the student can and cannot do. The specialist looks for patterns in
the child's gaps. For example, if the child fails to hear the separate
sounds in words, are there other sound discrimination problems? If there's
a problem with handwriting, are there other motor delays? Are there any
consistent problems with memory?
Special education teachers also identify the types of tasks the child can
do and the senses that function well. By using the senses that are intact
and bypassing the disabilities, many children can develop needed skills.
These strengths offer alternative ways the child can learn.
After assessing the child's strengths and weaknesses, the special education
teacher designs an Individualized Educational Program (IEP). The IEP outlines
the specific skills the child needs to develop as well as appropriate learning
activities that build on the child's strengths. Many effective learning
activities engage several skills and senses.
For example, in learning to spell and recognize words, a student may be
asked to see, say, write, and spell each new word. The student may also
write the words in sand, which engages the sense of touch. Many experts
believe that the more senses children use in learning a skill, the more
likely they are to retain it.
An individualized, skill-based approach--like the approach used by speech
and language therapists--often succeeds in helping where regular classroom
instruction fails. Therapy for speech and language disorders focuses on
providing a stimulating but structured environment for heating and practicing
For example, the therapist may help a child who has an articulation disorder
to produce specific speech sounds. During an engaging activity, the therapist
may talk about the toys, then encourage the child to use the same sounds
or words. In addition, the child may watch the therapist make the sound,
feel the vibration in the therapist's throat, then practice making the
sounds before a mirror.
Researchers are also investigating nonstandard teaching methods. Some create
artificial learning conditions that may help the brain receive information
in nonstandard ways. For example, in some language disorders, the brain
seems abnormally slow to process verbal information. Scientists are testing
whether computers that talk can help teach children to process spoken sounds
more quickly. The computer starts slowly, pronouncing one sound at a time.
As the child gets better at recognizing the sounds and heating them as
words, the sounds are gradually speeded up to a normal rate of speech.
Is Medication Available?
For nearly six decades, many children with attention disorders have benefited
from being treated with medication. Three rugs, Ritalin (methylphenidate),
Dexedrine (dextroamphetamine), and Cylert (pemoline), have been used successfully.
Although these drugs are stimulants in the same category as "speed" and
"diet pills," they seldom make children "high" or more jittery. Rather,
they temporarily improve children's attention and ability to focus. They
also help children control their impulsiveness and other hyperactive behaviors.
The effects of medication are most dramatic in children with ADHD. Shortly
after taking the medication, they become more able to focus their attention.
They become more ready to learn. Studies by NIMH scientists and other researchers
have shown that at least 90 percent of hyperactive children can be helped
by either Ritalin or Dexedrine. If one medication does not help a hyperactive
child to calm down and pay attention in school, the other medication might.
The drugs are effective for 3 to 4 hours and move out of the body within
12 hours. The child's doctor or a psychiatrist works closely with the family
and child to carefully adjust the dosage and medication schedule for the
best effect. Typically, the child takes the medication so that the drug
is active during peak school hours, such as when reading and math are taught.
In the past few years, researchers have tested these drugs on adults who
have attention disorders. Just as in children, the results show that low
doses of these medications can help reduce distractibility and impulsivity
in adults. Use of these medications has made it possible for many severely
disordered adults to organize their lives, hold jobs, and care for themselves.
In trying to do everything possible to help their children, many parents
have been quick to try new treatments. Most of these treatments sound scientific
and reasonable, but a few are pure quackery. Many are developed by reputable
doctors or specialists--but when tested scientifically, cannot be proven
to help. Following are types of therapy that have not proven effective
in treating the majority of children with learning disabilities or attention
Body stimulation or manipulation
Although scientists hope that brain research will lead to new medical interventions
and drugs, at present there are no medicines for speech, language, or academic
How Do Families Learn To Cope?
The effects of learning disabilities can ripple outward from the disabled
child or adult to family, friends, and peers at school or work.
Children with LD often absorb what others thoughtlessly say about them.
They may define themselves in light of their disabilities, as "behind,"
"slow," or "different."
Sometimes they don't know how they're different, but they know how awful
they feel. Their tension or shame can lead them to act out in various ways--from
withdrawal to belligerence. Like Wallace, they may get into fights. They
may stop trying to learn and achieve and eventually drop out of school.
Or, like Susan, they may become isolated and depressed.
Children with learning disabilities and attention disorders may have trouble
making friends with peers. For children with ADHD, this may be due to their
impulsive, hostile, or withdrawn behavior.
Some children with delays may be more comfortable with younger children
who play at their level. Social problems may also be a product of their
disability. Some people with LD seem unable to interpret tone of voice
or facial expressions. Misunderstanding the situation, they act inappropriately,
turning people away.
Without professional help, the situation can spiral out of control. The
more that children or teenagers fail, the more they may act out their frustration
and damage their self-esteem. The more they act out, the more trouble and
punishment it brings, further lowering their self-esteem. Wallace, who
lashed out when teased about his poor pronunciation and was repeatedly
suspended from school, shows how harmful this cycle can be.
Having a child with a learning disability may also be an emotional burden
for the family. Parents often sweep through a range of emotions: denial,
guilt, blame, frustration, anger, and despair. Brothers and sisters may
be annoyed or embarrassed by their sibling, or jealous of all the attention
the child with LD gets.
Counseling can be very helpful to people with LD and their families. Counseling
can help affected children, teenagers, and adults develop greater self-control
and a more positive attitude toward their own abilities. Talking with a
counselor or psychologist also allows family members to air their feelings
as well as get support and reassurance.
Many parents find that joining a support group also makes a difference.
Support groups can be a source of information, practical suggestions, and
mutual understanding. Self-help books written by educators and mental health
professionals can also be helpful. A number of references and support groups
are listed at the end of this booklet.
Behavior modification also seems to help many children with hyperactivity
and LD. In behavior modification, children receive immediate, tangible
rewards when they act appropriately. Receiving an immediate reward can
help children learn to control their own actions, both at home and in class.
A school or private counselor can explain behavior modification and help
parents and teachers set up appropriate rewards for the child.
Parents and teachers can help by structuring tasks and environments for
the child in ways that allow the child to succeed. They can find ways to
help children build on their strengths and work around their disabilities.
This may mean deliberately making eye contact before speaking to a child
with an attention disorder. For a teenager with a language problem, it
may mean providing pictures and diagrams for performing a task. For students
like Dennis with handwriting or spelling problems, a solution may be to
provide a word processor and software that checks spelling. A counselor
or school psychologist can help identify practical solutions that make
it easier for the child and family to cope day by day.
Every child needs to grow up feeling competent and loved. When children
have learning disabilities, parents may need to work harder at developing
their children's self-esteem and relationship-building skills. But self-esteem
and good relationships are as worth developing as any academic skill.
Susan is now in ninth grade and enjoys learning. She no longer believes
she's retarded, and her use of words has improved. Susan has become a talented
craftsperson and loves making clothes and furniture for her sister's dolls.
Although she's still in a special education program, she is making slow
but steady progress in reading and math.
Over the years, Wallace found he liked tinkering with cars and singing
in the church choir. At church, he met a woman who knew about learning
disabilities. She told him he could get help through his county social
services office. Since then, Wallace has been working with a speech therapist,
learning to articulate and notice differences in speech sounds. When he
complains that he's too old to learn, his therapist reminds him, "It's
never too late to work your good brain!" His state vocational rehabilitation
office recently referred him to a job-training program. Today, at age 46,
Wallace is starting night school to become an auto mechanic. He likes it
because it's a hands-on program where he can learn by doing.
Dennis is now age 23. As he walks into the college job placement office,
he smiles and shakes hands confidently. After shuffling through a messy
stack of papers, he finally hands his counselor a neatly typed resume.
Although Dennis jiggles his foot and interrupts occasionally, he's clearly
enthusiastic. He explains that because tape-recorded books and lectures
got him through college, he'd like to sell electronics. Dennis says he'll
also be getting married next year. He and his fiancee are concerned that
their children also will have LD. "But we'll just have to watch and get
help early--a lot earlier than I did!"
Can Learning Disabilities Be Outgrown or Cured?
Even though most people don't outgrow their brain dysfunction, people do
learn to adapt and live fulfilling lives. Dennis, Susan, and Wallace made
a life for themselves--not by being cured, but by developing their personal
strengths. Like Dennis' tape-recorded books and lectures, or Wallace's
hands-on auto mechanics class, they found alternative ways to learn. And
like Susan's crafts or Wallace's singing, they found ways to enjoy their
Even though a learning disability doesn't disappear, given the right types
of educational experiences, people have a remarkable ability to learn.
The brain's flexibility to learn new skills is probably greatest in young
children and may diminish somewhat after puberty. This is why early intervention
is so important. Nevertheless, we retain the ability to learn throughout
Even though learning disabilities can't be cured, there is still cause
for hope. Because certain learning problems reflect delayed development,
many children do eventually catch up. Of the speech and language disorders,
children who have an articulation or an expressive language disorder are
the least likely to have long-term problems. Despite initial delays, most
children do learn to speak.
For people with dyslexia, the outlook is mixed. But an appropriate remedial
reading program can help learners make great strides.
With age, and appropriate help from parents and clinicians, children with
ADHD become better able to suppress their hyperactivity and to channel
it into more socially acceptable behaviors. As with Dennis, the problem
may take less disruptive forms, such as fidgeting.
Can an adult be helped? For example, can an adult with dyslexia still learn
to read? In many cases, the answer is yes. It may not come as easily as
for a child. It may take more time and more repetition, and it may even
take more diverse teaching methods. But we know more about reading and
about adult learning than ever before.
We know that adults have a wealth of life experience to build on as they
learn. And because adults choose to learn, they do so with a determination
that most children don't have. A variety of literacy and adult education
programs sponsored by libraries, public schools, and community colleges
are available to help adults develop skills in reading, writing, and math.
Some of these programs, as well as private and nonprofit tutoring and learning
centers, provide appropriate programs for adults with LD.
What Aid Does the Government Offer?
As of 1981, people with learning disabilities came under the protection
of laws originally designed to protect the rights of people with mobility
handicaps. More recent Federal laws specifically guarantee equal opportunity
and raise the level of services to people with disabilities. Once a learning
disability is identified, children are guaranteed a free public education
specifically designed around their individual needs. Adolescents with disabilities
can receive practical assistance and extra training to help make the transition
to jobs and independent living. Adults have access to job training and
technology that open new doors of opportunity.
Increased Services, Equal Opportunity
The Individuals with Disabilities Education Act of 1990 assures a public
education to school-aged children with diagnosed learning disabilities.
Under this act, public schools are required to design and implement an
Individualized Educational Program tailored to each child's specific needs.
The 1991 Individuals with Disabilities Education Act extended services
to developmentally delayed children down to age 5. This law makes it possible
for young children to receive help even before they begin school.
Another law, the Americans with Disabilities Act of 1990, guarantees equal
employment opportunity for people with learning disabilities and protects
disabled workers against job discrimination. Employers may not consider
the learning disability when selecting among job applicants. Employers
must also make "reasonable accommodations" to help workers who have handicaps
do their job. Such accommodations may include shifting job responsibilities,
modifying equipment, or adjusting work schedules.
By law, publicly funded colleges and universities must also remove barriers
that keep out disabled students. As a result, many colleges now recruit
and work with students with learning disabilities to make it possible for
them to attend. Depending on the student's areas of difficulty, this help
may include providing recorded books and lectures, providing an isolated
area to take tests, or allowing a student to tape record rather than write
reports. Students with learning disabilities can arrange to take college
entrance exams orally or in isolated rooms free from distraction. Many
colleges are creating special programs to specifically accommodate these
Programs like these made it possible for Dennis to attend and succeed in
college. The HEATH Resource Center, sponsored by the American Council on
Education, assists students with learning disabilities to identify appropriate
colleges and universities. Information on the HEATH center and related
organizations appears at the end of this brochure.
Public Agency Support
Effective service agencies are also in place to assist people of all ages.
Each state department of education can help parents identify the requirements
and the process for getting special education services for their child.
Other agencies serve disabled infants and preschool children. Still others
offer mental health and counseling services. The National Information Center
for Children and Youth can provide referrals to appropriate local resources
and state agencies.
Counselors at each state department of vocational rehabilitation serve
the employment needs of adolescents and adults with learning disabilities.
They can refer adults to free or subsidized health care, counseling, and
high school equivalence (GED) programs. They can assist in arranging for
job training that sidesteps the disability. For example, a vocational counselor
helped Wallace identify his aptitude for car repair. To work around Wallace's
language problems, the counselor helped locate a job-training program that
teaches through demonstrations and active practice rather than lectures.
State departments of vocational rehabilitation can also assist in finding
special equipment that can make it possible for disabled individuals to
receive training, retain a job, or live on their own. For example, because
Dennis couldn't read the electronics manuals in his new job, a vocational
rehabilitation counselor helped him locate and purchase a special computer
that reads books aloud.
Finally, state-run protection and advocacy agencies and client assistance
programs serve to protect these fights. As experts on the laws, they offer
legal assistance, as well as information about local health, housing, and
What Hope Does Research Offer?
Sophisticated brain imaging technology is now making it possible to directly
observe the brain at work and to detect subtle malfunctions that could
never be seen before. Other techniques allow scientists to study the points
of contact among brain cells and the ways signals are transmitted from
cell to cell.
With this array of technology, NIMH is conducting research to identify
which parts of the brain are used during certain activities, such as reading.
For example, researchers are comparing the brain processes of people with
and without dyslexia as they read. Research of this kind may eventually
associate portions of the brain with different reading problems.
Clinical research also continues to amass data on the causes of learning
disorders. NIMH grantees at Yale are examining the brain structures of
children with different combinations of learning disabilities. Such research
will help identify differences in the nervous system of children with these
related disorders. Eventually, scientists will know, for example, whether
children who have both dyslexia and an attention disorder will benefit
from the same treatment as dyslexic children without an attention disorder.
Studies of identical and fraternal twins are also being conducted. Identical
twins have the same genetic makeup, while fraternal twins do not. By studying
if learning disabilities are more likely to be shared by identical twins
than fraternal twins, researchers hope to determine whether these disorders
are influenced more by genetic or by environmental factors. One such study
is being conducted by scientists funded by the National Institute of Child
Health and Human Development. So far, the research indicates that genes
may, in fact, influence the ability to sound out words.
Animal studies also are adding to our knowledge of learning disabilities
in humans. Animal subjects make it possible to study some of the possible
causes of LD in ways that can't be studied in humans.
One NIMH grantee is researching the effects of barbiturates and other drugs
that are sometimes prescribed during pregnancy. Another researcher discovered
through animal studies that certain prenatal viruses can affect future
learning. Research of this kind may someday pinpoint prenatal problems
that can trigger specific disabilities and tell us how they can be prevented.
Animal research also allows the safety and effectiveness of experimental
new drugs to be tested long before they can be tried on humans. One NIH-sponsored
team is studying dogs to learn how new stimulant drugs that are similar
to Ritalin act on the brain. Another is using mice to test a chemical that
may counter memory loss.
This accumulation of data sets the stage for applied research. In the coming
years, NIMH-sponsored research will focus on identifying the conditions
that are required for learning and the best combination of instructional
approaches for each child.
Piece by piece, using a myriad of research techniques and technologies,
scientists are beginning to solve the puzzle. As research deepens our understanding,
we approach a future where we can prevent certain brain and mental disorders,
make valid diagnoses, and treat each effectively. This is the hope, mission,
and vision of the National Institute of Mental Health.
What Are Sources of Information and Support?
Several publications, organizations, and support groups exist to help individuals,
teachers, and families to understand and cope with learning disabilities.
The following resources provide a good starting point for gaining insight,
practical solutions, and support. Further information can be found at libraries
and book stores.
Books for Children and Teens With Learning Disabilities
Fisher, G., and Cummings, R. The Survival Guide for Kids with LD.
Minneapolis: Free Spirit Publishing, 1990. (Also available on cassette)
Gehret, J. Learning Disabilities and the Don't-Give-Up-Kid. Fairport,
NY: Verbal Images Press, 1990.
Janover, C. Josh: A Boy with Dyslexia. Burlington, VT: Waterfront
Landau, E. Dyslexia. New York: Franklin Watts Publishing Co., 1991.
Marek, M. Different, Not Dumb. New York: Franklin Watts Publishing
Levine, M. Keeping A Head in School: A Student's Book about Learning
Abilities and Learning Disorders. Cambridge, MA: Educators Publishing
Services, Inc., 1990.
Books for Adults With Learning Disabilities
Adelman, P., and Wren, C. Learning Disabilities, Graduate School, and
Careers: The Student's Perspective. Lake Forest, IL: Learning Opportunities
Program, Barat College, 1990.
Cordoni, B. Living with a Learning Disability. Carbondale, IL: Southern
Illinois University Press, 1987.
Kravets, M., and Wax, I. The K&W Guide: Colleges and the Learning
Disabled Student. New York: Harper Collins Publishers, 1992.
Magnum, C., and Strichard, S., eds. Colleges with Programs for Students
with Learning Disabilities. Princeton, NJ: Petersons Guides, 1992.
Books for Parents
Greene, L. Learning Disabilities and Your Child: A Survival Handbook.
New York: Fawcett Columbine, 1987.
Novick, B., and Arnold, M. Why Is My Child Having Trouble in School?
New York: Villard Books, 1991.
Silver, L. The Misunderstood Child: A Guide for Parents of Children
with Learning Disabilities: 2d ed. Blue Ridge Summit, PA: Tab Books,
Silver, L. Dr. Silver's Advice to Parents on Attention-Deficit Hyperactivity
Disorder. Washington, DC: American Psychiatric Press, 1993.
Vail, P. Smart Kids with School Problems. New York: EP Dutton, 1987.
Weiss, E. Mothers Talk About Learning Disabilities. New York: Prentice
Hall Press, 1989.
Books and Pamphlets for Teachers and Specialists
Adelman, P., and Wren, C. Learning Disabilities, Graduate School, and
Careers. Lake Forest, Learning Opportunities Program, Barat College,
Silver, L. ADHD: Attention Deficit-Hyperactivity Disorder, Booklet for
Teachers. Summit, NJ: CIBA-GEIGY, 1989.
Smith, S. Success Against the Odds: Strategies and Insights from the
Learning Disabled. Los Angeles: Jeremy Tarcher, Inc., 1991.
Wender, P. The Hyperactive Child, Adolescent, and Adult. Attention Disorder
through the Lifespan. New York: Oxford University Press, 1987.
Related Pamphlets Available From NIH
Facts About Dyslexia
National Institute of Child Health and Human Development
Building 31, Room 2A32
9000 Rockville Pike
Bethesda, MD 20892 (301) 496-5133
Developmental Speech and Language Disorders--Hope through Research
National Institute on Deafness and Other Communicative Disorders
P.O. Box 37777
Washington, DC 20013 (800) 241-1044
Support Groups and Organizations
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, MD 20852 (800) 638-8255
Provides information on speech and language disorders, as well as referrals
to certified speech-language therapists.
Attention Deficit Information Network
475 Hillside Avenue
Needham, MA 02194 (617) 455-9895
Provides up-to-date information on current research, regional meetings.
Offers aid in finding solutions to practical problems faced by adults and
children with an attention disorder.
Candlelighters Childhood Cancer Foundation
7910 Woodmont Avenue, Suite 460
Bethesda, MD 20814 (800) 366-2223
Provides information and support for children treated for cancer who later
experience learning disabilities.
Center for Mental Health Services
Office of Consumer, Family, and Public Information
5600 Fishers Lane, Room 15-81
Rockville, MD 20857 (301) 443-2792
This new national center, a component of the U.S. Public Health Service,
provides a range of information on mental health, treatment, and support
Children with Attention Deficit Disorders (CHADD)
499 NW 70th Avenue, Suite 308
Plantation, FL 33317 (305) 587-3700
Runs support groups and publishes two newsletters concerning attention
disorders for parents and professionals.
Council for Exceptional Children
11920 Association Drive
Reston, VA 22091 (703) 620-3660
Provides publications for educators. Can also provide referral to ERIC
Clearinghouse for Handicapped and Gifted Children.
Federation of Families for Children's Mental Health
1021 Prince Street
Alexandria, VA 22314 703) 684-7710
Provides information, support, and referrals through federation chapters
throughout the country. This national parent-run organization focuses on
the needs of children with broad mental health problems.
HEATH Resource Center
American Council on Education
1 Dupont Circle, Suite 800
Washington, DC 20036 (800) 544-3284
A national clearinghouse on post-high school education for people with
Learning Disabilities Association of America
4156 Library Road
Pittsburgh, PA 15234 (412) 341-8077
Provides information and referral to state chapters, parent resources,
and local support groups. Publishes news briefs and a professional journal.
Library of Congress
National Library Service for the Blind and Physically Handicapped
1291 Taylor Street, NW
Washington, DC 20542 (202) 707-5100
Publishes Talking Books and Reading Disabilities, a fact sheet outlining
eligibility requirements for borrowing talking books.
National Alliance for the Mentally Ill
Children and Adolescents Network (NAMICAN)
2101 Wilson Boulevard, Suite 302
Arlington, VA 22201 (800) 950-NAMI
Provides support to families through personal contact and support meetings.
Provides education regarding coping strategies; reading material; and information
about what works--and what doesn't.
National Association of Private Schools for Exceptional Children
1522 K Street, NW Suite 1032
Washington, DC 20005 (202) 408-3338
Provides referrals to private special education programs.
National Center for Learning Disabilities
381 Park Avenue South, Suite 1420
New York, NY 10016 (212) 687-7211
Provides referrals and resources. Publishes "Their World" magazine describing
true stories on ways children and adults cope with LD.
National Information Center for Children and Youth with Disabilities
P.O. Box 1492
Washington, DC 20013 (800) 695-0285 or 202-884-8200
Publishes newsletter, arranges workshops. Advises parents on the laws entitling
children with disabilities to special education and other services.
Answers individual questions on reading disability. Provides information
and referrals to local resources.
Orton Dyslexia Society
Chester Building, Suite 382
8600 LaSalle Road
Baltimore, MD 21286-2044 (410) 296-0232
To arrange for special college entrance testing for LD adults, contact:
MESSAGE FROM THE NATIONAL INSTITUTE OF MENTAL HEALTH
ACT Special Testing (319) 337-1332
SAT Scholastic Aptitude Test (609) 771-7137
GED (202) 939-9490
Research conducted and supported by the National Institute of Mental
Health (NIMH) brings hope to millions of people who suffer from mental
illness and to their families and friends. In many years of work with animals
as well as human subjects, researchers have advanced our understanding
of the brain and vastly expanded the capability of mental health professionals
to diagnose, treat, and prevent mental and brain disorders.
Now, in the 1990s, which the President and Congress have declared "The
Decade of the Brain," we stand at the threshold of a new era in brain and
behavioral sciences. Through research we will learn even more about mental
disorders such as depression, manic-depressive illness, schizophrenia,
panic disorder, and obsessive-compulsive disorder. And we will be able
to use this knowledge to develop new therapies that can help more people
overcome mental illness.
The National Institute of Mental Health is part of the National Institutes
of Health (NIH), the Federal Government's primary agency for biomedical
and behavioral research. NIH is a component of the U.S. Department of Health
and Human Services.
This booklet was written by Sharyn Neuwirth, M.Ed., an education writer
and instructional designer in Silver Spring, MD. Scientific information
and review was provided by NIMH staff members L. Eugene Arnold, M.D.; F.
Xavier Castellanos, M.D.; and Judith Rumsey, Ph.D. Also providing review
and assistance were Marcia Henry, Ph.D., Orton Dyslexia Society; Reid Lyon,
Ph.D., National Institute of Child Health and Human Development; Jean Petersen,
Learning Disabilities Association; and Larry B. Silver, M.D., Georgetown
University. Editorial direction was provided by Lynn J. Cave, NIMH.
All material in this publication is free of copyright restrictions and
may be copied, reproduced, or duplicated without permission from NIMH;
citation of the source is appreciated.
U.S. Department of Health and Human Services
Public Health Service
National Institutes of Health
National Institute of Mental Health
NIH Publication No. 93-3611