The Learning Disorders of Adolescence: Organic and Nonorganic Failure to Strive

Symposium on Learning Disorders

The Learning Disorders of Adolescence: Organic and Nonorganic Failure to Strive Melvin D. Levine, M.D.* and Barry G. Zallen, M.D.t

No individual or group will be judged by whether they come up to or fall short of some fixed results, but by the direction in which they are moving. JOHN DEWEY,

Reconstruction in Philosophy (1919)

School underachievement and failure during adolescence pose a puzzling clinical challenge. Disappointing academic performance in this age group is the product of multiple convergent factors, including underlying, often concealed disabilities, secondary affective and motivational changes, responses to extrinsic pressures, and a repertoire of learned styles and face-saving strategies. It is common to wonder if a youngster lacks success as a consequence of not striving or fails to strive because of the unlikelihood of success. Conceivably, both explanations may pertain. As students proceed through late elementary and junior high school, academic demands change drastically. Any understanding of learning problems in this age group requires sensitivity to these abrupt shifts in expectations (Table 1). The altered requirements often give rise to seemingly new learning disorders, many of which may not have been conspicuous prior to adolescence. In other instances, evolving expectations aggravate or modify a preexisting recognized dysfunction. 35

DEVELOPMENTAL DYSFUNCTIONS In part as a result of intensified social, cognitive, and academic demand, certain vulnerable youngsters are apt to be encumbered with one or more developmental dysfunctions. The following sections present a taxonomy that includes seven common areas of disability in this age group (Table 2). *Associate Professor of Pediatrics, Harvard Medical School, Chief, Division of Ambulatory Pediatrics, The Children's Hospital, Boston, Massachusetts tFellow in Pediatrics, Director of Young Adult Team, The Children's Hospital, Boston, Massachusetts Pediatric Clinics of North America-Vol. 31, No. 2, April 1984

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Table l.

DESCRIPTION

EXPECTATION SHIFT

More encoding of thoughts

Increasing reliance on rapid retrieval memory (automatization) Greater demand for attention to visual and auditory detail Increased length of delay of gratification

More stress on resynthesis of ideas and skills Growing need to integrate skills and knowledge from multiple sources Greater stress on efficient and sophisticated language processing and production Heightened

demand

for

efficiency

The Ewlution of Academic Expectation in Late Childhood

and

organization Expanded use of higher order conceptualization

Growing stress on production and communication of ideas, especially on paper; higher volume output Need to retrieve data almost instantly and with little mechanical effort or expenditure of attention Increasingly complex stimulus sets for observing and listening; less opportunity to succeed via the "big picture" exclusively Longer range assignments; more time devoted to sustained effort with delayed rewards and feedback Process of taking in data, then restating, adapting, and applying what has been read or heard Recombining of skills and information, as from several books, from teachers, and from memory and new inputs Rapid comprehension; verbal inference; paradox, humor, irony. Expressive fluency; fast, effective word finding Maintenance of notebooks; scheduling or staging work; allocating time; completing tasks; summarizing, outlining, notetaking; test-taking Dealing with abstraction; symbols; rules; generalizations; extrapolations; conceptual frameworks; inferential reasoning

PRIMARY ACADEMIC IMPACT AREAS

Writing reports; taking written examinations

Writing; mathematics; reading comprehension; foreign language; spelling Mathematics, reading, lectures in class

All subject areas ~

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Reading comprehension (retelling), Lectures in class, studying All subject areas

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Understanding of verbal explanations in all areas; participation in class discussion; written language; foreign language Study skills in general; Test-taking ability; proficiency in long range assignments Content courses (e.g., science, social studies); mathematics

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Table 2.

A Classification of Common Developmental Dysfunctions in Adolescence

DYSFUNCTION

1. Attention Deficits

SUBTYPES

a. Primary

b. Secondary (to anxiety or poor information processing)

c. Situational (only evident in certain settings)

2. Memory Impairments

a. Generalized retrieval problems b. Modality-specific retrieval problems c.Attention-retention deficiencies

3. Language Disorders

a. Receptive

b. Expressive

FREQUENT MANIFESTATIO,NS*

Weak attention to detail; distractibility; impulsivity, restlessness; task impersistence; performance inconsistency; organizational

problems; reduced working capacity Deficient, undependable, and/or slow recall of data from longand/or short-term memory Problems with revisualization, auditory, motor, or sequential recall Poor recall associated with · superficial initial registration Poor verbal and reading comprehension; poor listening; trouble following directions and explanations Problems with word finding, sentence formulation.

Difficulty with written expression

4. Higher Order Cognitive Disabilities

5. Fine Motor Incoordination

6. Organizational Deficiencies

a. Inferential weakness b. Poor verbal reasoning c. Poor nonverbal reasoning d. Difficulty with abstraction, symbolization e. Weak generalization and rule application a. Eye:hand coordination problems b. Impaired propriokinesthetic feedback c. Dyspraxia d. Motor memory impairment a. Temporal-sequential disorientation

Problems understanding and assimilating new concepts;

Tendency to think "concretely" Delays in mathematics; reading c~mprehension; Science; Social Studies Slow, labored, sometimes illegible writing; awkward pencil grip; Dys-synchrony between cognitive tempo and writing speed; Output failurereduced productivity Problems with time allocation, schedules, planning, arranging ideas in writing

b. Material disarray

c.Integrative dysfunction

d. Resynthesis problems

e.Attentional disorganization

Tendency to lose, misplace, forget books, papers, etc; Trouble organizing notebook Varying inability to integrate data from multiple sources or sensory modalities Trouble extracting most salient details, retelling and adapting data to current demands Impulsivity, erratic tempo, poor self-monitoring, careless errors

7. Socialization Disabilities

a. Wide range of subtypes, including conduct disorder, social impulsivity, impaired social cognition or feedback, egocentricity

Antisocial behaviors; delinquency; withdrawal; excessive dependency on peer

support

*Manifestations are likely to vary somewhat depending upon compensatory strengths, quality of educational experience, and motivation.

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Attention Deficits Attention deficits are the commonest low-severity developmental problems. 29 • 38 In the past, it was commonly held that "hyperactivity" or difficulty with concentration was limited primarily to young school children and that it diminished or vanished near puberty. This belief is no longer tenable. Attention deficits in adolescents are a debilitating and widespread problem. 45, 55, 5G, 61 While overactivity commonly diminishes at adolescence, other associated traits persist or worsen. These include restlessness, difficulty in delaying gratification, impersistence at tasks, distractibility, inconsistency, problems with planning and organization, and a tendency to fatigue, deteriorate, or "burn out" during sustained cognitive effort. Like their younger counterparts, adolescents with attention deficits may have no trouble at all focusing upon stimuli or pursuits that are of high interest. Their problems with concentration emerge when they attempt to focus on data that contain considerable detail, that are not romantically alluring, and that demand persistence with some delay of gratification. A cardinal feature of adolescents with attention deficits is their performance inconsistency. More than any other subgroup of children, they have winning and losing streaks, a tendency to "tune in and out" capriciously. At times they can be highly productive, while at other moments inexplicably they accomplish little or nothing. The very inconsistency of their concentration and productivity creates problems for them. Because they are observed doing good things, the adult world assumes that they are capable of sustaining that level of quality all of the time. "We've seen you do it. We know you can concentrate when you really want to." This haunting presumption is itself a source of anxiety and even selfcondemnation. It is common to encounter early adolescents with no history of serious attention deficits who currently experience difficulty concentrating. In many cases, such youngsters with the "late onset" of inattention fail to focus commensurate with the amount of detail and sustained effort required at their grade level. Some such youngsters had mild f(Jcusing problems in the earlier grades, but this propensity caused little or no difficulty, insofar as they were good conceptualizers, able to grapple effectively with "the big picture." When the latter strategy failed them, when the volume of detail and its essential relevance for meaning grew exponentially in junior high school, their subclinical problems with attention became increasingly troublesome. Such youngsters are apt to be anxious about their deteriorating school performance, as they withstand the inevitable onslaught of adult accusations of laziness and moral turpitude. The resultant high levels of anxiety (and sometimes depression) can further compromise their ability to concentrate, frequently causing them to lose incentive and fail to strive. Memory Impairments

With the arrival of early adolescence, academic work makes increasing demands upon memory. There is a fundamental assumption that students will be able to draw effortlessly upon the steadily expanding bank of infor-

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mation and skill that they have acquired in earlier education. Furthermore, it is assumed that much of such data will be retrievable instantaneously and nearly unconsciously. In order to advance knowledge and skill, a youngster must superimpose new information and insight over a substrate that can be brought forth expeditiously from memory stores. If a youngster has to struggle inordinately to recall how to form a letter, when to use a comma, or what to capitalize, it may be difficult or impossible at the same time to write a sophisticated book report. Such increasingly efficient rapid retrieval memory entails a process commonly referred to as

progressive automatization. It is not unusual in late childhood or adolescence to encounter youngsters who are experiencing difficulties because of a lack of automatization of one or more components of rapid retrieval memory. 2· 6 • 7• 8 • 35 In some cases, dysfunctional adolescents are found to have globally inefficient retrieval, while in other instances poor recall may be more circumscribed. Some youngsters, for example, have trouble spelling because they cannot revisualize words quickly and accurately. They are likely to be better at recognizing correct spelling (as on a multiple choice test), but have trouble recalling it on demand. When confronted with a word such as "believe," a phonetic approximation, such as "baleeve," may be all that is readily available.5 In some cases, a student may have only a tenuous hold on revisualization, being able to spell words correctly in isolation, but, with the added demand of writing an essay or paragraph, this brittle visual retrieval memory is undependable, so that mispellings abound. Other retrieval memory problems also are common in this age group. There may be a relative expressive dysphasia or deficient rapid recall of precise words needed for spoken or written language. 25 The retrieval of rules (of punctuation, capitalization, grammar, etc.) may be elusive. Some youngsters may have trouble assimilating a foreign language because of weaknesses of auditory recall. Deficient mobilization of math facts, assimilation of new information in a history course, or application of new knowledge in science may result from memory disabilities. A key variable is the extent to which youngsters develop effective memory strategies. As students progress through elementary and into junior high school, their adeptness as memory tacticians expands insofar as they learn to employ accessory cues, mnemonics, rich visual and auditory associations, subvocalization techniques, and other cognitive "gimmicks" to reinforce storage and facilitate rapid retrieval. 42· 59 Some adolescents who have trouble with memory have failed to develop these effective mnemnistic devices. Memory abilities relate intimately to levels of competence in other areas of development. Many youngsters with attention deficits, for example, have trouble selectively retaining information and skill. Their memory problems in most instances are secondary to relative superficiality or lack of centrality of attention. They fail to focus intently upon an initial set of stimuli, and, consequently, what they recall is vague, superficial, or inaccurate. Or, they may focus upon incidental stimuli, thereby retaining irrelevant or trivial data. Such problems along the "attention-retention dimension" are common in older youngsters who are distractible and

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impulsive. They may appear to have true problems with memory but, in reality, they tend not to register the most salient data firmly in short term memory. The quality of information processing also influences retention. If a youngster has trouble grasping a new skill or concept (possibly because of a specific processing disability or poor teaching), that student is susceptible to its poor retention and nonretrieval. Language Disorders As with younger children, disorders of language in adolescents can be classified as either receptive or expressive (or both). That is to say, these impairments either can affect the receipt and interpretation of linguistically encoded data or communication can be compromised. 64 · 65 Language disorders include a broad spectrum of dysfunctions. Receptive language disabilities impair effective interpretation of spoken or written ideas. The wide range of such processing problems includes difficulties with auditory attention or listening skills. In this category are youngsters who have trouble distinguishing between auditory foreground and background. They may be inordinately distracted by noise or irrelevant verbal stimuli. Others are weak at discriminating between similar sounds and have problems establishing clearly the uniqueness of auditory perceptual units (phonemes). In other cases, youngsters have trouble appreciating language cues, including grammatical construction, syntax, intonation, and rhythm.l2. 46 In middle childhood, children become increasingly sophisticated in interpreting subtleties of language as new linguistic structures are mastered. ·51 For example, during this time, one begins to appreciate the difference between "Jim promised he would bring the candy" and "Jim asked if he would bring the candy." One learns how to deal with negative questions that are really positive, such as "\Von't you get wet if it rains?" Various tentative modifiers of meaning also are assimilated, such as the difference between "Mary believes Tom is good at sports" and "Tom is good at sports." Often, youngsters with receptive language disabilities arrive at adolescence without having mastered these nuances. They are likely to be disoriented in a classroom as they strive to follow directions and process verbal explanations. In some instances, they may tune out and become inattentive because of the futility of their efforts to understand. Some adolescents can process language well but not quickly enough. Such relative inefficiency makes it hard for them to keep pace with what is said in the classroom. Expressive language difficulties can be equally debilitating. Some students have trouble finding the right words quickly. 2·5 Such expressive dysphasia makes it difficult to participate in class discussions. Affected adolescents may live in perpetual fear of being called upon. These same students may have trouble with oral reading and with the expressive aspects of writing. In other instances, a student can find words effectively but have difficulty formulating the appropriate grammar and syntax to write or compose sentences while speaking. Impaired naming of objects correlates with poor reading. 14 In addition, expressive language disabilities can have a major

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impact upon socialization and life adjustment. The capacity to regulate relationships with language is of vital importance. In one recent study of neurodevelopmental problems among young juvenile delinquents, deficits of expressive language were the most prevalent of developmental dysfunctions.27 Some adolescents have both receptive and expressive language weaknesses, while some have only one or the othet. The fact that a student is extremely fluent and adept at verbal expression often obscures an underlying problem with verbal comprehension. Therefore, it is essential to consider the two areas of language separately for diagnostic purposes. Higher Order Cognitive Disabilities As children progress into adolescence, much of academic learning, thinking, and output stresses higher conceptual functions, some of which are summarized below:l9, 2o, 23, 43, 48, s2 Abstract-Symbolic Cognition: This entails the capacity to reason and manipulate ideas that are one or more steps removed from concrete reality. The use of symbols in algebraic equations and discussions of abstract values (such as empathy irony, and jealousy) in literature and social sciences are examples of this, Rule Application: The capacity to understand and see the relevance of conceptual rules in distinct circumstances is another aspect of higher order conceptualization. The recognition (or appreciation) of regularities in grammar, spelling, mathematics, and foreign languages greatly facilitates performance in these areas, while, at the same time, lessening demands on memory. If one recalls "i before e except after c," it is easy to spell the word "believe." Generalization and Classification: The capacity to deduce generalizations, to perceive relationships between old and new concepts or data, and to classifY information into appropriate categories allows for more disciplined and efficient approaches to problem-solving. Recognition of likenesses and differences, of regularities and discrepancies within categories is central in the reasoning process. Inferential Thought: In adolescence it becomes increasingly important for a youngster to draw inferences from what has been read, heard, or seen, to progress beyond literal interpretation. Analogy, implied or double meanings, and the interpretation of paradox and humor all draw upon the ability to extract inferences from data, to extrapolate from what actually is said or written to what should come next or to its truly intended meaning, and to interpolate one's own perspective. This is critically important in secondary school, commensurate with the demand for sophisticated comprehension and critical interpretative listening and reading. Saliency Determination: The capacity to extract what is most central and meaningful within a set of data becomes increasingly relevant in secondary school. In reading a passage or listening to a lecture, students must "separate the wheat from the chaff," identify central themes, tease out key facts from expanding volumes of information.

It is not unusual to encounter adolescents who are having difficulties in one or more of these higher cognitive functions. Frequently their teachers report that they are too "concrete." Some have trouble manipulating abstract ideas and symbols. Others may have problems drawing inferences, thinking critically, grasping concepts, problems that may compromise performance in content area subjects. Some youngsters show discrete conceptual weaknesses (and prefer-

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ences). For example, there are students who excel at verbal reasoning but are relatively inept at nonverbal conceptualization. They can generalize, apply rules, and draw inferences from language, but have difficulty doing so when they are confronted with a visual (nonverbal) stimulus set. They may be poor at interpreting or drawing inferences from geometric patterns or puzzles but have no trouble perceiving irony in a short story or expanding upon a teacher's explanations. Other youngsters have well-developed mechanical reasoning. They may grasp the workings of complicated machines, recognizing, transferring, and applying mechanical principles almost instinctively, yet be unable to interpret a poem. The identification of such conceptual preferences has major implications for vocational counseling and remediation. Fine Motor Incoordination During later childhood an.d adolescence, fine motor abilities assume a fair amount of importance. Fine motor disabilities in adolescence generate considerable stressespecially when it comes to writing. In a previous study, 37 it was demonstrated that a number of youngsters in this age group suffered from a condition called "developmental output failure." These often were students who had little or no difficulty taking in and interpreting information, but encountered con·siderable problems with productivity or output. In most cases, students with "developmental output failure" encounter a formidable barrier in transmitting thoughts to paper. Their writing problems stem from a number of causes, including deficiencies of memory, language, attention, or organization. Often such students also suffer from one or another form of fine motor dysfunCtion. In some cases there are problems with eye-hand coordination or difficulty implementing a fine motor response to visual input and feedback. In other instances, there is marked imperception of proprioceptive-kinesthetic information (finger agnosia). That is to say, some such youngsters have trouble monitoring pencil movement without very close visual scrutiny; the usual preferred feedback originating in muscles and joints of the digits is poorly perceived or interpreted. Many of these students ·have awkward pencil grasps which may cause still more problems. Another subgroup includes students with fine motor dyspraxia. These are youngsters who have weaknesses of the motor planning and spatial organization components of writing. Their breakdown is at the level of implementing a motor plan to form letters and write words smoothly and easily. Finally, there are those who have trouble with motor memory or the rapid retrieval of the engrams, or "kinetic melodies," the various motor patterns required to form letters and words. 40 Typically, affected students are hesitant in their writing. They frequently retrace letters. The same letter may be formed differently in different words in the same sentence. They cross out letters and seem to have a "fluctuating motor memory"; that is, they often lose the motor trace for symbols. Often adolescents with motor memory problems prefer printing to cursive writing. They find it

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easier to recall the motor patterns of discrete letters than to retrieve the comparatively long engrams of cursive words. Although not directly related to learning, it is important to recognize that some adolescents struggle with gross motor deficits. These may be similar in origin to fine motor impairments. They may lead to humiliation in physical education classes and loss of self-esteem and social confidence. Organizational De6ciencies It is not unusual to hear of an adolescent who is competent but has "organizational problems." Although sometimes considered to be trivial annoyances, difficulties "getting one's act together" may have a serious impact upon academic performance and life adjustment at home and in school. Such problems can be confusing to assess and treat. Nevertheless, their accurate description may alleviate anxiety and suggest helpful strategies. Organizational deficiencies can be subdivided into five major categories. These are summarized below: Problems Associated with Attention Deficits: Organizational problems may stem from difficulties with selective attention. Adolescents with attention deficits commonly experience problems with organization. Impulsivity or erratic cognitive tempo, inattention to detail, and distractibility engender careless errors, poorly planned output, and fluctuating forgetfulness. Because of their misplaced focus, youngsters with attention deficits may intermittently manifest all of the organizational shortcomings summarized in this section. Temporal-Sequential Disorientation: Some youngsters with organizational deficiencies become confused about time and serial order.-34 Many of them may have had a history of problems with temporal prepositions, difficulties mastering the days of the week and the months of the year, and delays in learning how to tell time. Impaired processing of multistep instructions and problems with multiplication tables also may be part of the earlier history of youngsters with this form of disorganization. Frequently, when such students arrive at junior high school, they are left with a significant residuum of organizational deficit. They may have trouble learning the order of classes at the beginning of the year, allocating time, using schedules, and planning work. When they need to complete multistep processes in mathematics, they become confused. Often writing is chaotic. In particular, it is hard for them to arrange their ideas in a proper sequence. They may have trouble getting started with assignments, real difficulty organizing time, and generalized "absentmindness". Material Disarray: Some disorganized students have particular problems establishing order in the physical/spatial domain. They cannot organize a notebook. They tend to keep losing books and papers. They have trouble bringing together a pencil, a paper, and the needed reference materials to complete an assignment and are overwhelmed in organizing a desk or a drawer. Some of them may complete assignments and then forget to take them to school the next day. Such difficulties managing the material gear for work output can result in inefficiency, loss of time, failure to strive, and consequent underachievement. Integrative Dysfunction: The capacity to pool data from multiple sources, from more than one sensory modality, from past experience, and present exposure constitute challenges to one's organizational competence. Some youngsters perform very well on simple, straightforward tasks, but experience much difficulty when required to actively and simultaneously combine several functions." 7 They may be unable to reconcile the points of view deriving from several sources. They may

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have trouble joining together subcomponent functions in a particular performance area. For example, a child may have no trouble understanding what he hears. He also may have no difficulty at all with fine motor function. On the other hand, when he has to integrate a verbal input with a fine motor output, he experiences frustration. The deficiency or difficulty is at the level of integration, of forming linkages between different functions. The resultant "disconnection" may lead to considerable academic frustration during secondary school. Resynthesis Problems: Closely related to integrative dysfunction and commonly occurring in the same youngsters is a disorder in which there are problems extracting the most salient details from the data, retrieving these data, restating them in one's own words, and thereby adapting them to current demands. Youngsters with resynthesis problems may encounter difficulties with reading comprehension. Although they arc able to answer questions about a paragraph, they may have difficulty retelling it, using it, truly understanding it. This may lead to problems writing a book report, taking a test on a reading assignment, or rendering an oral description of what is read or heard. Resynthesis may also require effective retrieval memory and language ability. 64

Disabilities of Socialization It is inappropriate to isolate the cognitive performance of youngsters from their social abilities, since many of those with learning problems also endure social failure. A wide range of environmental and cultural factors can influence the quality of relationships. However, there is increasing evidence that certain cognitive functions underlie socialization. 9, 1o, 18, 32, 57 Some adolescents with developmental dysfunctions have closely associated social disabilities. The following are commonly encountered (and sometimes overlapping) attributes: Social Impulsivity: This entails a tendency (often in youngsters with attention deficits) to commit social acts so quickly that they are poorly monitored, and, therefore, often unintentionally offensive to peers and/or adults. Poor Social Prediction and Cognition: Some youngsters have trouble foreseeing or forecasting the social consequences of their actions. They say and do things that damage their reputations but seem unable to predict that this might occur. Others seem not to comprehend or apply good rules of interaction (e.g., ways to share, to praise, to nurture relationships). Conduct Disorder: Adolescents with this propensity tend toward aggressive, "acting-out," and defiant behaviors-often in association with impulsivity. 50 Delinquency: Affected youngsters may be involved in violent, nonviolent, or status offenses, the end product of multiple contributing factors. ·19 Impaired Social Feedback: Some youngsters are not receptive to social feedback cues. They commit one faux pas after another without realizing that they are causing consternation, alienating peers, or losing friends in so doing. Egocentricity: Some youngsters seem unable to see beyond their own immediate desires and needs. Their extreme egocentricity is offensive, resulting in increasing alienation and isolation. Typically the lonely youngster has no idea why he lacks friends.

Not all unpopularity is due to the above disabilities. In some instances, a youngster's unique individuality in itself is offensive to peers. Such a child may tail' to conform to peer models and mores and thereby experience rejection. Furthermore, not all adolescents care enough about being popular.

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DEVELOPMENTAL COMPLICATIONS The preceding summary of common developmental dysfunctions in adolescents must be interpreted in the context of the whole child within a sociocultural milieu. The home environment is critical. Serious domestic turmoil, neighborhood and family violence, and cultural deprivation are significant impediments to school function. 3 The lack of an appropriate role model at home or in the neighborhood can be a further aggravating influence. If a teenager has never seen a family member write, he or she may not gain the incentive to overcome predispositions to "developmental output failure." The failure to strive in such cases may represent the combined effects of a disability and environmental underexposure. Substance abuse is a formidable impediment. The effects of certain drugs or alcohol on school performance may be catastrophic, often impairing attention and memory.2 4 Another important influence is that of peers. In junior high school, in particular, there exists "peer tyranny." Youngsters earnestly struggle to conform, to look good, to be accepted by their colleagues. If the local peer group tends to be anti-intellectual, if it attracts mainly those youngsters who cannot succeed in school, if it develops an ethos in which academic work is deemed unfashionable, a youngster may be coerced to fail to strive. A child's own affect is important. In adolescence it is common for youngsters to superimpose over their learning problems depression, performance anxiety, and inhibition. Some appear to be amotivational because previous efforts have gone unrewarded. There may be confusion, as teachers and parents insist that the child does not work because he is poorly motivated, whereas, in reality, the youngster has lost motivation as a result of repeated failures. 3. 9

ACADEMIC PERFORMANCE DELAYS The preceding sections have reviewed a range of developmental dysfunctions and complications in adolescence. In the next several sections specific forms of academic delay will be considered. Developmental dysfunctions and complications form the bases for these delays in performance occurring in various combinations. Although the end result is academic underachievement, the pathways leading to this state are diverse, quite unlikely to be precisely the same in any two youngsters. Moreover, prognosis and treatment may vary, depending upon the nature of compensatory strengths, available resources, and the degree to which intransigent failure to strive has supervened.

Delayed Reading Skills In this age group a wide range of factors may contribute to slow or inaccurate reading. Most affected youngsters generally can recognize individual words, especially if they are relatively succinct. However, when words are chunked into phrases, a single word approach to reading leads

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to significant delays in rate, accuracy, and comprehension. It may be said that reading is poorly "automatized." That is, the youngster still operates on a very mechanical level of associating symbols with sounds and sounds with meanings. While reading in such a primitive, immature fashion, the youngster is unable to extract sophisticated meaning, focus on critical detail, or infer the true significance of what he has decoded. Slow reading rate may become a particular problem when youngsters are given large volumes of material to read. A low and staccato mechanical reading process may significantly exceed a student's capacity for sustained attention. During reading one must simultaneously focus on five parameters or distinctive features of words. These characteristics can be classified as graphic (overall appearance), orthographic (spelling), phonologic (sounds), semantic (meaning), and syntactic (arrangement into grammatical units). 21 In reading, these five types of information must be integrated. As youngsters grow older semantic and syntactic characteristics of printed words take precedence. Students with language difficulties, sequencing problems, or trouble integrating data may fail at reading, revealing a diminished rate and reduced comprehension. H. 28, 53 Weaknesses of silent reading comprehension are common in adolescence. To understand this phenomenon, it is important to recognize some of the subcomponents of this complex process. To read a paragraph a youngster must first focus selective attention upon its details, then recognize and associate visual symbols with sounds and meanings. 4 · 60 Then follows prioritization, in which the most salient information is extracted and reordered. To accomplish this, cognition and language skills are applied. 17 Once having attributed meaning to what has been read, a youngster must be able to store and retrieve the newly acquired data. There then is a need either to answer specific questions based on the reading or to resynthesize, formulate in one's own words, and apply to some task that which has been decoded and interpreted. Reading comprehension problems occur whenever there is a breakdown in one or more steps of the above process. Thus, youngsters with attention deficits, those with disorders of language and memory, with impaired higher cognitive abilities, or with organizational problems may suffer from impairments of reading comprehension. By carefully observing error patterns during reading tasks, one can determine the level at which the breakdown occurs. 44 This can have implications for counseling and remediation. 22. 58 Delayed Writing Skills Writing represents the sine qua non of output and productivity during the adolescent years. In a sense, writing on a page is a tangible representation of much higher cortical function. Table 3 summarizes the impacts of various development dysfunctions upon writing in adolescence. It can be seen that motor dysfunctions exert a unique effect upon writing. In some cases they result in relatively illegible handwriting. There may be an extreme economy of written output, an inability to transcribe thoughts commensurate in their sophistication with those that are in the youngster's head. For some youngsters with these problems, writing may be inordinately slow and mechanical. By adoles-

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Table 3. AREA

Attention

Developmental Dysfunctions: Their Specific Impacts upon Writing DYSFUNCTION

a. Superficial concentration b. Impulsivity c.Cognitive fatigue

Memory

a. Poor revisualization

b. Deficient automatization

Fine Motor Function

a. Poor eye-hand coordination b. Impaired finger localization

c. Dyspraxia d. Motor memory deficit

Organization

a. Temporal-sequential disorientation

b. Material disarray

Language

a. Receptive deficits

b. Dysphasia

c. Formulation difficulty

Higher Order Cognition

a. Poor abstract reasoning

b. Deficient integration of ideas c. Impaired rule application

COMMON IMPACT(s) ON WRITING

Poor integration of detail (e.g., punctuation, capitalization) Careless errors; excessive need for self-correction lmpersistence; extreme economy of output Phonetically correct spelling errors; slow output, awkward letter formation Difficulty applying simultaneously elements and rules of writing (e.g., punctuation, grammar, spelling, organization, content) Awkward writing; eyes close to page; some problems with legibility Bizarre pencil grasp; slow writing; eyes close to page; "writer's cramp" Poorly planned writing; poor spacing and utilization of page Hesitant writing; frequent retracing; inconsistent letter formation; aversion to cursive writing Trouble arranging ideas in logical order; problems starting; confusion over syntax; poor allocation of time to written work Problems bringing together appropriate resources and utensils to accomplish a written assignment Problems appreciating (and using) grammar and syntax; phonetically poor spelling Trouble "finding" right words efficiently to express ideas on paper Weaknesses in sentence building; excessive use of short declarative sentences Overly concrete writing; inability to express abstract concepts on paper Inability to integrate data from several sources Difficulty conceptualizating and using simplifYing rules (e.g., spelling, grammar)

cence, letter and word formation should be nearly automatic. When such automatization does not occur, it is difficult for a youngster to simultaneously write and think, write and remember, or write and apply rules. In evaluating writing problems in this age group, it is particularly important to be aware of an "eclipse phenomenon." Some youngsters have to

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struggle so much with one aspect of written output that the other components are neglected or overshadowed. 37 Thus, if a child has to work very hard to form letters or to recall the spelling of a particular word, there may be a relative neglect of punctuation, grammar, or capitalization. On the other hand, in isolation, the youngster may have no difficulty reciting the rules governing these regularities. It is only when he has to integrate functions simultaneously that some aspects inevitably are omitted. Writing can provoke deep consternation and shame in adolescence. This is particularly true at the junior high school level, when many youngsters are extremely self-conscious, embarrassed about their poor writing, and apprehensive that peers will see their papers. They may dread having to copy something over, because the various motor and integrative components are so stressful and painful for them. In some cases, anxiety over writing leads to a pervasive loss of incentive in school; it seems preferable not to submit anything at all than to risk the onslaught of negative comments from teachers, peers, and parents. This can be particularly a problem when an adolescent has a high-achieving, productive sibling at home, one who has no difficulty whatsoever writing quickly and attractively and obtaining high grades with apparently little effort. This common domestic scenario plays a major role in causing some youngsters with writing problems to fail to strive. Delayed Mathematics Skills Problems keeping up with demands in mathematics are among the most common learning disorders in adolescents. Disability in mathematics may appear to be an isolated phenomenon but careful evaluation usually reveals other deficits and associated, underlying developmental dysfunctions. 30• 31 Virtually all of the developmental dysfunctions can contribute to mathematics disabilities. Youngsters with attention deficits may have trouble focusing on the detail required. They may understand mathematics facts but fail at applying them accurately. They may tend to ignore operational signs and commit abundant careless errors. Their impulsivity may interfere with mobilizing problem-solving strategies prior to undertaking an arithmetic task. Memory plays a central role in mathematics. Some youngsters with retrieval memory deficits are slow at recalling relevant mathematics rules. Initially they may have difficulty remembering multiplication tables. In geometry and algebra they may not be able to retrieve effectively the appropriate operations for a particular task. They may fail to recognize the right operation when they see a problem. They may not be able to hold symbols in memory long enough to manipulate the number concepts. Students with language disorders may experience a considerable amount of frustration in mathematics. 1 In particular, those with receptive language disabilities may have trouble understanding word problems, trar.sforming verbal syntax into mathematical operations. They may not extract critical inferences when presented as a linguistically coded mathematics challenge. Some youngsters with fine motor problems experience difficulty in

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mathematics. They make many careless errors because number formation, arrangement in columns, and spatial planning on the page are difficult for them. Various organizational deficiencies can result in problems in mathematics. 36 It is known that youngsters with temporal-sequential disorientation may have trouble mastering the multiplication tables. They also have difficulty accomplishing tasks that involve multiple steps in a particular order. Some of the most frequently encountered mathematics disabilities appear to relate to specific or circumscribed higher order cognitive deficiencies. Affected youngsters may not have completely mastered the conceptual framework of mathematics. In some cases, they may have been relatively superficial in their understanding of number concepts in the early grades. They may have been able to perform the manipulations simply out of rote memory, while their true understanding has been tenuous. Such children encounter frustration when they progress to more sophisticated mathematic systems. Thus if a child has not fully mastered basic number concepts, he may struggle with fractions and decimals, new acquisitions that presuppose a thorough understanding of numbers. Conceptual difficulties can also lead to problems with algebra and geometry. Youngsters may try to memorize postulates but not really comprehend their full significance, making it difficult for them to manipulate these rules in a flexible and efficient manner. In algebra a student may not fully grasp exponential equations. Although it may be possible to memorize certain of these processes, their application in word problems, under timed conditions and within a wide range of varying models, may be weak. Students also may encounter trouble with algebra because they have problems operating on an abstract level. Others have difficulty drawing inferences from symbolic representations. A constant interplay between higher order cognition and rapid retrieval memory characterizes much of mathematics in adolescence. The student must be able to comprehend the implications of mathematics concepts and, also, to retrieve specific processes for the right needs at the right time. Youngsters who overrely on conceptualization but have weak memory, or those who can retrieve but do not really understand what they are doing, risk mathematics failure. Moreover, there is a need to integrate, to discern relationships between several processes at the same time or in sequence. Some youngsters take a strongly verbal approach to mathematics. They can understand best by describing and thinking about processes in words. Others seem to operate through nonverbal reasoning, understanding mathematics principles without strong reliance on linguistic cues. Either style may lead to success. Finally, certain kinds of visual-spatial disorientation may cause difficulties in mathematics. This is particularly true in geometry, where strong visual reasoning facilitates performance. Although some youngsters can master geometry as a language, it is considerably easier to enrich verbal description with the capacity to visualize and revisualize spatial relationships. Students with poor visual processing may struggle inordinately with geometry while performing relatively well in other aspects of mathematics.

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Delays in Spelling Skills Spelling problems are a common source of annoyance in adolescence. While they do not directly cause academic failure, they can be seen in association with specific memory deficiencies and with writing problems in general. 5 It is helpful to determine whether spelling errors are largely visual or phonetic. Some youngsters with language disabilities spell words that are close visual approximations (e. g., "lagh" for "laugh") but fail to conform phonetically. Others have problems with revisualization and tend to make errors that are phonetically correct but are not good approximations of the configuration of the word (e. g., "bulleeve" for "believe"). Still others commit mixed errors. The latter subgroup has the poorest prognosis. Foreign Language Disabilities It is not unusual to encounter adolescents who have problems mastering a foreign language. 15 In some cases these are students who perform well in every other subject area. Foreign language disabilities can do a great deal to erode self-esteem and ultimately can have some ripple effects, causing failure to strive in other subject areas. In some instances, youngsters with foreign language disabilities have specific problems with memory that make it difficult for them to retain the vast influx of new vocabulary and grammatical rules. In other cases, there is evidence that some youngsters have had mild to moderate language processing disabilities all of their lives. These may have impaired their acquisition of English. However, with constant exposure and overlearning of the native tongue, their language disabilities in English remained subclinical. Then, when confronted with learning a foreign language in adolescence, the vulnerability becomes apparent. The total immersion, the frequent and multimodal repetition that they had had in English was not available for the foreign language. Thus, even with great diligence and excellent higher order cognitive fu~ction, such youngsters have difficulty mastering foreign language patterns. In still other instances, foreign language disabilities represent one more manifestation of life-long problems acquiring new skills. Thus, some youngsters who were slow learning to read initially may go on eventually to read well. However, when they are required to master a foreign language, they again encounter problems. They are unlikely to persevere at foreign languages to the extent to which they were required to do so with reading. Moreover, special help, lower group placement, and other modifications that may have been instituted when reading skills acquisition was delayed are generally not available for foreign language instruction. Also, just as with mathematics problems, those with foreign language disabilities may become inhibited, losing incentive, and generally failing to strive in this area.

Content Area Problems Some students experience failure in highly specific subject areas, such as social studies, history, or science. In some instances this is due to an inability to relate effectively to a particular teacher. Teaching and learning

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styles or personalities may be mismatched. In other cases, developmental dysfunctions may interfere with knowledge acquisition. Youngsters with one or another of the previously elucidated academic delays may not be able to make effective use of a particular skill in a content area. Those with writing problems, for example, may have trouble completing reports in social studies. In science courses it is assumed that good mathematics skills and keen reading comprehension abilities exist. Performance in the content area subjects can be strongly influenced by a youngster's intrinsic interest in the material. A student who is romantically attracted to history or sCience may be able to strive heroically and overcome any predispositions to failure. It is important to recognize that many content area teachers in secondary schools have not been oriented to look for individual differences among learners. Such instructors usually have a strong dedication to their subject areas, which they may love to impart. They may work to improve their teaching from year-to-year. On the other hand, they may not recognize that a particular youngster may be struggling because of a developmental dysfunction. False attributions are common. The student may be accused of poor motivation, of not really trying, of a bad attitude. This is often seen in youngsters who are active participants in class discussions, but who fail to get their ideas on paper because of some form of "development output failure." In particular, if a child is perceived as having good reading skills, impaired productivity may be construed as an emotional disorder or laziness. Problems with test-taking are commonly encountered in youngsters who have difficulties with specific content areas. Such students may feel that they have a good mastery of the subject, but persistently perform poorly on written examinations. The differential diagnosis in such cases is broad. Included are deficiencies of rapid retrieval memory, a wide range of writing disorders (some report that when they try to write they lose their memories), relatively poor automatization of subskills, underdeveloped strategies for studying, and test anxiety. Some youngsters encounter problems only with certain kinds of examinations. Multiple choice tests may tend to underrate the knowledge and ability of those ,who can demonstrate their knowledge best in their own words, using their own conceptual frameworks. They have difficulty identifying with the particular choices of words and formats of the standardized test makers. Conversely, some youngsters perform better with structured questions than when they are required to encode and organize their ideas, as in an essay response. Practice using a particular prototype of testing can be beneficial.

ASSESSMENT The assessment of an adolescent with developmental dysfunctions requires a very different set of skills and observations than is customarily employed in the evaluation of younger children. In general, there needs to be less emphasis on perceptual function and more stress on observations of attention, organization, memory, language production, and higher order

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cognition. This means that different assessment instruments are needed. A standardized intelligence test, such as the WISC-R, 63 along with a traditional examination of the child's ability to copy geometric forms, is never sufficient to uncover developmental dysfunctions in adolescents. Inadequate evaluations can lead to serious iatrogenic effects. Typically, a child who is struggling with developmental dysfunctions becomes anxious and may fail to strive. The youngster's poor self-image, incipient or actual depression, and relative amotivational state may be mistaken for the cause of poor academic performance rather than the secondary effect. This can lead to accusation, family tension, misdirected counseling, even greater anxiety, and failure to strive. In evaluating an adolescent with learning disorders, the developmental dysfunctions enumerated in this article should be ruled out. First, a careful history should be taken. This should include in-depth inquiry regarding specific patterns of academic strengths and failures, symptoms of specific developmental dysfunction (see Table 2), analyses of behavioral manifestations and affective symptoms (such as sadness, irritability, emotional lability), and an inventory of the youngster's own interests and perceived skills. Multiple viewpoints should be sought. These should include the perspectives of parents, teachers, and the student himself. To facilitate this process, standardized history-taking questionnaires can be used. One such set of questionnaires, The ANSER System, 33 has been developed at The Children's Hospital in Boston. It includes a specific set of data collection instruments designed for use in adolescents, including a form that parents fill out, a questionnaire completed by several teachers, and the youngster's own Self-Administered Student Profile (yielding the student's description of strengths, weaknesses, interests, and problems). In studying the history of an adolescent with learning problems, it is important to review patterns of academic performance in elementary school. One can often detect the antecedents of teenage dysfunction. For example, a youngster with organizational problems might turn out to have a long history of difficulties following multi-step instructions. There may have been problems mastering the days of the week and the months of the year, difficulties learning to tell time, and serious trouble retaining the multiplication tables. Such historical data would suggest strongly that the adolescent's current plight may be the result of long-standing temporalsequential disorganization. Similarly, early indicators of language disability, attentional weakness, and various forms of fine motor dysfunction may be elicited. The results of standardized tests performed in elementary school also may provide important clues. In addition to the careful historical review, the following components of a multidisciplinary evaluation are likely to be helpful: Interview With Parents and the Adolescent: The clinician should attempt to spend time alone with the parents, alone with the adolescent, and then with the family together. Such interviews can focus on highlights from the questionnaires. There should be an effort to identify major concerns, to bring forth any hidden preoccupations or sources of anxiety, and to assess the impact of the learning problem on the family and on the youngster. The clinician should attempt to identify

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any complicating family problems. An effort should be made to assess self-esteem, level of anxiety, and motivation. Physical, Sensory, and Neurologic Examination: A complete physical examination is critical in trying to identify any complicating medical factors, underlying neurologic or genetic disorder, and some relatively rare but critically important medical conditions that can cause academic deterioration in adolescents. Among the latter are brain tumor, Wilson's disease, chronic sinusitis, and iron deficiency. Visual and auditory sensory impairments may significantly complicate learning disorders. Neurodevelopmental Examination: Some health care personnel may wish to perform direct assessments of development in this age group. It is of interest that while developmental assessment in health care settings is fairly routine in youngsters under five, it is somewhat unusual in the school age child and almost unheard of for adolescents. This is ironic, since developmental problems among teenagers can be among the most significant, diagnostically elusive, and long-lasting functional disturbances. Therefore, the sensitive observations of a physician can be of crucial importance. Recently, a special neurodevelopmental examination has been developed largely for use in youngsters up to the age of sixteen. It is designed to elicit problems with attention, memory, language, fine motor function, and organization. It takes approximately 50 minutes to administer. Results of this examination, called the PEERA~ID (The Pediatric Examination of Educational Readiness in Middle Childhood), can be used in conjunction with data from other diagnostic sources. Other Cognitive Tests: A trained psychologist can administer various forms of psychological testing to assess further specific areas of development. It is important to recognize that many examinations tend to "ceiling out" at an earlier age. Some assessment tools, such as the Detroit Test of Learning Abilities, can tap into issues of attention, memory, motor function, and sequential organization in older youngsters. Observations from such tests can be useful. Intelligence tests can be given, not so much as to estimate overall IQ, but to make use of the subtests to define further specific developmental areas of strength and weakness. Psychoeducational Testing: Careful analysis of academic skills is critical. Individual testing of various aspects of reading ability (especially comprehension and retelling), spelling, writing, and mathematics is an essential part of an evaluation. In many cases, standardized group testing of adolescents is not a reliable indicator of true academic proficiency. In some instances, youngsters with serious difficulties perform well on these multiple choice tests. Moreover, they often are not specific enough to pinpoint a youngster's service needs. In general, individual educational testing should not emphasize grade levels; rather, there should be a stress on describing error patterns, defining absent or poorly automatized subskills, and noting various aspects of learning style (both good and bad). Personality Assessment: It is important to have a trained diagnostician assess a youngster's personality. There should be a determination of the extent to which the youngster is depressed, the degree to which significant emotional problems are interfering with performance, and the nature of any complicating environmental difficulties. In some cases, projective testing may be used, although the reliability and validity of such instruments in the pediatric age group has not been wellestablished. Therefore, with projective testing there exists the possibility of a considerable observer bias, inconsistent findings, and misleading data. Often, adolescents will have psychosocial problems consequent to their learning problems (perhaps with associated delays in social cognition). Testing of Aptitude and Interest: In the older adolescent it is especially useful to obtain data about vocational preference, specific aptitudes, and foci of interest.

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Often such testing, available in high school, can provide relevant information for career counseling.

At present, laws in both the United States and Canada entitle students with learning problems to multidisciplinary evaluations within school. Parents or teachers may request that a youngster have such an assessment and that an Individual Educational Plan be generated to provide for special help enabling the student to obtain an adequate education in the public schools. It is likely that, in most cases, such assessments are helpful and nonstigmatizing. Occasionally, however, an evaluation in a school setting may represent a conflict of interest. Budgetary considerations, the school's own pride in having educated the youngster for nearly a decade, disciplinary biases, and the absence of certain services may be major determinants of the outcome of an evaluation. There is likely to be considerable variation from school-to-school with regard to the competence and training of individuals who undertake such evaluations. For this reason, independent evaluations, outside opinions that are unbiased and comprehensive, may be particularly germain. In arranging for such consultations, parents may approach their family physician or pediatrician. That professional may be in the best position to coordinate such an evaluation.

MANAGEMENT It is difficult to generalize about the management of an adolescent with learning problems. As has been suggested throughout this review, there is considerable heterogeneity of neurodevelopmental strengths and weaknesses, unique coping styles, environmental influences, affective responses, interests, and cumulative educational experiences. For this reason, the authors have avoided judiciously the use of simplistic labels for these problems. The therapeutic implication is that management on all fronts must be individualized to meet the highly specific needs, to foster the unique strengths, and to implement what is most feasible for each adolescent. The ultimate goal is to nurture success and to prevent or minimize failure to strive. These goals notwithstanding, it is possible to provide a general outline of an approach to therapeutics. The following steps are recommended: Demystification: It is critically important to explain to a child and his parents the nature of the youngster's developmental dysfunctions. This can do a great deal to alleviate anxiety, to induce hopefulness, and to allow the child to feel that the continuation or resumption of striving may be worthwhile. In demystifying a youngster's difficulties, it is important to use analogies and nontechnical language whenever possible. The clinician always should include some discussion of a youngster's strengths as well as a description of disabilities. There should be an effort to show the relationship between specific dysfunctions and their academic or motivational manifestations. Whenever possible, such demystification should extend to the adolescent's teachers. They too need to develop an understanding of the roots of the youngster's failure. This may be communicated through a written report, a conference, a telephone conversation, or discussion between the school and the parents.

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Special Education: As the result of an evaluation, some specific special educational services may be required. Included could be two basic forms of intervention: improvement of academic skills and remediation of specific areas of development. Examples of the former would include tutorial help in reading comprehension, mathematics, or writing. In the latter category one might include exercises to help a child develop better retrieval memory skills, improved attention to detail, and enhanced sequential organization. Specific amounts of time are allocated in a learning center or resource room to accomplish such interventions. Special Services: Certain specialized interventions may be used to help a youngster in school. Speech and language therapy may be needed to enhance auditory processing, help the youngster formulate sentences, and improve expressive skills. The services of an occupational therapist might be utilized for certain youngsters with fine motor difficulties that interfere with written output. Counseling: A school social worker, guidance counselor, or psychologist may be needed to help a youngster understand his strengths and weaknesses better. The therapist can work on coping skills, on issues of self-esteem and socialization, and on thinking about the future. In some instances, counseling outside of the school setting may be desirable. The services should be provided by a mental health professional experienced in dealing with adolescents with learning problems. Regular Education: Modifications in a youngster's regular educational program can be of paramount importance. Certain bypass strategies are critical. For example, a student with writing problems should be permitted to write less or to type. One with a mathematics problem might use a calculator some of the time. There may need to be some prioritization, whereby a child with retrieval memory problems would not be required to spell correctly, punctuate, capitalize, use good grammar, and write legibly all in the same paragraph at the same time. On a particular assignment, the teacher might allow the youngster to ignore punctuation and spelling and just write down good ideas legibly. A subsequent essay could emphasize other subcomponents. Grading separately for content and mechanics is often appropriate. Teacher and Course Selection: Of great use is the sensitive assignment to teachers who are apt to understand a youngster's struggles. The old medical admonition of primum non nocerum is of the greatest importance. Regular classroom teachers must be sensitized to avoid public humiliation of teenagers with learning problems, to refrain from attributing all of their difficulties to laziness or poor motivation. They should hesitate to call upon a student with expressive language problems or one who is staring out of the window because of an attention deficit. They should avoid having the papers of a child with serious writing problems corrected by a classmate. They need to be keenly aware that adolescents have a desperate need to look good before their peers. Judicious selection of courses is critical. Exemptions may be needed as well as provision of courses in which success is likely. The Pursuit of Strengths: Many adolescents with learning problems and chronic failure to strive are seriously deprived of success. Often their parents can recall little if any mastery or triumphant accomplishment in the youngster's recent life. This should be construed as a neurodevelopmental emergency! Every effort needs to be made to identify strengths and to help a youngster pursue them. In this age group avocational guidance can be as important as vocational counseling. A selection of appropriate sports, musical pursuits, arts, crafts, mechanical activities, and hobbies can permit some youngsters to taste mastery. This can do much to rehabilitate self-esteem. Vocational Services: Particularly among older adolescents, there may be some benefit in having a youngster meet with a vocational counselor. The teenager's

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specific interests and aptitudes can be taken into consideration in helping to chart career pathways. In some instances, early placement in a vocational or technical school can enable a youngster to mobilize strengths and taste success. Some youngsters with language disabilities and very strong mechanical and visual-spatial skills may struggle inordinately to master English literature and French grammar, wondering all of the time about the long-term relevance of these subject areas. That same youngster might thrive (and strive) in a setting in which the design and repair of engines is an important component of the curriculum. It is essential in such cases to achieve a balance between a general education on the one hand, and more specialized usc of strengths on the other. One does not want to risk the constraint of a youngster's future opportunities by "tracking" too soon and too rigidly. Pharmacotherapy: In some instances it may be determined that an adolescent could benefit from a psychopharmacologic agent. Teenagers with attention deficit may be very responsive to the use of stimulant medications. 16· 4 L 54 · 62 Most often a long-acting preparation (such as Dexedrine Spansules or Ritalin SR) is given. Some significantly depressed youngsters might benefit from the use of antidepressant medications. The use of major tranquilizers and other psychopharmacologic agents is advisable only under the supervision of a clinician with a great deal of experience in prescribing such drugs. Follow-up, Monitoring, and Advocacy: The health care professional is in a unique position to offer ongoing monitoring and advocacy. Long-term continuity with the patient is crucial. A strong alliance should be built. The youngster should have a sense that the health care professional is a partner, a kind of coach, one who will look good if the child succeeds. The health care professional needs to provide some scientific consumer advocacy, helping parents sort out appropriate and worthwhile interventions while rejecting unscientific or inappropriate treatment techniques. There also needs to be advocacy for services in school. Periodic follow-up visits are critical when documenting the degree of progress and planning next moves. Short-term goals should be set. There should be a deemphasis on long-term objectives. Parents should not be wondering what college their seventh grader ultimately will enter! Instead, there should be careful consideration of the need for incremental improvement each month.

IMPLICATIONS The problems of adolescence in contemporary North America constitute major challenges for Public Health and Public Policy. 13 It is estimated that there are 5000 suicides per year in the age group from 15 to 19 in the United States. This represents a 75 per cent increase between 1968 and 1979. 47 Moreover, there are 50 to 200 suicide attempts for every completion. According to recent data from the National Institute on Drug Abuse, 37 per cent of youngsters between 12 and 17 are users of alcohol, 30 per cent have used marijuana, and 17 per cent are current users. 26 Other serious problems of nearly epidemic proportions in certain regions include delinquency (250,000 youngsters incarcerated yearly), teenage homicide, and adolescent pregnancy and venereal disease. High prevalances of these outcomes make it imperative that we enhance our understanding of the teenage population. The neurodevelopmental status of youngsters in this age group has been an area of serious neglect. Although it is unlikely that developmental dysfunctions explain most adolescent calamity, it is entirely feasible that learning disorders, the consequent inability to meet adult ex-

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pectations, and the condition of chronic success deprivation constitute a potentially malignant pathophysiologic process accounting for an unrecognized portion of teenage functional morbidity.27 . 39, 49 If so, there are crucial preventive and rehabilitative implications. Future clinical and investigative work must define and study the effects of endogenous hidden handicaps, which, especailly under suboptimal environmental conditions, induce failure to strive, thwart development, and foster serious and possibly irreversible maladaptation.

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