The child with developmental disabilities grown up: Adult residua of childhood disorders

A clinic specializing in learning disabilities and willing to assess adults receives referrals that parallel the three major reasons for referral in the pediatric and adolescent school-aged population: (1) 'Is this patient dyslexic'; (2) 'Does this patient 'have' ADHD residual type'; (3) 'Does this patient have some kind of learning disability?' The third is the most difficult and least well understood, the NVLD or so-called right-hemisphere group, most likely to be referred by mental health facilities and professionals. The first, dyslexia, has the most secure neuroscientific background and in some ways the most straightforward conceptualization yet is still controversial in terms of the subtle and well-masked ways in which its manifestations may be seen. Aptly placed in the second and hence middle position, straddling both dyslexia and NVLD, is that sprawling and emphatically heterogeneous collection of observations agglomerated under the title ADHD and affiliated with the pharmacotherapy of stimulants. Yet for all its sprawl, ADHD stands in relation to its cognitive overlap zone, executive dysfunction, as symptoms do to signs; and executive dysfunction, especially in adults, appears to be a cognitive-deficit cluster of special importance to the persistence of uncompensated or clinically significant learning disabilities. That is, the real question to be answered about adults with learning disabilities is why have they not compensated for cognitive deficits; or, if they have acquired basic academic skills, why have they not been able to use these skills? Unless linguistic or spatial deficits are extremely severe, academic skills can usually be acquired by compensatory strategies and, once acquired, can be used. Ability to compensate (and to generalize the compensation) are crucial determinants of adult learning disabilities outcome. Less is understood about nonacademic skills, of which the social domain seems least optional, i.e., most pervasively important. Spatially based skills are the least difficult to avoid or circumvent. Absent severe linguistic or spatial cognitive deficits, the most central neuropsychologic issues in adult learning-disability studies are executive dysfunction and social imperception/ineptitude. At present, executive dysfunction is the one of these two that can be evaluated in a behavioral neurology clinic.