Michael pressley believes that the key to education is helping students to:

section five

Each forward step we take we leave some phantom of ourselves behind.

—John Lancaster Spalding

American Educator, 19th Century

Middle and Late Childhood
In middle and late childhood, children are on a different plane, belonging to a generation and feeling all their own. It is the wisdom of the human life span that at no time are children more ready to learn than during the period of expansive imagination at the end of early childhood. Children develop a sense of wanting to make things—and not just to make them, but to make them well and even perfectly. They seek to know and to understand. They are remarkable for their intelligence and for their curiosity. Their parents continue to be important influences in their lives, but their growth also is shaped by peers and friends. They don’t think much about the future or about the past, but they enjoy the present moment. This section consists of two chapters: “Physical and Cognitive Development in Middle and Late Childhood” and “Socioemotional Development in Middle and Late Childhood.”

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chapter 9
PHYSICAL AND COGNITIVE DEVELOPMENT IN MIDDLE AND LATE CHILDHOOD
chapter outline
1 Physical Changes and Health

Learning Goal 1 Describe physical changes and health in middle and late childhood.

Body Growth and Change

The Brain

Motor Development

Exercise

Health, Illness, and Disease

2 Children with Disabilities

Learning Goal 2 Identify children with different types of disabilities and discuss issues in educating them.

The Scope of Disabilities

Educational Issues

3 Cognitive Changes

Learning Goal 3 Explain cognitive changes in middle and late childhood.

Piaget’s Cognitive Developmental Theory

Information Processing

Intelligence

Extremes of Intelligence

4 Language Development

Learning Goal 4 Discuss language development in middle and late childhood.

Vocabulary, Grammar, and Metalinguistic Awareness

Reading

Writing

Second-Language Learning and Bilingual Education

image1 ©Hero Images/Getty Images

The following comments were made Page 266by Angie, an elementary-school-aged girl:

When I was 8 years old, I weighed 125 pounds. My clothes were the size that large teenage girls wear. I hated my body, and my classmates teased me all the time. I was so overweight and out of shape that when I took a P.E. class my face would get red and I had trouble breathing. I was jealous of the kids who played sports and weren’t overweight like I was.

I’m 9 years old now and I’ve lost 30 pounds. I’m much happier and proud of myself. How did I lose the weight? My mom said she had finally decided enough was enough. She took me to a pediatrician who specializes in helping children lose weight and keep it off. The pediatrician counseled my mom about my eating and exercise habits, then had us join a group that he had created for overweight children and their parents. My mom and I go to the group once a week and we’ve now been participating in the program for 6 months. I no longer eat fast food meals and my mom is cooking more healthy meals. Now that I’ve lost weight, exercise is not as hard for me and I don’t get teased by the kids at school. My mom’s pretty happy too because she’s lost 15 pounds herself since we’ve been in the counseling program.

Not all overweight children are as successful as Angie at reducing their weight. Indeed, being overweight or obese in childhood has become a major national concern in the United States. Later in this chapter, we will further explore being overweight and obese in childhood, including obesity’s causes and outcomes.

topical connections looking back
Children grow more slowly in early childhood than in infancy, but they still grow an average of 2.5 inches and gain 4 to 7 pounds a year. In early childhood, the most rapid growth in the brain occurs in the prefrontal cortex. The gross and fine motor skills of children also become smoother and more coordinated. In terms of cognitive development, early childhood is a period in which young children increasingly engage in symbolic thought. Young children’s information-processing skills also improve considerably—executive and sustained attention advance, short-term memory gets better, executive function increases, and their understanding of the human mind makes considerable progress. Young children also increase their knowledge of language’s rule systems, and their literacy benefits from active participation in a wide range of language experiences. Most young children attend an early childhood education program, and there are many variations in these programs.

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preview

During the middle and late childhood years, children grow taller, heavier, and stronger. They become more adept at using their physical skills, and they develop new cognitive skills. This chapter is about physical and cognitive development in middle and late childhood. To begin, we will explore aspects of physical development.

1 Physical Changes and Health
LG1 Describe physical changes and health in middle and late childhood.

Body Growth and Change

The Brain

Motor Development

Exercise

Health, Illness, and Disease

Continued change characterizes children’s bodies during middle and late childhood, and their motor skills improve. As children move through the elementary school years, they gain greater control over their bodies and can sit and keep their attention focused for longer periods of time. Regular exercise is one key to making these years a time of healthy growth and development.

BODY GROWTH AND CHANGE
The period of middle and late childhood involves slow, consistent growth (Hockenberry, Wilson, & Rodgers, 2017). This is a period of calm before the rapid growth spurt of adolescence. During the elementary school years, children grow an average of 2 to 3 inches a year until, at the age of 11, the average girl is 4 feet, 10 inches tall, and the average boy is 4 feet, 9 inches tall. During the middle and late childhood years, children gain about 5 to 7 pounds a year. The weight increase is due mainly to increases in the size of the skeletal and muscular systems, as well as the size of some body organs.

developmental connection
Brain Development
Synaptic pruning is an important aspect of the brain’s development, and the pruning varies by brain region across children’s development. Connect to “Physical Development in Infancy.”

Proportional changes are among the most pronounced physical changes in middle and late childhood. Head circumference and waist circumference decrease in relation to body height (Kliegman & others, 2016; Perry & others, 2018). A less noticeable physical change is that bones continue to ossify during middle and late childhood but yield to pressure and pull more than mature bones.

THE BRAIN
The development of brain-imaging techniques such as magnetic resonance imaging (MRI) has led to increased research on changes in the brain during middle and late childhood and links between these brain changes and cognitive development (Khundrakpam & others, 2018; Mah, Geeraert, & Lebel, 2017). Total brain volume stabilizes by the end of late childhood, but significant changes in various structures and regions of the brain continue to occur. In particular, the brain pathways and circuitry involving the prefrontal cortex, the highest level in the brain, continue to increase during middle and late childhood (see Figure 1). These advances in the prefrontal cortex are linked to children’s improved attention, reasoning, and cognitive control (de Haan & Johnson, 2016; Wendelken & others, 2016, 2017).

image2 FIGURE 1 The Prefrontal Cortex. The brain pathways and circuitry involving the prefrontal cortex (shaded in purple) show significant advances in development during middle and late childhood. What cognitive processes are linked to these changes in the prefrontal cortex?

Leading developmental neuroscientist Mark Johnson and his colleagues (2009) proposed that the prefrontal cortex likely orchestrates the functions of many other brain regions during development. As part of this neural leadership role, the prefrontal cortex may provide an advantage to neural networks and connections that include the prefrontal cortex. In their view, the prefrontal cortex coordinates the best neural connections for solving a problem at hand.

image3 What characterizes children’s physical growth in middle and late childhood? ©Chris Windsor/Digital Vision/Getty Images

Changes also occur in the thickness of the cerebral cortex (cortical thickness) in middle and late childhood (Thomason & Thompson, 2011). One study used brain scans to assess cortical thickness in 5- to 11-year-old children (Sowell & others, 2004). Cortical thickening across a two-year time period was observed in the temporal and frontal lobe areas that function in language, which may reflect improvements in language abilities such as reading. Figure 6in “Physical Development in Infancy” shows the locations of the temporal and frontal lobes in the brain.

As children develop, some brain areas become more active Page 268while others become less so (Denes, 2016). One shift in activation that occurs as children develop is from diffuse, larger areas to more focal, smaller areas (Turkeltaub & others, 2003). This shift is characterized by synaptic pruning, a process in which areas of the brain that are not being used lose synaptic connections and areas that are used show increased connections. In one study, researchers found less diffusion and more focal activation in the prefrontal cortex from 7 to 30 years of age (Durston & others, 2006).

Increases in connectivity between brain regions also occurs as children develop (Faghiri & others, 2018). In a longitudinal study of individuals from 6 to 22 years of age, connectivity between the prefrontal and parietal lobes in childhood was linked to better reasoning ability later in development (Wendelken & others, 2017).

MOTOR DEVELOPMENT
During middle and late childhood, children’s motor skills become much smoother and more coordinated than they were in early childhood (Hockenberry, Wilson, & Rodgers, 2017). For example, only one child in a thousand can hit a tennis ball over the net at the age of 3, yet by the age of 10 or 11 most children can learn to play the sport. Running, climbing, skipping rope, swimming, bicycle riding, and skating are just a few of the many physical skills elementary school children can master. In gross motor skills involving large muscle activity, boys usually outperform girls.

Increased myelination of the central nervous system is reflected in the improvement of fine motor skills during middle and late childhood. Children can more adroitly use their hands as tools. Six-year-olds can hammer, paste, tie shoes, and fasten clothes. By 7 years of age, children’s hands have become steadier. At this age, children prefer a pencil to a crayon for printing, and reversal of letters is less common. Printing becomes smaller. At 8 to 10 years of age, the hands can be used independently with more ease and precision. Fine motor coordination develops to the point at which children can write rather than print words. Cursive letter size becomes smaller and more even. At 10 to 12 years of age, children begin to show manipulative skills similar to the abilities of adults. They can master the complex, intricate, and rapid movements needed to produce fine-quality crafts or to play a difficult piece on a musical instrument. Girls usually outperform boys in their use of fine motor skills.

EXERCISE
American children and adolescents are not getting enough exercise (Powers & Dodd, 2017; Powers & Howley, 2018). Increasing children’s exercise levels has a number of positive outcomes (Dumuid & others, 2017; Walton-Fisette & Wuest, 2018).

image4 What are some good strategies for increasing children’s exercise? ©Randy Pench/Zuma Press/Newscom

An increasing number of studies document the importance of exercise in children’s physical development (Dowda & others, 2017; Martin & others, 2018; Pan & others, 2017; Yan & others, 2018). A recent study of more than 6,000 elementary school children revealed that 55 minutes or more of moderate-to-vigorous physical activity daily was associated with a lower incidence of obesity (Nemet, 2016). Further, a research review concluded that exercise programs with a frequency of three weekly sessions lasting longer than 60 minutes were effective in lowering both systolic and diastolic blood pressure (Garcia-Hermoso, Saavedra, & Escalante, 2013).

developmental connection
Exercise
Experts recommend that preschool children engage in two hours of physical activity per day. Connect to “Socioemotional Development in Early Childhood.”

Aerobic exercise also is linked to children’s cognitive skills (Best, 2010; Lind & others, 2018; Martin & others, 2018). Researchers have found that aerobic exercise benefits children’s processing speed, attention, memory, effortful and goal-directed thinking and behavior, and creativity (Chu & others, 2017; Davis & Cooper, 2011; Davis & others, 2011; Khan & Hillman, 2014; Lind & others, 2018; Ludyga & others, 2018; Monti, Hillman, & Cohen, 2012; Pan & others, 2017). A recent meta-analysis concluded that sustained physical activity programs were linked to improvements in children’s attention, executive function, and academic achievement (de Greeff & others, 2018). Also, a recent study found that a 6-week high-intensity exercise program with 7- to 13-year-olds improved their cognitive control and working memory (Moreau, Kirk, & Waldie, 2018). Further, in a recent fMRI study of physically unfit 8- to 11-year-old overweight children, a daily instructor-led aerobic exercise program that lasted eight months was effective in improving the efficiency of neural circuits that support better cognitive functioning (Kraftt & others, 2014).

Parents and schools play important Page 269roles in determining children’s exercise levels (Brusseau & others, 2018; de Heer & others, 2017; Lind & others, 2018; Lo & others, 2018; Solomon-Moore & others, 2018). Growing up with parents who exercise regularly provides positive models of exercise for children (Crawford & others, 2010). In addition, a research review found that school-based physical activity was successful in improving children’s fitness and lowering their fat levels (Kriemler & others, 2011).

Screen time also is linked with low activity, obesity, and worse sleep patterns in children (Tanaka & others, 2017). A recent research review found that a higher level of screen time increased the risk of obesity for low- and high-activity children (Lane, Harrison, & Murphy, 2014). Also, a recent study of 8- to 12-year-olds found that screen time was associated with lower connectivity between brain regions, as well as lower levels of language skills and cognitive control (Horowitz-Kraus & Hutton, 2018). In this study, time spent reading was linked to higher levels of functioning in these areas.

Here are some ways to encourage children to exercise more:

· Offer more physical activity programs run by volunteers at school facilities.

· Improve physical fitness activities in schools.

· Have children plan community and school activities that interest them.

· Encourage families to focus more on physical activity, and encourage parents to exercise more.

HEALTH, ILLNESS, AND DISEASE
For the most part, middle and late childhood is a time of excellent health. Disease and death are less prevalent at this time than during other periods in childhood and in adolescence. However, many children in middle and late childhood face health problems that harm their development.

Accidents and Injuries Injuries are the leading cause of death during middle and late childhood, and the most common cause of severe injury and death in this period is motor vehicle accidents, either as a pedestrian or as a passenger (Centers for Disease Control and Prevention, 2017c). For this reason, safety advocates recommend the use of safety-belt restraints and child booster seats in vehicles because they can greatly reduce the severity of motor vehicle injuries (Eberhardt & others, 2016; Shimony-Kanat & others, 2018). For example, one study found that child booster seats reduced the risk for serious injury by 45 percent for 4- to 8-year-old children (Sauber-Schatz & others, 2014). Other serious injuries involve bicycles, skateboards, roller skates, and other sports equipment (Perry & others, 2018).

Overweight Children Being overweight is an increasingly prevalent health problem in children (Blake, 2017; Donatelle, 2019; Smith & Collene, 2019). Recall that being overweight is defined in terms of body mass index (BMI), which is computed by a formula that takes into account height and weight—children at or above the 97th percentile are included in the obesity category, at or above the 95th percentile in the overweight category, and children at or above the 85th percentile are described as at risk for being overweight (Centers for Disease Control and Prevention, 2017b). Over the last three decades, the percentage of U.S. children who are at risk for being overweight has increased dramatically. Recently there has been a decrease in the percentage of 2- to 5-year-old children who are obese, which dropped from 12.1 percent in 2009–2010 to 9.4 percent in 2013–2014 (Ogden & others, 2016). In 2013–2014, 17.4 percent of 6- to 11-year-old U.S. children were classified as obese, essentially the same percentage as in 2009–2010 (Ogden & others, 2016).

It is not just in the United States that children are becoming more overweight (Thompson, Manore, & Vaughan, 2017). For example, a study found that general and abdominal obesity in Chinese children increased significantly from 1993 to 2009 (Liang & others, 2012). Further, a recent Chinese study revealed that high blood pressure in 23 percent of boys and 15 percent of girls could be attributed to being overweight or obese (Dong & others, 2015).

developmental connection
Conditions, Diseases, and Disorders
Metabolic syndrome has increased in middle-aged adults in recent years and is linked to early death. Connect to “Physical and Cognitive Development in Middle Adulthood.”

Causes of Children Being Overweight Heredity and environmental contexts are related to being overweight in childhood (Insel & Roth, 2018; Yanovski & Yanovski, 2018). Genetic analysis indicates that heredity is an important factor in children becoming overweight (Donatelle, 2019). Overweight parents tend to have overweight children (Pufal & others, 2012). For example, one study found that the greatest risk factor for being overweight at 9 years of age was having an overweight parent Page 270(Agras & others, 2004). Parents and their children often have similar body types, height, body fat composition, and metabolism (Pereira-Lancha & others, 2012). In a 14-year longitudinal study, parental weight change predicted children’s weight change (Andriani, Liao, & Kuo, 2015).

Environmental factors that influence whether children become overweight include the greater availability of food (especially food high in fat content), energy-saving devices, declining physical activity, parents’ eating habits and monitoring of children’s eating habits, the context in which a child eats, and heavy screen time (Ren & others, 2017). In a recent Japanese study, the family pattern that was linked to the highest risk of overweight/obesity in children was a combination of irregular mealtimes and the most screen time for both parents (Watanabe & others, 2016). Further, a recent study found that children were less likely to be obese or overweight when they attended schools in states that had a strong policy emphasis on healthy foods and beverages (Datar & Nicosia, 2017). Also, a behavior modification study of overweight and obese children made watching TV contingent on their engagement in exercise (Goldfield, 2012). The intervention markedly increased their exercise and reduced their TV viewing time.

image5 What are some of the health risks for overweight and obese children? ©Image Source/Getty Images

Consequences of Being Overweight The high percentage of overweight children in recent decades is cause for great concern because being overweight raises the risk for many medical and psychological problems (Powers & Dodd, 2017; Schiff, 2019; Song & others, 2018). Diabetes, hypertension (high blood pressure), and elevated blood cholesterol levels are common in children who are overweight (Chung, Onuzuruike, & Magge, 2018; Martin-Espinosa & others, 2017). Research reviews have concluded that obesity was linked with low self-esteem in children (Gomes & others, 2011; Moharei & others, 2018). And in one study, overweight children were more likely than normal-weight children to report being teased by their peers and family members (McCormack & others, 2011).

Intervention Programs A combination of diet, exercise, and behavior modification is often recommended to help children lose weight (Insel & Roth, 2018; Martin & others, 2018; Morgan & others, 2016). Intervention programs that emphasize getting parents to engage in healthier lifestyles themselves, as well as to feed their children healthier food and get them to exercise more, can produce weight reduction in overweight and obese children (Stovitz & others, 2014; Yackobovitch-Gavan & others, 2018). For example, one study found that a combination of a child-centered activity program and a parent-centered dietary modification program helped overweight children lose pounds over a two-year period (Collins & others, 2011).

Cardiovascular Disease Cardiovascular disease is uncommon in children. Nonetheless, environmental experiences and behavior during childhood can sow the seeds for cardiovascular disease in adulthood (Schaefer & others, 2017). Many elementary-school-aged children already possess one or more of the risk factors for cardiovascular disease, such as hypertension (high blood pressure) and obesity (Chung, Onuzuruike, & Magge, 2018; Zoller & others, 2017). In a recent study, the combination of a larger waist circumference and a higher body mass index (BMI) placed children at higher risk for developing cardiovascular disease (de Koning & others, 2015). A recent study found that high blood pressure in childhood was linked to high blood pressure and other heart abnormalities in adulthood (Fan & others, 2018). Also in a longitudinal study, high levels of body fat and elevated blood pressure beginning in childhood were linked to premature death from coronary heart disease in adulthood (Berenson & others, 2016). Further, one study found that high blood pressure went undiagnosed in 75 percent of children with the disease (Hansen, Gunn, & Kaelber, 2007).

Cancer Cancer is the second leading cause of death in U.S. children 5 to 14 years of age. One in every 330 children in the United States develops cancer before the age of 19. The incidence of cancer in children has increased slightly in recent years (National Cancer Institute, 2018).

Childhood cancers mainly attack the white blood cells (leukemia), brain, bone, lymph system, muscles, kidneys, and nervous system. All types of cancer are characterized by an uncontrolled proliferation of abnormal cells (Marcoux & others, 2018). As indicated in Figure 2, the most common cancer in children is leukemia, a cancer in which bone marrow manufactures an abundance of abnormal white blood cells that crowd out normal cells, making the child highly susceptible to bruising and infection (Kato & Manabe, 2018; Shago, 2017).

image6 FIGURE 2 Types of Cancer in Children. Cancers in children have a different profile from adult cancers, which attack mainly the lungs, colon, breast, prostate, and pancreas.Page 271

connecting with careers
Sharon McLeod, Child Life Specialist
Sharon McLeod is a child life specialist who is senior clinical director in the Division of Child Life and Division of Integrative Care at the Children’s Hospital Medical Center in Cincinnati.

Under McLeod’s direction, the goals of her department are to promote children’s optimal growth and development, reduce the stress of health care experiences, and provide support to child patients and their families. These goals are accomplished by facilitating therapeutic play and developmentally appropriate activities, educating and psychologically preparing children for medical procedures, and serving as a resource for parents and other professionals regarding children’s development and health care issues.

McLeod says that human growth and development provides the foundation for her profession as a child life specialist. She also says her best times as a student were when she conducted fieldwork, had an internship, and experienced hands-on applications of the theories and concepts that she learned in her courses.

image7Sharon McLeod, child life specialist, works with a child at Children’s Hospital Medical Center in Cincinnati. Courtesy of Sharon McLeod

For more information about what child life specialists do, see the Careers in Life-Span Development appendix.

Because of advancements in cancer treatment, children with cancer are surviving longer than in the past (National Cancer Institute, 2018). Approximately 80 percent of children with acute lymphoblastic leukemia are cured with current chemotherapy treatment.

Child life specialists are among the health professionals who work to make the lives of children with diseases less stressful. To read about the work of child life specialist Sharon McLeod, see Connecting with Careers .

Review Connect Reflect
LG1 Describe physical changes and health in middle and late childhood.

Review
· What are some changes in body growth and proportions in middle and late childhood?

· What characterizes the development of the brain in middle and late childhood?

· How do children’s motor skills develop in middle and late childhood?

· What role does exercise play in children’s lives?

· What are some characteristics of health, illness, and disease in middle and late childhood?

Connect
· In this section, you learned that increased myelination of the central nervous system is reflected in the improvement of fine motor skills during middle and late childhood. What developmental advances were connected with increased myelination in infancy and early childhood?

Reflect Your Own Personal Journey of Life
· One way that children get exercise is to play a sport. If you played a sport as a child, was it a positive or negative experience? Do you think that playing a sport as a child likely made a difference in whether you have continued to exercise on a regular basis? Explain. If you did not play a sport, do you wish you had? Explain.

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2 Children with Disabilities
LG2 Identify children with different types of disabilities and discuss issues in educating them.

The Scope of Disabilities

Educational Issues

THE SCOPE OF DISABILITIES
Of all children in the United States, 12.9 percent from 3 to 21 years of age received special education or related services in 2012–2013, an increase of 3 percent since 1980–1981 (Condition of Education, 2016). Figure 3 shows the five largest groups of students with a disability who were served by federal programs during the 2012–2013 school year (Condition of Education, 2016). As indicated in Figure 3, students with a learning disability were by far the largest group of students with a disability to be given special education, followed by children with speech or hearing impairments, autism, intellectual disability, and emotional disturbance. Note that the U.S. Department of Education includes both students with a learning disability and students with ADHD in the category of learning disability.

image8 FIGURE 3 U.S. CHILDREN WITH A DISABILITY WHO RECEIVE SPECIAL EDUCATION SERVICES. Figures are for the 2012–2013 school year and represent the five categories with the highest number and percentage of children. Both learning disability and attention deficit hyperactivity disorder are combined in the learning disabilities category (Condition of Education, 2016).

Learning Disabilities The U.S. government created a definition of learning disabilities in 1997 and then reauthorized the definition with a few minor changes in 2004. Following is a summary of the government’s definition of the characteristics that determine whether a child should be classified as having a learning disability. A child with a learning disability has difficulty in learning that involves understanding or using spoken or written language, and the difficulty can appear in listening, thinking, reading, writing, and spelling. A learning disability also may involve difficulty in doing mathematics (McCaskey & others, 2017, 2018). To be classified as a learning disability, the learning problem is not primarily the result of visual, hearing, or motor disabilities; intellectual disability; emotional disorders; or environmental, cultural, or economic disadvantage (Friend, 2018; Heward, Alber-Morgan, & Konrad, 2017).

About three times as many boys as girls are classified as having a learning disability. Among the explanations for this gender difference are a greater biological vulnerability among boys and referral bias. That is, boys are more likely to be referred by teachers for treatment because of troublesome behavior.

Approximately 80 percent of children with a learning disability have a reading problem (Shaywitz & Shaywitz, 2017). Three types of learning disabilities are dyslexia, dysgraphia, and dyscalculia:

· Dyslexia is a category reserved for individuals who have a severe impairment in their ability to read and spell (Shaywitz & Shaywitz, 2017).

· Dysgraphia is a learning disability that involves difficulty in handwriting (Hook & Haynes, 2017). Children with dysgraphia may write very slowly, their writing products may be virtually illegible, and they may make numerous spelling errors because of their inability to match sounds and letters.

· Dyscalculia , also known as developmental arithmetic disorder, is a learning disability that involves difficulty in math computation (McCaskey & others, 2017, 2018; Nelson & Powell, 2018).

The precise causes of learning disabilities have not yet been determined (Friend, 2018). Researchers have used brain-imaging techniques, such as magnetic resonance imaging, to explore whether specific regions of the brain might be involved in learning disabilities (Ramus & others, 2018; Shaywitz, Lyon, & Shaywitz, 2006) (see Figure 4). This research indicates that it is unlikely learning disabilities reside in a single, specific brain location. More likely, learning disabilities involve difficulty integrating information from multiple brain regions or subtle impairments in brain structures and functions.

image9 FIGURE 4 BRAIN SCANS AND LEARNING DISABILITIES. An increasing number of studies are using MRI brain scans to examine the brain pathways involved in learning disabilities. Shown here is 9-year-old Patrick Price, who has dyslexia. Patrick is going through an MRI scanner disguised by drapes to look like a child-friendly castle. Inside the scanner, children must lie virtually motionless as words and symbols flash on a screen, and they are asked to identify them by clicking different buttons. ©Manuel Balce Ceneta/AP Images

Interventions with children who have a learning disability often focus on improving reading ability (Cunningham, 2017; Shaywitz & Shaywitz, 2017; Temple & others, 2018). Intensive instruction over a period of time by a competent teacher can help many children (Thompson & others, 2017).

Attention Deficit Hyperactivity Disorder (ADHD) Attention deficit hyperactivity disorder (ADHD) is a disability in which children consistently show one or more of the following characteristics over a period of Page 273time: (1) inattention, (2) hyperactivity, and (3) impulsivity. Children who are inattentive have such difficulty focusing on any one thing that they may get bored with a task after only a few minutes—or even seconds. Children who are hyperactive show high levels of physical activity, seeming to be almost constantly in motion. Children who are impulsive have difficulty curbing their reactions; they do not do a good job of thinking before they act. Depending on the characteristics that children with ADHD display, they can be diagnosed as having (1) ADHD with predominantly inattention, (2) ADHD with predominantly hyperactivity/impulsivity, or (3) ADHD with both inattention and hyperactivity/impulsivity.

The number of children diagnosed and treated for ADHD has increased substantially in recent decades, by some estimates doubling in the 1990s. The American Psychiatric Association (2013) reported in the DSM-V that 5 percent of children have ADHD, although estimates are higher in community samples. For example, the Centers for Disease Control and Prevention (2016) estimates that ADHD has continued to increase in 4- to 17-year-old children from 8 percent in 2003 to 9.5 percent in 2007 and to 11 percent in 2016. According to the Centers for Disease Control and Prevention, 13.2 percent of U.S. boys and 5.6 of U.S. girls have ever been diagnosed with ADHD.

There is controversy, however, about the reasons for the increased diagnosis of ADHD (Friend, 2018; Hallahan, Kauffman, & Pullen, 2019). Some experts attribute the increase mainly to heightened awareness of the disorder; others are concerned that many children are being incorrectly diagnosed (Watson & others, 2014).

One study examined the possible misdiagnosis of ADHD (Bruchmiller, Margraf, & Schneider, 2012). In this study, child psychologists, psychiatrists, and social workers were given vignettes of children with ADHD. Some vignettes matched the diagnostic criteria for the disorder, while others did not. The child in each vignette was sometimes identified as male and sometimes as female. The researchers assessed whether the mental health professionals gave a diagnosis of ADHD to the child described in the vignette. The professionals overdiagnosed ADHD almost 20 percent of the time, and regardless of the symptoms described, boys were twice as likely as girls to be diagnosed as having ADHD.

Adjustment and optimal development are difficult for children who have ADHD, so it is important that the diagnosis be accurate (Hechtman & others, 2016; Hallahan, Kauffman, & Pullen, 2019). Children diagnosed with ADHD have an increased risk of lower academic achievement, problematic peer relations, school dropout, adolescent pregnancy, substance use problems, and antisocial behavior (Machado & others, 2018; Regnart, Truter, & Meyer, 2017). For example, a recent study found that childhood ADHD was associated with long-term underachievement in math and reading (Voigt & others, 2017). Also, a recent research review concluded that in comparison with typically developing girls, girls with ADHD had more problems in friendship, peer interaction, social skills, and peer victimization (Kok & others, 2016). Further, a recent research review concluded that ADHD in childhood was linked to the following long-term outcomes: failure to complete high school, other mental and substance use disorders, criminal activity, and unemployment (Erskine & others, 2016). And a recent study revealed that individuals with ADHD were more likely to become parents at 12 to 16 years of age (Ostergaard & others, 2017).

Definitive causes of ADHD have not been found. However, a number of possible causes have been proposed (Hallahan, Kauffman, & Pullen, 2019; Lewis, Wheeler, & Carter, 2017). Some children likely inherit a tendency to develop ADHD from their parents (Hess & others, 2018; Walton & others, 2017). Other children likely develop ADHD because of damage to their brain during prenatal or postnatal development (Bos & others, 2017). Among early possible contributors to ADHD are cigarette and alcohol exposure, as well as a high level of maternal stress during prenatal development and low birth weight (Scheinost & others, 2017).

image10Many children with ADHD show impulsive behavior, such as this boy reaching to pull a girl’s hair. How would you handle this situation if you were a teacher and this were to happen in your classroom? ©Nicole Hill/Rubberball/Getty Images

As with learning disabilities, advances in brain-imaging technology are facilitating a better understanding of ADHD (Riaz & others, 2018; Sun & others, 2018). One study revealed that peak thickness of the cerebral cortex occurred three years later (at 10.5 years) in children with ADHD than in children without ADHD (at 7.5 years) (Shaw & others, 2007). The delay was more prominent in the prefrontal regions of the brain that are particularly important in attention and planning Page 274(see Figure 5). Another study also found delayed development of the brain’s frontal lobes in children with ADHD, likely due to delayed or decreased myelination (Nagel & others, 2011). Researchers also are exploring the roles that various neurotransmitters, such as serotonin and dopamine, might play in ADHD (Auerbach & others, 2017; Baptista & others, 2017).

image11 FIGURE 5 REGIONS OF THE BRAIN IN WHICH CHILDREN WITH ADHD HAD A DELAYED PEAK IN THE THICKNESS OF THE CEREBRAL CORTEX. Note: The greatest delays occurred in the prefrontal cortex.

The delays in brain development just described are in areas linked to executive function (Munro & others, 2018). An increasing focus of interest in the study of children with ADHD is their difficulty with tasks involving executive function, such as behavioral inhibition when necessary, use of working memory, and effective planning (Krieger & Amador-Campos, 2018; Toplak, West, & Stanovich, 2017). Researchers also have found deficits in theory of mind in children with ADHD (Maoz & others, 2018; Mary & others, 2016). Stimulant medication such as Ritalin or Adderall (which has fewer side effects than Ritalin) is effective in improving the attention of many children with ADHD, but it usually does not improve their attention to the levels seen in children who do not have ADHD (Wong & Stevens, 2012). A recent research review also concluded that stimulant medications are effective in treating ADHD during the short term but that longer-term benefits of stimulant medications are not clear (Rajeh & others, 2017). A meta-analysis concluded that behavior management treatments are useful in reducing the effects of ADHD (Fabiano & others, 2009). Researchers have often found that a combination of medication (such as Ritalin) and behavior management improves the behavior of some but not all children with ADHD better than medication alone or behavior management alone (Parens & Johnston, 2009).

The sheer number of ADHD diagnoses has prompted speculation that psychiatrists, parents, and teachers are in fact labeling normal childhood behavior as psychopathology (Mash & Wolfe, 2019; Molina & Pelham, 2014). One reason for concern about overdiagnosing ADHD is that the form of treatment in well over 80 percent of cases is psychoactive drugs, including stimulants such as Ritalin and Adderall (Garfield & others, 2012). Further, there is increasing concern that children who are given stimulant drugs such as Ritalin or Adderall are at risk for developing substance abuse problems, although evidence supporting this concern so far has been mixed (Erskine & others, 2016; Zulauf & others, 2014).

Recently, researchers have been exploring the possibility that neurofeedback might improve the attention of children with ADHD (Alegria & others, 2017; Gelade & others, 2018; Jiang, Abiri, & Zhao, 2017; Moreno-Garcia & others, 2018). Neurofeedback trains individuals to become more aware of their physiological responses so they can attain better control over their brain’s prefrontal cortex, where executive control primarily occurs. Individuals with ADHD have higher levels of electroencephalogram (EEG) abnormalities, and neurofeedback produces audiovisual profiles of these abnormal brain waves so that individuals can learn how to achieve normal EEG functioning. In a recent study, 7- to 14-year-olds with ADHD were randomly assigned to either receive a neurofeedback treatment that consisted of 40 sessions or to take Ritalin (Meisel & others, 2013). Both groups showed a lower level of ADHD symptoms 6 months after the treatment, but only the neurofeedback group performed better academically.

developmental connection
Cognitive Processes
Mindfulness training is being used to improve students’ executive function. Connect to “Socioemotional Development in Adolescence.”

Recently, mindfulness training also has been given to children and adolescents with ADHD (Edel & others, 2017; Evans & others, 2018; Sibalis & others, 2018). A recent meta-analysis concluded that mindfulness training significantly improved the attention of children with ADHD (Cairncross & Miller, 2018).

Exercise also is being investigated as a possible treatment for children with ADHD (Den Heijer & others, 2017; Grassman & others, 2017; Pan & others, 2018). For example, a recent study confirmed that an 8-week yoga program was effective in improving the sustained attention of children with ADHD (Chou & Huang, 2017). Also, a recent meta-analysis concluded that physical exercise is effective in reducing cognitive symptoms of ADHD in individuals 3 to 25 years of age (Tan, Pooley, & Speelman, 2016). And a second recent meta-analysis concluded that a short-term aerobic exercise program was effective in reducing symptoms such as inattention, hyperactivity, and impulsivity (Cerillo-Urbina & others, 2015). Also, a third recent meta-analysis indicated that exercise is associated with better executive function in children with ADHD (Vysniauske & others, 2018). Among the reasons that exercise might reduce ADHD symptoms in children are (1) better allocation of attention resources, (2) positive influence on prefrontal cortex functioning, and (3) exercise-induced dopamine release (Chang & others, 2012).

image12 How can neurofeedback reduce the symptoms of ADHD in children? ©Jerilee Bennett/KRT/Newscom

Despite the encouraging results of Page 275recent studies involving the use of neurofeedback, mindfulness training, and exercise to improve the attention of children with ADHD, it still remains to be determined whether these non-drug therapies are as effective as stimulant drugs and/or whether they benefit children as add-ons to stimulant drugs to provide a combination treatment (Den Heijer & others, 2017).

Emotional and Behavioral Disorders Most children have minor emotional difficulties at some point during their school years. However, some children have problems so serious and persistent that they are classified as having an emotional or behavioral disorder (Mash & Wolfe, 2019). These problems may include internalized disorders such as depression or externalized disorders such as aggression.

image13 What characterizes autism spectrum disorders? ©Rob Crandall/Alamy

Emotional and behavioral disorders consist of serious, persistent problems that involve relationships, aggression, depression, and fears associated with personal or school matters, as well as other inappropriate socioemotional characteristics (Lewis, Asbury, & Plomin, 2017; Weersing & others, 2017). Approximately 8 percent of children who have a disability and require an individualized education plan fall into this classification. Boys are three times as likely as girls to have these disorders.

Autism Spectrum Disorders Autism spectrum disorders (ASD) , also called pervasive developmental disorders, range from the severe disorder labeled autistic disorder to the milder disorder called Asperger syndrome. Autism spectrum disorders are characterized by problems in social interaction, problems in verbal and nonverbal communication, and repetitive behaviors (Boutot, 2017; Gerenser & Lopez, 2017). Children with these disorders may also show atypical responses to sensory experiences (National Institute of Mental Health, 2018). Intellectual disability is present in some children with autism; others show average or above-average intelligence (Bernier & Dawson, 2016).

Recent estimates of autism spectrum disorders indicate that they are dramatically increasing in occurrence (or are increasingly being detected). Once thought to affect only 1 in 2,500 children decades ago, they were estimated to be present in about 1 in 150 children in 2002 (Centers for Disease Control and Prevention, 2007). However, in the most recent survey, the estimated percentage of 8-year-old children with autism spectrum disorders had increased to 1 in 68 (Christensen & others, 2016). In the recent surveys, autism spectrum disorders were identified five times more often in boys than in girls, and 8 percent of individuals aged 3 to 21 with these disorders were receiving special education services (Centers for Disease Control and Prevention, 2017a).

developmental connection
Conditions, Diseases, and Disorders
Autistic children have difficulty in developing a theory of mind, especially in understanding others’ beliefs and emotions. Connect to “Physical and Cognitive Development in Early Childhood.”

Also, in recent surveys, only a minority of parents reported that their child’s autistic spectrum disorder was identified prior to 3 years of age and that one-third to one-half of the cases were identified after 6 years of age (Sheldrick, Maye, & Carter, 2017). However, researchers are conducting studies that seek to identify earlier determinants of autism spectrum disorders (Reiersen, 2017).

Autistic disorder is a severe developmental autism spectrum disorder that has its onset during the first three years of life and includes deficiencies in social relationships, abnormalities in communication, and restricted, repetitive, and stereotyped patterns of behavior.

Asperger syndrome is a relatively mild autism spectrum disorder in which the child has relatively good verbal language skills, milder nonverbal language problems, and a restricted range of interests and relationships (Boutot, 2017). Children with Asperger syndrome often engage in obsessive, repetitive routines and preoccupations with a particular subject. For example, a child may be obsessed with baseball scores or specific videos on YouTube.

Children with autism have deficits in cognitive processing of information (Jones & others, 2018). For example, a recent study found that a lower level of working memory was the executive function most strongly associated with autism spectrum disorders (Ziermans & others, 2017). Children with these disorders may also show atypical responses to sensory experiences (National Institute of Mental Health, 2017). Intellectual disability is present in some children with autism; others show average or above-average intelligence (Volkmar & others, 2014).

In 2013, the American Psychiatric Association published the new edition (DSM-V) of its psychiatric classification of disorders. In the new classification, autistic disorder, Asperger’s syndrome, and several other autistic variations were consolidated in the overarching category of autism spectrum disorder (Autism Research Institute, 2013). Distinctions are made in terms of the severity of problems based on amount of support needed due to challenges involving social communication, restricted interests Page 276, and repetitive behaviors. Critics argue that the umbrella category proposed for autism spectrum disorder masks the heterogeneity that characterizes the subgroups of autism (Lai & others, 2013).