Educating Children with Complex Conditions: Understanding Overlapping and Co-Existing Developmental Disorders


Winand H. Dittrich & Rona Tutt

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    This book is dedicated to children and young people who have developmental disorders, the families who support them, the schools who educate them, and the neuropsychologists and other professionals who try to unearth the nature of their difficulties. Also to those involved in initial teacher training or continuing professional development, who are helping to ensure that there are closer links between researchers and those whose work has a direct effect on children with complex conditions.

    About The National Associataion of Head Teachers

    With a membership of over 28,000, the National Association of Head Teachers is the largest organisation of its kind in Europe. Representing headteachers, principals, deputies, vice-principals and assistant headteachers, it has provided over a century of dedicated support to its members. The union speaks with authority and strength on educational issues covering early years, primary, secondary and special sectors.

    National Association of Head Teachers

    1 Heath Square, Boltro Road, Haywards Heath, West Sussex, RH16 1BL

    Tel: +44(0) 1444 472472; email:; website:

    About the Authors

    The authors of this book are listed in alphabetical order as they shared equal responsibility for writing it.

    Winand H. Dittrich is a Reader in Experimental Psychology at the University of Hertfordshire. His main research interests are in cognitive neuropsychology and the workings of the human mind. He was one of the first researchers to make a systematic study of the damaging effects of neurotropic viruses (similar to HIV or BSE) on brain functions in 1989. He has published empirical studies on attention, working memory and movement control in Parkinson's disease, on the perception of human movement and emotional dance displays, on the recognition of facial expressions in adults, the elderly and children with autistic spectrum disorders. He has proposed a new theoretical framework for movement perception in animal as well as human vision. Together with colleagues, he has extended the understanding of the cognitive control of simple motor skills in healthy and brain-damaged people. His theoretical approach has been applied in sport and exercise sciences as well as in medical sciences. Recently, he co-developed a new diagnostic instrument to evaluate the neuropsychological profile of obsessions and compulsions in anxiety disorders. Several of his research papers on diverse topics have been cited over 100 times.

    Winand enjoys the challenges of teaching students of all abilities and from diverse backgrounds, particularly those who, until a few years ago, would have had no opportunity to develop their educational achievements at such a level.

    Rona Tutt has taught children with SEN in state and independent, residential and day, mainstream and special schools. Trained originally as a teacher of the deaf, she became the head teacher of Woolgrove School in Hertfordshire, a school for pupils who have moderate learning difficulties. She established the local authority's first provision for pupils with autistic spectrum disorders within the school. In 2003, Rona was the winner of the Leadership in Teaching Award. In 2004, she received an OBE for her services to special needs education. From 2004 to 2005, she was President of the National Association for Head Teachers. She continues to work for them as a SEN consultant.

    Rona writes on a number of educational issues and is much in demand as a speaker. In 2007, her first book, Every Child Included, was published, which looks beyond the inclusion debate to illustrate, by means of case studies of schools, the range of provision that is developing. The book also looks at how schools are addressing the Every Child Matters (ECM) agenda alongside their provision for SEN.

    Rona is Chair of Governors at Heathlands School in St Albans, which caters for severely and profoundly deaf children, and Vice Chair of Governors at The Valley School in Stevenage, which is for secondary pupils with MLD and ASD.


    The authors would like to offer their sincere thanks to:

    Professor Stuart Powell for introducing the authors to each other;

    The University of Hertfordshire for enabling the necessary research to take place;

    Professor Wendy Purcell for her encouragement to pursue this interdisciplinary research;

    The National Association for Special Educational Needs (Nasen) for their support;

    Mirko Schuessler, a visiting placement student from the University Duisburg-Essen for his illustrations of the brain and his assistance with research.

    How to use this Book

    This book is designed to help those who are leading schools or working with children who have complex conditions to:

    • become more familiar with what is meant by overlapping and co-existing disorders
    • increase their understanding of the links between how the brain works and how children learn
    • use this knowledge to develop ways of teaching that will help all pupils and particularly those who have difficulties to overcome
    • consider other factors that can impinge on learning, including nutrition and the use of therapists
    • take a holistic view in order to provide the best possible support to the child
    • look at what more needs to be done to improve that support in the future.

    The layout of each chapter is similar, and includes:

    • a list of what will be covered, at the beginning of the chapter
    • key points that are highlighted where appropriate
    • questions for reflection to make the book more interactive, and to serve as the basis for discussion and debate elsewhere
    • key terms, described in the glossary, are written in bold
    • a summary at the end.

    In addition, some of the pages are photocopiable in order to provide resources that can be used to record the nature of a pupil's difficulties, their progress over time, and strategies for meeting their needs.

    Although some readers may prefer to turn to particular chapters first, most will be gained from reading through the book from the start, as each chapter builds on the preceding ones.

    The first chapter gives an overview of a group of four developmental disorders which have been selected because they are becoming increasingly common, have overlapping symptoms and links in the form of co-existence. This is followed by a chapter on the workings of the brain in relation to neurological disorders. The third chapter considers diagnostic labels and how far they are useful. The next chapter moves on to focusing on how the information gathered so far can be translated into helping pupils in the classroom. The penultimate chapter looks at what part non-pedagogical approaches should play in helping to ameliorate pupils' difficulties, including nutrition and the role of other professionals. The final chapter pulls together the threads that have been running through the book, ties these in with some of the current developments in schools, and makes suggestions as to what should happen in future to meet more effectively the needs of an increasingly complex population of pupils to be found in today's classroom.

  • Useful Addresses

    ADDIS (Attention Deficit Disorder Information Services)

    Autism Education Trust

    Afasic (for speech and language difficulties)

    BDA (The British Dyslexia Association)

    The Communication Trust

    Dyslexia Action (formerly The Dyslexia Institute)

    The Dyslexia-SpLD Trust

    The Dyspraxia Foundation

    ICAN (for communication difficulties)

    The Inclusion Development Programme

    Nasen (National Association for Special Educational Needs)

    The National Austistic Society


    adrenaline: a hormone secreted by the adrenal glands and a central nervous system neurotransmitter released by some neurons. It is a potent stimulator of the sympathetic nervous system, increasing blood pressure, stimulating the heart muscle, accelerating the heart rate, and increasing cardiac output.

    aetiology: a) the study of the causes or origins of disease or the cause; b) the origin of a disease or disorder as determined by medical diagnosis.

    amygdala: one of two small, almond-shaped masses of grey matter that are part of the limbic system and are located deep inside the brain between the temporal lobes of the cerebral hemispheres; involved in emotions, emotional learning and memory.

    anterior cingulate: is the frontal part of the cingulate cortex, which resembles a ‘collar’ formed around the corpus callosum, the fibrous bridge-like bundle that relays neural signals between the right and left cerebral hemispheres of the brain.

    Asperger's syndrome: is one of several autistic spectrum disorders characterised by difficulties in social interaction and by restricted and stereotyped interests and activities. Asperger's syndrome is distinguished from the other ASDs in having no general delay in language or cognitive development. Developmental dyspraxia and atypical use of language are frequently reported.

    attention deficit hyperactivity disorder (ADHD): a developmental disorder, largely neurological in nature, affecting about 5 per cent of the world's population. The disorder typically presents itself during childhood, and is characterised by a persistent pattern of inattention and/or hyperactivity, as well as forgetfulness, poor impulse control and distractibility.

    auditory stimuli: sound stimuli that may be detected by ear.

    autism: a pervasive developmental disorder characterised by a wide range of symptoms, such as severe deficits in social interaction and communication, by an extremely limited range of activities and interests, and often by the presence of repetitive, stereotyped behaviours (also called Kanner's syndrome).

    autistic spectrum disorders (ASD): are a spectrum of psychological conditions characterised by widespread abnormalities of social interactions and communication, as well as severely restricted interests and highly repetitive behaviour. The three main forms of ASD are autism, Asperger's syndrome, and pervasive developmental disorder – not otherwise specified (PDD-NOS).

    autobiographical memory: a personal representation of general or specific events and personal facts; it also refers to memory of a person's history.

    axon: a long, slender projection of a nerve cell, or neuron, that conducts electrical impulses away from the neuron's cell body (also known as nerve fibre).

    basal ganglia: a group of nuclei in the brain interconnected with the cerebral cortex, thalamus and brainstem; basal ganglia are associated with a variety of functions: motor control, cognition, emotions and learning.

    bipolar: a term used to define things with two (usually opposing) poles.

    brainstem: the lower part of the brain, adjoining and structurally continuous with the spinal cord.

    Broca's area: an area on the frontal lobe related to the production of speech.

    caudate nucleus: a nucleus located within the basal ganglia of the brain; originally thought to be involved primarily with control of voluntary movement, now recognised as important for learning and memory.

    cerebellum: a region of the brain that plays an important role in the integration of body sensation and motor output. Many neural pathways link the cerebellum with the motor cortex, which sends information to the muscles causing them to move, and the spinocerebellar tract (fibres between the spinal cord and the cerebellum), which provides feedback on the position of the body in space.

    cerebrum: the largest and uppermost portion of the brain. The cerebrum consists of two cerebral hemispheres (cortex) and accounts for two-thirds of the total weight of the brain.

    childhood disintegrative disorder (CDD): a rare condition characterised by late onset (after three years of age) of developmental delays in language, social function, and motor skills.

    cingulate cortex: a prominent part (a ridge of the infolded cerebral cortex) found near the middle plane of the brain, above the bridge connecting the two halves. The cingulate gyrus forms part of the limbic system, which is associated with mood and emotions.

    circle time: refers to any time that a group of people are sitting together for an activity involving everyone; nowadays of wide spread use in schools (also known as group time).

    cognition: mind processes which include perception, attention, thinking, memory, language, problem solving, consciousness.

    cognitive neuropsychology: aims to understand how the structure and function of the brain relates to specific cognitive processes. Particular emphasis is given to the study of effects of brain injury or neurological illness on mental health with a view to inferring models of how the brain works.

    cognitive behavioural therapy (CBT): is a psychology-based treatment for mental health conditions. Instead of focussing on the past, it concentrates on relearning ways of thinking that lead to more balanced emotions and behaviour.

    co-morbidity: the presence of one or more disorders (or diseases) in addition to a primary disease or disorder; or the effect of such additional disorders or diseases.

    conduct disorder (CD): a pattern of repetitive behaviour where the rights of others or the social norms are violated.

    cortex: a layer of grey matter in the brain that constitutes the layer of the cerebrum (cerebral cortex) and is responsible for integrating sensory and motor impulses and for cognitive functions.

    corticosteroids: refers to a group of natural steroid hormones, for example cortisol or synthetic drugs.

    declarative memory: a type of long-term memory in which we store memories of fact; in addition, declarative memory is divided further into semantic and episodic memories (for example, the date Isaac Newton was born or the name of the child's first teacher).

    dendrite: is the branched projections of a neuron that act to conduct the electrical stimulation received from other neural cells to the cell body of the neuron from which the dendrites project. Electrical stimulation is transmitted onto dendrites by upstream neurons via synapses which are located at various points throughout the dendritic arbor.

    developmental coordination disorder (DCD): a term used to describe the difficulties some children experience with movement and postural control, including eye-hand coordination, in the absence of any specific neurological causes such as cerebral palsy (see also dyspraxia).

    developmental delay syndrome: a general term for developmental disorders such as dyslexia, dyspraxia, ADD, ADHD, obsessive-compulsive disorder, Tourette's syndrome, Asperger's syndrome and autistic spectrum disorders.

    developmental disorders: a term for disorders that occur at some stage in a child's development, often retarding the development. These may include psychological or physical disorders.

    dopamine: is a hormone and neurotransmitter released by some neurons.

    dyscalculia: a term for an impairment of the ability to solve mathematical problems; often linked to a brain disorder.

    dysgraphia: a term for an impairment of the ability to write, usually caused by a brain disorder.

    dyslexia: a learning disorder marked by impairment of the ability to recognise and comprehend written words.

    dyspraxia: a term for an impairment of the ability to execute purposeful, voluntary movement (recently also called developmental coordination disorder).

    educationally subnormal: subnormal intellectual functioning which originates during the developmental period.

    e-learning: learning that is facilitated and supported through the use of information communications technology (ICT) including the internet and intranet.

    emotional intelligence: refers to how people relate to others, have social skills and show emotional awareness.

    emotional literacy: the ability to be aware of your own and others' emotional states and self-control skills to contain and handle these. The impact of a child's relative emotional maturity or immaturity on their behaviour, performance and personal happiness is being recognised more and more in schools and included in the curriculum.

    epilepsy: any of a group of syndromes characterised by transient disturbance of the electrical activity of the brain that may be manifested as some impairment or loss of consciousness, abnormal motor phenomena, psychic or sensory disturbances.

    episodic memory: the type of long-term, declarative memory in which we store memories of personal experiences that are tied to particular times and places; often linked to eye-witness testimony.

    executive control: a central feature control of human actions such as the ability to flexibly adapt to changing situations, realise new intentions, or schedule intended actions; it guides thoughts and behaviour through planning and goal-setting.

    foetal alcohol syndrome: a range of birth defects including heart, head and brain abnormalities and mental retardation, occurring in an infant due to excessive alcohol consumption by the mother during pregnancy.

    forebrain: is the largest part of the brain, most of which is made up of the cerebrum. Other important structures found in the brain include the thalamus, the hypothalamus and the limbic system.

    frontal lobe: the largest of five lobes constituting each of the two cerebral hemispheres. The frontal lobe lies beneath the forehead. The frontal lobe significantly influences personality and is associated with the higher mental activities, such as planning, judgment, and conceptualising.

    germination area: the area of the brain in which the development of neurons starts.

    Gilles de la Tourette's syndrome: a neurological disorder characterised by tics – involuntary, rapid, sudden movements or vocalisations that occur repeatedly in the same way.

    glial cells: provide support (nutrients and oxygen) and protection (insulate, destroy pathogens and dead neurons) for neurons, the other main type of cell in the nervous system.

    glucose: simple sugar present in the blood, belongs to chemicals known as carbohydrates. Reactions inside cells involves oxygen and glucose to produce the body's energy.

    handicapped (physically): a child who has a disability of locomotor and neurological orgin which constitutes a disadvandage or restriction in one or more aspects of daily living activities.

    hemisphere (cerebral): one of two sides of the brain addressed either as ‘left’ or ‘right’.

    hippocampus: a structure of the limbic system that consists mainly of grey matter and has a central role in spatial mapping and memory processes.

    hyperlexia: an ability to recognize written words, which is for in advance of being able to comprehend what has been read.

    hypersensitive: highly or excessively sensitive.

    hyposensitive: less than the normal ability to respond to stimuli.

    hypothalamus: a part of the brain that lies below the thalamus regulating bodily temperature and biochemical processes.

    labelling: defining or describing a child in terms of his or her behaviour or brain damage. The term also describes the attachment of a mental illness to a person who has been given a specific diagnostic description.

    lexical retrieval deficit: the impairment of the retrieval of verbal information from memory.

    limbic system: a group of interconnected deep structures of the brain, bordering the thalamus and hypothalamus, and involved in olfaction, emotion and motivation.

    maladjusted: inadequately adjusted to the demands or stresses of daily living.

    meningitis: acute inflammation of the meninges, the membranes that cover and protect the brain and spinal cord.

    mirror neurons: are neurons that fire both when one acts and when one observes the same action performed by another person.

    moderate learning difficulties (MLD): a general developmental delay. Key features include: short attention span; lack of logical reasoning; immature social and emotional skills; inability to generalise what they learn and apply it to other situations; difficulties with reading and writing, and comprehension; poor understanding of basic mathematical concepts; limited communication skills; underdeveloped coordination skills.

    morphology: is a branch of linguistics which studies the phonological structure of the smallest units of speech sounds.

    motor cortex: a part of the frontal cortex controlling movement.

    multiple intelligences: term originally coined to describe more fully the different and equally important ways of processing the environment.

    myelin sheath: the insulating envelope of myelin that surrounds the core of a nerve fibre or axon and that facilitates the transmission of nerve impulses.

    neurodevelopmental disorders: a fairly new term in medicine and related fields. It refers to a range of difficulties wherein there are gaps, delays or variations in the way a child's brain develops. It can be caused by genetic, environmental, or unspecified reasons, many of which are not yet known. We do know however that these dysfunctions often interfere with learning, behaviour and adaptability across environments. Neurodevelopmental problems may affect one out of every twenty children.

    neurological abnormalities: damage to the brain resulting in behavioural deficits.

    neuron: specialised cells that make up the body's nervous system. These nerve cells process, store and transmit information from one part of the body to another.

    neuronal migration: a process by which neurons travel from their birth place to their final position in the brain.

    neurotransmitter: a chemical that is released from a nerve cell which thereby transmits an impulse from a nerve cell to another nerve, muscle, organ, or other tissue. A neurotransmitter is a messenger of nervous information from one cell to another. Often, drugs/medications operate to change the activity or availability of neurotransmitters.

    obsessive-compulsive disorder (OCD): a psychiatric anxiety disorder most commonly characterised by a subject's obsessive, distressing, intrusive thoughts and related compulsions or rituals.

    occipital lobe: the rear part, somewhat pyramid-shaped part of each cerebral hemisphere processing visual information.

    oppositional defiant disorder (ODD): a recurring pattern of negative, hostile, disobedient, and defiant behaviour in a child or adolescent, lasting for at least six months with serious violation of the basic rights of others.

    orbitofrontal cortex: a region within the frontal lobes, above the eyes, involved in cognitive processes such as decision making emotions, risk taking and suppression of behaviours.

    orthography: the study of correct spelling in written language according to established usage.

    parietal lobe: The upper middle lobe of each cerebral hemisphere, located above the temporal lobe, processing complex sensory information from the body and movement-related vision; also controls the ability to understand language.

    perception: the process by which organisms interpret and organise sensation to produce a meaningful experience of the world. Note: sensation usually refers to the immediate, relatively unprocessed result of stimulation of sensory receptors in the eyes, ears, nose, tongue or skin.

    pervasive developmental disorders (PDD): a group of disorders characterised by delays in the development of socialisation and communication skills.

    phonology: the study of how sounds are organised and used in natural languages.

    phonological disorder: a child does not develop the ability to produce some or all sounds necessary for speech that are normally used at his or her age.

    planum temporale: the surface within the temporal lobe of the cerebrum, involved with language.

    plasticity: refers to the brain's ability to change and learn consistently.

    Polgar sisters: Three Hungarian sisters, Zsuzsa, Zsofia, and Judit Polgar, have achieved chess ‘grandmaster’ results in their teens, and the youngest Judit, is the highest-ranked player of her age, higher even than Bobby Fischer at a comparable age.

    pragmatics: the study of the aspects of meaning and language use that are dependent on the speaker, the addressee and other features of the context of utterance.

    prefrontal cortex: part of the frontal lobes nearly above the nose, involved in planning complex cognitives behaviours in the expression of personality and appropriate social behaviour.

    pretend play: a prominent ability to represent experience in some kind of thinking. In this complex type of play, children carry out action plans, take on roles, and transform objects as they express their ideas and feelings about the social world.

    procedural memory: the long-term memory of skills and procedures, or ‘how to’ knowledge.

    profound and multiple learning difficulties (PMLD): learners who are likely to have more than one severe disability.

    proprioceptive sense: the sense of the position of parts of the body, relative to other neighbouring parts of the body.

    resilience: the property of the brain to return some of its structure after deformation that does not exceed its elastic limit. Also used to describe a person's abiity to persevere.

    restitution: the act of making good, or compensating for loss, damage, or injury of the brain.

    Rett's syndrome: a disorder of the nervous system that leads to developmental reversals, especially in the areas of expressive language and hand use, mainly affects girls.

    selective/elective mutism: a psychiatric disorder characterised by a persistent failure to speak in selected settings, which continues for more than one month. These children understand spoken language and have the ability to speak normally.

    semantic memory: one of the three types of long-term memory in which we store general world knowledge like facts, ideas, words, problem solving.

    semantic-pragmatic disorder: children with this disorder have problems understanding the meaning (semantics) of what other people say, and they do not understand how to use speech appropriately themselves (pragmatics) despite having a fluent, clearly articulated and expressive language themselves.

    semantics: the study of relationships between signs and symbols and what they represent.

    sensation: the neural synaptic firing of our receptors and the transmission of these firings to the brain. For example, when you touch something, receptors send impulses that travel to the spinal cord and then into the brain for processing and awareness of the stimulation. Sensation normally requires the possibility to become aware. Note that once the stimulation is sent to the brain, is processed further and/or enters awareness, one speaks of perception.

    sensitive period: a broad term that applies whenever the effects of experience on the brain are unusually strong during a limited period in development. Sensitive periods are of interest to scientists and educators (for example, Montessori) because they represent periods in development during which certain capacities are readily shaped or altered by experience.

    sensorimotor coordination: a system that links sensory information and motor skills, for example vision and prehension or eye-hand coordination.

    sensorimotor cortex: an area of the parietal cortex combining sensory and motor functions.

    serotonin: a neurotransmitter. It plays a part for example in the regulation of mood, sleep, learning and constriction of blood vessels.

    severe learning difficulties (SLD): learners are likely to have extreme difficulty with reading and writing, and may also require help with face-to-face communication.

    somatosensory cortex: the area of the cerebral cortex to which the sensory signals are sent. The somatic senses include vision, hearing, taste, smell and equilibrium.

    specific learning difficulties (SpLD): a difficulty that is specific to a particular area, or that affects a particular process (as distinct from a general learning difficulty, which affects the learning of many different skills) or specific skills.

    spindle cells: a specific group of neurons, characterised by a large spindle-shaped cell body, gradually tapering into a single apical fibre in one direction, with only a single fibre facing opposite; appearing late in animal evolution.

    synapse: the junction between two neurons or between a neuron and a gland or muscle cell. Neurotransmitters carry impulses across the tiny gap between the cells.

    syntax: the study of the rules whereby words or other elements of sentences are combined to form grammatical structures.

    tactile sense/tactile stimuli: a group of senses by which contact with objects gives evidence as to certain of their qualities, as registered by pressure-sensitive sense organs in the skin.

    temporal lobe: the lower lateral lobe of either cerebral hemisphere, located in front of the occipital lobe and containing the sensory centre of hearing in the brain and systems for object recognition and associative learning.

    thalamus: a collection of nerve cells deep in the brain. Although it performs many functions, the primary role of the thalamus is to relay sensory information from other parts of the brain to the cerebral cortex.

    tics: a habitual spasmodic muscular movement or contraction, usually of the face or extremities.

    turn-taking: taking turns is one of the hardest lessons for children under five years to learn. The young child cannot without much experience believe that ‘her or his turn’ really will come in due time.

    vestibular sense: a sensory system located in structures of the inner ear that registers the orientation of the head/body.

    visual cortex: part of the brain located in the occipital lobes and devoted to processing all aspects of visual input, for example form, colour, size, texture, distance and depth.

    visual stimuli: the light rays which elicit a stimulation in the eye, a signal then transmitted to the brain.

    visuospatial memory: of or relating to visual perception of spatial relationships among objects which are stored.

    Wernicke's area: the area on the temporal lobe on the left side of the brain responsible for the comprehension of speech.

    working memory: a system for temporarily storing and managing the information required to carry out complex cognitive tasks such as learning, reasoning and comprehension. Working memory is involved in the selection, initiation and termination of information-processing functions, such as encoding, storing and retrieving data.

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    Beaney, J. and Kershaw, P. (2003) Inclusion in the Primary Classroom. London: National Autistic Society.
    Biel, L. and Perske, N. (2005) Raising a Sensory Smart Child. London: Penguin.
    Biggs, V. (2005) Caged in Chaos. London: Jessica Kingsley.
    Bird, R. (2007) The Dyscalculia Toolkit. London: Paul Chapman Publishing.
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    Bishop, D.V.M. and Snowling, M.J. (2004) Developmental dyslexia and specific language impairment: same or different?Psychological Bulletin130: 858–86.
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