Denckla M B
Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Neurol Clin. 1993 Feb;11(1):105-25.
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.
一家专门诊治学习障碍且愿意对成年人进行评估的诊所收到的转诊病例，与儿科和青少年学龄人群转诊的三大主要原因相似：（1）“该患者是否患有诵读困难症”；（2）“该患者是否患有‘残留型注意力缺陷多动障碍’”；（3）“该患者是否患有某种学习障碍？”第三个问题最难且最不为人所理解，即非言语学习障碍（NVLD）或所谓的右脑组，最有可能由心理健康机构和专业人员转诊。第一个问题，诵读困难症，有最坚实的神经科学背景，在某些方面其概念化最为直接，但在其表现可能被观察到的微妙且隐匿的方式方面仍存在争议。恰当地处于第二位也就是中间位置，横跨诵读困难症和非言语学习障碍的，是那一大堆杂乱且明显异质的观察结果，它们被归在注意力缺陷多动障碍名下，并与兴奋剂药物治疗相关联。然而，尽管注意力缺陷多动障碍涵盖范围很广，但它与其认知重叠区域——执行功能障碍的关系，就如同症状与体征的关系；而执行功能障碍，尤其是在成年人中，似乎是一个对未得到代偿或具有临床意义的学习障碍的持续存在特别重要的认知缺陷集群。也就是说，对于患有学习障碍的成年人，真正要回答的问题是他们为什么没有对认知缺陷进行代偿；或者，如果他们已经掌握了基本的学术技能，为什么却无法运用这些技能？除非语言或空间缺陷极其严重，学术技能通常可以通过代偿策略习得，并且一旦习得就能被运用。代偿能力（以及将代偿能力推广应用）是成年学习障碍结果的关键决定因素。对于非学术技能的了解较少，其中社交领域似乎最没有可选择性，也就是说最为普遍重要。基于空间的技能最容易避免或规避。如果没有严重的语言或空间认知缺陷，成人学习障碍研究中最核心的神经心理学问题就是执行功能障碍和社交感知/社交无能。目前，执行功能障碍是这两者中能够在行为神经科诊所进行评估的一项。
