what is a problem solving deficit

Cognitive Remediation Therapy: 13 Exercises & Worksheets

This can result in concentration, organizational, and planning difficulties that impact their quality of life and independent living.

Cognitive Remediation Therapy (CRT) helps by increasing awareness of intellectual difficulties and improving thinking skills. While originally designed for people with thinking problems associated with schizophrenia, it has also proven successful for those with other diagnoses (Bristol Mental Health, n.d.).

CRT works by encouraging a range of exercises and activities that challenge memory, flexible thinking, planning, and concentration problems.

This article explores CRT and its potential to help clients and includes techniques, activities, and worksheets to build effective therapy sessions.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is cognitive remediation therapy (crt), how does cognitive remediation work, 8 techniques for your sessions, 7 exercises, activities, & games, 6 helpful worksheets and manuals, implementing online crt programs, 3 best software programs for helping your clients, a take-home message.

“Cognitive remediation is a behavioral treatment for people who are experiencing cognitive impairments that interfere with daily functioning” (Medalia, Revheim, & Herlands, 2009, p. 1).

Successful cognitive functions, including memory, attention, visual-spatial analysis, and abstract reasoning, are vital for engaging with tasks, the environment, and healthy relationships.

CRT improves cognitive processing and psychosocial functioning through behavioral training and increasing individual confidence in people with mental health disorders (Corbo & Abreu, 2018). Training interventions focus on the skills and supports required to “improve the success and satisfaction people experience in their chosen living, learning, working, and social environments” (Medalia et al., 2009, p. 2).

Exercises typically focus on specific cognitive functions, where tasks are repeated (often on a computer) at increasing degrees of difficulty. For example:

• Paying attention
• Remembering
• Being organized
• Planning skills
• Problem-solving
• Processing information

Based on the principles of errorless learning and targeted reinforcement exercises , interventions involve memory, motor dexterity, and visual reading tasks. Along with improving confidence in personal abilities, repetition encourages thinking about solving tasks in multiple ways (Corbo & Abreu, 2018).

While initially targeted for patients with schizophrenia, CRT is an effective treatment for other mental health conditions , including mood and eating disorders (Corbo & Abreu, 2018).

CRT is particularly effective when the cognitive skills and support interventions reflect the individual’s self-selected rehabilitation goals. As a result, cognitive remediation relies on collaboration, assessing client needs, and identifying appropriate opportunities for intervention (Medalia et al., 2009).

Cognitive remediation vs cognitive rehabilitation

CRT is one of several skill-training psychiatric rehabilitation interventions. And yet, cognitive remediation is not the same as cognitive rehabilitation (Tchanturia, 2015).

Cognitive rehabilitation typically targets neurocognitive processes damaged because of injury or illness and involves a series of interventions designed to retrain previously learned cognitive skills along with compensatory strategies (Tsaousides & Gordon, 2009).

While initially done in person, they can subsequently be performed remotely as required (Corbo & Abreu, 2018; Bristol Mental Health, n.d.).

Well-thought-out educational software provides multisensory feedback and positive reinforcement while supporting success, choice, and control of the learning process. Its design can target either specific cognitive functions or non-specific learning skills and mechanisms (Medalia et al., 2009).

CRT successfully uses the brain’s neuroplasticity and is often more effective in younger age groups who haven’t experienced the effects of long-term psychosis. It works by increasing activation and connectivity patterns within and across several brain regions involved in working memory and high-order executive functioning (Corbo & Abreu, 2018).

The Neuropsychological Educational Approach to Cognitive Remediation (NEAR) is one of several approaches that provide highly individualized learning opportunities. It allows each client to proceed at their own pace on tasks selected and designed to engage them and address their cognitive needs (Medalia et al., 2009).

NEAR and other CRT techniques are influenced by learning theory and make use of the following (Medalia et al., 2009):

• Errorless learning Encouraging the client to learn progressively, creating a positive experience without relying on trial and error.
• Shaping and positive feedback Reinforcing behaviors that approximate target behaviors (such as good timekeeping) and offering rewards (for example, monthly certificates for attendance).
• Prompting Using open-ended questions that guide the client toward the correct response.
• Modeling Demonstrating how to solve a problem.
• Generalizing Learning how to generalize learned skills to other situations.
• Bridging Understanding how to apply skills learned inside a session outside  in everyday life.

Encouraging intrinsic motivation (doing the tasks for the satisfaction of doing them rather than for external rewards) and task engagement are also essential aspects of successful CRT programs (Medalia et al., 2009).

Therapy is most effective when it successfully supports clients as they transfer learning skills into the real world.

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Cognitive remediation techniques must be selected according to the skills and needs of the client and typically fall into one of three major intervention categories (Medalia et al., 2009):

• Planning exercises, such as planning a trip to the beach to practice cognitive strategies
• Cueing and sequencing , such as adding signs or placing reminder notes at home to encourage completing everyday tasks (for example, brushing teeth)

Such techniques rely on several key principles, including “(1) teaching new, efficient, information processing strategies; (2) aiding the transfer of cognitive gains to the real world; and (3) modifying the local environment” (Medalia et al., 2009, p. 5).

• Restorative approaches Directly target cognitive deficits by repeating task practices and gradually increasing difficulty and complexity; along with regular feedback, they encourage accurate and high levels of performance.

Practice is often organized hierarchically, as follows:

• Elementary aspects of sensory processing (for example, improving auditory processing speed and accuracy)
• High-order memory and problem-solving skills (including executive functioning and verbal skills)

This technique assumes a degree of neuroplasticity that, with training, results in a greater degree of accuracy in sensory representations, improved cognitive strategies for grouping stimuli into more meaningful groups, and better recall.

• Repetition and reaching for increasing levels of task difficulty
• Modeling other people’s positive behavior
• Role-play  to re-enact experienced or imagined behavior from different perspectives
• Corrective feedback to improve and correct unwanted or unhelpful behavior

Complex social cognitive processes are typically broken down into elemental skills for repetitive practice, role-play, and corrective feedback.

Professor Dame Til Wykes: cognitive remediation therapy

It is vital that activities within CRT are interesting and engaging for clients. They must foster the motivation required to persevere to the end of the task or game.

The following three games and puzzles are particularly valuable for children and adolescents (modified from Tchanturia, 2015):

SET is a widely available card game that practices matching based on color, shape, shading, etc.

Clients must shift their thinking to identify multiple ways of categorizing and grouping cards, then physically sort them based on their understanding.

It may be helpful to begin with a limited set of cards to reduce the likelihood of the clients becoming overwhelmed by the game or finding it less enjoyable.

2. Rush Hour

Rush Hour is another fun game that balances problem-solving skills with speed.

Puzzles start simple and increase in complexity, with additional elements involved. Skills developed include problem-solving and abstract thinking, and the game requires a degree of perseverance.

Other activities require no specialist equipment and yet can be highly engaging and support clients in learning transferable skills (modified from Tchanturia, 2015).

• Bigger picture thinking This involves the client picturing a shape in their minds or looking at one out of sight of the therapist. They then describe the shape (without naming it), while the therapist attempts to draw it according to the instructions. This practice is helpful with clients who get overwhelmed by detail and cannot see the bigger picture.
• Word searches Word searches encourage the client to focus on relevant information and ignore everything else – an essential factor in central coherence. Such puzzles also challenge memory, concentration, and attention.
• Last word response Last word response is a challenging verbal game promoting cognitive flexibility. The first player makes up and says a sentence out loud. Each subsequent player makes up a new sentence, starting with the last word of the previous player’s sentence. For example, ‘ I like cheese’ may be followed by the next player saying, ‘ Cheese is my favorite sandwich ingredient ,’ etc.
• Dexterity Using your non-dominant hand once a week (for example, combing your hair or brushing your teeth) stimulates different parts of your brain, creating alternative patterns of neuron firing and strengthening cognitive functions.

The following therapy worksheets help structure Cognitive Remediation Therapy sessions and ensure that the needs of clients are met using appropriately targeted CRT interventions (modified from Medalia et al., 2009; Medalia & Bowie, 2016):

Client referral to CRT

The Cognitive Remediation Therapy Referral Form captures valuable information when a client is referred from another agency or therapist so that the new therapist can identify and introduce the most appropriate CRT interventions. The form includes information such as:

Primary reasons

Secondary reasons

• Self-confidence
• Working with others
• Time management
• Goal-directed activities

Cognitive Appraisal for CRT

The Cognitive Appraisal for CRT form is helpful for identifying and recording areas of cognitive processing that cause difficulty for the client and require focus during Cognitive Remediation Therapy sessions.

Clients are scored on their degree of difficulty with the following:

• Paying attention during conversation
• Maintaining concentration in meetings
• Completing tasks once started
• Starting tasks
• Planning and organizing tasks and projects
• Reasoning and solving problems

Software Appraisal for CRT

The Software Appraisal for CRT form helps assess which software would be most helpful in a specific Cognitive Remediation Therapy session. It provides valuable input for tailoring treatment to the needs of the client.

For example:

• Level of reading ability required
• Cognitive deficits addressed by the software
• What is the multimedia experience like?
• How much input is required by the therapist?

Appraisal records become increasingly important as more software is acquired for clients with various cognitive deficits from multiple backgrounds.

Software Usage for CRT

The Software Usage for CRT form helps keep track of the software clients have tried and how effectively it supports them as they learn, develop, and overcome cognitive deficits.

The client considers the software they use and whether they practiced the following areas of cognition:

• Concentration
• Processing speed
• Multitasking
• Logic and reasoning
• Organization
• Fast responses
• Working memory

Thought Tracking During Cognitive Remediation Therapy

Thought Tracking During Cognitive Remediation Therapy is valuable for identifying and recording the client’s goals for that day’s Cognitive Remediation Therapy session and understanding how it relates to their overall treatment goals.

Planning to Meet Goals in CRT

The Planning to Meet Goals in CRT worksheet is for clients requiring support and practice in planning, goal-setting, and goal achievement.

Working with the client, answer the following prompts:

• What goal or project are you working toward?
• What date should it be completed by?
• Are there any obstacles to overcome to complete the goal?
• Are there any additional resources required?
• Then consider the steps needed to achieve the goal.

Other free resources

Happy Neuron provides several other free resources that are available for download .

Consider the five Cs when selecting online CRT programs (modified from Medalia et al., 2009):

• Cognitive – What target deficits are being addressed?
• Client – What interests and level of functioning does the client have?
• Computer – What computing requirements and compatibility factors need to be considered?
• Context – Does the software use real-world or fantasy activities and environments? Are they age and cognitive ability appropriate?
• Choice – Is the learner given choice and options to adapt the activity to their preferences?

Once you’ve ordered the software, give it a thorough review to understand when it is most appropriate to use and with whom.

For online CRT programs to be effective as teaching tools and activities, they should include the following features (modified from Medalia et al., 2009, p. 53):

• Intrinsically motivating
• Active use of information
• Multisensory strategies
• Frequent feedback
• Control over the learning process
• Positive reinforcement
• Application of newly acquired skills in appropriate contexts
• Errorless learning – challenging yet not frustrating

Therapists must become familiar with each program’s content and processes so that targeted deficits are fully understood and clients are engaged without confusion or risk of failure.

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A great deal of software “targets different skills and offers a variety of opportunities for contextualization and personalization” (Medalia et al., 2009, p. 43).

We focus on three suppliers of extensive CRT software resources below (recommended by Medalia et al., 2009).

1. Happy Neuron

Happy Neuron provides a wide variety of online brain training exercises and activities to stimulate cognitive functioning in the following areas:

• Visual-spatial

When you’re performing well, the exercises become increasingly difficult.

The exercises are grouped into the following areas:

• Brain speed
• People skills
• Intelligence

3. Games for the Brain

Cognitive difficulties, such as challenges with paying attention, planning, remembering, and problem-solving, can further compound and exacerbate mental health issues

While initially created for schizophrenia, CRT is also valuable for other mental health problems, including eating and mood disorders. Treatments are effective in one-to-one and group sessions, and lessons can be transferred to the outside world, providing crucial gains for a client’s mental wellbeing and social interaction.

Through repeated and increasingly challenging skill-based interventions, CRT benefits cognitive functioning and provides confidence gains to its users. The treatment adheres to learning theory principles and targets specific brain processing areas such as motor dexterity, memory, and visual-spatial perception, along with higher-order functioning.

Involving clients in treatment choices increases the likelihood of ongoing perseverance, engagement, and motivation as activities repeat with increasing degrees of difficulty.

This article offers a valuable starting point for exploring CRT and its benefits, with several worksheets and forms to encourage effective treatment.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Bristol Mental Health. (n.d.). Cognitive remediation therapy: Improving thinking skills . Retrieved December 15, 2021, from http://www.awp.nhs.uk/media/424704/cognitive-remediation-therapy-022019.pdf
• Corbo, M., & Abreu, T. (2018). Cognitive remediation therapy: EFPT psychotherapy guidebook . Retrieved December 15, 2021, from https://epg.pubpub.org/pub/05-cognitive-remediation-therapy/release/3
• Medalia, A., & Bowie, C. R. (2016). Cognitive remediation to improve functional outcomes . Oxford University Press.
• Medalia, A., Revheim, N., & Herlands, T. (2009). Cognitive remediation for psychological disorders: Therapist guide . Oxford University Press.
• Tchanturia, K. (2015). Cognitive remediation therapy (CRT) for eating and weight disorders . Routledge.
• Tsaousides, T., & Gordon, W. A. (2009). Cognitive rehabilitation following traumatic brain injury: Assessment to treatment. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine , 76 (2), 173-181.

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What our readers think.

To my surprise this is a treatment that has not been discussed in the area I live and work. I just stumbled upon this when I was researching cognitive impairments with schizophrenia. I currently work on a team with multiple mental health professionals that go out into the community, to work with people diagnosed with Schizophrenia. It seems like most of what we do is manage and monitor symptoms. Are you aware of anyone or any agency in Buffalo, NY that uses this method of treatment? I am trying to figure out how to get trained and use it in practice, if that is possible. Any help will be greatly appreciated.

This looks like the treatment my daughter needs. She has struggled for years with the cognitive problems associated with depression. How do we find a therapist near us who can use these techniques?

I’m sorry to read that your daughter is struggling. You can find a directory of licensed therapists here (and note that you can change the country setting in the top-right corner). You’ll also find that there are a range of filters to help you drill down to the type of support you need: https://www.psychologytoday.com/us/therapists

I hope you find the help you need.

– Nicole | Community Manager

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Problem Solving Deficit Disorder

Creative versus Programmed Play

In November 2005, I participated in an early childhood educators’ conference in South Korea. One of the highlights occurred on a tour of Seoul. While awaiting the opening of a very impressive palace, I saw a group of about twelve 7- or 8-year-old children on a school trip. They had gotten out of their bus and were standing by a large tree with beautifully colored autumn leaves. As I watched them, one child caught a leaf that was floating to the ground. He paused a moment, took off his jacket, and threw it up into the tree. As it fell, it brought down at least a dozen more leaves that he, and a couple of other children tried to catch. Several other children began to throw their jackets into the tree and they all tried to catch the resulting falling leaves. They began calling out. Our translator said the children were counting how many leaves they had caught. After several throwing and catching cycles, the activity evolved into a game in which one child loudly called out what my Korean tour leader told us was “one, two, three.” Then all the children threw up their coats in unison and cheered as they ran around catching the flood of leaves that came cascading down. After about 15 minutes, their teacher called them over to go into the palace that was about to open. The activity was over (Levin, 2007).

When the children lined up to leave, I marveled at:

• how resourceful they were at creating a game using nothing but leaves and coats;
• how the game evolved and changed over time in a natural and spontaneous way;
• how quickly it became a cooperative activity involving the whole group without discussion, stress, or rules;
• how even in a cramped space, no adult limit setting or intervention was necessary; and,
• how long it had been since I had seen a spontaneous, joyful, and playful creation of this sort occur among children in the U.S.

Beginning in infancy, children are bombarded with noise and electronic stimulation, from crib mobiles with flashing lights and music to DVD entertainment systems for the car. Quiet time? Children are programmed never to have it. The gadgets may distract babies from crying, but I wonder do they ever discover their toes?

I imply this on two levels. Literally, the fussy baby who is left alone long enough to find her toes (not more than a few minutes, after all) is making the first step in a long journey. She’s figuring out that she can entertain and distract herself and, she’s also learning something profound: that she has the capacity to solve her own problem.

In terms of human development, that’s an “Aha!” and essential moment. The infant whose parent pushes the button to turn on the mobile may also be comforted and distracted, but he learns nothing about his capacity to solve his own problem or the awareness that he can do so and it is a satisfying experience. This may seem like too much credit to give to 10 toes, but toes are a metaphor for what I see as erosion in opportunities for children to develop critical thinking skills.

The Korean children’s play reminded me of something I had seen a few months before in a classroom closer to home, at a preschool in the U.S. The teacher put play dough on a small table. A child sat down, poked and squeezed it a few times, and left the table. Then another child came over, poked it, and asked, “What does it do?” When I was a group therapist of emotionally disturbed young children and then as a kindergarten teacher many years ago, play dough was a favorite material for both the children and me. It offered endless possibilities that could grow, change, and evolve based on the age, stage, experience, and interests of each child.

When I describe to other teachers the bored or puzzled reactions to play dough I have observed among many children in the U.S., they often nod knowingly and say that they encounter more and more children who have trouble engaging in open-ended play. “Beth Dimock sees this play out in her prekindergarten class at Cambridge Friends School. Children are easily frustrated and bored. ‘They don’t know how to carry through with a project — any project — on their own,’ she says. ‘Why do two playmates at your house end up in front of a video? Because they’re 'bored'. They can’t even solve the problem of what to play’” (Meltz, 2004). As I watched these children fail to interact with play dough, I worried that they were missing out on most of the social, emotional, and cognitive learning opportunities that the South Korean children created so spontaneously with the leaves.

There are not a lot of studies on this yet; but researchers and educators do know that children learn best by initiating, manipulating, and observing cause and effect. And one recent study found that even having a TV on in the background reduced levels of toddler play. (Schmidt, et al, 2008).

Play in Development and Learning

Comparing Korean children’s play with U.S. children’s lack of play concerns me because play is a primary vehicle through which children learn to interact with, control, and master their world. Creative play has enormous power in promoting children’s development and learning. It is in play that children find interesting problems to work on, and develop the skills for solving them.

When children see themselves as problem finders and problem solvers, they develop curiosity about their world and confidence in their ability to figure things out for themselves. Solving one problem leads to a new problem, which they solve by using the skills they developed from solving previous problems. In the course of playing this way, children develop deep interests, improve at, and become “experts” at problem solving. This problem finding and solving process provides a powerful foundation that helps children be motivated, competent learners who are actively engaged with their environment in school and in life.

“’We (Americans) are often told by media and toy marketers that we are giving our kids an edge when we use software to introduce them to art, language, nature, you name it,’ says Pittsburgh psychologist Sharna Olfman. ‘All it does is teach them to be dependent on the screen for instant gratification,’ she says. ‘They are not developing the capacity to use their own creative intelligence.’ Without a doubt problem solving is a cumulative skill that gives a child a sense of inner power” (Meltz, 2004).

What if children do not become problem solvers and experts in tasks of their own choosing over which they have control? They often develop what I have named PSDD — Problem Solving Deficit Disorder (Lohr, 2003).

What Is PSDD? The concept of PSDD grew out of my work on the impact of contemporary society on children. Parents and professionals have observed children who say they are bored a lot. They have trouble becoming deeply engaged in unstructured activities. They lack creativity and imagination and experience difficulty in playing cooperatively with others or resolving conflicts without aggression. They do better when they are told what to do. They prefer structured activities at school, DVDs to watch, or video games to play at home. They ask for new things all the time, but quickly become bored once they have them. When they are able, parents often enroll their children in organized afterschool activities, so the children will not be bored or spend their free time watching TV.

Except for urging parents to limit screen time (the American Academy of Pediatrics recommends no TV for children under 2), few researchers say we have to eliminate all screen time and gadgets. However, I would stress that establishing carefully thought out rules and routines for screen time and gadgets is vital and less is usually better. Also keep in mind that for many children, the more they use them, the more they will need them, which can set up a never-ending cycle of increasing dependence.

PSDD describes the condition in which children are no longer active agents of their involvement with the world. It interferes with their ability to engage in play that promotes optimal development, learning, social skills, and conflict resolution. In the long run, it can lead to remote-controlled people who exhibit conformist behavior, accept orders without questioning, and miss out on the joy the Korean children demonstrated in their play.

What Causes PSDD? There are several factors that contribute to PSDD. These include:

• The replacement of free time and free-play activities with media such as TV, video games, computers and DVDs which involve children in a world of someone else’s choosing rather than their own (Levin, 1998; Steyer, 2002).
• Highly structured toys, including sophisticated electronic toys and toys linked to media, that tell children what and how to play and that help them imitate the scripts they see on the screen (Levin & Carlsson-Paige, 2006).
• The growing emphasis on academic, skill-based curricula in early childhood settings that undermine children’s creative play and problem solving.
• An increasingly commercial culture that teaches young children “I want it” rather than “I can do it.” (Levin, 2004) “I can do it” is an essential part of problem solving, playing and learning. (See: commercialfreechildhood.org )

Finding a Cure!

Understanding PSDD and its causes and impact on children can give us a powerful tool for meeting children’s needs through play. Parents and educators can:

• Limit children’s involvement with electronic media;
• Encourage creative play in which children are the scriptwriters, directors, and actors;
• Help children find problems to solve and strategies for doing so;
• Choose toys and play materials that allow children to be the creators of what happens (see www.truceteachers.org);
• Create connections between parents and early childhood professionals supporting creative play and problem solving; and,
• Become advocates for creative play.

References and Resources:

This article appeared in Paradigm Magazine, Winter 2009. It is an adapted version of an article which appeared in Where Do the Children Play? by E. Goodenough.

Levin, D. (2007). Problem Solving Deficit Disorder: Creative vs Programmed Play in Korea and the U.S. In: Where Do the Children Play? Goodenough, E. (Ed.). Detroit, MI: Michigan Television.

Levin, D. (2004, September/October). From “I Want It!” to “I Can Do It!” Promoting Healthy Development in the Consumer Culture. Child Care Information Exchange, 159, 34-37.

Levin, D. (2003). Teaching Young Children in Violent Times: Building a Peaceable Classroom (2nd Edition). Cambridge, MA: Educators for Social Responsibility and Washington, DC: National Association for the Education of Young Children.

Levin, D. (1998). Remote Control Childhood? Combating the Hazards of Media Culture. Washington, DC: NAEYC.

Levin, D. (1996). Endangered Play, Endangered Development: A Constructivist View of the Role of Play in Development and Learning. Playing for Keeps, A. Phillips (Ed.). St. Paul, MN: Redleaf Press.

Levin, D. & Carlsson-Paige, N. (2006). The War Play Dilemma: What Every Parent and Teacher Needs to Know (2nd Ed.). New York: Teachers College.

Lohr, S. (2003, December 7). If the Shoe Ties, They Don’t Wear It. New York Times.

Meltz, B. (2004, January 22). Child Caring: There Are Benefits to Boredom. Boston Globe. Retrieved November 18, 2008 from http://www.boston.com/yourlife/home/articles/2004/01/22/there_are_benefits_to_boredom/

Schmidt, M.E., Pempek, T.A., Kirkorian, H.L., Lund, A.F., & Anderson, D.R. (2008, July). The effects of background television on the toy play behaviors of very young children. Child Development, 79, 1137- 1151.

Steyer, J. (2002). The Other Parent. New York: Atria Books.

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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Math disability in children: an overview

by: The GreatSchools Editorial Team | Updated: June 13, 2023

Print article

Recently, increased attention has focused on students who demonstrate challenges learning mathematics skills and concepts that are taught in school across the grade levels. Beginning as early as preschool, parents, educators, and researchers are noticing that some students seem perplexed learning simple math skills that many take for granted. For example, some young children have difficulty learning number names, counting, and recognizing how many items are in a group. Some of these children continue to demonstrate problems learning math as they proceed through school. In fact, we know that that 5% to 8% of school-age children are identified as having a math disability.

Research on understanding more completely what a math disability means and what we can do about it in school has lagged behind similar work being done in the area of reading disabilities. Compared to the research base in early reading difficulties, early difficulties in mathematics and the identification of math disability in later years are less researched and understood. Fortunately, attention is now being directed to helping students who struggle learning basic mathematics skills, mastering more advance mathematics (e.g., algebra), and solving math problems. This article will explain in detail what a math disability is, the sources that cause such a disability, and how a math disability impacts students at different grade levels.

What is a math disability?

A learning disability in mathematics is characterized by an unexpected learning problem after a classroom teacher or other trained professional (e.g., a tutor) has provided a child with appropriate learning experiences over a period of time. Appropriate learning experiences refer to practices that are supported by sound research and that are implemented in the way in which they were designed to be used. The time period refers to the duration of time that is needed to help the child learn the skills and concepts, which are challenging for the child to learn. Typically, the child with a math disability has difficulty making sufficient school progress in mathematics similar to that of her peer group despite the implementation of effective teaching practices over time. Studies have shown that some students with a math disability also have a reading disability or Attention-Deficit/Hyperactivity Disorder (AD/HD). Other studies have identified a group of children who have only a math disability.

Several sources of math disability

When a child is identified as having a math disability, his difficulty may stem from problems in one or more of the following areas: memory, cognitive development, and visual-spatial ability.

Memory problems may affect a child’s math performance in several ways. Here are some examples:

• A child might have memory problems that interfere with his ability to retrieve (remember) basic arithmetic facts quickly.
• In the upper grades, memory problems may influence a child’s ability to recall the steps needed to solve more difficult word problems,to recall the steps in solving algebraic equations, or to remember what specific symbols (e.g., å, s, ?, ?) mean.
• Your child’s teacher may say, “He knew the math facts yesterday but can’t seem to remember them today.”
• While helping your child with math homework, you may be baffled by her difficulty remembering how to perform a problem that was taught at school that day.

Cognitive development

Students with a math disability may have trouble because of delays in cognitive development, which hinders learning and processing information. This might lead to problems with:

• understanding relationships between numbers (e.g., fractions and decimals; addition and subtraction; multiplication and division)
• solving word problems
• understanding number systems
• using effective counting strategies

Visual-spatial

Visual-spatial problems may interfere with a child’s ability to perform math problems correctly. Examples of visual-spatial difficulties include:

• misaligning numerals in columns for calculation
• problems with place value that involves understanding the base ten system
• trouble interpreting maps and understanding geometry.

What math skills are affected?

According to the Individuals with Disabilities Education Act of 2004 (IDEA), a learning disability in mathematics can be identified in the area of mathematics calculation (arithmetic) and/or mathematics problem solving. Research confirms this definition of a math disability.

Math calculations

A child with a learning disability in math calculations may often struggle learning the basic skills in early math instruction where the problem is rooted in memory or cognitive difficulties. For example, research studies have shown that students who struggle to master arithmetic combinations (basic facts) compared to students who demonstrated mastery of arithmetic combinations showed little progress over a two-year period in remembering basic fact combinations when they were expected to perform under timed conditions. According to Geary (2004), this problem appears to be persistent and characteristic of memory or cognitive difficulties. Students with math calculations difficulties have problems with some or most of the following skills:

• Identifying signs and their meaning (e.g., +, -, x, <, =, >, %, ?) Automatically remembering answers to basic arithmetic facts (combinations) such as 3 + 4 =?, 9 x 9 = ?, 15 – 8 = ?.
• Moving from using basic (less mature) counting strategies to more sophisticated (mature) strategies to calculate the answer to arithmetic problems. For example, a student using a basic “counting all” strategy would add two objects with four objects by starting at 1 and counting all of the objects to arrive at the answer 6. A student using a more sophisticated “counting on” strategy would add two with four by starting with 4 and counting on 2 more to arrive at 6.
• Understanding the commutative property (e.g., 3 + 4 = 7 and 4 + 3 = 7)
• Solving multi-digit calculations that require “borrowing” (subtraction) and “carrying” (addition)
• Misaligning numbers when copying problems from a chalkboard or textbook
• Ignoring decimal points that appear in math problems
• Forgetting the steps involved in solving various calculations

Math word problems

A learning disability in solving math word problems taps into other types of skills or processes. Difficulties with any of these skills can interfere with a child’s ability to figure out how to effectively solve the problem.Your child may exhibit difficulty with some or most of the processes involved in solving math word problems such as:

• Reading the word problem
• Understanding the language or meaning of the sentences and what the problem is asking
• Sorting out important information from extraneous information that is not essential for solving the problem
• Implementing a plan for solving the problem
• Working through multiple steps in more advanced word problems
• Knowing the correct calculations to use to solve problems

Math rules and procedures

Students with a math disability demonstrate developmental delay in learning the rules and procedures for solving calculations or word problems. An example of a math rule includes “any number × 0 = 0.” A procedure includes the steps for solving arithmetic problems such as addition, subtraction, multiplication, and division. A delay means the child may learn the rules and procedures at a slower rate than his peer group and will need assistance in mastering those rules and procedures.

Math language

Some children have trouble understanding the meaning of the language or vocabulary of mathematics (e.g., greater than, less than, equal, equation). Unfortunately, unlike reading, the meaning of a math word or symbol cannot be inferred from the context. One has to know what each word or symbol means in order to understand the math problem. For instance, to solve the following problems, a child must understand the meaning of the symbols they contain: (3 + 4) x (6 + 8) =? or 72 < 108 True or False?

Math disability at different grade levels

As the curriculum becomes more demanding, a math disability is manifested in different ways across the grade levels. For example, the specialized language of mathematics — including terms and symbols — must be mastered in more advanced mathematics curriculum. Problems with counting strategies, retrieving basic facts quickly, and solving word problems seem to persist across grade levels and require extra instruction to reinforce learning.

Ongoing research in math disabilities

We do not fully understand how a math disability affects a child’s ability to learn mathematics in all of the different areas because of the limited research base on math disability. To date, the majority of research has focused mostly on the skills associated with mathematics calculations including number, counting, and arithmetic (e.g., arithmetic combinations or basic facts) and on solving word problems. Much less is known about development and difficulties in areas such as algebra, geometry, measurement, and data analysis and probability.

We know that a group of students exhibit problems learning mathematics skills and concepts that persist across their school years and even into adulthood. We understand that specific problems in the areas of memory, cognitive development, and visual-spatial ability contribute to difficulties learning mathematics. Fortunately, researchers and educators are focusing efforts on better understanding the issues these students face as they encounter the math curriculum across the grade levels. In my next article, I will explore methods for identifying a math disability and offer parents ideas for working with their children and teachers to address such difficulties.

Get more information on math disabilities — also known as dyscalculia — at Understood.org , a comprehensive free resource for parents of kids with learning and attention issues .

• Geary, D. C. (2004). Mathematics and learning disabilities. Journal of Learning Disabilities, 37, 4-15.
• Robinson, C., Menchetti, B., and Torgesen, J. (2002). Toward a two-factor theory of one type of mathematics disabilities. Learning Disabilities Research and Practice, 17(2), 81-89.
• Hallahan, D. P., Lloyd, J. W. Kauffman, J. M., Weiss, M. & Martinez, E. A. (2005). Learning disabilities: Foundations, characteristics, and effective teaching. Boston : Allyn and Bacon.
• Bryant, D. P., Bryant, B. R., & Hammill, D. D. (1990). Characteristic behaviors of students with LD who have teacher-identified math weaknesses. Journal of Learning Disabilities, 33, 168-177.
• Geary, D. C. (2000). Mathematical disorders: An overview for educators. Perspectives, 26, 6-9.
• Geary, D. C. (2003). Learning disabilities in arithmetic. In H. L. Swanson, K. R. Harris, & S. Graham (Eds.), Handbook of learning disabilities (pp. 199-212). New York: Guilford.
• Jordan, N., Hanich, L., & Kaplan, D. (2003). A longitudinal study of mathematical competencies in children with specific mathematics difficulties versus children with comorbid mathematics and reading difficulties. Child Development, 74(3), 834-850.
• Garnett, K., & Fleischner, J. E. (1983). Automatization and basic fact performance of normal and learning disabled children. Learning Disability Quarterly, 6, 223-231.
• Bryant, D. P., Bryant, B. R., & Hammill, D.D. (1990). Characteristic behaviors of students with LD who have teacher-identified math weaknesses. Journal of Learning Disabilities, 33, 168-177.
• Hallahan, D. P., Lloyd, J. W. Kauffman, J. M., Weiss, M. & Martinez, E. A. (2005). Learning disabilities: Foundations, characteristics, and effective teaching. Boston: Allyn and Bacon.
• Gersten, R., Jordan, N., & Flojo, J. R. (2005). Early identification and interventions for students with mathematics difficulties. Journal of Learning Disabilities, 38, 293-304.
• Montague, M., Applegate, B., & Marquard, K. (1993). Cognitive strategy instruction and mathematical problem-solving performance of students with learning disabilities. Learning Disabilities Research and Practice, 29, 251-261.
• Rivera, D. P. (1997). Mathematics education and students with learning disabilities: Introduction to the special series. Journal of Learning Disabilities, 30, 2-19, 68.
• Bryant, D. P. (2005). Commentary on early identification and intervention for students with mathematics difficulties. Journal of Learning Disabilities, 38, 340-345.

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• Patient Care & Health Information
• Diseases & Conditions
• Mild cognitive impairment (MCI)

Mild cognitive impairment (MCI) is the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia. MCI may include problems with memory, language or judgment.

People with MCI may be aware that their memory or mental function has "slipped." Family and close friends also may notice changes. But these changes aren't bad enough to impact daily life or affect usual activities.

MCI may increase the risk of dementia caused by Alzheimer's disease or other brain disorders. But some people with mild cognitive impairment might never get worse. And some eventually get better.

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• A Book: Day to Day: Living With Dementia
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• A Book: Mayo Clinic on Healthy Aging

The brain, like the rest of the body, changes with age. Many people notice they become more forgetful as they age. It may take longer to think of a word or to recall a person's name.

If concerns with mental function go beyond what's expected, the symptoms may be due to mild cognitive impairment (MCI). MCI may be the cause of changes in thinking if:

• You forget things more often.
• You miss appointments or social events.
• You lose your train of thought. Or you can't follow the plot of a book or movie.
• You have trouble following a conversation.
• You find it hard to make decisions, finish a task or follow instructions.
• You start to have trouble finding your way around places you know well.
• You begin to have poor judgment.
• Your family and friends notice any of these changes.

If you have MCI , you also may experience:

• Depression.
• A short temper and aggression.
• A lack of interest.

When to see a doctor

Talk to your health care provider if you or someone close to you notices you're having problems with memory or thinking. This may include trouble recalling recent events or having trouble thinking clearly.

• Changes in brain structure with MCI and Alzheimer's disease

Some changes in brain structure — such as the decrease in size of the brain's memory center (hippocampus) — are typical with aging. However, this reduction in size is greater in those with mild cognitive impairment and even more dramatic in people with Alzheimer's disease.

• Brain shrinkage in MCI and Alzheimer's disease

Dementia causes the brain to lose mass, especially in critical areas. Note the difference in size between a healthy brain (top), a mild cognitive impairment brain (middle) and an Alzheimer's disease brain (bottom).

There's no single cause of mild cognitive impairment (MCI), although MCI may be due to early Alzheimer's disease. There's no single outcome for the disorder. Symptoms of MCI may remain stable for years. Or MCI may progress to Alzheimer's disease dementia or another type of dementia. In some cases, MCI may improve over time.

MCI often involves the same types of brain changes seen in Alzheimer's disease or other forms of dementia. In MCI , those changes occur at a lesser degree. Some of these changes have been seen in autopsy studies of people with MCI .

These changes include:

• Clumps of beta-amyloid protein, called plaques, and tangles of tau proteins that are seen in Alzheimer's disease.
• Microscopic clumps of a protein called Lewy bodies. These clumps are associated with Parkinson's disease, dementia with Lewy bodies and some cases of Alzheimer's disease.
• Small strokes or reduced blood flow through brain blood vessels.

Brain-imaging studies show that the following changes may be associated with MCI :

• Decreased size of the hippocampus, a brain region important for memory.
• Increased size of the brain's fluid-filled spaces, known as ventricles.
• Reduced use of glucose in key brain regions. Glucose is the sugar that's the main source of energy for cells.

Risk factors

The strongest risk factors for MCI are:

• Increasing age.
• Having a form of a gene known as APOE e4 . This gene also is linked to Alzheimer's disease. But having the gene doesn't guarantee that you'll have a decline in thinking and memory.

Other medical conditions and lifestyle factors have been linked to an increased risk of changes in thinking, including:

• High blood pressure.
• High cholesterol.
• Obstructive sleep apnea.
• Lack of physical exercise.
• Low education level.
• Lack of mentally or socially stimulating activities.

Complications

People with MCI have an increased risk — but not a certainty — of developing dementia. Overall, about 1% to 3% of older adults develop dementia every year. Studies suggest that around 10% to 15% of people with MCI go on to develop dementia each year.

Mild cognitive impairment can't be prevented. But research has found some lifestyle factors may lower the risk of getting MCI . Studies show that these steps may help prevent MCI :

• Don't drink large amounts of alcohol.
• Limit exposure to air pollution.
• Reduce your risk of a head injury.
• Don't smoke.
• Manage health conditions such as diabetes, high blood pressure, obesity and depression.
• Practice good sleep hygiene and manage any sleep problems.
• Eat a healthy diet full of nutrients. Include fruits and vegetables and foods low in saturated fats.
• Stay social with friends and family.
• Exercise at a moderate to vigorous intensity most days of the week.
• Wear a hearing aid if you have hearing loss.
• Stimulate your mind with puzzles, games and memory training.

Mild cognitive impairment (MCI) care at Mayo Clinic

• Knopman DS, et al. Alzheimer disease. Nature Reviews. Disease Primers. 2021; doi:10.1038/s41572-021-00269-y.
• Jankovic J, et al., eds. Alzheimer disease and other dementias. In: Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Zhuang L, et al. Cognitive assessment tools for mild cognitive impairment screening. Journal of Neurology. 2021; doi:10.1007/s00415-019-09506-7.
• What is mild cognitive impairment? National Institute on Aging. https://www.nia.nih.gov/health/what-mild-cognitive-impairment. Accessed Sept. 21, 2022.
• Mild cognitive impairment (MCI). Alzheimer's Association. https://www.alz.org/alzheimers-dementia/what-is-dementia/related_conditions/mild-cognitive-impairment. Accessed Sept. 21, 2022.
• Lewis JE, et al. The effects of twenty-one nutrients and phytonutrients on cognitive function: A narrative review. Journal of Clinical and Translational Research. 2021; doi:10.18053/jctres.07.202104.014.
• Kellerman RD, et al. Alzheimer's disease. In: Conn's Current Therapy 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Ferri FF. Mild cognitive impairment. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Petersen RC, et al. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018; doi:10.1212/WNL.0000000000004826.
• Budson AE, et al. Subjective cognitive decline, mild cognitive impairment and dementia. In: Memory Loss, Alzheimer's Disease, and Dementia. 3rd ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Sept. 21, 2022.
• Cognitive impairment in older adults: Screening. U.S. Preventive Services Task Force recommendation statement. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening. Accessed Sept. 21, 2022.
• Levenson JL, ed. Dementia. In: The American Psychiatric Association Publishing Textbook of Psychosomatic Medicine and Consultation-Liaison Psychiatry. 3rd ed. American Psychiatric Association Publishing; 2019. https://psychiatryonline.org. Accessed Sept. 21, 2022.
• Livingston G, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet. 2020; doi:10.1016/S0140-6736(20)30367-6.
• Cummings J, et al. Alzheimer's disease drug development pipeline: 2022. Alzheimer's and Dementia. 2022; doi:10.1002/trc2.12295.
• Memory, forgetfulness and aging: What's normal and what's not? National Institute on Aging. https://www.nia.nih.gov/health/memory-forgetfulness-and-aging-whats-normal-and-whats-not. Accessed Sept. 26, 2022.
• Ami T. Allscripts EPSi. Mayo Clinic. April 21, 2022.
• Alzheimer's disease research centers. National Institute on Aging. https://www.nia.nih.gov/health/alzheimers-disease-research-centers#minnesota. Accessed Sept. 26, 2022.
• About the Alzheimer's Consortium. Arizona Alzheimer's Consortium. https://azalz.org/about/#institutes. Accessed Sept. 26, 2022.
• Shi M, et al. Impact of anti-amyloid-β monoclonal antibodies on the pathology and clinical profile of Alzheimer's disease: A focus on aducanumab and lecanemab. Frontiers in Aging and Neuroscience. 2022; doi:10.3389/fnagi.2022.870517.
• Graff-Radford J (expert opinion). Mayo Clinic. Sept. 30, 2022.
• HABIT program orientation

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25 Developmental Problems, Learning Disabilities, and Critical Thinking, Creativity, and Problem Solving

Developmental problems.

Children’s cognitive and social skills are evaluated as they enter and progress through school. Sometimes this evaluation indicates that a child needs special assistance with language or in learning how to interact with others. Evaluation and diagnosis of a child can be the first step in helping to provide that child with the type of instruction and resources needed. But diagnosis and labeling also have social implications. It is important to consider that children can be misdiagnosed and that once a child has received a diagnostic label, the child, teachers, and family members may tend to interpret actions of the child through that label. The label can also influence the child’s self-concept. Consider, for example, a child who is misdiagnosed as learning disabled. That child may expect to have difficulties in school, lack confidence, and out of these expectations, have trouble indeed. This self-fulfilling prophecy or tendency to act in such a way as to make what you predict will happen comes true, calls our attention to the power that labels can have whether or not they are accurately applied.

It is also important to consider that children’s difficulties can change over time; a child who has problems in school, may improve later or may live under circumstances as an adult where the problem (such as a delay in math skills or reading skills) is no longer relevant. That person, however, will still have a label as learning disabled. It should be recognized that the distinction between abnormal and normal behavior is not always clear; some abnormal behavior in children is fairly common. Misdiagnosis may be more of a concern when evaluating learning difficulties than in cases of autism spectrum disorder where unusual behaviors are clear and consistent. Keeping these cautionary considerations in mind, let’s turn our attention to some developmental and learning difficulties.

Click on each box for information.

Autism Spectrum Disorders

The estimate published by the Center for Disease Control (2006) is that about 1 out of every 166 children in the United States has an autism spectrum disorder. Autism spectrum disorders include autism, Asperger’s disorder and pervasive developmental disabilities. Many of these children are not identified until they reach school age. In 2003, about 141,000 children received special education through the public schools (Center for Disease Control, 2006). These disorders are found in all racial and ethnic groups and are more common in boys than in girls. All of these disorders are marked by difficulty in social interactions, problems in various areas of communication, and in difficulty with altering patterns or daily routines. There is no single cause of ASDs and the causes of these disorders are to a large extent, unknown. In cases involving identical twins, if one twin has autism, the other is also autistic about 75 percent of the time. Rubella, fragile X syndrome and PKU that has been untreated are some of the medical conditions associated with risks of autism.

None of these disorders is curable. Some individuals benefit from medications that alleviate some of the symptoms of ASDs. But the most effective treatments involve behavioral intervention and teaching techniques used to promote the development of language and social skills, and to structure learning environments that accommodate the needs of these children.

Autism is a developmental disorder more commonly known than Asperger’s or Pervasive Developmental disorders. A person with autism has difficulty with and a lack of interest in learning language. An autistic child may respond to a question by repeating the question or might rarely speak. Sometimes autistic children learn more difficult words before simple words or complicated tasks before easier ones. The person has difficulty reading social cues such as the meanings of non-verbal gestures such as a wave of the hand or the emotion associated with a frown. Intense sensitivity to touch or visual stimulation may also be experienced. Autistic children have poor social skills and are unable to communicate with others or empathize with others emotionally. An autistic views the world differently and learns differently than others. Autistic children tend to prefer routines and patterns and become upset when routines are altered. For example, moving the furniture or changing the daily schedule can be very upsetting.

Asperger’s Syndrome

Asperger’s syndrome is considered by some to be the same as high functioning autism. Others suggest that Asperger’s disorder is different from autism in that language development is generally not delayed (Medline Plus, 2006). A person with Asperger’s syndrome does not experience cognitive developmental delays, but has difficulty in social interactions. This person may be identified as strange by others, may have difficulty reading or identifying with other people’s emotions, and may prefer routine and become upset if routines are disrupted. Many people with Asperger’s syndrome may have above average intelligence and may have an intense focus of interests in a particular field. For example, a person may be extremely interested in and knowledgeable about cars. Another might be very interested in the smell of people’s shoes.

Pervasive Developmental Disorder

Pervasive developmental disorder  is a term used to refer to difficulties in socialization and delays in developing communicative skills. This is usually recognized before 3 years of age. A child with PDD may interact in unusual ways with toys, people, or situations, and may engage in repetitive movement.  (58)

Learning Disabilities

What is a learning disability? The spectrum disorders just described impact many areas of the child’s life. And if a child is mentally retarded, that child is typically slow in all areas of learning. However, a child with a learning disability has problems in a specific area or with a specific task or type of activity related to education. A learning difficulty refers to a deficit in a child’s ability to perform an expected academic skill (Berger, 2005). These difficulties are identified in school because this is when children’s academic abilities are being tested, compared, and measured. Consequently, once academic testing is no longer essential in that person’s life (as when they are working rather than going to school) these disabilities may no longer be noticed or relevant, depending on the person’s job and the extent of the disability.

• Dyslexia  is one of the most commonly diagnosed disabilities and involves having difficulty in the area of reading. This diagnosis is used for a number of reading difficulties. For example, the child may reverse letters or have difficulty reading from left to right or may have problems associating letters with sounds. It appears to be rooted in some neurological problems involving the parts of the brain active in recognizing letters, verbally responding, or being able to manipulate sounds (National Institute of Neurological Disorders and Stroke, 2006). Treatment typically involves altering teaching methods to accommodate the person’s particular problematic area.
• Attention Deficit Hyperactivity Disorder  is considered a neurological and behavioral disorder in which a person has difficulty staying on task, screening out distractions, and inhibiting behavioral outbursts. The most commonly recommended treatment involves the use of medication, structuring the classroom environment to keep distractions at a minimum, tutoring, and teaching parents how to set limits and encourage age-appropriate behavior (NINDS, 2006). (58)

Critical Thinking, Creativity, and Problem Solving

Critical thinking  requires skill at analyzing the reliability and validity of information, as well as the attitude or disposition to do so. The skill and attitude may be displayed with regard to a particular subject matter or topic, but in principle it can occur in any realm of knowledge (Halpern, 2003; Williams, Oliver, & Stockade, 2004). A critical thinker does not necessarily have a negative attitude in the everyday sense of constantly criticizing someone or something. Instead, he or she can be thought of as astute: the critical thinker asks key questions, evaluates the evidence for ideas, reasons for problems both logically and objectively, and expresses ideas and conclusions clearly and precisely. Last (but not least), the critical thinker can apply these habits of mind in more than one realm of life or knowledge.  (59)

Creative thinking is the ability to make or do something new that is also useful or valued by others (Gardner, 1993). The “something” can be an object (like an essay or painting), a skill (like playing an instrument), or an action (like using a familiar tool in a new way). To be creative, the object, skill, or action cannot simply be bizarre or strange; it cannot be new without also being useful or valued, and not simply be the result of accident. If a person types letters at random that form a poem by chance, the result may be beautiful, but it would not be creative by the definition above. Viewed this way, creativity includes a wide range of human experience that many people, if not everyone, have had at some time or other (Kaufman & Baer, 2006). The experience is neither restricted to a few geniuses, nor exclusive to specific fields or activities like art or the composing of music.

Especially important are two facts. The first is that an important form of creativity is  creative thinking  , the generation of ideas that are new as well as useful, productive, and appropriate. The second is that creative thinking can be stimulated parents and teacher efforts. Teachers can, for example, encourage students’  divergent thinking  ——ideas that are open-ended and that lead in many directions (Torrance, 1992; Kim, 2006). Divergent thinking is stimulated by open-ended questions—questions with many possible answers, such as the following:

• How many uses can you think of for a cup?
• Draw a picture that somehow incorporates all of these words: cat, fire engine, and banana.
• What is the most unusual use you can think of for a shoe?

Note that answering these questions creatively depends partly on having already acquired knowledge about the objects to which the questions refer. In this sense divergent thinking depends partly on its converse, convergent thinking, which is focused, logical reasoning about ideas and experiences that lead to specific answers. Up to a point, then, developing childrens’  convergent thinking  —as schoolwork often does by emphasizing mastery of content—facilitates students’ divergent thinking indirectly, and hence also their creativity (Sternberg, 2003; Runco, 2004; Cropley, 2006). But carried to extremes, excessive emphasis on convergent thinking may discourage creativity.  (60)

Problem-Solving

Somewhat less open-ended than creative thinking is problem solving, the analysis and solution of tasks or situations that are complex or ambiguous and that pose difficulties or obstacles of some kind (Mayer & Wittrock, 2006). Problem solving is needed, for example, when a physician analyzes a chest X-ray: a photograph of the chest is far from clear and requires skill, experience, and resourcefulness to decide which foggy-looking blobs to ignore, and which to interpret as real physical structures (and therefore real medical concerns). Problem solving is also needed when a grocery store manager has to decide how to improve the sales of a product: should she put it on sale at a lower price, or increase publicity for it, or both? Will these actions actually increase sales enough to pay for their costs?  (61)

Critical thinking, creativity, and problem solving are all cognitive skills that can be cultivated and developed across childhood. Brain development and cognitive development in general, all facilitate the development of these skills.  (1)

Child and Adolescent Psychology Copyright © by Lumen Learning is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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• v.50(3); 2013 Sep

Language: English | Turkish

The Effectiveness of an Interpersonal Cognitive Problem-Solving Strategy on Behavior and Emotional Problems in Children with Attention Deficit Hyperactivity

Kişilerarası sorun Çözme eğitiminin dikkat eksikliği ve hiperaktivite bozukluğu olan Çocukların davranışsal ve emosyonel sorunları Üzerindeki etkisi, celale tangül Özcan.

1 Gulhane Military Medical Academy, School of Nursing, Ankara, Turkey

Fahriye Oflaz

Tümer türkbay.

2 GGulhane Military Medical Academy, Department of Child and Adolescent Mental Health, Ankara, Turkey

Sharon M. FREEMAN CLEVENGER

3 Gülhane Indiana/Purdue University Center for Brief Therapy, Fort Wayne, Indiana, USA

Introduction

This study was designed to evaluate the effectiveness of the “I Can Problem Solve” (ICPS) program on behavioral and emotional problems in children with attention deficit hyperactivity disorder (ADHD).

The subjects were 33 children with ADHD aged between 6 to 11 years. The study used a pre- and post-test quasi-experimental design with one group. The researchers taught 33 children with ADHD how to apply ICPS over a period of 14 weeks. The Child Behavior Checklist for Ages 6–18 (Teacher Report Form) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition Text Revision (DSM-IV-TR) Based Disruptive Behavior Disorders Screening and Rating Scale (parents’ and teacher’s forms) were used to evaluate the efficacy of the program. The scales were applied to parents and teachers of the children before and after the ICPS program.

The findings indicated that the measured pre-training scores for behavioral and emotional problems (attention difficulties, problems, anxious/depressed, withdrawn/depressed, oppositional defiant problems, rule breaking behaviors, and aggressive behaviors) were significantly decreased in all children post-training. In addition, children’s total competence scores increased (working, behaving, learning and happy) after the ICPS program.

According to the results, it is likely that, ICPS would be a useful program to decrease certain behavioral and emotional problems associated with ADHD and to increase the competence level in children with ADHD. An additional benefit of the program might be to empower children to deal with problems associated with ADHD such as attention difficulties, hyperactivity-impulsivity, and oppositional defiant problems.

ÖZET

Giriş.

Bu araştırma dikkat eksikliği hiperaktivite bozukluğu (DEHB) tanısı konulan çocuklara uygulanan bir kişilerarası sorun çözme eğitim programı olan “Ben Sorun Çözebilirim (BSÇ)” eğitiminin etkilerini incelemek amacıyla yapılmıştır.

Yöntemler

Araştırma örneklemini DEHB tanısı konulan 6–11 yaş arası 33 çocuk oluşturmuş, tek gruplu ön-son test deseninde, yarı deneysel olarak planlanmıştır. DEHB tanısı olan bu çocuklara 14 hafta boyunca bilişsel yaklaşıma dayalı BSÇ eğitimi uygulanmıştır. Programın etkinliğini değerlendirmek için “Dikkat Eksikliği ve Yıkıcı Davranış Bozuklukları için DSM-IV’e Dayalı Tarama ve Değerlendirme Ölçeği” (anne-baba ve öğretmen formu) ve “6–18 Yaş Grubu Çocuk ve Gençler için Davranış Değerlendirme Ölçeği (öğretmen formu-TRF/6–18)” kullanılmıştır. BSÇ eğitimi öncesi ve sonrasında anne-baba ve öğretmenlerden bu ölçekleri doldurmaları istenmiştir.

BSÇ eğitimi sonrasında karşı gelme, dikkatsizlik, hiperaktivite/dürtüsellik, anksiyete/depresyon, sosyal içe dönüklük, suça yönelik davranışlar ve saldırgan davranışların azaldığı saptanmıştır. TRF/6–18′nin yeterlilik alanına ilişkin “sıkı çalışma, uyum, öğrenme ve mutlu olma” alt testlerin toplamından oluşan “toplam yeterlilik” alt testinde BSÇ eğitim sonrasında yeterlilik düzeyinin önemli oranda arttığı görülmüştür.

Sonuç

Bu çalışmanın sonuçlarına göre, BSÇ eğitim programı DEHB olan çocukların duygusal ve davranışsal sorunların azaltılmasında ve çocukların yeterlilik düzeylerinin artırılmasında faydalı olabilir. Bu programın bir diğer yararı ise bu çocukların DEHB ile ilişkili sorunlar (dikkat eksikliği, hiperaktivite/dürtüsellik ve karşı gelme sorunları) ile baş etmelerini güçlendirebilir.

Attention deficit hyperactivity disorder (ADHD), which is one of the most prevalent childhood psychiatric disorders, is a neuropsychiatric disorder characterized by developmentally inappropriate levels of activity, distractibility, and impulsivity ( 1 , 2 ).

Behavioral problems in children with ADHD include acting without adequate forethought as to the consequences of their actions and inability to postpone gratification with impulsive decisions and behaviors. ADHD negatively influences social interactions with peers, interpersonal relationships with parents, teachers and peers as well as academic success and social functions ( 2 , 3 ). Children with ADHD face problems such as increased incidence of defiant and aggressive behaviors, and are at higher risk of comorbid disorders (such as oppositional defiant disorder, conduct disorder) compared to typically developing children ( 4 , 5 ). Behavioral problems commonly seen in children with ADHD affect the overall quality of children’s lives ( 2 , 6 , 7 ), and reduce the quality of life of their family members. Specifically, the family experiences overall increased levels of stress, decreased feelings of belonging and competence and disruption of routines and structure ( 2 ). Additional problems include: conflicts and exclusion among peers, inability to manage or prevent anger efficiently, communication/social skill difficulties, inadequate problem solving, and difficulties in relationships ( 2 , 5 , 8 ).

Multifocal treatment programs for children with ADHD may improve outcomes in a more robust manner than medication alone or behavior/cognitive management programs alone. Social skills training programs encourage problem-solving ability and support cognitive and behavioral skills ( 2 , 9 , 10 ). Some cognitive-behavioral approaches consisting of psychosocial treatments result in improved impulse control, increased assessment capability before reaction and enhance considered and tempered actions ( 11 ).

The “I Can Problem Solve” (ICPS) program is based on Interpersonal Cognitive Problem-Solving methods. The basic objectives of this program are developed mainly to deal with the social problems of children ( 12 ). The ICPS is a problem solving approach to prevention of high risk behaviors in children and provide children with assessment abilities to help them solve their problems ( 12 , 13 , 14 ). By strengthening the capacity of children with ADHD to solve problems that lead to socially undesirable behaviors such as physical and verbal aggression, impulsivity, inability to wait, inability to take turns, inability to delay gratification, over emotionality in the face of frustration, inability to maintain friendships, high risk behaviors may be reduced ( 12 ). It should be noted that, children with ADHD need extra support and structured training although other children easily can learn problem-solving skills through these programs and adapt them to real life as well ( 15 ). However, there is limited data relating the ICPS training program for children suffering from ADHD ( 10 , 12 ).

The primary aim of this study was to evaluate the effectiveness of the ICPS program on children with ADHD. It was hypothesized that ICPS program would be useful to decrease behavioral and emotional problems (oppositional defiant problems, attention problems, hyperactivity problems, anxious/depressed, withdrawn/depressed, rule breaking behavior, and aggressive behavior), and would increase the total competence scores (working, behaving, learning and happy) in children with ADHD.

Study Design and Sampling

The main purpose of this study was to evaluate the improvements between pre- and post-ICPS training in measured behavioral and emotional problems in children with ADHD and their competence in term of the effectiveness of the ICPS program. This study was designed as a pre-post-test quasi-experimental design with a single group. The study group consisted of children diagnosed with ADHD in two elementary schools in Ankara/Turkey, between ages of 6 and 11, diagnosed with ADHD according to DSM-IV-TR criteria ( 1 ). The mean age of the participants was 9.1±1.1 years. All of the children were Caucasian. The socio-demographic characteristics of the children such as gender, grade, mother’s and father’s education years, father’s/mother’s profession as well as medication use for ADHD are outlined in Table 1 .

The Socio-demographic characteristics of the participants (n=33)

Inclusion criteria were: the diagnosis of ADHD according to DSM-IV-TR criteria, 6 to 12 years of age, and child/parents volunteered for the research. Exclusion criteria were: the history of head trauma or neurological illness, developmental delay or any other axis I psychiatric disorder except for oppositional defiant disorder, making a change in her/his medications during the study if the child has been taking any medication for ADHD, and failure to attend the training.

Instruments

Data collection and assessment tools used in the research were as follows:

The DSM-IV-TR Based Disruptive Behavior Disorders Screening and Rating Scale

This is a screening and assessment instrument, which was developed based on DSM-IV-TR diagnostic criteria, consists of 9 items inquiring attention problems; 6 items inquiring hyperactivity; 3 items inquiring impulsivity; 8 items inquiring oppositional defiant disorder and 15 items inquiring conduct disorder. The adaptation of this scale to Turkish society, and the validation and reliability analyses were completed in the year 2001. The Cronbach’s alpha was 0.88 for the sub-scale attention problems and 0.92 for the sub-scale disruptive behavior disorder in the reliability analysis ( 16 ).

The Child Behavior Checklist for Ages 6–18 (Teacher Report Form-TRF/6–18)

This form was developed to evaluate 6–18 age group students’ adaptation to school and their faulty behavior through information obtained from teachers in a standardized way. TRF includes 118 items related to behavioral and emotional problems. 93 of these items correspond to the items on the Child Behavior Checklist for Ages 6–18. The scale provides information regarding adaptation as well as basic functions such as school- and student-related information. In the second part of the scale, behavior problems are inquired under the categories “internalizing” and “externalizing”. Within the “internalizing” category, there are withdrawn/depressed, somatic complaints and anxious/depressed subtests, while within the “externalizing” category, there are disobedience to rules and aggressive behaviors sub-tests. There are also sub-tests such as social problems, thought problems, attention problems and other problems that do not belong to either of the two categories ( 17 ). TRF was first developed by Achenbach in 1991, and verification and validation studies in our country were conducted by Erol at al. ( 18 ). The Validity and reliability of the Turkish version of the TRF was 0.82 for Internalizing; 0.81 for Externalizing and Cronbach alpha=0.87 for total problem.

The 49 children from two elementary schools were interviewed and examined by a psychiatric practitioner trained in child psychiatry. To exclude other psychiatric disorders, the Children Depression Inventory, the State-Trait Anxiety Inventory and the Learning Disorders Checklist were applied. 37 of the 49 children met the diagnostic criteria for ADHD. The study was introduced to 37 children and their parents in an introductory meeting. Permission and written informed consent were obtained from them (n=37). Parent reports were obtained with the DSM-IV-TR based Disruptive Behavior Disorders screening and assessment scale; teacher reports were obtained with both the DSM-IV-TR Based Disruptive Behavior Disorders Screening and Assessment Scale, and “Child Behavior Checklist for Ages 6–18 (Teacher Report Form)(TRF/6–18).

Due to various reasons, such as being diagnosed with another psychiatric disorder besides ADHD and the failure to attend the training etc., four students were excluded from the study. Finally, the remaining 33 children were taken for evaluation.

The lessons of ICPS were taught to the children in small groups. The children fell into the groups based upon their school and whether they attended morning or afternoon classes resulting in 7–9 children per group. The training program was 14 weeks in length and included 83 structured lessons. Each lesson was completed in approximately 30 minutes twice per week which could be prolonged considering children’s motivation.

The ICPS training program is based on “Interpersonal Cognitive Problem-Solving Strategy”. The ICPS program was developed by Myrna B. Shure (1992) ( 19 ) for purposes of social skills training in children and adolescents. The adaptation of this training to Turkish has been made by Öğülmüş ( 14 ). The training was provided by a primary researcher who had previously been trained exclusively by Öğülmüş. The ICPS program teaches children how to think and how to evaluate their own thoughts. Behaviors are modified by focusing on the thinking processes. The ICPS program encourages children to think about finding as many alternative solutions as possible when they deal with a problem. It teaches children to learn how to think of solutions to a problem and of potential consequences to an act. The ICPS encourages children to do their own thinking instead of offering solutions and consequences ( 12 , 13 , 14 ). ICPS with enhanced critical thinking, creativity, and reasoning skills are concerned more with how a person thinks rather than what a person thinks. ICPS attempt to enhance interpersonal cognitive skills, and thus, lead to successful alterations in overt social behavior ( 12 , 13 , 14 ). The guideline book of ICPS program included 83 structured lessons using pictures, toys, puppets, games, stories, drama, role-plays, and dialogues based on real life conversations. There is a defined goal of each structured lesson in the ICPS program book ( 19 ). The examples of goals of the ICPS lessons are as follows:

To Think About their own Feelings

To learn to identify people’s feelings and to become sensitive to them (other’s feelings) or (to gain the ability to put themselves in other’s shoes)

To increase their awareness that other’s point of view might differ from their own

To recognize that there is more than one way to solve a problem

To learn being assertive without physical and verbal aggression

To learn that different people can feel different ways about the same issue

To think of both alternative solutions and means-ends plans (weighing pros and cons)

To be aware of what might happen next and to learn how to think of solutions to a problem and consequences to an act

To decide for themselves whether their idea was or was not good in the light of their own and others’ feelings and of the possible consequences.

To learn that sensitivity to the preferences of others is also important in deciding what to do in situations which situation?

To increase understanding that thinking about what is happening may, in the long run, be more beneficial than immediate action to stop the behavior

To control impulse, including to delay gratification and to cope with frustrations

Examples of ICPS Dialoguing (Problem-solving process) ( 12 ).

“What happened, what’s the problem, what’s the matter?”

“How do you think she/he feels when.. ?” (e.g., “When you hit him/her?”)

“What happened (might happen) next when you did (do) that?”

“How did that make you feel?”

“Can you think of a different way to solve the problem (tell him/her/me how you feel)?”

“Do you think that is or is not a good idea? Why (why not)?”

Ethical Approval

This study was approved by the local ethics committee of Gülhane Military Medical Academy and School of Medicine, and Ankara Provincial Education Directorate. For ethical considerations, the purposes and methods of the study were explained to the children and their parents. After receiving their consent, the study was started.

Statistical Analysis

SPSS Ver. 13.0 for Windows (SPSS Inc., IL, USA) was used for the statistical analysis. All descriptive statistics were presented as mean ± standard deviation (SD), median and number/percentage universal tests, then normal distribution fit tests (Shapiro-Wilk test) were employed for the data used. Pre- and post-test measurement data were evaluated as dependent variables scores were compared by using the Paired-Samples T-Test or the Wilcoxon Signed-Rank Test (when variances are unequal). The significance level was assumed p<0.05.

The differences between pre-and post-training scores were statistically significant for all subscales of the DSM-IV-TR Based Disruptive Behavior Disorders Screening and Rating Scale ( Table 2 ).

Comparison of the Subscales Scores of the DSM-IV-TR Based Disruptive Behavior Disorders Screening and Rating Scale before and after the ICPS Training

t: Paired-Samples T Test, z: Wilcoxon Signed Rank Test (when variances were unequal),

According to the TRF/6–18 test scores for both pre-and post-training, the all internalizing problem behaviors including “anxious/depressed”, “withdrawn/depressed” and “somatic complaints”, and the all externalizing problem behaviors including “rule-breaking behavior” and “aggressive behaviors” were found to be significantly reduced after the ICPS training ( Table 3 ). The sum of the scores for four adaptive characteristics (“working”, “behaving”, “learning” and “happy”) displays an “adaptive functioning profile” on the TRF/6–18. The difference between competence levels of these sub-tests were found to be statistically significant based on the comparison of these levels for pre- and post-ICPS training (p=0.03). The higher total competence scores indicate the better competence ( Table 3 ).

Comparison of Problematic Behaviors Scores Identified by TRF/6–18 for Pre- and Post-ICPS Training

t: Paired-Samples T Test, z: Wilcoxon Signed-Rank Test (when variances were unequal),

The effectiveness of ICPS training for children with ADHD resulted in significant improvement in ADHD symptoms as well as in such problem areas like internalizing and externalizing behavior problems. These results suggest that ICPS training might reduce problematic behaviors and improve problem-solving skills and behavior among children with ADHD.

Pharmacotherapy tends to be a first-line therapy targeting biological implications for children with ADHD. Approved pharmacological agents for the treatment of ADHD include psychostimulants and atomoxetine. Psychostimulant medication has positive effects on children with ADHD in their ability to focus and pay attention in school settings, thereby, resulting in improvement in the overall learning environment. The therapeutic effects of pharmacological agents may be temporary, as symptom reduction occurs only when medication is active in the system. The lack of long-term efficacy has been issue of concern ( 2 , 20 ). Although the effectiveness of psychostimulants for reducing ADHD symptoms have demonstrated efficacy ( 21 , 22 ), there are potential unwanted side effects of pharmacological agents ( 23 , 24 ). Because of worrying about potential and known/unknown negative effects of pharmacotherapy, some children with ADHD may be reluctant to use any medication for ADHD, and may possibly discontinue medication treatments without their prescribers’ knowledge. Furthermore, follow-up studies have demonstrated that ADHD frequently persists into adolescence and adulthood ( 2 , 25 , 26 ). In addition, adults and those in whom ADHD was diagnosed in childhood often continue to suffer ongoing significant behavior problems ( 2 , 9 , 27 ). Accordingly, if these people with ADHD use a medication as the first and only treatment for ADHD, they will have to use the medication throughout life. As a result, non-pharmacological treatment seeking, and the use of complementary are on the rise ( 26 ). In addition, children with ADHD have not only core ADHD symptoms, but have also comorbid disorders that increase complexity of treatment such as anxiety, disobedience to rules, aggressive behaviors, oppositional defiant behaviors and other social problems ( 2 , 4 ). These comorbid conditions and associated features not only add to ADHD’s clinical complexity, but also have significant implications for treatment ( 28 ). Therefore, alternative options, including psychosocial treatment approaches, may have utility for amelioration of ADHD symptoms, and have significance in reversing the risks and long-term outcomes associated with ADHD, especially if combined with medication ( 3 , 9 , 28 , 29 ). However, some studies indicated that treatment with a combination of medicine and psychosocial treatment has little or no better result compared to medicine only treatment ( 20 , 30 , 31 ). The Multimodal Treatment Study of Children with ADHD (MTA) compared four treatment options in a 4-group parallel design. Combination treatment and medication management were both significantly superior to behavioral treatment and community care in reducing the symptoms. In certain conditions (such as oppositional-defiant/aggressive symptoms, internalizing symptoms, teacher rated social skills, parent-child relations, and reading achievement), combined treatment was superior to behavioral treatment and/or community care ( 21 ).

On the contrary, other studies have demonstrated incremental results for adding behavior therapy to psychostimulant medication in terms of reductions of ADHD symptoms ( 32 , 33 ). Similarly, psychosocial interventions such as ICPS have been found to be effective for children with ADHD ( 34 ). In support of this, some studies have reported that, psychosocial therapies provided along with medication had positive effects on comorbid internalizing and externalizing behaviors ( 35 , 36 ). Diller and Goldstein ( 37 ) have emphasized: “more than one hundred studies demonstrate that parent and teacher training programs improve child compliance, reduce disruptive behaviors, and improve parent/teacher-child interactions and a number of short-term studies have scientifically demonstrated the effectiveness of psychosocial interventions for ADHD”.

Problem-solving strategies that is one of psychosocial treatments engages both the cognitive and social skills that arise from daily life experiences. Problem-solving skills are considered an important aspect that effects how one reacts and deals with these problems ( 38 ). ICPS program might be useful for both children with and without medication and may contribute to reductions in problematic behaviors. These strategies may also reduce the severity of comorbid disruptive disorders and emotional problems. ICPS training improve problematic behaviors by engaging children in thinking about their actions, the impact of their behavior on themselves and others, the possible consequences of their actions, and other options they have. However, previous studies evaluating the effectiveness of ICPS program in normal children ( 12 , 39 ) concluded that that non-ADHD children with naturally developed problem-solving thinking skills and behavior strategies benefit from ICPS as well as children with ADHD ( 12 , 38 ). There are limited studies related to children with ADHD in the literature to evaluate the effectiveness of ICPS program which we used in our research ( 12 ). In one of the initial studies with single subject design, Shure (1999) has cited that, Aberson (1996) taught ICPS to parents of 3 children with ADHD (12. ??, problem-solving skills and behavior may be improved through the use of ICPS strategies. It is important to recognize that children with ADHD trained in ICPS might learn how to find alternative ways to express their anger, handle anger, and to recognize consequences of their behavior. However, the above mentioned improvement in social and emotional adjustment lasted 4 years after training ended ( 40 ). In another study ( 10 ), also with single subject design, ICPS was conducted to teach 8 children with ADHD who already had been maintaining treatment with psychostimulant drug. While the researcher was teaching ICPS to 8 children with ADHD at an observation class, their mothers observed the ICPS lessons. The mothers applied the learned strategies to their children and used the ICPS dialogs during problem-solving process at home in real-life situations. It was suggested that ICPS program may make an additional contribution into the children treated with a psychostimulant medication to deal with their problems. In parallel with the emphasized idea of the studies ( 12 , 40 ), our data have shown that both ADHD related symptoms and non-ADHD related symptoms were observed to decrease through the use of ICPS strategies.

It was proposed that children with ADHD would need help in learning those skills and the training should be provided in a controlled setting, although normal children might easily learn problem solving skills ( 15 ). Aberson et al. ( 40 ) emphasized that, such initiatives, if applied under special circumstances, could have significant effects on problematic behaviors in children with ADHD. These special conditions were meant for parents to teach their children the skills, and to implement ICPS childrearing techniques altogether; the child learns to internalize the newly acquired skills, and to adapt them to real life. Children with ADHD may need help to generalize and internalize these skills because they could have difficulty to adaptation these skills for a changing environment and generalizing to conditions in real life. In addition, because, rehearsals through games could complement these techniques, during our study, drama and envisaging techniques were used in order to enhance and generalize the acquired skills.

The limitations of this study include: small sample size and the absence of a control group. Other significant limitations of the study could be regarded as not making a comparison with other treatment modalities and, the grading scales used were based on declaration rather than being objective. The present study was planned in a pre-posttest quasi-experimental design with one group. Further research comparing ICPS with other treatment modalities and different factors are needed.

Conclusions

ICPS training based on Interpersonal Problem Solving skills may reduce the level of problems in behaviors of children with ADHD and increase the quality of interpersonal communications. Although American Pediatrics Academy ( 41 ) stated that, psychosocial interventions were found to be effective in treating mild and moderate symptoms of such cases as in the ADHD treatment guidebook published, there is not sufficient evidence for this treatment to be applied alone. Hence, integrated and multimodal treatment approaches may be more convenient hypotheses. ICPS training is relatively easy to learn and to utilize in school settings, and may be conveniently used by most disciplines working with children. Consequently, it is thought that, the ICPS is beneficial training for children with ADHD in order to modify problematic behaviors that interfere with quality of learning, socialization and overall quality of life.

Process of the study

Conflict of interest: The authors reported no conflict of interest related to this article.

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Common Deficits With Learning Disabilities in Math

• Applied Math

Behavioral Problems

• If Your Child Is Struggling

Identifying specific skill deficits is the first step educators take when they attempt to design appropriate instruction for a child diagnosed with learning disabilities in basic math or applied math.

Special education teachers typically use  standardized diagnostic assessment , observations, and analysis of student work to identify specific areas of weakness. Teachers then develop instruction and select appropriate strategies.

Are you concerned that your child might have a learning disability in math? Speak with your child's teacher, principal or school counselor if she has any of the signs of math learning disabilities covered in this review.

Learning Disabilities in Basic Math

Children with learning disabilities in math may have difficulty with remembering math facts, steps in problem-solving, complex rules, and formulas. They may struggle to understand the meaning of math facts, operations, and formulas.

Such children also tend to struggle to solve problems quickly and efficiently or focus attention on details and accuracy. They might have difficulty mentally computing answers and fail to understand math terms.

Learning Disabilities in Applied Math

Students with a learning disability in applied math, in particular, may fail to understand why problem-solving steps are needed and how rules and formulas affect numbers and the problem-solving process.

They may get lost in the problem-solving process and find themselves unable to apply math skills in new problem-solving situations.

Remembering and following multi-step instructions may prove especially challenging for these children. In some cases, they might make errors while problem-solving due to poor handwriting. They may also be unable to make logical leaps in problem-solving based on previous learning or experience the inability to find the important information in a word problem. Choosing the right problem-solving strategy to correctly solve word problems will stump these children as well.

While their peers may be able to to find errors in their own work or to identify mistakes they made in solving the problem, children with learning disabilities in applied math will find it impossible or painstaking to do so.

Parents and teachers may notice the student's struggles while assessing his work or may hear him directly mentioning such problems.

Some students with learning disabilities in math may act out to avoid doing math work.

If a normally well-behaved child is acting out in math class, a learning disability may be the cause.

Some students with disabilities won't act out but will avoid math class by feigning sickness or withdrawing from the teacher or their peers in class.

What to Do If Your Child Is Struggling

When you observe these problems in your child's work, share the information with his teachers to help develop appropriate instructional strategies that target your child's specific needs. You can also ask your child where he feels he struggles most with math and request that he be evaluated.

If you suspect that your child has a learning disability in either basic or applied math, consult a school faculty member at once. Remember that early intervention is key. Rather than ignoring the problem, it's best to address it immediately to prevent it from taking a toll on your child's grades and self-esteem.

By Ann Logsdon Ann Logsdon is a school psychologist specializing in helping parents and teachers support students with a range of educational and developmental disabilities. 

Math Learning Disabilities: Symptoms, Causes, Treatment

• Dyscalculia and Math Difficulties
• Susan du Plessis
• August 6, 2023

Math is an unavoidable and required knowledge. Whether in science, business, or daily living, we cannot escape the use of numbers. Every job, from the rocket scientist to the sheepherder, requires math! Math is needed no matter the country you live in or the language you speak. The effects of math failure can seriously handicap both daily living and vocational prospects. It may shut the door on a student’s occupational dreams and undermine their aspirations to be president, a doctor, or an engineer.

Table of contents:, what is a math learning disability, why does numeracy matter, how common are math learning disabilities, what are the symptoms of math learning disabilities, what causes math learning disabilities, what is the best treatment for math learning disabilities.

The definition of a math learning disability includes well below average mathematical academic performance for a person ’ s age that is not attributable to an intellectual disability (which is defined by IQ below 70). The DSM-5 ( American Psychiatric Association, 2013 ) uses the term ‘Specific Learning Disorder with impairment in mathematics.’

The term dyscalculia , which means inability to calculate, is commonly used to describe math learning disabilities. Other terms include developmental dyscalculia, mathematical learning difficulty, arithmetic learning disability, number fact disorder, math dyslexia, and number dyslexia.

Mathematics is integral to our lives, from basic trading at a market stall in Marrakesh or Beijing to the complex algorithms that guide international banking. Math is utilized to work out the time of a journey to see a friend in a nearby town, to the time it takes a sub-atomic particle to travel around CERN’s Large Hadron Collider. We use math when planning a holiday, deciding on a mortgage, or decorating a room. Good numeracy is essential to us as parents helping our children learn, as patients understanding health information, and as citizens making sense of statistics and economic news.

The effects of math failure during the years of schooling, as well as math illiteracy in adult life, can seriously handicap both daily living and vocational prospects.

Low numeracy is a substantial financial cost to governments and a personal cost to individuals. A large UK cohort study found that low numeracy was more of a handicap for an individual’s life chances than low literacy: They earn less, spend less, are more likely to be sick, are more likely to be in trouble with the law, and need more help in school ( Parsons & Bynner, 2005 ).

Research by economists, led by Pro Bono Economics , reveals the damaging impact of poor numeracy on the UK economy. Their report estimates the cost of outcomes associated with low levels of adult numeracy at around £20.2 billion per year, or about 1.3 percent of the UK’s GDP.

In the US, individuals with the lowest literacy and numeracy levels have a higher unemployment rate and earn lower wages than the national average. Low literacy costs the US at least $225 billion each year in non-productivity in the workforce, crime, and loss of tax revenue due to unemployment.

Math learning disabilities can lead to social isolation due to an inability to be at the right place at the right time or to understand the rules and scoring systems of games and sports. In addition, some adults with dyscalculia never learn to drive because of the numerical demands of driving ( Hornigold, 2015 ).

Despite the importance of numeracy, math learning disabilities have received little attention, and the general public’s familiarity with it as a problem is relatively low. For example, between 2000 and 2010, the NIH spent $107.2 million funding dyslexia research but only $2.3 million on dyscalculia ( Butterworth et al., 2011 ).

Among students classified as learning disabled, math difficulties are as prevalent as reading difficulties. According to McLeod and Crump , about one-half of students with learning disabilities require supplemental work in mathematics.

Symptoms include:

• The most generally agreed-upon feature of children with dyscalculia is difficulty learning and remembering arithmetic facts.
• The second feature of children with dyscalculia is difficulty executing calculation procedures, with immature problem-solving strategies, long solution times, and high error rates.
• Poor number sense is a core deficit. Number sense refers to a person’s ability to use and understand numbers. For example, they cannot see that 29 + 30 + 31 is the same as 3 x 30.
• An inability to subitize (perceive without counting) even very small quantities. Most people can subitize up to six or seven objects. Children with math learning disabilities may find this very hard and may need to count even small numbers of objects. If, for example, they are presented with two objects, they may count them rather than just knowing there are two.
• Poor understanding of the signs +, -, ÷, and x; may confuse these mathematical symbols.
• Difficulty with addition, subtraction, multiplication, and division or may find it challenging to understand the words “plus,” “add,” and “add-together.”
• Poor mental arithmetic skills.
• An inability to estimate whether a numerical answer is reasonable.
• Immature strategies such as counting all instead of counting on. The child may work out 137 + 78 by drawing 137 dots and then 78 dots and then counting them all.
• They may have trouble even with a calculator due to difficulties in the process of feeding in variables.
• Inability to notice patterns. The world of math is full of patterns, and the ability to see, predict and continue patterns is a key math skill. For example, take the sequence of the 5 x table: 5, 10, 15, 20, 25, et cetera. This is a clear pattern, but a student with math learning disabilities may not spot it readily.
• An inability to generalize. The ability to generalize makes life so much simpler in math, but a student with math learning disabilities may find this very hard. For example, they might not see that knowing that 3 + 4 = 7 means they also know that 30 + 40 = 70, or even that 3 inches + 4 inches = 7 inches.
• Children with math learning disabilities may experience directional confusion, i.e., have difficulty discriminating left from right, and north, south, east, and west. They may have a poor memory for remembering learned navigational concepts: starboard and port, longitude and latitude, horizontal and vertical, and so on.
• They may reverse or transpose numbers, for example, 63 for 36 or 785 for 875.
• Children with math learning disabilities may encounter problems with numbers associated with the measurement of time, for example, one day is equal to 24 hours.
• They may struggle to read a digital and analog clock.
• They may have difficulty with time management, be unable to recall schedules and sequences of past or future events, be unable to keep track of time, and be chronically late. They may be unable to memorize sequences of historical facts and dates; historical timelines may be vague.
• They may have difficulty with everyday tasks like checking change.
• They may have difficulty keeping scores during games.
• They may be unable to grasp and remember mathematical concepts, rules, formulae, and sequences.

Three key factors may influence dyscalculic students’ acquisition of numeracy and later mathematics. These are (1.) cognitive skills, (2.) mathematical language and skills, and (3.) the affective domain, especially anxiety.

Cognitive skills

Research has shown that math’s most important foundational skills are perception, memory, and logical reasoning (which makes problem-solving possible).

Mercer and Pullen (2008) identified three basic problem areas in the perceptual field that affect performance in mathematics: figure-ground differentiation, discrimination, and spatial orientation.

• Figure-ground problems may cause difficulties in keeping individual problems separate from each other. As a result, the student may lose their place on a worksheet, confuse problem numbers with digits in the problem itself, or not finish the problem.
• Visual discrimination problems tend to cause inversions in number recognition, confusion among coins, confusion among operation symbols, confusion between the hands of the clock, and the like.
• Auditory discrimination problems cause confusion in oral counting and among endings of number words, such as /fourteen/, /forty/, et cetera.
• Spatial problems may cause reversals and affect the ability to write problems horizontally or vertically, to understand before-after concepts, to understand the importance of directionality which, in turn, could affect regrouping, and to align rows of numbers with varying digits. Additionally, the child may have problems putting decimals in the right place, using the number line, understanding positive and negative integers, et cetera. Also affected are the ability to tell time, to understand geometry, and any other mathematical concepts related to spatial and temporal orientations and relationships.

Students with math learning disabilities may encounter difficulties with s hort-term memory ,  long-term memory ,  working memory , and  visual memory . They may find it challenging to begin a given task because they cannot remember the instructions or need help recalling what they must do to see it through.

Several studies have shown that children with mathematical difficulties underperform on tests of various aspects of working memory, while visual memory may also be problematic for dyscalculic learners. Long-term memory related to mathematical information also plays a key role in learning and remembering important mathematical facts such as simple addition (e.g., 5 + 4) and multiplication facts (e.g., 5 x 4).

Szűcs and team (2013) set out to compare various potential theories of dyscalculia in more than a thousand 9-year-old children. The researchers found that children with dyscalculia showed poor visuospatial memory performance. For example, they performed poorly when they had to remember the locations of items in a spatial grid.

Since problem-solving involves numerous cognitive and linguistic processes, the ability to reason logically is at the heart of mathematics.

Mathematical language and skills

Mathematics has its own language. Mathematics comprises unique words and symbols. From a very young age, children are presented with mathematical terms such as “before,” “after,” “equals,” “more,” and “less.” Moreover, they encounter symbols of which they must learn the meaning, such as +, -,  and x. Another key difficulty of math language is found when students with math learning disabilities are asked to tackle word problems.

There are also many things in mathematics that the student must learn  to do , such as counting, adding and subtracting, multiplication and division, applying place value and fractions, and reading time.

Math anxiety

Math anxiety is an adverse reaction to math associated with negative emotions. Ashcraft and Faust  (1994) define math anxiety as a feeling of tension, helplessness, mental disorganization, and dread produced when one is required to manipulate numbers or solve mathematical problems.

Mathematical tasks can cause high anxiety levels, particularly in mathematics, rather than any other given challenging activity. Ashcraft and Faust found that high math anxious subjects were quite willing to sacrifice accuracy in order to maintain or improve speed. In addition, children with dyscalculia may experience intense fear, which may cause an inability to learn math concepts and skills or perform well on math tests.

It should also be noted that learning is a stratified process . Certain skills have to be mastered first, before it becomes possible to master subsequent skills.

To be a basketball player, a person must  first  master the foundational skills, e.g., passing, dribbling, defense, and shooting. In the same way, to do math, a child  must first  learn foundational math skills like visual perception and visual memory.

The second step would be to ensure that a student catches up on mathematical language and skills, which must be done sequentially. One has to learn to count before it becomes possible to learn to add and subtract. Suppose one tried to teach a child, who had not yet learned to count, to add and subtract. This would be quite impossible, and no amount of effort would ever succeed in teaching the child these skills. The child must learn to count first, before it becomes possible for him to learn to add and subtract.

Edublox offers help to students with mild to severe math learning disabilities. Our math help consists of the following:

• Developing foundational math skills such as visual and auditory processing; visual, sequential, and working memory; and reasoning.
• Teaching math skills  sequentially , such as counting and skip counting, adding and subtracting, multiplication and division, applying place value, fractions, understanding money, reading time, et cetera.
• Teaching an in-depth understanding of math terminology.

Watch our playlist below and book a free consultation  to discuss your child’s math learning needs.

Key takeaways

. Bibliography:

Butterworth, B., & Yeo, D. (2004). Dyscalculia guidance: helping pupils with specific learning difficulties in maths. London: Fulton Publishers.

Chinn, S. J. (2004). The trouble with maths: a practical guide to helping learners with numeracy difficulties. London: Routledge Falmer.

Cockcroft, W. (1982). Mathematics counts. London: HMSO.

Faust, M. W., Ashcraft, M. H., & Fleck, D. E. (1996). Mathematics anxiety effects in simple and complex addition. Mathematical Cognition, 2, (1) , 25-62.

Price, G., & Ansari, D. (2013). Dyscalculia: Characteristics, causes, and treatments.  Numeracy ,  6 (1).

Rosselli, M., Matute, E., Pinto, N., & Ardila, A. (2006). Memory abilities in children with subtypes of dyscalculia. Developmental Neuropsychology 30, (3), 801-818.

Rubinsten, O., & Tannock, R. (2010). Mathematics anxiety in children with developmental dyscalculia.  Behavioral and Brain Functions    6 , 46. 

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What is a Cognitive-Communication Disorder?

 7 min read

Cognitive-communication disorders are problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit.

A cognitive-communication disorder results from impaired functioning of one or more cognitive processes, including the following:

• Attention (selective concentration)
• Memory (recall of facts, procedures, and past & future events)
• Perception (interpretation of sensory information)
• Insight & judgment (understanding one’s own limitations & what they mean)
• Organization (arranging ideas in a useful order)
• Orientation (knowing where, when, & who you are, as well as why you’re there)
• Language (words for communication)
• Processing speed (quick thinking & understanding)
• Problem-solving (finding solutions to obstacles)
• Reasoning (logically thinking through situations)
• Executive functioning (making a plan, acting it out, evaluating success, & adjusting)
• Metacognition (thinking about how you think)

These cognitive processes are not isolated abilities. They work together. A problem with one or more cognitive functions can cause  difficulty performing activities of daily living safely & efficiently as well as communicating effectively . An evaluation by a speech-language pathologist can determine where impairments exist & how to treat them.

A person with a cognitive-communication disorder may have difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions.

Cognitive-communication disorders vary in severity. Someone with a mild deficit may simply have difficulty concentrating in a loud environment, whereas a person with a more severe impairment may be unable to communicate at all.

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What Causes Cognitive-Communication Disorders

Since cognitive processes are controlled by many cortical and subcortical structures within the brain, any damage to the brain can cause a cognitive-communication disorder.

Thirty-five to 44 percent of stroke survivors find themselves with cognitive impairments 3 months after their strokes. About a third of these people experience long-term cognitive problems. They are most common after a right hemisphere stroke – one that affects the left side of the body.

A cognitive-communication disorder can also result from a  traumatic brain injury (TBI) , a brain infection, a brain tumor, or a degenerative disease such as multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, or another form of dementia.

Cognitive-communication disorders can occur alone or in combination with other conditions, such as  dysarthria  (slurred speech),  apraxia  (inability to move the face and tongue muscles correctly to form words), or  aphasia  (impaired language).

How Cognitive-Communication Disorders Are Identified

Anyone who has suffered a brain injury or a stroke should be screened for cognitive and perceptual disorders. Cognitive-communication disorders can be identified using the  Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) , a free online screening tool. Once cognitive-communication disorders are identified, a referral should be made to the speech-language pathologist for a full assessment.

An assessment is likely to include several tools (both formal and informal), including some of the following:

• Montreal Cognitive Assessment (MoCA)
• Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI)
• Cognitive Linguistic Quick Test (CLQT)
• Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)
• Assessment of Language-Related Functional Activities (ALFA)

After assessing the client, the speech-language pathologist prepares a personalized treatment plan, targeting goals to meet the client’s functional needs.

If a person can’t speak, it’s important to determine whether the problem is aphasia or a cognitive-communication deficit. Most standardized tests for cognitive functioning use language. People with aphasia, however, have trouble generating and/or understanding speech. They should therefore be assessed with nonverbal measures (both formal and informal), which may include the following:

• Raven’s Progressive Matrices (RPM)
• Test of Nonverbal Intelligence (TONI)
• Butt Nonverbal Reasoning Test (BNVR)

People with aphasia are likely to have difficulty with cognitive processes such as attention, short-term memory, working memory, declarative memory, and executive functioning.

What You Might Notice

People with cognitive-communication disorders often have trouble participating in conversations. They may have difficulty understanding what is said, or be unable to respond in a timely fashion. They may have trouble speaking clearly, or conveying their thoughts efficiently and effectively.

Someone with a cognitive-communication disorder may have trouble reasoning and making decisions while communicating. They may have trouble remembering their conversations and experiences.

People with cognitive-communication disorders sometimes have trouble responding in an appropriate or a socially acceptable manner. They often lack filters, expressing their sexual thoughts and speaking without regard for the feelings of others.

In addition to conversational problems, those with cognitive-communication disorders may find it hard to understand instructions, presentations, movies, television, and radio.

Some have trouble reading and/or writing. This can make it hard for them to complete job tasks and schoolwork, participate in their communities, or simply enjoy books, magazines, newspapers, and online media.

Treating Cognitive-Communication Disorders

People with cognitive-communication disorders often benefit from assessment and personalized treatment by a speech-language pathologist, since each case is unique.

Therapy may include a combination of techniques. The three main goals are to restore function, compensate for deficits, and educate the client and family about the disorder and its treatment.

Techniques for restoring the client’s previous level of functioning include the following:

• Using exercises or software to retrain discrete cognitive processes such as attention
• Using internal memory strategies or  spaced retrieval training  to solidify memories
• Completing practice tasks that are difficult, while offering support, to build independence

Techniques designed to compensate for the client’s cognitive-communication deficits include:

• Using external strategies for improving memory (e.g. memory books, smartphone apps)
• Teaching strategies for approaching problems to strengthen executive functioning (e.g. “plan, do, review”)
• Establishing routines and schedules

Techniques for educating the client and his or her family include the following:

• Using video or audio recordings to make the client and his or her family aware of what the deficit looks and sounds like
• Discussing the assessment results with the client and his or her family
• Problem-solving around errors as they occur
• Providing group therapy for the client and his or her family, including a discussion of the client’s deficits and group practice of the treatment strategies
• Teaching family members and caregivers to recognize and help the client overcome his or her deficits

If You Have a Cognitive-Communication Disorder

There are many things you can do to help yourself if you are a brain injury survivor or find that your mental skills are not as sharp as they used to be. You may need to try a few things before finding the tips and tricks that will work best for you, since everyone is different. Try some of these things:

• If you have memory problems, be sure to write down all your appointments, lists, and important notes in a calendar or digital organizer and always keep it in the same place.
• If you have attention problems, set yourself up for success by limiting background noise or keep a consistent background noise if you find it helps you to focus.
• If you have problems with executive functioning, make a detailed plan, use checklists, and check-in along the way to make sure you’re on track with timing.
• Talk with other people who have similar challenges to learn from their experience. If you have a mild brain injury (the kind that doesn’t feel mild at all, but the doctors keep telling you it is), you may enjoy reading the book  Over My Head  by Claudia Osborn .
• Check out this helpful website with information about right hemisphere disorder, or cognitive-communication issues after a right-sided stroke.

6 Ways to Help Someone with a Cognitive-Communication Disorder

A person with a cognitive-communication deficit can benefit a great deal from therapy. Meanwhile, you can help the person communicate by taking a few simple actions:

• Allow the person extra time to process what you’ve said. Try waiting for up to 90 seconds before repeating yourself.
• Provide information in short chunks. If you’re giving directions, break them down into small steps. Instead of saying, “Brush your teeth,” try saying, “Go to the sink . . . Take out your toothbrush . . . Put toothpaste on the toothbrush . . . ” and so on.
• If the person has  left neglect , provide a challenge by standing to the person’s left. For an important conversation, however, sit on the person’s right side.
• Write down key instructions and information, or encourage the person to write it down themselves.
• Verify any important information the person gives you with a third party, to be sure it’s reliable. People with memory deficits or insight problems may not be accurate communicators, even if their speech sounds good.
• Speak simply. Don’t talk too loudly, though, and don’t talk down to the person.

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Megan S. Sutton , MS, CCC-SLP is a speech-language pathologist and co-founder of Tactus Therapy. She is an international speaker, writer, and educator on the use of technology in adult medical speech therapy. Megan believes that technology plays a critical role in improving aphasia outcomes and humanizing clinical services.

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More in ‘ What Is ’

What is the Communication Problem?

Learn about the 4 types of acquired communication disorders that may affect the way a stroke survivor speaks. Find out what you can do once you understand what's happening.

 4 min read

What is Brain Injury?

Damage to the brain can result in problems in every area of life. Learn more about the types, causes, and effects of brain injury, as well as how SLPs can help to recover function.

 6 min read

What is Dysphagia?

Dysphagia means difficulty swallowing. Learn more about the causes, symptoms, diagnosis, and treatment of dysphagia for people with swallowing disorders.

What is a Stroke?

Find out the types, causes, how to prevent a stroke, how to spot one happening, and what happens afterwards as survivors try to recover through rehabilitation.

What is Dysarthria?

Dysarthria, or slurred speech, is common after stroke or in neurological disorders like Parkinson's. Find out what dysarthria is, how to help, & what to do.

What is Apraxia?

Apraxia of speech is common after a stroke, leaving the patient with impaired communication. Find out what this acquired disorder is all about & what to do.

What is Primary Progressive Aphasia?

PPA is a type of dementia that gradually impairs the ability to use language over time. Learn what it is, how it is diagnosed & treated, and what you can do to help.

What is Global Aphasia?

Global aphasia is the most severe and devastating type of aphasia. Learn what it is and how you can better communicate with a person who has global aphasia.

What is Fluent Aphasia?

Fluent aphasia is a disorder with effortless but largely meaningless speech. Learn what it is, see a video, and find out how to help Wernicke's-type aphasia.

What is Broca’s Aphasia?

Learn what Broca's aphasia is, see a video of what it sounds like, and find out how to help a person with the frustrating condition of expressive or non-fluent aphasia.

What is Aphasia?

Aphasia is a language disorder after a stroke. Learn what causes it, what you can do when you meet a person with aphasia, and how it can vary.

What is Left Neglect?

A step-by-step guide to visual scanning treatment, an evidence-based cognitive therapy technique to improve visual attention for right or left neglect.

 8 min read

Problem-solving deficits and depressive symptoms among children

• PMID: 6655149
• DOI: 10.1007/BF00917078

Depressive symptoms among 40 fourth- and fifth-grade students as measured by the Children's Depression Inventory, correlated highly with impaired problem solving at block designs (r = .64) and anagrams (r = .67). Similar impairments have been found among depressed adults, suggesting that depression among children may be continuous with depression among adults.

Publication types

• Research Support, U.S. Gov't, P.H.S.
• Cognition Disorders / psychology
• Depressive Disorder / psychology*
• Problem Solving*
• Psychological Tests
• Psychometrics

Grants and funding

• MH-19604/MH/NIMH NIH HHS/United States

Behavior Management: Getting to the Bottom of Social Skills Deficits

When someone mentions behavior management, our first thought may be about controlling students or stopping them from performing inappropriate behaviors. We expend a great deal of energy managing students so that inappropriate behaviors will not occur. However, successful termination of inappropriate behavior is no guarantee that appropriate behavior will take its place. One of the most puzzling and frustrating problems encountered by parents and teachers of students with learning disabilities (LD) is not the student who obviously acts out or engages in overtly antisocial behaviors, but rather the one who simply fails to perform the appropriate behavior for a given circumstance or setting. This problem is frequently labeled a social skill deficit (Gresham & Elliott, 1 989).

Students with LD may exhibit social skill deficits that are either skill-based or performance-based. In other words, either the skill may not be in the student’s repertoire or the student may have acquired the skill but it is not performed at an acceptable level. Effective intervention requires identification and remediation of the specific type of deficit exhibited by the student. This article will delineate the differences between skill-based and performance-based social skills deficits and present intervention approaches in each area.

Skill-based deficits

A skill-based deficit exists when a student has not learned how to perform a given behavior. For example, a student who has not learned to do long division could be said to have a long division skill deficit. Similarly, a student who hasn’t mastered the skill of greeting others appropriately may have a skill deficit in that area. Few parents or teachers would punish a student for not knowing how to do long division. Unfortunately, however, we sometimes become angry with students when they don’t demonstrate the social skill we d desire them to display. Reprimands and loss of privileges are common reactions. A critical issue is whether the student actually possesses the desired skill. If not, it is unreasonable to demand that it occur or scold the student if it doesn’t. Our anger and punishment can only add to the frustration of the student who knows he or she did something wrong, but has no clue as to how to fix it.

We may determine if a student has a skill deficit by observing whether the desired skill has ever been performed. If not, one may hypothesize that the skill is not in the student’s repertoire. This may be tested further by providing strong incentives to perform the desired behavior. If the student fails to perform under these conditions, it is likely that the problem stems from a skill deficiency. The bottom line: don’t scold or reprimand the student for having a skill based deficit; instead, teach the skill.

Teaching social skills

Generally, a skill-based deficit is due to lack of opportunity to learn or limited models of appropriate behavior (Gresham & Elliott, 1989). Even given the opportunity to learn and the appropriate model, students with LD may not learn these skills incidentally or intuitively. In these instances, direct instruction , or skill training, is necessary. The same principles apply to teaching social skills as to academic skills: provide ample demonstration/modeling, guided practice with feedback, and independent prac tice.

Hazel, Schumaker, Sherman, and SheldonWildgen (1981) listed eight fundamental social skills which can be taught through direct instruction:

• Giving positive feedback (e.g., thanking and giving compliments),
• Giving negative feedback (e.g., giving criticism or correction),
• Accepting negative feedback without hostility or inappropriate reactions,
• Resisting peer pressure to participate in delinquent behavior,
• Solving personal problems,
• Negotiating mutually acceptable solutions to problems,
• Following instructions, and
• Initiating and maintaining a conversation.

They recommended teaching these skills by providing definitions, illustrations with examples, modeling, verbal rehearsal, behavioral rehearsal, and additional practice.

Similarly, Walker, Colvin, and Ramsey (1995) recommended a nine step direct instructional procedure, the ACCEPTS instructional sequence. The steps include:

• Definition of the skill with guided discussion of examples,
• Modeling or video presentation of the skill being correctly applied,
• Modeling or video presentation of incorrect application (non example),
• Modeling or video presentation of a second example with debriefing,
• Modeling a range of examples, coupled with hypothetical practice situations,
• Modeling or video presentation of another positive example if needed,
• Role playing, and
• Informal commitment from student to try the skill in a natural setting.

In summary, students with LD who have not acquired social skills are not likely to learn casually or incidentally. Intervention for skill-based deficits should focus on direct instruction of the skill. Effective instructional methods include demonstration/modeling with guided practice and feedback.

Performance-based deficits

A performance-based deficit exists when the student possesses a skill but doesn’t perform it under the desired circumstances. This may occur if there is a problem with either motivation or with ability to discriminate as to when to exhibit the appropriate behavior.

Motivational deficit

When a motivational deficit exists, the student possesses the appropriate skill, but doesn’t desire to perform it. A motivational deficit may be hypothesized if observations reveal that the student has acquired the desired skill, but motivational conditions are not sufficiently strong to elicit it. The hypothesis may be confirmed if the student performs the behavior following introduction of a motivational strategy. For example, in the area of conversation skills, we may suspect that a student is capable of interpreting cues from peers that indicate that it is someone else’s turn to talk, but instead chooses to interrupt. This theory may be verified if the student waits to speak when rewarded for taking turns. The student could then be considered to have a motivational deficit. In situations such as this, behavioral interventions are effective.

Motivational strategies

Parents and teachers of students with motivational deficits can manipulate contingencies that will encourage performance of prosocial behaviors by using the principles of Applied Behavior Analysis (ABA). The steps include defining the target behavior operationally, identifying antecedents and consequences related to the behavior, and finally developing and carrying out a plan to alter the antecedents and consequences so that the desired behavior will occur. For example, the behavior of “interrupting” may be defined as “speaking before your partner has completed his or her sentence.” The antecedents to this behavior may be poor models and the consequence to interrupting may be attention from the listener. The next step is to develop a plan which encourages turn taking during conversations. An antecedent technique may be to remind the student about taking turns prior to a conversation and a consequence may be to pay attention only when the student waits his or her turn prior to speaking. Good school/home communication and collaboration can ensure consistency of carrying out the plan in both settings.

Most students of ABA who have succeeded at a self-improvement program such as a diet or exercise regime will confirm that the principles of ABA can be effectively used on oneself. Bos and Vaughn (1995) postulated that these same principles can be taught to adolescents so that they can implement a self-management program. The adolescent with LD would first learn to identify the behavior he or she wants to change, then identify the antecedents and consequences connected to the behavior, and, finally, develop an intervention which alters the antecedents and provides consequences that will maintain the desired behavior. A further suggestion would be to have the adolescent chart his or her progress toward a self-selected reward. To summarize, once identified, motivational deficits can be remediated using behavior management techniques, either by the adult in the situation, or by the student in question.

Discrimination deficit

A student with a discrimination deficit has the desired skill in his or her repertoire, is motivated to behave properly, but can’t discriminate, (i.e., doesn’t know when to exhibit the desired behavior). A discrimination deficit may be confirmed if the student frequently performs the desired behavior, but fails to perform it under specific conditions. This may be due to an inability to glean relevant information from social situations. When a discrimination deficit exists, the student possesses the desired behavior but may not be sure as to when, where, and how much to engage in that behavior.

Bryan (1991) reviewed research on social competence of students with LD. Most studies found that students with LD had poorer social cognition than non-disabled or low achieving students. A deficit in social cognition may be apparent in a student who is oblivious to social cues or who lacks understanding of the social demands of a situation (Bryan, 1994).

The hidden curriculum

Given the same information as everyone else, students with LD may not demonstrate appropriate social skills because they do not understand the hidden curriculum ascertained by more socially adept student. Lavoie (1994) suggested assessment of the student’s knowledge of the hidden curriculum as a step in teaching the student to discriminate the appropriate behavior for a given situation.

The first step is to determine the hidden curriculum, or culture, pertaining to the school the student attends. For example, what extracurricular activities are viewed by others as important? What are the hidden rules governing social functions? What is the administrative framework? Which teachers emphasize completion of daily assignments, punctuality, and/or class participation? This information can be obtained from teachers, support staff, and school publications such as the yearbook or school newsletter.

Once the hidden curriculum is identified, the next step is to assess the student’s knowledge in key areas. There are many things which we may take for granted about which the student may be embarrassed or incapable of obtaining an explanation. Specifically, the following questions should be answered:

• Does the student understand how the schedule works?
• Does the student know how to get from one place to another in the school building,
• Is the student aware of the requirements for participation in extracurricular activities, including deadlines and eligibility procedures?
• Can the student identify the social cliques?
• Can the student identify support staff (e.g., the school nurse, the guidance counselor)? Does he or she know how to gain access to their services?

In short, the hidden curriculum must first be identified and then the student’s level of understanding of it must be assessed. Only then can information be provided to the student to fill in the gaps.

Teaching discrimination

A common characteristic of students with LD is impulsivity, the tendency to act without considering the consequences or appropriateness of one’s behavior. This may be seen as an interfering behavior, which will be discussed in the following section. However, what on first glance appears to be impulsivity may in reality be an inability to understand the limits of acceptable behavior. Acceptability of behavior frequently varies according to the setting or circumstance. For example, a student may not know which teachers tolerate conversation and when it is appropriate to talk with peers. What is acceptable behavior on the playground may not be acceptable in the classroom.

According to Smith and Rivera (1993), “educators must help students learn to discriminate among the behavioral options in each school situation and match that situation with the proper behavior pattern” (p. 24). Some social skill problems occur simply because students do not understand how to read environmental cues that indicate whether or not a behavior is acceptable. In short, when there is a discrimination deficit, we must help the student size up the social situation and determine what to do. If the student cannot discriminate, we must teach what is acceptable in a given circumstance.

Lavoie (1994) introduced a problem solving approach to teaching discrimination called the social autopsy. A social autopsy is the examination or inspection of a social error in order to determine why it occurred and how to prevent it from occurring in the future. When a student makes an academic error, we provide the right answer and use the mistake as an opportunity to learn. I n other words, we teach the student how to “fix” the mistake. Similarly, Lavoie (1994) suggested that instead of punishing the student for making a social mistake, we should analyze it and use it as an opportunity to learn . The process involves asking the student, “What do you think you did wrong? What was your mistake?” By actively involving the student in discussion and analysis of the error, a lesson can be extracted from the situation which enables the student to see the cause effect relationship between his or her behavior and the consequences or reactions of others.

Underlying the social autopsy are the following principles:

• Teach all adults who have regular contact with the student to perform social autopsies. This includes family members, custodial staff, cafeteria workers, bus drivers, teachers, secretaries, and administrators. This will foster generalization by ensuring that the student participates in dozens of autopsies daily.
• Conduct social autopsies immediately after the error occurs. This will provide a direct and instantaneous opportunity to demonstrate the cause and effect of social behaviors.
• Use social autopsies to analyze socially correct behaviors as well as errors. This will provide reinforcement which may assist the student in repeating the appropriate behavior in another setting.
• Help students identify and classify their own feelings or emotions.

There are several advantages of this method: (a) It uses the sound learning principles of immediate feedback, drill and practice, and positive reinforcement; (b) It is constructive and supportive rather than negative or punishing; (c) It provides an opportunity for the active involvement of the student, rather than an adult controlled intervention; and (d) It generally involves one-on-one assistance to the student.

To summarize, limited awareness of the conventions of behavior and inability to decode the hidden curriculum and social cues contribute to deficits in discrimination of social skills. Interventions for students with these problems should be geared toward helping the student analyze the components of social situations so that discrimination can occur.

Self-control

This article has discussed the classification and remediation of social skills deficits. However, there is one problem that may inhibit success, even if we are able to classify successfully the student’s problem and design an appropriate intervention. Interfering or competing behaviors may interrupt the student’s ability to learn or demonstrate appropriate social skills. Such problems can contribute to both skill and performance deficits so that a student may have difficulty either learning a new skill or performing it when appropriate.

Common interferences experienced by students with LD are impulsivity (the tendency to act without considering consequences or to choose the first solution that comes to mind), distractibility (tendency to focus on minor details, to pay attention to everything), and perseveration (repetition of behavior due to inability to change motoric or verbal responses; inability to shift gears). Hyperactivity (excessive motor activity) can also interfere. Either a systematic behavioral approach or self-management techniques may be helpful, depending on the student, the situation, and the interfering behavior. For the distractible student, self-monitoring and charting of attention or work completed may be helpful. Students who are impulsive can learn problem solving strategies which force them to dissect problems and evaluate possible consequences. Bos and Vaughn (1994) recommended a strategy called FAST for this purpose.

The steps in FAST are:

• Freeze and think! What is the problem?
• Alternatives? What are my possible solutions?
• Solution evaluation. Choose the best solution: safe? fair?
• Try it! Slowly and carefully. Does it work (p.371)?

In conclusion, remediation must be directly related to the type of social skill deficit. If the student has a skill-based deficit, the appropriate intervention strategy is to teach the deficient skill. If motivation is a problem, behavioral interventions are appropriate. If the student has difficulty discriminating what is the acceptable behavior for a given circumstance, we must provide the information needed so that discrimination is possible and assist the student in analyzing positive social behaviors as well as social errors. Interfering behaviors must also be considered. Educators and parents can do much to alleviate social skills problems by discerning whether social skills deficits are skill based or performance based and designing interventions accordingly.

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Bos, C. S., & Vaughn, S. (1994). Strategies for teaching students with learning and behavior problem (3rd ed. ) . Needham Heights, MA: Allyn & Bacon.

Bryan, T. (1991). Assessment of social cognition: Review of research in learning disabilities. In H. L. Swanson (Ed.), Handbook on the Assessment of Learning Disabilities: Theory, Research, and Practice (pp. 285-311). Austin, TX: Proed.

Bryan, T. (1994). The social competence of students with learning disabilities over time: A response to Vaughn and Hogan. Journal of Learning Disabilities, 27, 304-308.

Gresham, F., & Elliott, S. (1989). Social skills deficits as a primary learning disability. Journal of Learning Disabilities, 22, 120-124.

Hazel, J. S., Schumaker, J. B., Sherman, J. A., & SheldonWildgen J. (1981). ASSET: A social skills program for adolescents. Champaign, ll: Research Press.

Lavoie, R. D. (1994). Learning disabilities and social skills with Richard Lavoie: Last one picked...First one picked on [Video and Teacher's Guide]. (Available from PBS Video, 1320 Braddock Place, Alexandria, VA 22314-1698).

Smith, D. D., & Rivera, D. M. (1993). Effective discipline (2nd ed.). Austin, TX: Proed.

Walker, H., Colvin, G., & Ramsey, E. (1995). Antisocial behavior in school: Strategies and best practices. Pacific Grove, CA: Brooks/Cole.

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6 facts about Americans’ views of government spending and the deficit

As President Joe Biden and congressional Republicans continue to negotiate on raising the U.S. debt ceiling , the public has nuanced views on related issues such as the preferred size of government, the amount of government assistance to the poor, and the priority of reducing the budget deficit. Here are six facts about Americans’ views of the government, spending and the deficit based on Pew Research Center surveys from this year.

Pew Research Center conducted this analysis to provide insight into the public’s views about the size of government and aspects of government spending and revenue as President Joe Biden and Congress continue negotiations around the debt ceiling. For this analysis, we included data from two surveys in 2023: one with 5,152 U.S. adults conducted Jan. 18-24 and the second with 5,079 U.S. adults conducted March 27-April 2.

Everyone who took part in these surveys is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here is the question from the Jan. 18-24 survey used in this analysis, along with responses, and its methodology . Here are materials for the questions on taxes and government size and role from the March 27-April 2 survey, along with its methodology .

The public remains split on what the government’s size should be. About half of Americans (49%) say they would rather have a bigger government providing more services, while a similar share (48%) would prefer a smaller government providing fewer services, according to a Center survey conducted March 27-April 2. These views have remained relatively stable since 2019. Democrats and Democratic-leaning independents are more than three times as likely as Republicans and Republican leaners to say they would prefer a bigger government (75% vs. 22%).

The public is also divided on the role of government. While 52% say government should be doing more to solve problems, 46% say government is doing too many things that would be better left to businesses and individuals. These attitudes are also deeply divided along partisan lines: While about three-quarters of Democrats (77%) say the government should do more to solve problems, a similar share of Republicans (75%) say the government is doing too many things.

Americans are more likely to want to increase than reduce the size of the U.S. military. About four-in-ten Americans (43%) say that the size of the U.S. military should be increased, compared with 17% who say it should be reduced; 38% say it should be kept about as is. The share of the public saying the military should expand has risen 6 percentage points since July 2021. Currently, military spending makes up about 12% of the overall federal budget but nearly half of so-called discretionary spending, which excludes entitlement programs such as Social Security and Medicare.

Republicans are far more likely than Democrats (62% vs. 27%) to favor increasing the size of the military. There also are age differences: Older adults are more supportive than younger adults when it comes to expanding the size of the military.

More Americans also favor increasing, rather than reducing, government aid to the poor. While 43% favor increasing aid to the poor, 26% say the government should provide less assistance, and 30% say the current level of aid is about right. Democrats are much more likely than Republicans to say the government should provide more assistance to those in need, but Republicans’ views vary by age and income. Younger and lower-income Republicans are more likely than older and higher-income Republicans to say that the government should provide more assistance to those in need.

Majorities favor raising taxes on large companies and high earners. About two-thirds of Americans (65%) say that tax rates on large businesses and corporations should be raised. A somewhat similar share (61%) support raising tax rates on household incomes over $400,000. On both questions, Democrats are much more likely than Republicans to say that tax rates should be increased.

Reducing the budget deficit is a higher priority for the public than it was last year. The share of the public saying that reducing the budget deficit should be a top priority for the president and Congress this year has increased by 12 points since 2022, according to a January 2023 Center survey . Today, 57% say that reducing the budget deficit should be a top priority, compared with 45% in 2022. Both Republicans and Democrats are more likely now than in 2022 to say this should be a top priority, but Republicans are still much more likely to prioritize this than Democrats are (71% vs. 44%).

Note: Here is the question from the Jan. 18-24 survey used in this analysis, along with responses, and its methodology . Here are materials for the questions on taxes and government size and role from the March 27-April 2 survey, along with its methodology .

• Government Spending & the Deficit
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What the data says about food stamps in the u.s., 5 facts about the u.s. national debt, how the political typology groups compare, biden loses ground with the public on issues, personal traits and job approval, most popular.

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I'm the superintendent of Ann Arbor schools. Fixing our budget shortfall will be painful. | Letters

Ann Arbor Public Schools is dedicated to providing world-class learning opportunities for our students, and keeping our families, staff, students and community informed about the financial challenges we face. 

With our nearly 91% graduation rate, amazing staff and students and supportive community, it is no surprise our district has been hailed as one of the best public school systems in the nation.  

That is why we are up to the challenge before us and appreciate the opportunity to detail the factors at play in our financial situation, as highlighted in a recent opinion piece in this newspaper . 

More on Ann Arbor schools budget crisis: Layoffs expected as Ann Arbor Public Schools must cut $25 million from budget

This past November, as part of our regular budget review and audit process, the prior superintendent made the Board of Education aware of a shortfall in our current school year budget. After being named interim superintendent, to thoroughly assess our financial picture, I authorized a comprehensive top-to-bottom review of school finances — and called in a third-party financial expert to ensure we have an accurate picture to proceed on solid footing.  

More on Ann Arbor schools budget crisis: Ann Arbor Public Schools is short $25 million. How did we get here?

As a result of that work, it was determined the district will need to reduce approximately $25 million from the 2024-25 operating budget to comply with State of Michigan and Ann Arbor Public Schools Board of Education requirements. This represents approximately a 10% reduction to our district’s overall budget of more than $300 million. Our team is committed to navigating these challenges while continuing to provide our students with a world-class education. 

Our budget challenges stem from three main historical factors:  

• Over the past four years, student enrollment has decreased by 1,123, which decreased the district’s revenue.  
• An increase in employees over the past decade.  
• Increases in operational costs. 

I worked with our district leaders to identify immediate actions we could take to reduce costs and begin planning long-term solutions to ensure this does not happen again. We know some of these steps will be painful.  

We are reducing central office and administrative staff positions, freezing hiring, conducting in-depth reviews of all central office, district and school budgets for efficiencies and cost savings and renegotiating contracts with vendors to identify cost savings on contracted services.   

This will not solve the shortfall on its own given the magnitude of the budget challenges we face.  

We know this has been a difficult process. We are committed to working together with staff and the AAPS community to ensure a comprehensive district budget plan is developed and implemented in a way that minimizes the impact on classrooms and student learning.  

To build a thoughtful plan that moves us forward in a fiscally responsible way, we are seeking feedback from our valued staff and community members. As we continue to gather this feedback, we are hosting a virtual town hall meeting on Monday, April 15, that will allow us to share information and answer questions. It will be online at 6:30 p.m. Monday at  access.live/annarborpublicschools . We also will host additional in-person venues for staff and community feedback and engagement.  

Throughout this process, our district leadership team has remained steadfast in its commitment to transparency and openness. Together we can, and will, get through this challenging situation as a district and community.  

Jazz Parks  

The writer is interim superintendent of the Ann Arbor Public Schools   

Submit a letter to the editor at freep.com/letters , and we may publish it online and in print.

Here's why economists are so worried about soaring US debt levels

• The government's soaring debt balance poses problems for the US economy.
• Those include higher inflation, greater market volatility, and a lower quality of life for Americans.
• Slowing the pace of borrowing is critical for the future, economists told Business Insider.

The US is sitting on the biggest pile of public debt in its history, and economists are getting nervous about it. 

The federal debt balance hit $34 trillion this year, with the government on pace to rack up another $1 trillion in debt every 100 days , per an estimate from Bank of America. 

Why is that so worrying?

The mountain of debt is a breeding ground for economic problems, including higher inflation, lower quality of life, and — in the worst-case scenario — a destabilization of the wider financial system, according to Les Rubin, a markets veteran who has called the US debt situation one of the "greatest Ponzi schemes" in the world.

It's critical for the US to sell its debt to investors, which range from institutions, individuals, and other countries. But higher debt levels cast doubt on whether the US will be able to make good on its promises to keep paying it back, and the more people hesitate to buy the US debt securities, the more the economy is hurt, Rubin says. 

The US Treasury sold $22 trillion in government bonds last year, but Treasury auctions recently have seen weak demand , suggesting that investors could soon have difficulty absorbing the huge rush of new bond issuance.

The most recent auctions of 10 and 30-year bonds were met with low enthusiasm as investors see higher for longer interest rates and stick inflation. The US will hit the market again in May with a $385 billion sale of new bonds.  

"What would happen if we can't sell the debt is that we end up with an inability to function as an economy. The government survives on debt. If we literally could not sell our debt, we could not pay our bills," Rubin told Business Insider in an interview.

Debt itself is inherently inflationary , meaning consumers can expect higher prices if the government doesn't slow its borrowing.

Related stories

That's because debt provides a measure of stimulus to the economy, which speeds up hiring and wage growth. If the economy is already at full employment, that means higher inflation as well, according to Jay Zagorsky, an economist at Boston University. 

Inflation has been at least a full percentage point above the Fed's 2% target for nearly the last two years. Prices accelerated 3.5% year-per-year in March, the third-straight month inflation came in hotter-than-expected.

A smaller budget

Higher debt could also lead to a poorer quality of life for Americans, Zagorsky added. That's because the more the debt grows, the more the government has to shell out in interest to service that debt — and the less money the US has to spend on other priorities like Social Security and other crucial parts of the social safety net. 

The US spent $429 billion last year on interest payments alone, according to Treasury data. That's 240% of what the government spent on transportation, commerce, and housing combined.

"Pretty soon one of the most important things the federal government's going to be spending money on is not defense, not on education. It won't be on housing, it'll be on interest," Zagorsky said.

Economic fallout

For investors to widely lose faith in US government debt as a safe haven would spark turmoil in financial markets, Rubin warned, thanks to the sheer amount of US debt held by institutions worldwide.

In the worst-case scenario, he sees markets melting down if debt levels get too high and people believe the US might not pay it back. 

"Trillions of dollars that are on the balance sheets around the world will become substantially reduced in value or worthless. Interest payments could be curtailed. It would be a devastating blow to the world economy that would lead to eventually, chaos. We can't let it get there," he said. 

There's little the government can do to stop those problems from brewing, other than to stop taking on so much new debt, Zagorsky and Rubin say. Technically, the government could print money to pay off its dues, but that would result in hyperinflation as the money supply skyrockets. 

Robust economic growth can make debt more sustainable, but the debt is growing way faster than the economy — the national debt balance rose 86% over the last decade, while GDP grew by 63%, according to Fed data.

Economists are uncertain of when exactly the national debt will become a true problem for the US. If the pace of borrowing doesn't slow, Rubin anticipates a crisis of some sort materializing within the next decade.

"It starts slowly and then it accelerates rapidly. Right now I don't think anything is imminent. I would say we have 10 years or less to fix this problem. I think that may be the optimistic scenario," Rubin said. 

Watch: What happens when the US debt reaches critical levels?

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Opinion | Why turn off lights for Earth Day when…

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Opinion | Why turn off lights for Earth Day when California is already growing dark?

Earth Day 2024 is today and Californians are being encouraged to turn off their lights. For now, it would be a voluntary exercise in futility. In a few years, though, maybe even this summer, the lights will go out on their own, as the grid becomes shakier while the state plunges into a dim future.

“Lights out” is primarily associated with Earth Hour, which usually arrives on the last Saturday in March. “Individuals from around the globe” are expected to turn “off their lights to show symbolic support for the planet and to raise awareness of the environmental issues affecting it.” Los Angeles has marked Earth Hour by turning off the lighted gateway pylons that lead to Los Angeles International Airport. City Hall, where critics would say the lights don’t shine too brightly anyway, has also flipped the switch. The 174,000 LED lights of the Pacific Wheel at the Santa Monica Pier, the only solar-powered Ferris wheel in the world, have turned off to “honor” Earth.

But Earth Day, which has been around since 1970, also has its own tribute to primitive living. Earth Day “tips” from local governments include turning off lights when leaving a room and unplugging electronics that aren’t in use. Schools observe Earth Day by disconnecting and shutting down technology.

How odd that rather than recognize the abundance of resources on Earth Day and Earth Hour, we are expected to celebrate what economist and American Enterprise Institute fellow Mark J. Perry calls “ ignorance/poverty/backwardness ,” and George Mason University economist Donald J. Boudreaux sees as “a collective effort to return humankind to the dark ages .”

While looking like North Korea for an hour here and part of a day there might be fashionable, there’s reason to believe that California is facing a future in which the lights will go out even when we don’t touch the switches. There’s an oncoming power crunch. It’s avoidable, but policymakers have nevertheless committed – and then recommitted – to it.

If California continues on its current path of closing gas-fired and nuclear power plants, falling behind in replacing lost energy with unreliable renewable sources, and outlawing sales of new fossil fuel-burning cars and light trucks in 2035, then it will be unable to produce enough electricity to meet demand. By 2045, when the grid is to be, by legislation, connected to only renewables such as solar and wind, there will be a 21.1% power deficit .

Based on historical consumption patterns and adjusted for the 22 million or so EVs that will be on the road in 2045, California will need ​​more than 336,000 gigawatt hours of electricity. However, the state will be producing only about 280,000 gigawatt hours unless it builds replacement capacity at a pace much faster than it has in recent history. And this doesn’t even consider the rising ​electricity needs caused by the state-required conversion of water heaters, stoves, and other appliances from natural gas to electricity.

But that’s merely the first chapter in a longer story. New players have entered the game, and the strain they will place on power production threatens “ the nation’s creaking power grid ,” the Washington Post reports. “Vast swaths of the United States are at risk of running short of power as electricity-hungry data centers and clean-technology factories proliferate around the country.”

Naturally California, along with Texas and Virginia, is a leading data-center hub. To grasp just how much more power will be required to operate the “ gold rush of AI” and other new artificial intelligence apps, consider Google. Based in Mountain View, Ca., Google alone will need, according to the International Electricity Agency, “a tenfold increase of their electricity demand in the case of fully implementing AI in it.”

Earth Day should not be a time for looking back but rather an occasion to congratulate ourselves for moving forward, solving the problem of darkness that took man quite a few millennia to solve.

Kerry Jackson is the William Clement Fellow in California Reform at the Pacific Research Institute

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