Learning Disorders

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Learning Disordersor Disabilitiesor Differences
Jess P. Shatkin, MD, MPH Vice Chair for
Education NYU Child Study Center New York
University School of Medicine
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Learning Objectives

• Residents will be able to
• Provide a legal definition of learning disorders.
• Describe how IQ and achievement tests are used in
  determining the presence of learning disorders,
  and draw the IQ bell curve.
• Identify the 3 primary learning disorders.
• Choose which neuropsychiatric tests are most
  appropriate for assessing educational level,
  visual/motor integration, adaptive skills level,
  memory, executive function, and thought content.
• Describe the differences between the 2 public
  laws which provide educational support for
  learning disordered children.

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Neuron Cell Migration

• The human brain develops through cell division
  and then cell migration
• Cell migration occurs when neurons develop and
  then travel through the brain to pre-programmed
  areas
• In most cases, cell migration proceeds in
  expected ways
• Sometimes, cell migration proceeds in an
  abnormal or atypical way

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Differences in Blood Flow
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Blood Flow Abnormalities
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Blood Flow Abnormalities (2)
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Remediation
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Diagnostic Features

• Diagnosed when an individuals achievement on
  individually administered, standardized tests in
  reading, math, or written expression is
  substantially below that expected for age,
  schooling, and level of intelligence
• substantially below is usually defined as a
  discrepancy of more than two standard deviations
  (one standard deviation 15 points) between
  achievement and IQ (or roughly 20 points)

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The IQ Bell Curve (1)

• IQ is plotted on a bell-shaped curve
• 100 is the defined average for both IQ and
  achievement tests at a given age level
• The usual (but not invariable) standard deviation
  is 15 points

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The IQ Bell Curve (2)

• Roughly 70 of individuals fall between 85 115
• 130 above Gifted (2)
• 120 129 Superior (7)
• 110 119 High Average (16)
• 90 109 Average (50)
• 80 89 Low Average (16)
• 71 79 (84 per DSM) Borderline (7)
• 70 below Mental Retardation (2)

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Associated Features

• Demoralization, low self-esteem, and deficits in
  social skills are common
• Children with LDs are not as socially competent
  as peers and have more difficulty understanding
  affective states in complex/ambiguous situations
• School drop-out rate for children with LDs is
  nearly 40
• Great overlap between Axis I disorders and LD
• 10 25 cross over with
• CD, ODD, ADHD, MDD, Dysthymia

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Prevalence

• Range from 2 10
• Estimated to include 5 of American children
• Approximately 50 of children receiving special
  services at school are LD

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Reading Disorderaka Dyslexia

• Oral reading is characterized by distortions,
  substitutions, or omissions both oral and silent
  reading are slow with comprehension errors
• Rare to find Math D/O and/or Written Expression
  D/O in the absence of Reading D/O
• 60 80 are males
• Prevalence estimated at 4 of school-aged
  children
• Aggregates in families (35 40 have a 1st
  degree relative also effected)

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What does Dyslexia mean?

• Dyslexia is an unexpected difficulty with reading
  in children who otherwise have the intelligence
  to learn to read
• Dyslexia is not outgrown
• Word retrieval and identification is slowed
• Affects spoken and written language

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Dyslexia versus IQ

• In typical readers, IQ and reading not only track
  together, but also influence each other over
  time.
• In children with dyslexia, IQ and reading are not
  linked over time and do not influence one
  another.
• Data from the Connecticut Longitudinal Study (12
  year study of 445 kids given regular reading and
  IQ tests)
• Shaywitz et al, 2010

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Reading Disorder (2)

• Thought to be a left hemisphere defect planum
  temporale has been found to be lacking in
  expected symmetry more disorganized and smaller
  cell bodies in the visual magnocellular system
• Persist into adolescence and adulthood
• Initial severity of reading disorder is the best
  predictor of adult reading levels (prior to
  Shaywitz study, last slide, intelligence was also
  thought to be a predictor here)

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Mathematics Disorder

• Prevalence roughly 1 of school children
• Usually apparent by 2nd or 3rd grade
• Many skills may be affected
• Linguistic skills (e.g., understanding terms,
  operations, concepts, decoding, etc.)
• Perceptual skills (e.g., recognizing or reading
  numerical symbols, mathematical signs, clustering
  objects into groups, etc.)
• Attention skills (e.g., copying numbers or
  figures correctly, remembering to carry
  numbers, observing operational signs, etc.)
• Mathematical skills (e.g., following steps,
  counting objects, multiplication tables, etc.)

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Mathematics Disorder (2)

• Associated with a pattern of deficits in
  neurocognitive adaptive functions generally
  attributed to R hemisphere, including spatial
  recognition, visuoperceptual/simultaneous info
  processing and social emotional functioning
  often referred to as Nonverbal Learning Disorder
  (NVLD)
• NVLD generally persists into adulthood and may
  worsen over time increased risk for
  internalizing d/o (anxiety and depression) and
  socio-emotional difficulties
• The abnormal language characteristics (e.g., poor
  prosody and pragmatics but good vocabulary) and
  pronounced social difficulties lead to questions
  about a connection with PDD (esp Aspergers) and
  Schizoid PD

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Disorders of Written Expression

• Prevalence unknown
• Difficult to diagnose b/c standardized tests are
  not particularly useful
• Generally involves a combination of difficulties
  with
• Composing written text (grammar punctuation
  errors)
• Poor paragraph organization
• Multiple spelling errors
• Excessively poor handwriting

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Assessment

• IQ tests correlate with predict school
  achievement a measure of academic intelligence
• IQ tests are relatively stable but not unchanging
  (stability increases with age)
• Heredity and environment influence IQ scores
• No test is free from cultural influences
• IQ is a score on a test it is descriptive, not
  explanatory
• IQ fails to measure many factors creativity,
  perseverance discipline, social ability, etc.

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Tests of Intelligence

• Wechsler Scales (most common)
• Wechsler Preschool Primary Scale of
  Intelligence
• WPPSI-III (2.6 7.3 yrs)
• Wechsler Intelligence Scale for Children
• WISC-IV (6.0 16.11 yrs)
• Wechsler Adult Intelligence Scale
• WAIS-III (16 89 yrs)
• Other commonly used scales
• Stanford-Binet Intelligence Scale
• Kaufman Assessment Battery for Children
• Woodcock-Johnson Tests of Cognitive Ability, etc.

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WISC-III

• WISC-III
• Verbal IQ
• Performance IQ
• Full Scale IQ

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WISC-IV

• Verbal Comprehension Index
• Similarities, vocabulary, comprehension,
  information, word reasoning
• Perceptual Reasoning Index
• Block design, picture concepts, matrix
  reasoning, picture completion
• Working Memory Index
• Digit span, letter-number sequencing, arithmetic
• Processing Speed Index
• Coding, symbol search, cancellation

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Special Purpose Measures

• Infant/Early Childhood
• Gessell Developmental Scales, etc.
• Mental Retardation
• Vineland Adaptive Behavior Scale
• AAMR Adaptive Behavior Scale
• Physically Handicapped
• Hiskey Nebraska Test of Learning Aptitude
  (hearing impaired)
• Leiter International Perf Scale (limited reading)
• Cross Cultural Testing

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Achievement Tests

• Group Administered Tests
• Stanford Achievement Tests (Stanford 9)
• California Achievement Tests (CAT)
• IOWA Tests of Basic Skills, etc.
• Individually Administered Tests
• Wide Range Achievement Tests 3 (WRAT 3)
• Wechsler Individual Achievement Tests (WIAT)
• Woodcock-Johnson Psychoeducational Battery, rev
  (WJ-R), etc.

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Neuropsychological Tests

• Standardized Batteries (general)
• Halstead Reitan
• Luria-Nebraska
• NEPSY
• Component Tests
• Motor Function
• Purdue Pegboard
• Dynamometer Grip Strength

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Neuropsych Tests (2)

• Component Tests contd
• Perception
• Reitan-Klove Sensory-Perceptual Examination
• Visual-Motor Integration
• Bender Gestalt
• Developmental Test of Visual Motor Integration
• Language (expressive/receptive, phonology, etc.)
• Peabody Picture Vocabulary Test
• Boston Naming Test
• Memory (short/long term, verbal/visual, storage,
  etc.)
• Wide Range Assessment of Memory Learning
  (WRAML)
• Buschke Selective Reminding Test

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Neuropsych Tests (3)

• Component Tests contd
• Intelligence Tests
• IQ (as above)
• Academic Abilities
• Individual Achievement Tests (as above)
• Executive Functions
• Stroop-Color Word Test
• Wisconsin Card Sort
• Trail Making
• Continuous Performance Tests
• Tower of London

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Projective Testing

• Drawings
• Rorschach
• Human Figures
• Kinetic Family
• Other Methods
• Thematic Apperception Test (CAT/TAT)
• Sentence Completion

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New Treatment Avenues in Dyslexia

• Fast Forward
• Computer based program to help kids to blend
  speech sounds (to speed the normal process of
  phonological manipulation)
• Learning Specialists
• To train children in strategies for decoding
  words (Lindamood/Bell, Orton Gillingham,
  Preventing Academic Failure, etc.)
• Accomodations
• 504, IEP

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Educational Support (1)

• Rehabilitation Act of 1973 (PL 93-112)
• Protects those w/disabilities from discrimination
  (physical, mental, emotional) in federally funded
  programs (e.g., schools)
• Established 504 reasonable accommodation
• An accommodation allows a student to complete
  the same assignment or test as other students,
  but with a change in timing, formatting, setting,
  scheduling, response and/or presentation.
• A modification is an adjustment to an
  assignment or a test that changes the standard or
  what the test assignment is supposed to measure.

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Educational Support (2)

• Typical 504 Accommodations or Modifications
  may include
• Alternative books with similar concepts but at an
  easier reading level
• Audiotapes of textbooks
• Chapter summaries
• Shorter assignments focused on mastering the key
  concepts
• Substituting alternatives for written assignments
  (clay models, posters, collections, etc.)
• Providing a computer for written work (alpha
  smart)

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Educational Support (3)

• 504 Accommodations or Modifications contd
• Alternative seating
• Using both oral and printed directions
• Providing visual aids
• Providing time for transitions
• Allowing additional time for tasks (e.g.,
  homework) without a penalty
• Using worksheets that require minimal handwriting
• Reading test questions aloud
• Grading spelling separately from content
• Allowing use of a calculator for math

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Educational Support (4)

• PL 94-142 of 1975 reauthorized repeatedly as
  Individuals with Disability Education Act (PL
  101-476)
• Guarantees a free and appropriate education to
  each child with a disability in every state and
  locality across the country
• Requires schools to provide a customized
  educational environment for learning disabled
  children
• Established the IEP (Individual Educational Plan)
• Other Health Impaired added in 1991 with IDEA
  Amendments/Reauthorization

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Educational Support (5)

• The IEP Process
• Request or referral for an evaluation
• Child is evaluated (testing varies)
• Eligibility is decided
• IEP meeting is held
• IEP is written
• Services are provided
• Annual follow-up of progress (IEP meeting)
• Child is reevaluated (q3 years)

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Educational Support (6)

• Timing
• 15 working days from request to school response
• 10 work weeks to complete testing and evaluation
• 10 working days to meet with the parents and IEP
  team upon completion of testing
• 10 working days for the parents to respond to the
  IEP meeting
• If the parents are unsatisfied, they can try and
  reach agreement with the school
• Parents can then request mediation
• Parents can then request due process
• Parents can write a letter of complaint to the DOE

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Educational Support (7)

• Contents of the IEP
• Current performance
• Annual Goals
• Special Education and related services
• Participation with non-disabled children
• Participation in state/district tests
• Dates and places of service
• Transition services
• Measuring progress

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Educational Support (8)

• Children may require related services those
  listed under IDEA include
• Audiology services
• Counseling services
• Early ID and assessment of disabilities in
  children
• Medical services
• Occupational therapy
• Orientation and mobility services
• Parent counseling and training
• Physical therapy
• Psychological services
• Recreation
• Rehabilitation counseling services
• School health services
• Social work services in schools
• Speech-language pathology services
• Transportation

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Educational Support (9)

• Special factors to consider include
• Behavior
• Limited proficiency in English
• Blindness or visual impairment
• Special communication needs
• Deaf or hearing impaired

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References

• Neuropsychological Assessment by Lezak, Howieson,
  and Loring
• Psychological Testing by Kaplan and Saccuzzo