Learning Disorders…or Disabilities…or Differences

Jess P. Shatkin, MD, MPH

Vice Chair for Education

NYU Child Study Center

New York University School of Medicine

Learning ObjectivesLearning Objectives Residents will be able to:Residents will be able to:

1)1) Provide a legal definition of learning disorders.Provide a legal definition of learning disorders.2)2) Describe how IQ and achievement tests are Describe how IQ and achievement tests are

used in determining the presence of learning used in determining the presence of learning disorders, and draw the IQ bell curve.disorders, and draw the IQ bell curve.

3)3) Identify the 3 primary learning disorders.Identify the 3 primary learning disorders.4)4) Choose which neuropsychiatric tests are most Choose which neuropsychiatric tests are most

appropriate for assessing educational level, appropriate for assessing educational level, visual/motor integration, adaptive skills level, visual/motor integration, adaptive skills level, memory, executive function, and thought memory, executive function, and thought content.content.

5)5) Describe the differences between the 2 public Describe the differences between the 2 public laws which provide educational support for laws which provide educational support for learning disordered children.learning disordered children.

Neuron Cell MigrationNeuron Cell Migration The human brain develops through The human brain develops through

cell division and then cell migrationcell division and then cell migration Cell migration occurs when neurons Cell migration occurs when neurons

develop and then travel through the develop and then travel through the brain to pre-programmed areasbrain to pre-programmed areas

In most cases, cell migration proceeds In most cases, cell migration proceeds in expected waysin expected ways

Sometimes, cell migration proceeds in Sometimes, cell migration proceeds in an an ““abnormalabnormal”” or atypical way or atypical way

Typical vs. Atypical Typical vs. Atypical MigrationMigration

Cell Migration in Cell Migration in DyslexiaDyslexia

Differences in Blood Differences in Blood Flow Flow

Blood Flow Blood Flow AbnormalitiesAbnormalities

Blood Flow Blood Flow Abnormalities (2)Abnormalities (2)

RemediationRemediation

Diagnostic FeaturesDiagnostic Features

Diagnosed when an individualDiagnosed when an individual’’s s achievement on individually achievement on individually administered, standardized tests in administered, standardized tests in reading, math, or written expression is reading, math, or written expression is substantially below that expected for substantially below that expected for age, schooling, and level of intelligenceage, schooling, and level of intelligence ““substantially belowsubstantially below”” is usually defined as is usually defined as

a discrepancy of more than two standard a discrepancy of more than two standard deviations (one standard deviation = 15 deviations (one standard deviation = 15 points) between achievement and IQ (or points) between achievement and IQ (or roughly 20+ points)roughly 20+ points)

The IQ Bell Curve (1)The IQ Bell Curve (1)

IQ is plotted on a bell-shaped curveIQ is plotted on a bell-shaped curve 100 is the defined 100 is the defined ““averageaverage”” for both IQ for both IQ

and achievement tests at a given age and achievement tests at a given age levellevel

The usual (but not invariable) standard The usual (but not invariable) standard deviation is 15 pointsdeviation is 15 points

The IQ Bell Curve (2)The IQ Bell Curve (2) Roughly 70% of individuals fall between Roughly 70% of individuals fall between

85 – 11585 – 115 130 & above = Gifted (2%)130 & above = Gifted (2%) 120 – 129 = Superior (7%)120 – 129 = Superior (7%) 110 – 119 = High Average (16%)110 – 119 = High Average (16%) 90 – 109 = Average (50%)90 – 109 = Average (50%) 80 – 89 = Low Average (16%)80 – 89 = Low Average (16%) 71 –79 (84 per DSM) = Borderline (7%)71 –79 (84 per DSM) = Borderline (7%) 70 & below = Mental Retardation (2%)70 & below = Mental Retardation (2%)

Associated FeaturesAssociated Features Demoralization, low self-esteem, and deficits in Demoralization, low self-esteem, and deficits in

social skills are commonsocial skills are common Children with LDs are not as socially Children with LDs are not as socially

competent as peers and have more difficulty competent as peers and have more difficulty understanding affective states in understanding affective states in complex/ambiguous situationscomplex/ambiguous situations

School drop-out rate for children with LDs is School drop-out rate for children with LDs is nearly 40%nearly 40%

Great overlap between Axis I disorders and LD:Great overlap between Axis I disorders and LD: 10 – 25% cross over with:10 – 25% cross over with:

CD, ODD, ADHD, MDD, DysthymiaCD, ODD, ADHD, MDD, Dysthymia

PrevalencePrevalence

Range from 2 – 10%Range from 2 – 10% Estimated to include 5% of American Estimated to include 5% of American

childrenchildren Approximately 50% of children Approximately 50% of children

receiving special services at school receiving special services at school are LDare LD

Reading Disorder…aka Reading Disorder…aka DyslexiaDyslexia

Oral reading is characterized by distortions, Oral reading is characterized by distortions, substitutions, or omissions; both oral and silent substitutions, or omissions; both oral and silent reading are slow with comprehension errorsreading are slow with comprehension errors

Rare to find Math D/O and/or Written Rare to find Math D/O and/or Written Expression D/O in the absence of Reading D/OExpression D/O in the absence of Reading D/O

60 – 80% are males60 – 80% are males Prevalence estimated at 4% of school-aged Prevalence estimated at 4% of school-aged

childrenchildren Aggregates in families (35 – 40% have a 1Aggregates in families (35 – 40% have a 1stst

degree relative also effected)degree relative also effected)

What does Dyslexia What does Dyslexia mean?mean?

Dyslexia is an unexpected difficulty Dyslexia is an unexpected difficulty with reading in children who with reading in children who otherwise have the intelligence to otherwise have the intelligence to learn to readlearn to read

Dyslexia is not Dyslexia is not ““outgrownoutgrown”” Word retrieval and identification is Word retrieval and identification is

slowedslowed Affects spoken and written languageAffects spoken and written language

Dyslexia versus IQDyslexia versus IQ

In typical readers, IQ and reading not In typical readers, IQ and reading not only track together, but also influence only track together, but also influence each other over time. each other over time.

In children with dyslexia, IQ and reading In children with dyslexia, IQ and reading are not linked over time and do not are not linked over time and do not influence one another.influence one another.

Data from the Connecticut Longitudinal Data from the Connecticut Longitudinal Study (12 year study of 445 kids given Study (12 year study of 445 kids given regular reading and IQ tests)regular reading and IQ tests)

Shaywitz et al, 2010Shaywitz et al, 2010

Reading Disorder (2)Reading Disorder (2) Thought to be a left hemisphere defect; Thought to be a left hemisphere defect;

planum temporale has been found to be planum temporale has been found to be lacking in expected symmetry; more lacking in expected symmetry; more disorganized and smaller cell bodies in disorganized and smaller cell bodies in the visual magnocellular systemthe visual magnocellular system

Persist into adolescence and adulthoodPersist into adolescence and adulthood Initial severity of reading disorder is the Initial severity of reading disorder is the

best predictor of adult reading levels best predictor of adult reading levels (prior to Shaywitz study, last slide, (prior to Shaywitz study, last slide, intelligence was also thought to be a intelligence was also thought to be a predictor here)predictor here)

Mathematics DisorderMathematics Disorder Prevalence roughly 1% of school childrenPrevalence roughly 1% of school children Usually apparent by 2Usually apparent by 2ndnd or 3 or 3rdrd grade grade Many skills may be affected:Many skills may be affected:

Linguistic skills (e.g., understanding terms, Linguistic skills (e.g., understanding terms, operations, concepts, decoding, etc.)operations, concepts, decoding, etc.)

Perceptual skills (e.g., recognizing or reading Perceptual skills (e.g., recognizing or reading numerical symbols, mathematical signs, numerical symbols, mathematical signs, clustering objects into groups, etc.)clustering objects into groups, etc.)

Attention skills (e.g., copying numbers or figures Attention skills (e.g., copying numbers or figures correctly, remembering to correctly, remembering to ““carrycarry”” numbers, numbers, observing operational signs, etc.)observing operational signs, etc.)

Mathematical skills (e.g., following steps, Mathematical skills (e.g., following steps, counting objects, multiplication tables, etc.)counting objects, multiplication tables, etc.)

Mathematics Disorder (2)Mathematics Disorder (2) Associated with a pattern of deficits in Associated with a pattern of deficits in

neurocognitive & adaptive functions generally neurocognitive & adaptive functions generally attributed to R hemisphere, including spatial attributed to R hemisphere, including spatial recognition, visuoperceptual/simultaneous info recognition, visuoperceptual/simultaneous info processing and social emotional functioning; processing and social emotional functioning; often referred to as Nonverbal Learning Disorder often referred to as Nonverbal Learning Disorder (NVLD)(NVLD) NVLD generally persists into adulthood and may NVLD generally persists into adulthood and may

worsen over time; increased risk for internalizing d/o worsen over time; increased risk for internalizing d/o (anxiety and depression) and socio-emotional (anxiety and depression) and socio-emotional difficultiesdifficulties

The abnormal language characteristics (e.g., poor The abnormal language characteristics (e.g., poor prosody and pragmatics but good vocabulary) and prosody and pragmatics but good vocabulary) and pronounced social difficulties lead to questions about a pronounced social difficulties lead to questions about a connection with PDD (esp Aspergerconnection with PDD (esp Asperger’’s) and Schizoid PDs) and Schizoid PD

Disorders of Disorders of Written ExpressionWritten Expression

Prevalence unknownPrevalence unknown Difficult to diagnose b/c standardized tests Difficult to diagnose b/c standardized tests

are not particularly usefulare not particularly useful Generally involves a combination of Generally involves a combination of

difficulties with:difficulties with: Composing written text (grammar & punctuation Composing written text (grammar & punctuation

errors)errors) Poor paragraph organizationPoor paragraph organization Multiple spelling errorsMultiple spelling errors Excessively poor handwritingExcessively poor handwriting

AssessmentAssessment IQ tests correlate with & predict school IQ tests correlate with & predict school

achievement; a measure of academic achievement; a measure of academic intelligenceintelligence

IQ tests are relatively stable but not IQ tests are relatively stable but not unchanging (stability increases with age)unchanging (stability increases with age)

Heredity and environment influence IQ scoresHeredity and environment influence IQ scores No test is free from cultural influencesNo test is free from cultural influences IQ is a score on a test – it is descriptive, not IQ is a score on a test – it is descriptive, not

explanatoryexplanatory IQ fails to measure many factors – creativity, IQ fails to measure many factors – creativity,

perseverance & discipline, social ability, etc.perseverance & discipline, social ability, etc.

Tests of IntelligenceTests of Intelligence Wechsler Scales (most common):Wechsler Scales (most common):

Wechsler Preschool & Primary Scale of Wechsler Preschool & Primary Scale of IntelligenceIntelligence

WPPSI-III (2.6 – 7.3 yrs)WPPSI-III (2.6 – 7.3 yrs) Wechsler Intelligence Scale for ChildrenWechsler Intelligence Scale for Children

WISC-IV (6.0 – 16.11 yrs)WISC-IV (6.0 – 16.11 yrs) Wechsler Adult Intelligence ScaleWechsler Adult Intelligence Scale

WAIS-III (16 – 89 yrs)WAIS-III (16 – 89 yrs)

Other commonly used scales:Other commonly used scales: Stanford-Binet Intelligence ScaleStanford-Binet Intelligence Scale Kaufman Assessment Battery for ChildrenKaufman Assessment Battery for Children Woodcock-Johnson Tests of Cognitive Ability, etc.Woodcock-Johnson Tests of Cognitive Ability, etc.

WISC-IIIWISC-III

WISC-IIIWISC-III Verbal IQVerbal IQ Performance IQPerformance IQ Full Scale IQFull Scale IQ

WISC-IVWISC-IV Verbal Comprehension IndexVerbal Comprehension Index

Similarities, vocabulary, comprehension, Similarities, vocabulary, comprehension, information, *word reasoninginformation, *word reasoning

Perceptual Reasoning IndexPerceptual Reasoning Index Block design, picture concepts, *matrix reasoning, Block design, picture concepts, *matrix reasoning,

picture completionpicture completion Working Memory IndexWorking Memory Index

Digit span, *letter-number sequencing, arithmeticDigit span, *letter-number sequencing, arithmetic Processing Speed IndexProcessing Speed Index

Coding, *symbol search, *cancellationCoding, *symbol search, *cancellation

Special Purpose MeasuresSpecial Purpose Measures Infant/Early ChildhoodInfant/Early Childhood

Gessell Developmental Scales, etc.Gessell Developmental Scales, etc. Mental RetardationMental Retardation

Vineland Adaptive Behavior ScaleVineland Adaptive Behavior Scale AAMR Adaptive Behavior ScaleAAMR Adaptive Behavior Scale

Physically HandicappedPhysically Handicapped Hiskey Nebraska Test of Learning Aptitude Hiskey Nebraska Test of Learning Aptitude

(hearing impaired)(hearing impaired) Leiter International Perf Scale (limited Leiter International Perf Scale (limited

reading)reading) Cross Cultural TestingCross Cultural Testing

Achievement TestsAchievement Tests Group Administered TestsGroup Administered Tests

Stanford Achievement Tests (Stanford 9)Stanford Achievement Tests (Stanford 9) California Achievement Tests (CAT)California Achievement Tests (CAT) IOWA Tests of Basic Skills, etc.IOWA Tests of Basic Skills, etc.

Individually Administered TestsIndividually Administered Tests Wide Range Achievement Tests 3 (WRAT 3)Wide Range Achievement Tests 3 (WRAT 3) Wechsler Individual Achievement Tests Wechsler Individual Achievement Tests

(WIAT)(WIAT) Woodcock-Johnson Psychoeducational Woodcock-Johnson Psychoeducational

Battery, rev (WJ-R), etc.Battery, rev (WJ-R), etc.

Neuropsychological Neuropsychological TestsTests

Standardized Batteries (general):Standardized Batteries (general): Halstead ReitanHalstead Reitan Luria-NebraskaLuria-Nebraska NEPSYNEPSY

Component Tests:Component Tests: Motor FunctionMotor Function

Purdue PegboardPurdue Pegboard Dynamometer Grip StrengthDynamometer Grip Strength

Neuropsych Tests (2)Neuropsych Tests (2) Component Tests contComponent Tests cont’’d:d:

PerceptionPerception Reitan-Klove Sensory-Perceptual ExaminationReitan-Klove Sensory-Perceptual Examination

Visual-Motor IntegrationVisual-Motor Integration Bender GestaltBender Gestalt Developmental Test of Visual Motor IntegrationDevelopmental Test of Visual Motor Integration

Language (expressive/receptive, phonology, etc.)Language (expressive/receptive, phonology, etc.) Peabody Picture Vocabulary TestPeabody Picture Vocabulary Test Boston Naming TestBoston Naming Test

Memory (short/long term, verbal/visual, storage, Memory (short/long term, verbal/visual, storage, etc.)etc.)

Wide Range Assessment of Memory & Learning (WRAML)Wide Range Assessment of Memory & Learning (WRAML) Buschke Selective Reminding TestBuschke Selective Reminding Test

Neuropsych Tests (3)Neuropsych Tests (3) Component Tests contComponent Tests cont’’d:d:

Intelligence TestsIntelligence Tests IQ (as above)IQ (as above)

Academic AbilitiesAcademic Abilities Individual Achievement Tests (as above)Individual Achievement Tests (as above)

Executive Functions Executive Functions Stroop-Color Word TestStroop-Color Word Test Wisconsin Card SortWisconsin Card Sort Trail MakingTrail Making Continuous Performance TestsContinuous Performance Tests Tower of LondonTower of London

Projective TestingProjective Testing

DrawingsDrawings Rorschach Rorschach Human FiguresHuman Figures Kinetic FamilyKinetic Family

Other MethodsOther Methods Thematic Apperception Test (CAT/TAT)Thematic Apperception Test (CAT/TAT) Sentence CompletionSentence Completion

New Treatment Avenues in New Treatment Avenues in DyslexiaDyslexia

Fast ForwardFast Forward Computer based program to help kids to Computer based program to help kids to

blend speech sounds (to speed the normal blend speech sounds (to speed the normal process of phonological manipulation)process of phonological manipulation)

Learning SpecialistsLearning Specialists To train children in strategies for decoding To train children in strategies for decoding

words (Lindamood/Bell, Orton Gillingham, words (Lindamood/Bell, Orton Gillingham, Preventing Academic Failure, etc.)Preventing Academic Failure, etc.)

AccomodationsAccomodations 504, IEP504, IEP

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.

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)

Educational Support (3)• 504 “Accommodations” or “Modifications” cont’d:

• 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

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

Educational Support (5)

• The IEP Process:1. Request or referral for an evaluation2. Child is evaluated (testing varies)3. Eligibility is decided4. IEP meeting is held5. IEP is written6. Services are provided7. Annual follow-up of progress (IEP meeting)8. Child is reevaluated (q3 years)

Educational Support (6)• Timing:

1. 15 working days from request to school response2. 10 work weeks to complete testing and evaluation3. 10 working days to meet with the parents and IEP

team upon completion of testing4. 10 working days for the parents to respond to the

IEP meeting5. If the parents are unsatisfied, they can try and reach

agreement with the school6. Parents can then request mediation7. Parents can then request due process8. Parents can write a letter of complaint to the DOE

Educational Support (7)

• Contents of the IEP:1. Current performance2. Annual Goals3. Special Education and related services4. Participation with non-disabled children5. Participation in state/district tests6. Dates and places of service7. Transition services8. Measuring progress

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

Educational Support (9)

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

ReferencesReferences

Neuropsychological Assessment by Neuropsychological Assessment by Lezak, Howieson, and LoringLezak, Howieson, and Loring

Psychological Testing by Kaplan and Psychological Testing by Kaplan and SaccuzzoSaccuzzo