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 Objectives
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Residents will be able to:
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5)
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.
Neuron Cell Migration
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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
Typical vs. Atypical Migration
Cell Migration in Dyslexia
Differences in Blood Flow
Blood Flow Abnormalities
Blood Flow Abnormalities (2)
Remediation
Diagnostic Features
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Diagnosed when an individual’s achievement on
individually administered, standardized tests in
reading, math, or written expression is substantially
below that expected for age, schooling, and level of
intelligence
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“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)
The IQ Bell Curve (1)
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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
The IQ Bell Curve (2)
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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
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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:
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10 – 25% cross over with:
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CD, ODD, ADHD, MDD, Dysthymia
Prevalence
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Range from 2 – 10%
Estimated to include 5% of American children
Approximately 50% of children receiving special
services at school are LD
Reading Disorder…aka
Dyslexia
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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)
What does Dyslexia mean?
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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
Dyslexia versus IQ
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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)
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Shaywitz et al, 2010
Reading Disorder (2)
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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)
Mathematics Disorder
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Prevalence roughly 1% of school children
Usually apparent by 2nd or 3rd grade
Many skills may be affected:
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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.)
Mathematics Disorder (2)
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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)
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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
Asperger’s) and Schizoid PD
Disorders of
Written Expression
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Prevalence unknown
Difficult to diagnose b/c standardized tests are not
particularly useful
Generally involves a combination of difficulties with:
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Composing written text (grammar & punctuation errors)
Poor paragraph organization
Multiple spelling errors
Excessively poor handwriting
Assessment
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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.
Tests of Intelligence
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Wechsler Scales (most common):
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Wechsler Preschool & Primary Scale of Intelligence
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Wechsler Intelligence Scale for Children
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WISC-IV (6.0 – 16.11 yrs)
Wechsler Adult Intelligence Scale
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WPPSI-III (2.6 – 7.3 yrs)
WAIS-III (16 – 89 yrs)
Other commonly used scales:
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Stanford-Binet Intelligence Scale
Kaufman Assessment Battery for Children
Woodcock-Johnson Tests of Cognitive Ability, etc.
WISC-III
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WISC-III
Verbal IQ
 Performance IQ
 Full Scale IQ
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WISC-IV
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Verbal Comprehension Index
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Perceptual Reasoning Index
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Block design, picture concepts, *matrix reasoning, picture
completion
Working Memory Index
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Similarities, vocabulary, comprehension, information, *word
reasoning
Digit span, *letter-number sequencing, arithmetic
Processing Speed Index
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Coding, *symbol search, *cancellation
Special Purpose Measures
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Infant/Early Childhood
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Gessell Developmental Scales, etc.
Mental Retardation
Vineland Adaptive Behavior Scale
 AAMR Adaptive Behavior Scale
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Physically Handicapped
Hiskey Nebraska Test of Learning Aptitude (hearing
impaired)
 Leiter International Perf Scale (limited reading)
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Cross Cultural Testing
Achievement Tests
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Group Administered Tests
Stanford Achievement Tests (Stanford 9)
 California Achievement Tests (CAT)
 IOWA Tests of Basic Skills, etc.
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Individually Administered Tests
Wide Range Achievement Tests 3 (WRAT 3)
 Wechsler Individual Achievement Tests (WIAT)
 Woodcock-Johnson Psychoeducational Battery, rev (WJR), etc.
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Neuropsychological Tests
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Standardized Batteries (general):
Halstead Reitan
 Luria-Nebraska
 NEPSY
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Component Tests:
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Motor Function
Purdue Pegboard
 Dynamometer Grip Strength
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Neuropsych Tests (2)
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Component Tests cont’d:
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Perception
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Visual-Motor Integration
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Bender Gestalt
Developmental Test of Visual Motor Integration
Language (expressive/receptive, phonology, etc.)
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Reitan-Klove Sensory-Perceptual Examination
Peabody Picture Vocabulary Test
Boston Naming Test
Memory (short/long term, verbal/visual, storage, etc.)
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Wide Range Assessment of Memory & Learning (WRAML)
Buschke Selective Reminding Test
Neuropsych Tests (3)
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Component Tests cont’d:
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Intelligence Tests
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Academic Abilities
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IQ (as above)
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
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Drawings
Rorschach
 Human Figures
 Kinetic Family
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Other Methods
Thematic Apperception Test (CAT/TAT)
 Sentence Completion
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New Treatment Avenues in Dyslexia
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Fast Forward
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Learning Specialists
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Computer based program to help kids to blend speech
sounds (to speed the normal process of phonological
manipulation)
To train children in strategies for decoding words
(Lindamood/Bell, Orton Gillingham, Preventing
Academic Failure, etc.)
Accomodations
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504, 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:
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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)
Educational Support (6)
• Timing:
1. 15 working days from request to school response
2. 10 work weeks to complete testing and evaluation
3. 10 working days to meet with the parents and IEP
team upon completion of testing
4. 10 working days for the parents to respond to the
IEP meeting
5. If the parents are unsatisfied, they can try and reach
agreement with the school
6. Parents can then request mediation
7. Parents can then request due process
8. Parents can write a letter of complaint to the DOE
Educational Support (7)
• Contents of the IEP:
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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
Educational Support (8)
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Children may require related services; those listed under IDEA
include:
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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:
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Behavior
Limited proficiency in English
Blindness or visual impairment
Special communication needs
Deaf or hearing impaired
References
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Neuropsychological Assessment by Lezak,
Howieson, and Loring
Psychological Testing by Kaplan and Saccuzzo