Learning Disorders…or Disabilities…or Differences

1. 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

3. 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.

4. 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

5. Typical vs. Atypical Migration

6. Cell Migration in Dyslexia

7. Differences in Blood Flow

8. Blood Flow Abnormalities

9. Blood Flow Abnormalities (2)

10. Remediation

11. Diagnostic Features • 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 • “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)

12. 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

13. 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%)

16. 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

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

18. Reading Disorder…aka 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)

19. 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

20. 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

21. 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)

22. 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.)

23. 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 Asperger’s) and Schizoid PD

24. 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

25. 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.

26. 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.

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

28. 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

29. 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

30. 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.

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

32. Neuropsych Tests (2) • Component Tests cont’d: • 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

33. Neuropsych Tests (3) • Component Tests cont’d: • 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

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

35. 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

36. 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.

37. 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)

38. 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

39. 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

40. 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)

41. 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

42. 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

44. 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

45. Educational Support (9) • Special factors to consider include: • Behavior • Limited proficiency in English • Blindness or visual impairment • Special communication needs • Deaf or hearing impaired

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