Learning Disorders Department of Education

Learning Disorders

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

2. 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 used in Describe how IQ and achievement tests are used in
determining the presence of learning disorders, and draw the determining the presence of learning disorders, and draw the
IQ bell curve.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 appropriate Choose which neuropsychiatric tests are most appropriate
for assessing educational level, visual/motor integration, for assessing educational level, visual/motor integration,
adaptive skills level, memory, executive function, and adaptive skills level, memory, executive function, and
thought content.thought content.
5)5)Describe the differences between the 2 public laws which Describe the differences between the 2 public laws which
provide educational support for learning disordered provide educational support for learning disordered
children.children.

3. Neuron Cell MigrationNeuron Cell Migration

The human brain develops through cell division The human brain develops through cell division
and then cell migrationand then cell migration

Cell migration occurs when neurons develop and Cell migration occurs when neurons develop and
then travel through the brain to pre-programmed then travel through the brain to pre-programmed
areasareas

In most cases, cell migration proceeds in expected In most cases, cell migration proceeds in expected
waysways

Sometimes, cell migration proceeds in an Sometimes, cell migration proceeds in an
““abnormalabnormal”” or atypical way or atypical way

4. Differences in Blood Flow Differences in Blood Flow

5. Blood Flow AbnormalitiesBlood Flow Abnormalities

6. Blood Flow Abnormalities (2)Blood Flow Abnormalities (2)

7. RemediationRemediation

8. Diagnostic FeaturesDiagnostic Features

Diagnosed when an individualDiagnosed when an individual’’s achievement on s achievement on
individually administered, standardized tests in individually administered, standardized tests in
reading, math, or written expression is substantially reading, math, or written expression is substantially
below that expected for age, schooling, and level of below that expected for age, schooling, and level of
intelligenceintelligence

““substantially belowsubstantially below”” is usually defined as a discrepancy is usually defined as a discrepancy
of more than two standard deviations (one standard of more than two standard deviations (one standard
deviation = 15 points) between achievement and IQ (or deviation = 15 points) between achievement and IQ (or
roughly 20+ points)roughly 20+ points)

9. 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 and for both IQ and
achievement tests at a given age levelachievement tests at a given age level

The usual (but not invariable) standard deviation is The usual (but not invariable) standard deviation is
15 points15 points

10. The IQ Bell Curve (2)The IQ Bell Curve (2)

Roughly 70% of individuals fall between 85 – 115Roughly 70% of individuals fall between 85 – 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%)

13. Associated FeaturesAssociated Features

Demoralization, low self-esteem, and deficits in social skills Demoralization, low self-esteem, and deficits in social skills
are commonare common

Children with LDs are not as socially competent as peers Children with LDs are not as socially competent as peers
and have more difficulty understanding affective states in and have more difficulty understanding affective states in
complex/ambiguous situationscomplex/ambiguous situations

School drop-out rate for children with LDs is nearly 40%School drop-out rate for children with LDs is 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

14. PrevalencePrevalence

Range from 2 – 10%Range from 2 – 10%

Estimated to include 5% of American childrenEstimated to include 5% of American children

Approximately 50% of children receiving special Approximately 50% of children receiving special
services at school are LDservices at school are LD

15. Reading Disorder…aka Reading Disorder…aka
DyslexiaDyslexia

Oral reading is characterized by distortions, substitutions, Oral reading is characterized by distortions, substitutions,
or omissions; both oral and silent reading are slow with or omissions; both oral and silent reading are slow with
comprehension errorscomprehension errors

Rare to find Math D/O and/or Written Expression D/O Rare to find Math D/O and/or Written Expression D/O
in the absence of Reading D/Oin the absence of Reading D/O

60 – 80% are males60 – 80% are males

Prevalence estimated at 4% of school-aged childrenPrevalence estimated at 4% of school-aged children

Aggregates in families (35 – 40% have a 1Aggregates in families (35 – 40% have a 1
stst
degree relative degree relative
also effected)also effected)

16. What does Dyslexia mean?What does Dyslexia mean?

Dyslexia is an unexpected difficulty with reading in Dyslexia is an unexpected difficulty with reading in
children who otherwise have the intelligence to learn to children who otherwise have the intelligence to learn to
readread

Dyslexia is not Dyslexia is not ““outgrownoutgrown””

Word retrieval and identification is slowedWord retrieval and identification is slowed

Affects spoken and written languageAffects spoken and written language

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

18. Reading Disorder (2)Reading Disorder (2)

Thought to be a left hemisphere defect; planum Thought to be a left hemisphere defect; planum
temporale has been found to be lacking in temporale has been found to be lacking in
expected symmetry; more disorganized and smaller expected symmetry; more disorganized and smaller
cell bodies in the visual magnocellular systemcell bodies in the visual magnocellular system

Persist into adolescence and adulthoodPersist into adolescence and adulthood

Initial severity of reading disorder is the best Initial severity of reading disorder is the best
predictor of adult reading levels (prior to Shaywitz predictor of adult reading levels (prior to Shaywitz
study, last slide, intelligence was also thought to be study, last slide, intelligence was also thought to be
a predictor here)a predictor here)

19. Mathematics DisorderMathematics Disorder

Prevalence roughly 1% of school childrenPrevalence roughly 1% of school children

Usually apparent by 2Usually apparent by 2
ndnd
or 3 or 3
rdrd
grade grade

Many skills may be affected:Many skills may be affected:

Linguistic skills (e.g., understanding terms, operations, concepts, Linguistic skills (e.g., understanding terms, operations, concepts,
decoding, etc.)decoding, etc.)

Perceptual skills (e.g., recognizing or reading numerical symbols, Perceptual skills (e.g., recognizing or reading numerical symbols,
mathematical signs, clustering objects into groups, etc.)mathematical signs, clustering objects into groups, etc.)

Attention skills (e.g., copying numbers or figures correctly, Attention skills (e.g., copying numbers or figures correctly,
remembering to remembering to ““carrycarry”” numbers, observing operational signs, numbers, observing operational signs,
etc.)etc.)

Mathematical skills (e.g., following steps, counting objects, Mathematical skills (e.g., following steps, counting objects,
multiplication tables, etc.)multiplication tables, etc.)

20. Mathematics Disorder (2)Mathematics Disorder (2)

Associated with a pattern of deficits in neurocognitive & Associated with a pattern of deficits in neurocognitive &
adaptive functions generally attributed to R hemisphere, adaptive functions generally attributed to R hemisphere,
including spatial recognition, visuoperceptual/simultaneous including spatial recognition, visuoperceptual/simultaneous
info processing and social emotional functioning; often info processing and social emotional functioning; often
referred to as Nonverbal Learning Disorder (NVLD)referred to as Nonverbal Learning Disorder (NVLD)

NVLD generally persists into adulthood and may worsen over NVLD generally persists into adulthood and may worsen over
time; increased risk for internalizing d/o (anxiety and depression) time; increased risk for internalizing d/o (anxiety and depression)
and socio-emotional difficultiesand socio-emotional difficulties

The abnormal language characteristics (e.g., poor prosody and The abnormal language characteristics (e.g., poor prosody and
pragmatics but good vocabulary) and pronounced social pragmatics but good vocabulary) and pronounced social
difficulties lead to questions about a connection with PDD (esp difficulties lead to questions about a connection with PDD (esp
AspergerAsperger’’s) and Schizoid PDs) and Schizoid PD

21. Disorders of Disorders of
Written ExpressionWritten Expression

Prevalence unknownPrevalence unknown

Difficult to diagnose b/c standardized tests are not Difficult to diagnose b/c standardized tests are not
particularly usefulparticularly useful

Generally involves a combination of difficulties with:Generally involves a combination of difficulties with:

Composing written text (grammar & punctuation errors)Composing written text (grammar & punctuation errors)

Poor paragraph organizationPoor paragraph organization

Multiple spelling errorsMultiple spelling errors

Excessively poor handwritingExcessively poor handwriting

22. AssessmentAssessment

IQ tests correlate with & predict school achievement; a IQ tests correlate with & predict school achievement; a
measure of academic intelligencemeasure of academic intelligence

IQ tests are relatively stable but not unchanging (stability IQ tests are relatively stable but not unchanging (stability
increases with age)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 explanatoryIQ is a score on a test – it is descriptive, not explanatory

IQ fails to measure many factors – creativity, perseverance IQ fails to measure many factors – creativity, perseverance
& discipline, social ability, etc.& discipline, social ability, etc.

23. Tests of IntelligenceTests of Intelligence

Wechsler Scales (most common):Wechsler Scales (most common):

Wechsler Preschool & Primary Scale of IntelligenceWechsler Preschool & Primary Scale of Intelligence

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.

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

25. WISC-IVWISC-IV

Verbal Comprehension IndexVerbal Comprehension Index

Similarities, vocabulary, comprehension, information, *word Similarities, vocabulary, comprehension, information, *word
reasoningreasoning

Perceptual Reasoning IndexPerceptual Reasoning Index

Block design, picture concepts, *matrix reasoning, picture Block design, picture concepts, *matrix reasoning, picture
completioncompletion

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

26. 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 (hearing Hiskey Nebraska Test of Learning Aptitude (hearing
impaired)impaired)

Leiter International Perf Scale (limited reading)Leiter International Perf Scale (limited reading)

Cross Cultural TestingCross Cultural Testing

27. 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 (WIAT)Wechsler Individual Achievement Tests (WIAT)

Woodcock-Johnson Psychoeducational Battery, rev (WJ-Woodcock-Johnson Psychoeducational Battery, rev (WJ-
R), etc.R), etc.

28. Neuropsychological TestsNeuropsychological Tests

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

29. 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, etc.)Memory (short/long term, verbal/visual, storage, etc.)

Wide Range Assessment of Memory & Learning (WRAML)Wide Range Assessment of Memory & Learning (WRAML)

Buschke Selective Reminding TestBuschke Selective Reminding Test

30. 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

31. 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

32. New Treatment Avenues in DyslexiaNew Treatment Avenues in Dyslexia

Fast ForwardFast Forward

Computer based program to help kids to blend speech Computer based program to help kids to blend speech
sounds (to speed the normal process of phonological sounds (to speed the normal process of phonological
manipulation)manipulation)

Learning SpecialistsLearning Specialists

To train children in strategies for decoding words To train children in strategies for decoding words
(Lindamood/Bell, Orton Gillingham, Preventing (Lindamood/Bell, Orton Gillingham, Preventing
Academic Failure, etc.)Academic Failure, etc.)

AccomodationsAccomodations

504, IEP504, IEP

33. 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.

34. 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)

35. 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

36. 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

37. Educational Support (5)
•The IEP Process:
1.Request or referral for an evaluation
2.Child is evaluated (testing varies)
3.Eligibility is decided
4.IEP meeting is held
5.IEP is written
6.Services are provided
7.Annual follow-up of progress (IEP meeting)
8.Child is reevaluated (q3 years)

38. 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

39. Educational Support (7)
•Contents of the IEP:
1.Current performance
2.Annual Goals
3.Special Education and related services
4.Participation with non-disabled children
5.Participation in state/district tests
6.Dates and places of service
7.Transition services
8.Measuring progress

41. 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

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

43. ReferencesReferences

Neuropsychological Assessment by Lezak, Neuropsychological Assessment by Lezak,
Howieson, and LoringHowieson, and Loring

Psychological Testing by Kaplan and SaccuzzoPsychological Testing by Kaplan and Saccuzzo