Chapter 8. Learning Disorders

 

Chapter 8. Learning Disorders

INTRODUCTION

Learning disorders are, by definition, heterogeneous as they reflect unexpected failure in distinct

academic areas. Disorders in reading, written expression, and mathematics are specific types of

learning disorder (LD) as defined by the DSM-IV-TR (American Psychiatric Association 2000). While

comorbidity across learning disorders is notably high, treatments typically target the particular

features of each specific type of LD. Nevertheless, a review of the literature indicates that there are

guiding principles for treatment that apply to all areas of LD. In this chapter we begin with a

discussion of these general guidelines, then describe treatments for specific types of LD, and finally

describe the implications of disorders often comorbid with LD. Whereas most academic

interventions will take place within the school system or through specialized programming

available elsewhere, this chapter focuses on what has been shown to work and what characteristics

specific to LD can be effectively targeted for intervention.

GENERAL TREATMENT GUIDELINES

Facilitate Intervention and Identification as Early as Possible

The importance of early intervention cannot be overstated, as the earlier the intervention, the

better the outcome (Fletcher et al. 1994). Given the persistent nature of LD and increased

likelihood of complicating factors, when LD is left untreated, later intervention will be more

intensive and costly as well as less effective (Steele 2004). Early intervention that is more directed

toward prevention than treatment and that helps families obtain access to these programs before

the child is allowed to fail for several grades is of particular value. The most common early risk is

delayed language development. Specific language factors of particular note include mispronouncing

words, word-finding problems, trouble rhyming, and difficulty learning the alphabet (Catts 1997;

Shaywitz 2003).

Refer for Individualized Assessment

This guideline is especially important for older children or those who have not responded to early

intervention. The assessment should include standardized and well-validated tests to determine the

child’s level of functioning and relative strengths and weaknesses in both cognitive and academic

domains. Reliance on an IQ–achievement discrepancy as the sole requirement for diagnosing LD,

however, is not advised given ample evidence that this discrepancy is not particularly informative,

is psychometrically problematic, and is typically unrelated to intervention outcomes (Fletcher et al.

2002).

Opt for Evidence-Based Treatments

There is a growing understanding that evidence-based interventions are of maximal benefit both for

helping the individual child and for moving the field of treatment research forward. The U.S. federal

No Child Left Behind Act of 2001 calls on practitioners to use scientifically based research in their

decision making and intervention practices. The best research design for evaluating an

intervention’s effectiveness is a randomized controlled trial, and treatments that stand up to this

test should be recommended over those that do not. Although specific recommendations are

included in the discussion of LD subtypes below, general guidelines on how best to determine if an

intervention is evidence-based may be helpful to both clinicians and families advocating on behalf

of their child. This information is available in peer-reviewed journals and academic books as well asPrint: Chapter 8. Learning Disorders http://www.psychiatryonline.com/popup.aspx?aID=252476&print=yes…

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through the What Works Clearinghouse, which hosts a Web-based informational site created by the

U.S. Department of Education, Institute of Educational Science (www.w-w-c.org).

Track Response to Treatment Over Time and Design Treatments to Target

Particular Aspects of Development Within an Academic Domain

Gains resulting from a specific intervention may be differentially maintained over time, and

academic demands change as a child progresses. Thus, a specific intervention may be helpful for a

particular child at one age but not address issues that arise at a later age. For example, while the

core deficit of reading disorder is typically difficulty with recognizing and manipulating the

individual sounds in words (phonological awareness), intervention should go beyond this specific

skill and include other aspects of reading as the reader progresses. In addition, given that there is

no “one size fits all” treatment for LD, tracking an individual child’s response to treatment and his

or her progress across academic and developmental domains is essential.

TREATMENTS FOR LEARNING DISORDER

Reading Disorders

Reading disorder or disability (RD) occurs in isolation or in combination with another LD in

70%–80% of children with LD (Lyon et al. 2003). Reading difficulties can be encountered at several

levels, including problems with recognizing and decoding single words, comprehending continuous

text, or reading speed and fluency. There is now widespread consensus among reading researchers

that the core deficit for RD is difficulty with phonological awareness—the ability to recognize and

manipulate individual sounds in words (Mody 2003). Awareness of individual sounds in words is

important for learning to associate sounds to the letters that represent them in print. Thus,

phonological awareness is a necessary, though not sufficient, first step to reading acquisition. Given

its importance, many interventions for RD focus on enhancing phonological awareness. This is often

coupled with phonics training in which children are taught the correspondence between letters and

sounds when “sounding out” unfamiliar words and spelling patterns typically used to represent

these sounds. In a review and meta-analysis of research studies on reading interventions and

instructional approaches, the National Reading Panel concluded that phonemic awareness

instruction produced improvements in reading development in both young normally achieving

children and older RD children (Ehri et al. 2001; National Reading Panel 2000). Furthermore, they

reported that the most effective instruction was direct, explicit, and systematic (rather than

unstructured), focused on a limited set of phonemes at one time, and took place in small groups or

with one-to-one instruction. They went on to warn, however, that phonemic awareness training

should constitute a part and not the whole focus for reading intervention. Other aspects of reading,

including instruction in letter-sound correspondences, reading fluency, and comprehension, are also

required.

The National Reading Panel noted that systematic phonics instruction (e.g., instruction involving

tightly controlled and sequentially organized instructional materials) was superior to more

incidental approaches in which phonics are highlighted as they are encountered in text (National

Reading Panel 2000). Systematic phonics instruction was shown to have benefits for students

across a range of grades, abilities, and income levels. Phonics instruction was clearly identified as a

means to an end, however, in that it is a tool for helping children learn to decode text. As with

phonological awareness, phonics instruction needs to be applied to reading and spelling and should

not be the sole focus for intervention. These findings provide clear support for the importance of

providing structured and focused instruction in phonics and phonemic awareness as part of the

treatment for children with RD. In addition to school-based programs, many commercial treatment

programs are available that target phonological processing skills. A recent critical review article on

treatments for dyslexia by Alexander and Slinger-Constant (2004), for example, includes listings of

web sites featuring reviews of commercially available programs, including an excellent site

reviewing a number of commercial programs from the Torgesen Center for Reading Research

(www.fcrr.org).

Instructional strategies for reading skills beyond single-word decoding were also reviewed by thePrint: Chapter 8. Learning Disorders http://www.psychiatryonline.com/popup.aspx?aID=252476&print=yes…

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National Reading Panel. These included providing vocabulary instruction, often enhanced by use of

computers, and explicitly teaching a combination of text comprehension techniques (National

Reading Panel 2000). There is empirical support for a reading comprehension disability subtype of

RD in which comprehension difficulties occur while word recognition skills are not impaired (Lyon

et al. 2003). It less clear, however, how well the teaching strategies identified by the National

Reading Panel will generalize to children whose RD is specific to reading comprehension disability.

Studies of RD children who have adequate single-word reading skills but are impaired in

comprehension indicate that this subgroup of children have problems in oral language skills,

including problems with vocabulary knowledge or semantics (Nation and Snowling 1998), syntax

(Stothard and Hulme 1996), inferencing (Nation and Norbury 2005), and syntactic comprehension

(Nation and Snowling 1998). A comprehensive assessment that includes oral language functioning

as well as assessment of reading skills beyond reading of single words is recommended for all RD

children.

While less research has focused on treating the comprehension-based subtype of RD, some

promising results have been reported. Yuill and Oakhill (1988), for example, reported that an

intervention targeting inference making from text was superior to both standard comprehension

and word decoding training for comprehension-impaired RD children. Given that the core difficulties

associated with comprehension RD appear to lie in nonphonological language skills (Nation and

Norbury 2005), targeting these directly through language therapy warrants further investigation.

Finally, the rate or fluency with which children read has implications for reading comprehension.

Children with RD are also exposed to less text than their average reading peers, in part because

their reading difficulties reduce the likelihood that they will read for pleasure or be able to master

longer, more challenging texts. Thus, intervening to improve reading rate can have numerous

benefits. To date, the most efficacious method to improve fluency in both normally developing

readers and those with RD is the repeated reading method (Samuels 1979). This technique, which

is easily adapted for use both in the home and in school, involves having the child repeatedly read a

passage of text aloud until he or she is able to do so fluently and accurately. Assisted repeated

reading has been shown to enhance fluency when the child is reading along with an adult, skilled

peer, or audio recording of the text (Shany and Biemiller 1995; Young et al. 1996). The text chosen

for rereading should be easy enough that the child can read most of the words accurately.

Taken together, the research to date clearly indicates that most efficacious treatments for RD are

structured, targeted interventions addressing core deficits in the areas of phonological awareness

and phonemic decoding skills, comprehension skills, and reading fluency. It is important to note,

however, that not all children will respond to these interventions (Torgesen 2000). In fact, lack of

response to intervention has been proposed as an alternative to the widely used, although much

criticized, ability–achievement criteria for identifying a child as RD (e.g., Speece and Case (2001).

More research is required, however, to clarify how best to treat children with treatment-resistant

characteristics. Increasing the intensity or frequency of established interventions may be helpful,

although this is yet to be demonstrated. The impact of learner characteristics on treatment

responsiveness underscores the need for thorough assessment and follow-up of children even after

they have received treatment.

Mathematics Disorders

It has been estimated that 5%–8% of school-aged children have some form of mathematics

learning disorder (MD) (Geary 2004). Children can encounter difficulties in math for a variety of

reasons, and as a group, children with MD are highly heterogeneous. Diagnosis of MD is typically

based on underachievement on standardized measures of math achievement that contain an array

of problem types. Thus, two children with MD may have very different patterns of strengths and

weaknesses (Geary 2004). Children with a history of language impairment (Fazio 1996; Young et

1. (2002) and those with RD are also prone to having difficulties in math, with estimates of overlap

between RD and MD as high as 50% (Badian and Ghublikian 1983). Children with both disorders

tend to have lower math achievement and to progress in math skills more slowly than those withPrint: Chapter 8. Learning Disorders http://www.psychiatryonline.com/popup.aspx?aID=252476&print=yes…

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MD alone (Jordan et al. 2003). This is important, because understanding the cognitive underpinning

of MD in both the combined RD–MD and the MD-only subtypes is essential to treating these

disorders.

Geary (2004) identified three types of problems associated with MD. The first, labeled a procedural

subtype, is characterized by difficulties executing math procedures such as counting strategies for

addition or borrowing for subtraction. In the early grades, these procedures include counting and

learning the rules that underlie effective counting, such as knowing that the order in which items

are counted is irrelevant. Geary (2004) determined that children with MD use more immature than

atypical procedures, such as finger counting when solving simple arithmetic problems, show an

incomplete understanding of underlying concepts in procedures, and make frequent execution

errors. Problems with working memory and executive functions (e.g., planning and self-monitoring)

may also contribute to procedural deficits (Geary 2004).

The second class of problems, for children with both MD and RD, involves representing and

retrieving number facts from long-term memory (Geary 2004). These number fact difficulties are

associated with a high error rate and slow performance. Unlike the procedural problems that tend

to improve with age, these memory problems tend to persist, even with extensive practice (Howell

et al. 1987). Given the association with both RD and language disorders (Fazio 1996), phonological

processing and verbal working memory have been posited as likely contributors. A two-factor

model has also been proposed in which number sense, or a child’s ability to understand number

sequences and concepts, may underlie the number fact difficulties of children with MD alone, while

weak phonological skills may underlie these difficulties in children with comorbid MD and RD

(Robinson et al. 2002).

The third possible subtype of MD described by Geary (2004) involves visuospatial processing

difficulties that are posited to interfere with spatial aspects of math, including using geometry

concepts and aligning number columns. Despite the finding that many children with MD, especially

those without co-occurring RD, have some difficulty with visuospatial processing (Rourke 1993),

recent examinations have not supported separate spatial representation and math processes

(Geary et al. 2000).

In keeping with the differing demands of math problem solving across different ages and grades,

interventions typically target a specific set or subset of skills. At the youngest ages, intervention is

focused on preparatory arithmetic skills and number sense (Gersten et al. 2005). Intervention and

treatment for older children with MD are often focused on developing fluency and accuracy with

number facts. A key feature of effective treatment is moving the child with MD away from relying

on finger counting toward using retrieval or other more mature strategies (e.g., Hasselbring et al.

1988). Thorough assessment of an individual child’s acquisition of basic number concepts and

strategies is essential for targeting intervention appropriately.

Improvements in more complex math problem-solving skills can be facilitated through the use of a

highly structured program on problem-solving skills (e.g., problem content, labeling, computation).

Effective intervention must explicitly teach rules for transferring solutions to novel problems and

self-regulation of problem-solving performance (Fuchs et al. 2004). Learner characteristics play an

important role in response to treatment, however, as children with combined MD and RD have been

found to respond less to this intervention than those with MD alone (Fuchs et al. 2004). Thus, as

with all other treatments for MD, examination of the learner characteristics is an essential first step

before initiating any intervention.

Written Expression Disorders

Given the complex nature of writing, the characteristics of disorders of written expression (WLD)

also vary widely. Problems with motor control, for example, make the mechanics of writing difficult,

while language-based difficulties can negatively impact the representation of letters and words in

text, spelling, grammar, and punctuation (Berninger and Amtmann 2003). All of these difficulties

affect the speed or fluency with which an individual with WLD can perform writing activities.Print: Chapter 8. Learning Disorders http://www.psychiatryonline.com/popup.aspx?aID=252476&print=yes…

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Finally, higher-level skills, such as planning, generating and organizing ideas into text, and

reviewing and editing, have all been shown to be particularly problematic for individuals with WLD

(Graham and Harris 2003). Although there is a high degree of overlap between RD and WLD, these

disorders do not always co-occur, and WLD can be a unique area of difficulty for some individuals

(James and Selz 1997).

Treatments for WLD can be roughly divided into two main areas: those that focus on transcription

(i.e., the production of letters and spelling) and those that focus on composition skills (e.g., idea

generation, organization, and editing). These interventions are far from independent, however, as

improvements in lower-level skills, like handwriting speed and accuracy, can free up resources for

other writing components, such as planning and reviewing (Berninger and Amtmann 2003).

Educational and remedial interventions for transcription problems include direct modeling of letter

formation followed by extensive practice to enhance automaticity. Effective handwriting training

has also been shown to improve composition fluency and quality (Berninger et al. 1997). Spelling

interventions typically include a combination of training in phonological awareness,

phoneme-spelling correspondences, and direct instruction in spelling convention rules (for a

review, see Berninger and Amtmann 2003).

A particularly promising approach to improving composition skills of individuals with WLD involves

explicitly teaching the same strategies for writing used by skilled writers. A recent review and

meta-analysis of this approach, called Self-Regulated Strategy Development (SRSD), revealed

substantial improvements in the quality of writing produced by individuals with WLD (Graham and

Harris 2003). Key components of SRSD include direct instruction in identifying and using effective

writing strategies and enhancement of self-regulation by modeling and instructing students to

memorize and repeatedly apply strategies so that they can use them independently in their writing.

Finally, given that writing problems tend to persist even with intervention (Silver 1995),

accommodations—including extra time allowances on tests and written assignments and access to

computers for word processing—are important for the academic and vocational success of

individuals with WLD. It is important to note, however, that, as pointed out by Berninger and

Amtmann (2003), computer technology may not be a “quick fix” for writing problems. Issues to

consider include the individual’s needs and abilities, the likelihood that computer technology will be

feasible in addressing these needs, the time and resources needed to make use of the technology,

and the environment in which the tool will need to be used.

COMORBID DISORDERS: APPROACH TO INTERVENTION

Children with LDs are at increased risk for other psychiatric disorders, including emotional and

behavioral disorders and social difficulties that interfere with their functioning in a variety of

domains. This increased risk for psychiatric disorders has been reported in both clinical and

community samples (Beitchman and Young 1997; Young and Beitchman 2002) and is documented

for a range of diagnoses. Although the most extensive evidence relates to comorbidity with

disruptive behavior disorders, in particular attention-deficit/hyperactivity disorder (ADHD) and

conduct disorder, studies have also reported increased rates of anxiety disorders (Willcutt and

Pennington 2000) and depression (Boetsch et al. 1996; Maughan et al. 2003).

Internalizing disorders, particularly anxiety and depression, also frequently co-occur with LDs,

although this area has received considerably less research attention than that of behavioral

disorders. Adolescents with LDs have been shown to have higher levels of trait anxiety (reviewed

by Huntington and Bender 1993) than adolescents without LDs. Furthermore, children with an early

history of speech and/or language delay, a condition often predictive of later LD, are at twice the

risk of developing anxiety disorders during young adulthood compared with control subjects

without speech and language delays (Beitchman et al. 2001b).

The appropriate assessment of LDs includes the assessment for comorbid psychiatric disorders and

related behavioral and emotional difficulties. For children who require intervention for a comorbid

condition, some general principles apply.Print: Chapter 8. Learning Disorders http://www.psychiatryonline.com/popup.aspx?aID=252476&print=yes…

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The least intrusive approach should be the first form of intervention. This may involve home and

family intervention if there is evidence that interpersonal conflicts or anxieties within the family

contribute to or maintain the current level of symptoms. For example, a child may feel anxious that

he or she cannot live up to the high standards of an older, academically advanced sibling. Helping

the parents and child to accept realistic expectations is an important step toward reducing the level

of the child’s comorbid symptoms.

Parent support and management training may be needed to help the family develop a supportive

home environment and a consistent home/school reinforcement program. An important corollary

for successful treatment when behavioral or emotional difficulties are comorbid is to help the

parents and school appreciate the intimate connections between the learning problems and the

child’s behavioral and emotional problems.

Modifications of the classroom environment should always be considered in formulating treatment

for LD children with comorbid conditions. For the LD child with ADHD, placing the child near the

front of the class in clear view of the teacher and reducing the level of distractibility for the child

are important components in the overall approach to intervention. This may also include placing the

child in a small class, with an increased staff-to-child ratio.

Individual treatment of the child or adolescent should include goals of minimizing disability and

maximizing potential through problem solving, social support, study habits, encouragement in

extracurricular athletic or other activities, and help with further educational and career decisions.

Once it is determined that environmental interventions, including home, school, and family

approaches, have not achieved the desired result, additional approaches may include the use of

medication. When psychotropic medication is prescribed to a child with an LD, special attention

must be given to the therapeutic effects and the side effects that may influence a child’s cognitive

function, attention, learning, and memory. No known medications are specifically indicated for the

treatment of LDs. Still, removing behavioral or emotional barriers may lead to increased task time

and hence improved academic progress.

For children with a concurrent ADHD disorder, successfully treating the ADHD will usually lead to an

improved response to the demands of the learning environment. Stimulant medication is the most

effective treatment for ADHD (American Academy of Child and Adolescent Psychiatry 2002; Jensen

et al. 2001). The choice, timing, and dose of medication will depend on the severity of the child’s

symptoms, the portion of the school day during which the symptoms interfere with classroom

performance, and the size and weight of the child. Available medications range from single-dose,

immediate-release methylphenidate to a variety of new once-a-day, long-acting, extended-release

formulations, which include OROS-methylphenidate (Concerta) and Adderall (American Academy of

Child and Adolescent Psychiatry 2002). Although more expensive, these new stimulant formulations

are easier for patients to use than older stimulants, are more resistant to abuse and misuse, and

allow for increased privacy of ADHD treatment at school (Connor and Steingard 2004). Other

medications, such as atomoxetine, have also been shown to be effective in the treatment of

children with ADHD (Michelson et al. 2002, 2003) and would be considered second-line choices.

However, with recent concerns about an increase in suicidal thinking, close clinical monitoring is

essential.

Because ADHD is also commonly comorbid with other externalizing disorders such as oppositional

defiant disorder (ODD) and conduct disorder, comprehensive treatment options should include

cognitive-behavioral therapy (CBT) approaches, behavioral monitoring, and parent management

training (e.g., Farmer et al. 2002). Remediating the LD may lead to improvements in behavioral

symptoms in some children, while modifying the academic expectations to be more in keeping with

the child’s current level of functioning may also assist in reducing the child’s oppositional and

acting-out behaviors. Finally, opportunities to pursue and develop athletic, musical, or other

abilities can help improve the child’s self esteem and reduce acting-out behaviors.

Anxiety disorders also commonly occur among children with LD. The reasons are poorly understood,Print: Chapter 8. Learning Disorders http://www.psychiatryonline.com/popup.aspx?aID=252476&print=yes…

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but it is likely that in many instances the anxiety is related to the child’s difficulty in the learning

environment. This may be performance anxiety, anxiety about speaking in front of the class, and

anxiety about becoming a skilled reader. Helping a child to acquire these skills and master the

requisite tasks will help reduce the level of the child’s anxiety.

Individual or group CBT for anxiety disorders should be available for children with continuing

symptoms (Compton et al. 2004), with medication as an additional option. Although the use of

selective serotonin reuptake inhibitors (SSRIs) has generated considerable controversy because of

concerns regarding increased suicidal ideation and attempts, these agents should nevertheless be

considered as a treatment alternative if the child continues to show anxiety and responds poorly to

nonpharmacological interventions. Close clinical monitoring of the child’s response to the SSRI is a

must, especially in the early stages of treatment.

Emotional problems, including low self-esteem, elevated rates of depression, and dysthymia, have

also been associated with RD (American Psychiatric Association 1994; Maughan et al. 2003). The

treatment of the associated dysthymia/depression would include appropriate attention to

environmental factors that contribute to and maintain symptomatology and the use of CBT and

other psychotherapeutic approaches as appropriate. SSRIs—in particular, fluoxetine—should be

considered for a child with comorbid depression who is unresponsive to psychosocial interventions

(March et al. 2004). As noted above, careful monitoring of the child’s response to the medication is

imperative given concerns regarding an increase in suicidal thinking and attempts. Although these

agents are not approved for use with children, sertraline or citalopram should be considered as a

second-line medication (National Institute for Health and Clinical Excellence 2005).

Finally, as the child with LD matures into adolescence, it is important to assist him or her in

learning to advocate for himself or herself because these skills will increase his or her chances of

success into adulthood. In treating adolescents, it is important to be aware of coexisting disruptive

behavior disorders, mood and anxiety disorders, and substance use disorders, which may lead to

school dropout, truancy, and delinquency (Beitchman et al. 2001a, 2001b). Prevocational and

vocational skill development may be needed, and helping the family to evaluate the need and/or

potential for postsecondary education is an appropriate role for the clinician (Scott 1994).

Multimodal treatment based on assessment of all clinical factors has been shown to improve

children’s academic, behavioral, and emotional adjustment (Osman 1997). Direct treatment is

warranted for concurrent psychiatric and other secondary emotional and social problems (Kauffman

1997). Studies suggest that children and adolescents with LD who received specialized attention at

school, support at home, and mental health services when warranted had the most positive

outcomes (Osman 2000). Educational and clinical services must be coordinated and individualized

to achieve the most effective outcome.

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