Chapter- 39Learning Disorders

Introduction

• Define learning disorders• Learning disorders in a child or

adolescent are characterized by academic underachievement in reading, written expression, or mathematics in comparison with the overall intellectual ability of the child.

• 5% of school-age children

The most recent revised version of the DSM-IV (DSM-IV-TR) includes

four diagnostic categories

• reading disorder,• mathematics disorder, • disorder of written expression, • learning disorder not otherwise

specified.

Reading Disorder• 75 percent of children and adolescents

with learning disorders• Defined as reading achievement below

the expected level for a child's age, education, and intelligence, with the impairment interfering significantly with academic success or the daily activities that involve reading.

characterized by

• an impaired ability to recognize words,

• slow and inaccurate reading, • poor comprehension

• children with ADHD are at high risk for reading disorder

• The term Developmental alexia was accepted and defined as a developmental deficit in the recognition of printed symbols.

• Dyslexia was used extensively for many years to describe a reading disability syndrome that often included speech and language deficits and right-left confusion.

Epidemiology

• 4 percent of school-age children in the United States have reading disorder

• Three to four times as many boys as girls are reported to have reading disability

Comorbidity

• 25 percent of children with reading disorder also have ADHD.

• Family studies indicate, ADHD and reading disorder may be genetically transmitted together.

• Children with reading disorders have higher than average rates of depression on self-report measures and experience higher levels of anxiety symptoms than children without learning disorders.

Etiology

• most accurately described as a neurobiological disorder with a genetic origin.

• Children with reading disorders are slower than average in naming letters and numbers, even when controlling for IQ.

• Given that reading disorder is essentially a language deficit, the left brain has been hypothesized to be the anatomical site of the dysfunction.

Etiology • Positron emission tomographic (PET) studies have led

some researchers to conclude that left temporal blood flow patterns during language tasks differ between children with and without learning disorders.

• The hypothesis that genetic factors play a major role in the presence of reading disorders.

• recent studies have suggested that phonological awareness (i.e., the ability to decode sounds and sound out words) is linked to chromosome 6.

Etiology • the ability to identify single words has been

linked to chromosome 15.• Impairment in reading spelling has now

been linked to chromosomes 1, 2, 3, 6, 15, and 18.

• The first myth is that reading disorders are primarily caused by visual-motor problems, or what has been termed scotopic sensitivity syndrome.

Etiology • Complications during pregnancy and prenatal

and perinatal difficulties are common in the histories of children with reading disorder.

• Extremely low birthweight and severely premature children are at higher risk.

• Recent evidence suggests that certain peptides, such as those derived from activity-dependent neurotrophic factor-12, may mitigate alcohol-induced fetal death and developmental learning disabilities.

DiagnosisDSM-IV-TR Diagnostic Criteria for Reading Disorder

A.Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

B.The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills.

C.If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Clinical Features

• identified by the age of 7 years (second grade).

• Children with reading disorder make many errors in their oral reading.

• The errors are characterized by omissions, additions, and distortions of words.

• Children have difficulty in distinguishing between printed letter characters and sizes, especially those that differ only in spatial orientation and length of line.

Clinical Features

• Associated problems include language difficulties, exhibited often as impaired sound discrimination and difficulty in sequencing words properly.

• Older children tend to be angry and depressed and exhibit poor self-esteem.

•Case

Pathology and Laboratory Examination

• Psychoeducational testing is critical in determining this diagnosis

• standardized intelligence test • an educational assessment of achievement. • diagnostic battery generally includes a

standardized spelling test, written composition, processing and using oral language, design copying, and judgment of the adequacy of pencil use.

Differential Diagnosis

• often accompanied by comorbid disorders: • expressive language disorder, • disorder of written• expression, and ADHD.• expressive language disorder or • mixed receptive-expressive language disorder• Hearing and visual impairments should be

ruled out with screening tests.

Treatment

• focus a child's attention to the connections between speech sounds and spelling.

• Improvements were noted on measures of reading accuracy, reading comprehension, reading efficiency, passage reading fluency, and spelling.

• After individual letter-sound associations have been mastered, remediation can target larger components of reading such as syllables and words.

• individual education program (IEP)

Treatment

• Reading instruction programs such as the Orton Gillingham and Direct Instructional System for Teaching and Remediation (DISTAR).

• As in psychotherapy, the therapist patient relationship is important to a successful treatment outcome in remedial educational therapy.

Mathematics Disorder

• have difficulty learning and remembering numerals, cannot remember basic facts about numbers, and are slow and inaccurate in computation.

• Poor achievement in four groups of skills have been identified in mathematics disorder:

1) linguistic skills 2) perceptual skills 3) mathematical skills 4) attentional skills

• A variety of terms over the years, including dyscalculia, congenital arithmetic disorder, acalculia, Gerstmann syndrome, and developmental arithmetic disorder have been used to denote the difficulties present in mathematics disorder.

Epidemiology

• 1 of every 5 children with learning disorder

• 6 percent of school-age children have some difficulty with mathematics

• Mathematics disorder may occur with greater frequency in girls

Comorbidity

• commonly found comorbid with reading disorder and disorder of written expression.

• mathematics disorder may also be at higher risk for expressive language disorder, mixed receptive-expressive language disorder, and developmental coordination disorder.

Etiology• partly caused by genetic factors.• neurological deficit in the right

cerebral hemisphere, particularly in the occipital lobe areas.

• the cause is thought to be • multifactorial,• maturational,• cognitive, • emotional, • educational, and • socioeconomic factors

Diagnosis• a child's skills in mathematics fall

significantly below what is expected.• a child's skills in mathematics fall

significantly below what is expected.• Conceptual skills involve recognition of

mathematical symbols and being able to use mathematical signs correctly.

• Computational skills include the ability to line up numbers correctly

• A definitive diagnosis can be made only after a child takes an individually administered standardized arithmetic test and scores markedly below the level expected

Clinical FeaturesDSM-IV-TR Diagnostic Criteria for Mathematics Disorder

A.Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

B.The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require mathematical ability.

C.If a sensory deficit is present, the difficulties in mathematical ability are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

•Case

Pathology and Laboratory Examination

• educational testing.• standardized measurement of

intellectual function.• Keymath Diagnostic Arithmetic

Test

Differential Diagnosis• must be differentiated from global

causes of impaired functioning such as mental retardation syndromes.

• accompanied by generalized impairment in overall intellectual functioning.

• Inadequate schooling can often affect a child's poor arithmetic performance.

• Conduct disorder or ADHD can occur with mathematics disorder and, in these cases, both diagnoses should be made.

Treatment• teaching mathematics concepts

with continuous practice in solving math problems.

• Flash cards, workbooks, and computer games can be a viable part of this treatment.

• Project MATH, a multimedia self-instructional or group-instructional in-service training program, has been successful

Disorder of Written Expression

• the most complex skill acquired to convey an understanding of language and to express thoughts and ideas.

• the most complex skill acquired to convey an understanding of language and to express thoughts and ideas.

• Spelling mistakes are most often phonetic errors

Disorder of Written Expression

• Historically, dysgraphia (i.e., poor writing skills) was considered to be a form of reading disorder.

• Evidence indicates that disorder of written expression can occur.

Comorbidity

• Children with writing disorder are at higher risk.

• mathematics disorder, and expressive and receptive language disorders can occur.

• ADHD occurs with greater frequency in children with writing disorders than in the general population.

Etiology

• a deficit in the use of the components of language related to letter sounds.

• the combined effects of one or more of the following:

• expressive language disorder, • mixed receptive-expressive

language disorder,• reading disorder.

Diagnosis

• based on a child's poor performance on composing written text

• addition to spelling mistakes, a child with writing disorder may have serious grammatical mistakes, such as using incorrect tenses, forgetting words in sentences, and placing words in the wrong order.

• child may have poor ability to remember which words begin with capital letters.

Clinical FeaturesDSM-IV-TR Diagnostic Criteria for Disorder of Written Expression

A.Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.

B.The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).

C.If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Pathology and Laboratory Examination• educational testing

• Currently available tests of written language include • Test of Written Language (TOWL), • DEWS, • Test of Early Written Language (TEWL).

• A child suspected of having disorder of written expression should first be given a standardized intelligence test, such as WISC-III or the revised Wechsler Adult Intelligence Scale (WAIS-R) to determine the child's overall intellectual capacity.

Differential Diagnosis

• such as ADHD or a depressive disorder.• Common associated disorders are • reading disorder,• mixed receptive-expressive language disorder,• expressive language disorder,• mathematics disorder, • developmental coordination disorder, • disruptive behavior disorder and ADHD.

Treatment

• direct practice in spelling and sentence writing.

• review of grammatical rules. • Intensive and continuous

administration of individually tailored.

• one-on-one expressive and creative writing therapy.

Learning Disorder Not Otherwise Specified

Diagnostic Criteria for Learning Disorder Not Otherwise Specified

This category is for disorders in learning that do not meet criteria for any specific learning disorder.

This category might include problems in all three areas (reading, mathematics, written expression) that together significantly interfere with academic achievement even though performance on tests measuring each individual skill is not substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.

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