Learning Disorders, Learning Disabilities

by James Chandler, MD, FRCPC

What is a learning Disorder?

Steps in learning

More about Learning disorders

What causes a learning disorder or a learning disability?

Prevalence

Co-morbidity

Diagnosing learning disabilities and learning disorders

Prognosis

Specific learning disorders

What can be done?

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Learning Disabilities, Learning Disorders

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Jim Chandler, FRCPC, MD

What is a learning disorder?

If you have a learning disorder, it means that for someone who is as smart as you, you are especially bad at something. Here are three examples which should explain what this is and what it is not.

Doug is 8 years old. He can not read. He knows his letters, but still is stuck at a grade 1 level in reading. He also is poor in math. He is more clumsy than most children his age. He has a limited vocabulary. His memory is not that good. His printing is very poor. There is nothing that Doug does which is up to what a person would expect of an 8 year old boy. He has always been behind, and he is a very slow learner.

This is the profile one sees in mental retardation. That is, Doug is poor at reading, but he is no worse at reading than he is at everything else. I would not say that Doug has a learning disorder

Christian is also 8. He can not read either. He knows his letters, but when he reads he reads backwards, skips lines, and can't seem to understand how words are organized on the page. He is good in math, loves to build things, is a good drawer, has a good vocabulary and is on two sports teams.

Christian has a learning disorder in reading. He is of overall average intelligence and his reading is much worse than what you would expect of a person who is of average intelligence.

Karen is also 8. She can not read in school, however her mom swears she can at home. She knows the letters and sounds, but doesn't pay attention to what she is doing and gives up. She has a hard time paying attention to other things, too. She is interested in horses. Once she found a book about horses that she was very interested in reading, she read it without problem and shocked her teacher.

Karen has Attention Deficit Disorder. Although some children have ADD and a learning disorder, she just has ADD. That is, she has no problem reading, if she can pay attention.

In a class room all three of these children can not read, but only one has a learning disorder. I could have cited many more causes of not reading which are not learning disabilities. Perhaps the most obvious other cause is not being able to see properly. Here is the clinical definition of a learning disorder. I will use reading as an example, but I could also use writing, math, coordination or memory.

a. Reading skills, as measured by an individually administered test, is substantially below that which is expected, given the person's chronological age, measured intelligence, and age-appropriate education.

b. The disturbance in reading significantly interferes with academic achievement or activities of daily living that require reading

c. If a sensory deficit is present ( hearing loss, vision problems) the learning difficulty is in excess of what one would expect.

The learning disorders are grouped by skills. That is there is a learning disorder for each of the major skills. There is a Developmental Reading Disorder, A developmental Mathematics Disorder, a developmental disorder of written expression, and a developmental coordination disorder. There are also language disorders which follow the same pattern.

What is the difference between a learning disorder and a learning disability?

Learning disabilities are the basic brain functions which are abnormal in a child with a learning disorder. A learning disability is what makes up a learning disorder. A learning Disorder is what you see is wrong from the outside. You see a child that can not read, write, do math, or run properly. The best way to understand this is to see what the learning disabilities are. To understand this, you have to know a little bit about how we currently think people use their brains to learn. click here to go to contents

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Steps in learning

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To learn something a number of things need to happen. Problems at any level can lead to a learning disability. Here are the steps in the usual order. If the brain ins not functioning correctly at any of these steps, we call it a learning disability.

Step 1 Attention

If you can't pay attention to something, you are not going to be able to learn. This learning disability has special status. It is called Attention deficit Hyperactivity disorder (ADHD).

Step 2 Perception

We perceive things through our eyes, ears, nose, mouth and skin. If we do not perceive them correctly, we can't learn. If you can not perceive the difference between a toothbrush and a comb, you can not learn to brush your teeth. There can be problems at different levels of perception. For hearing, the problem could be not hearing due to wax, ear infections, or damage to the ear. It also could be a problem in distinguishing sounds such as the difference between "ch" and "sh".

The same can apply to vision. A person may not see well because there is something wrong with their eyes, but another possibility is that their brain has a hard time things. Other types of visual perception problems are not being able to tell what is in front and what is in back. Another common one is not being able to figure out what is important and what is the background. or distinguishing what is important from what is just backround. If you can not tell a "p" from a "q", it is very hard to read. If a "9" looks the same as a "6", math is very hard. These are examples of visual perception problems.

Processing refers to the ability to filter out unimportant sounds and attend to what you want to. For example, an Auditory processing problem might show up as an inability to focus on what the teacher is saying when other children are talking or someone is mowing a lawn outside the window. A visual processing disorder might make it difficult to read and process the instructions on the board when there are other things written there.

Step 3 - Integration

Once you perceive something correctly, you need to do three things to make sense of it. You must place it in the right order , understand what the context is (abstraction), and then join it with other perceptions and your old memories (organization). You can have a learning problem with any of these things.

Sequencing (ordering)

What is the difference between "god" and "dog"? The order of the letters. Reading requires constant attention to what direction you are going. Likewise many tasks such as math problems and computers require strict attention to ordering. A child might know the days of the week, but not be able to say them in order.

Abstraction (placing in context)

How do you tell the meaning of the word "run"? You need to know the rest of the sentence to know which of the many meanings apply. People with this problem have difficulty with all the concepts which they can not see or hear. Understanding geometry concepts is a good example.

Organization

To live and learn efficiently, different concepts need to be put in order or importance. They have to be related to things we already know or else we can not "retrieve" them from our minds when we need them. Without organization, the brain works like a messy room. That is, you can't find anything that you are looking for and you get sidetracked by what you do find.

Step 4 Memory

Long term memory is not effected in learning disabilities. Short term memory can be. Even if you finally understand how to measure the height of a tree using angles and a tape measure, it will do you no good if you can't recall it. We all recall better when we repeat something over and over. People with short term memory problems have to repeat things over and over until they finally have it stuck in their brain. However, once it is "stuck" in their mind, it stays there. Some people have auditory (hearing) memory problem. They can't recall what they hear. Others have visual (seeing) memory problems. They can't recall what they see.

Step 5 Output

Just as it may be hard to get information into the brain accurately and efficiently, it can also be hard to get information out of the brain. A common one is language problems where people can not speak is well as they should for their intelligence. Others have horrible problems with the coordination of the small muscles of their hands which can cause problems like a learning disability for writing. Others have trouble making their larger muscles coordinate. They would be clumsy and have trouble with sports.

The learning disorders are made up of each of the above elements. Sometimes one or two are present, sometimes five or six. Whereas two children both might have the same Reading disorder usually it is caused by a different combination of the learning disabilities. For example,

Kevin is 10 years old. He reads at a grade two level. An assessment shows that this Developmental Reading Disorder is made up of learning disabilities in visual perception (He can't tell "b" from "d"), Visual sequencing (He reads backwards sometimes), and Auditory perception ( He things "ch" and "sh" sound the same).

Laura is 10 years old. She also reads at a grade two level. This is due to very severe learning disability in visual short term memory. She can read fine, but in order to recall and comprehend, it takes ten readings of a passage.

To make things confusing, some people use the term learning disability for both learning disorders and learning disabilities.

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 What causes a learning disorder or a learning disability?

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A learning disability is caused by the brain not working correctly. Some of these learning disabilities actually involve multiple sites in the brain and often can involve different sites in men and women. This damage to the brain can be genetic or it can be caused by problems at birth or during pregnancy. Alcohol exposure during pregnancy can cause this damage, too. The nerve cells aren't where they are supposed to be, the cells are not organized correctly, and some are missing. If a child has a stroke and ends up with deficits like a learning disability, we don't call it that, even though it may look exactly like a learning disability. Learning disabilities can be strongly inherited. In the case of reading disabilities, 35-45 % of the family members will have a learning disability in reading (1) In some cases, if a father has a learning disability, half their children will also.

What can look like a learning disability but really isn't? In other words, could it really be a brain tumor or something like that?

People are born with learning disabilities. They do not increase in number with time or suddenly appear in a child who has always shown no evidence of a learning disability. If there is a pattern like this, many, many tests are done to determine if a tumor, stroke, unusual blood vessel growth, or some other disease is the cause. However, if the signs of the learning disability have been present lifelong and are unchanging, you can be sure it is not caused some other neurologic disease.

On the other hand, there are some things that can make a mild learning disability lots worse. Family chaos, drugs and alcohol, malnutrition, other neuropsychiatric disorders, abuse, and sickness and death in the family can worsen any learning disability.

Definition

No one can quite agree what a Learning Disability is. Each country and different groups in each country may use a different standard. It is quite likely that two groups will not agree whether or not someone has a Learning Disability as a result. Overall, it means that someone is having major problems with some aspect of learning when one would not expect that given their overall intelligence. Even this can be hard to define. For example social skills and coordination are much harder to define normal values for than reading and arithmetic.

Prevalence

How many children have learning disorders? It is hard to say because no one can agree how far behind you have to be to in the disorder category. Using two grade levels behind where they should be, 10-20% of all persons have a learning disorder. This makes it by far the most common neuropsychiatric disorder. About 2-10% of children have a reading disability. About 1-6 % have an arithmetic disorder. Girls are more likely than boys to have an arithmetic disorder. Learning disabilities in written expression are found in 2-8% of children, with three times as many boys as girls. (1)

Co-morbidity

Co-morbidity means that certain diseases and disorders tend to occur together. For example heart disease and stroke often occur in the same person. There are many neuropsychiatric disorders which tend to occur together. This is very sad, because it is bad enough to have a learning disorder, much less one to three other neuropsychiatric disorders. About 50% of children with Learning Disabilities have another neuropsychiatric disorder. If you have seen me, your child probably has at least two disorders, counting the learning disorder. Your child may have five. Assessing children for only learning disabilities and learning disorders without looking for other co-morbid conditions is a waste of time. The most important advances in pediatric psychiatry have been the result of researchers carefully checking children for all possible conditions. Here are the common ones.

Attention Deficit Hyperactivity Disorder (ADHD). If you have a learning disorder, you have a 20-25% chance of having ADHD. That is about a five times increase over the general population. Looking at it the other way, if you have ADHD, you have a 30-70% chance of having a learning disorder. Everyone who is checked for ADHD needs to be checked for a learning disorder and vice versa.

Tourettes Disorder. This is tics which are disabling. About 60% of children with Tourette's have a learning disorder.

Personality Disorders - Some people have particularly nasty parts of their personalities. Common names of these are Conduct Disorder and Oppositional Defiant Disorder. About one third have learning disorders.

Language Disorders - Children who are not developing language well often have other learning disorders.

Diagnosing learning disabilities and learning disorders

The diagnosis of these conditions is based on three things. A history from the person and his family, a clinical examination, and testing.

The history should show that these problems have been present since school began to one degree or another. The clinician should be able to get a fairly good idea where the problems lie by finding out what teachers and parents have found when they work with the child.

The examination consists of reading with the person, asking them questions about how they read, having them write, do math, draw, and check their coordination.

The testing consists of a test of the child's overall intelligence, a test of how good they are at school skills compared to other children, and tests for each of the learning disabilities noted above. This testing can only be done by a psychologist.

The difficulty in diagnosing learning disorders and disabilities is with the testing. First of all, it is not easy or cheap. It takes about 4-8 hours to test and at least as much to score and prepare a report. Our clinic contracts out this service to private psychologists. It costs about 700-800 dollars to do the testing on one child. Parts of this can be done by a special education teacher or aide. There is usually about one testing school psychologist to 5-15 schools. If the psychologist just did testing every day, he or she could never test everyone with a learning disorder. Our clinic has a budget for testing about 10-20 children a year. That is about 10% of the children who actually come in with a learning disability.

Secondly, it isn't always accurate, partly because of co-morbidity with ADHD. If people have ADHD, they have a hard time paying attention to boring things. Testing is sort of boring and totally inflexible. I have seen many children with marked ADHD who I was sure had a learning disability. Sure, that is, until we treated the ADHD and the learning disability disappeared!

Therefore, testing is usually reserved for more complicated cases and for those who can convince the schools to do it or pay for it themselves. I don't think this is a big problem. A clinical examination as noted above, along with a careful history, can pick up the vast majority of learning disabilities and disorders.

The future

Most parents want to know, will my son ever read? Will he ever learn math? Will he every write legibly? The answer is dependent on the age of the child when the learning disability is identified and what is done about it. With early intervention (ages 4-7) and vigorous treatment of the learning disability and any co-morbid condition, people can usually overcome their learning disorders to an extent that they are no longer disabling. Children are more liley to improve markedly if their disability is less servere, if they are diagnosed early, have higher Iqs, and if they come from higher socioeconomic status and lack comorbid neuropsychiatric disorders. (1) On the other hand, if a learning disability is first identified at age 10 and nothing is done about it and other neuropsychiatric disorders are left untreated, the future is bleak indeed.

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Specific learning disorders

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Developmental Reading Disorder

At this moment in the history of mankind, no skill is as important as reading. The learning disabilities which cause this learning disorder are usually language related and not visually related. Reading disorders come in three types, depending on if decoding and/or comprehension is affected.

Decoding is the ability to read accurately aloud or to yourself. You must translate the characters on the page into language.

Comprehension is the ability to make sense of the language which you read.

Some people decode fine, but do not comprehend. That is, they can read to you just fine but can not answer any questions about what they have just accurately read to you. This is relatively rare.

Other people have a hard time decoding, but have good comprehension. That is, they have a hard time reading to you, but once they do read it correctly, they understand it. This is the most common.

Others have both problems. They can 't decode well and they can't understand it well once they finally do read it correctly. This is more likely the case with multiple learning disabilities or mental retardation.

If you can't read, usually you can't spell. They usually go together.

Developmental Mathematics Disorder

The number of different ways that this learning disorder can present is very great. To start with, some children reverse numbers and can not align them properly. Math requires great attention to doing things in a specific order and an ability to work abstractly with no real - life context at all. Some people have great problems with understanding the relationship between different shapes and the concepts that go with them. Most math is now taught using concepts like halves (of objects), area for teaching multiplication, and parts of a whole for teaching adding and subtracting. with this learning disorder, this can be baffling. Later on the application of the basic operations to real world math problems is very difficult. Flexibility in teaching is more likely to be beneficial in this disorder than the others.

Developmental Writing disorder

There are two main ways this presents. Some children have very bad coordination of the small muscles of their hand. It is hard to make the letters and they are slow at it. They are also bad with scissors, coloring, drawing, and other handiwork. Others have normal fine motor control, but have a great deal of problem with the rules of writing. Spelling, Grammar, punctuation, capitalization, and composition are very difficult. In a normal writer, these skills come nearly as automatically as speaking. In this disorder, the person is having to consciously recall these rules at all times. This makes writing slow, painful, and of poor quality. This disorder often is related to reading problems.

Developmental Coordination Disorder

These children are clumsy. They are always falling, tripping. and they do badly in most sports, but especially those involving catching and throwing. Things like swimming and biking and less affected. It is a horrible blow to a child's self esteem, especially boys. In a recent Swedish Study, this was a quite common condition. About 5-8% of children had significant problems with coordination. Boys are about seven times more likely to have this problem than girls. ADHD is quite common in children with Developmental Coordination disorders. At least 20% of children with Developmental Coordination disorders have ADHD. Children with Developmental Coordination disorders also have evidence of other learning disorders and language disorders, especially problems with reading. (1)

In my experience, this problem can lead to very poor self esteem in boys when present with ADHD and learning problems. It certain warrants an aggressive intervention.

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What can be done?

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At the moment, there is no medical or dietary treatment for learning disability. the treatment is all hard work and has three elements. These are remediation, adaptation, and enhancing people's strengths.

Remediation

This basically means that you have to work a lot harder to learn something than the average person. In most people, these learning disabilities are not a wall. It is hard to learn, but not impossible. With a lot of sweat, repetition, and time, most people with learning disorders can overcome them to some extent.

The problem with remediation is it is not fun. It is frustrating and requires great patience. It takes away time that could be spent doing more interesting things. It also requires a person to do the teaching.

This means that if your child has ADHD, too, you are in for a royal battle. Persistence with a boring and frustrating task is about the last thing they can do.

This means someone or a group of someone's is going to have to spend a lot of time working with this child. In 1996, it isn't going to be the school in most cases. These kids need a huge amount of one on one teaching time. Many children with learning disorders are getting 1-2 hours a week of intensive remediation. They need more like 1-2 hours a day. So who is going to do it?

Most often, the parent with the most patience. In some cases, outside tutors can be hired. Sometimes there is another relative or friend who will help.

The type of remediation depends on the disorder and the learning disabilities present. Exactly what to do? That is beyond this handout. Here is an example.

Yvette is 8. She can not read. She can not figure out the sounds by looking at the letters. This is called phonics. So, her father and her go through exercises each day where they practice making the sounds from the letters and the letters from the sounds. It is sort of a game. It is not that fun. It is hard work. Yvette is getting better at it, but not very quickly.

Remediation works if...

There is a lot of patience and perseverance by both the person doing the teaching and the person with the disorder.

A lot of time is put in to it.

Other psychiatric disorders are treated, especially ADHD.

Adaptation.

Learning can be conceived of as a path or road from perception to processing to memory. A learning disability is like a road block. With Adaptation you find a way around the road block. That is, you look for the detours. For example, if a person has a visual perception problem such that they are always getting letters backwards, book reports might be done by using books on tape or, in some circumstances, a text reader on a computer. Someone with a great difficulty recalling math facts might use a calculator. If you have great difficulty writing, a computer might help, as it does not require fine motor skills. If you have trouble with spelling and grammar, a word processor with these abilities could be used. Here is an example.

Ashley is 10. She has a horrible time reading and writing. She can not decode well. This is because she has a learning disability in integration involving sequencing and organization. She reads words backwards and also sentences. To read well, her Aunt has to point to each word in order. It is very slow going. When she does a science project, her older brother takes her to the library. They go to the computer and get the information off of a encyclopedia CD and sometimes the internet. Then the brother puts it in a form their text reader can read. Ashley then listens as the computer read. She can stop it and have it repeat if necessary. This way she can do as well as the other children with her science projects.

Adaptation works if...

You know exactly where the road blocks are.

The person with the learning disorder and the parent are creative and resourceful

Resources like libraries, computers, and certain software are available.

People have not given up trying.

Enhancing strengths

Any way you look at it, a learning disability can be quite a burden. Even when it is detected early and everything possible is done, it does not build self-esteem. It is a nasty experience to see your peers easily grasp something and leave you in the dust. No one likes to feel stupid. There are few neuropsychiatric disorders as frustrating as a learning disability. Yet many people who have learning disabilities live happy and productive lives. What is the difference between those kids who thrive in the face learning problems and those who do not?

Part of the reason is self esteem. If children do not think they are worth anything, they do not thrive. A good analogy is a bank account of self esteem. With a learning disability, even in the best of circumstances, you are always making "withdrawals" from the self esteem account. Eventually you will go broke if you do not make any deposits. Therefore much energy must be put into figuring out how to enhance a child's self esteem (making deposits).

How do you do this? You find out what this child is good at and likes to do and you help that child pursue it. The whole experience should be fun for the child. He should find success relatively easy compared to his learning disorder. People outside the family should naturally praise him or her for his accomplishments. In some children, this is obvious. In others, it is not.

Here are some ideas

Team Sports - soccer, Baseball, Swimming, Gymnastics, Hockey,

Individual sports - running, biking, kayaking, canoeing, sailing, fishing, golf, martial arts

Arts - singing, playing instruments, bands, dance groups, sewing, painting, building with wood, crafts, models, theater, cooking

Mechanics - repairing and building cars, bikes, houses, computers, boats

Help related - baby sitting, day care, tutoring others, big brothers and big sisters, any paying job.

Activities - church, scouts, girl guides, swimming lessons, music lessons, school clubs, internet user groups, pets, service groups (SPCA, Red Cross, Cadets)

Since there are only 24 hours in each day, that means that sometimes remediation is going to take a back seat to activities such as this. It must be so. Every episode of remediation has to be balanced by something that will be fun and build self esteem.

Example:

Terry is now 11. He reads at a grade two level. School is not easy for him. Virtually everything he learns comes from someone reading to him or telling him. That means that his testing is oral, his book reports are books on tape, and many other adaptations. Certainly Terry could feel like he was special, but not exactly in a good way. But hardly anyone even notices that terry needs special help. Why? Because terry can fix anyone's three wheeler, dirt bike, or anything else with a motor. So with a little help from his dad and his uncle, Terry now rebuilds and fixes three wheelers and dirt bikes. Since he has the time to take old ones apart, he can usually find an old part for a fraction of the price of a new part. Terry's friends (and their families) are very impressed. Everyone talks about how smart Terry is. Terry is full of grease, but also full of self confidence.

Where to go from here?

Find out as best you can what learning disability is present. Get help from teachers, Special education teachers, psychologists, books, and other sources as to what remediation and adaptation strategies to use. Identify and treat all psychiatric disorders, especially ADHD.

Think just as much about enhancing their strengths as about remediation. This is the best prevention possible for depression, substance abuse, and worse psychiatric problems.

Make sure you are not trying to do too much. If parents are exhausted or rarely present or preoccupied, none of this can work.

Be the squeaky wheel! Don't let your child be written off by the schools or the community. With determination and creativity, a learning disorder can be treated, but it isn't easy.

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