Learning Disorders and Brain Organization

Introduction

Sometimes bright kids have trouble learning.

Matt, in 3rd grade, can't seem to spell simple words and often reverses letters and numbers. He had trouble in kindergarten learning to rhyme words and write his name.

Arnold, in 4th grade, can understand complex math problems, but can't seem to add 5 + 7 accurately. He can't tell time and confuses left and right.

Nicole, in 6th grade, can express her ideas well verbally, but can't organize and write them. She has trouble producing an outline for essays.

Jennifer, in 8th grade, reads quickly and accurately, but has difficulty getting the point of stories or comprehending her history and science texts. She can't remember the sequence of the events in the stories nor can she recall specific facts.

In addition, parents, teachers, psychologists and other school personnel have other concerns; they may report that a child

•     is inconsistent in learning
•     can't sustain his attention
•     struggles with homework
•     has uneven academic achievement
•     has not mastered the specific skills expected by a certain age or grade
•     has difficulty organizing or prioritizing assignments

Learning involves the integration of a complex set of tasks. In order to acquire and use new information, the brain has to receive, process, analyze and store this new information. Because of recent advances in technology, we now know more about how the brain works. When a bright kid, or any kid, has trouble learning, a neuropsychological evaluation, using both quantitative and qualitative observations, can investigate the child's abilities to process information of many different types and to make sense of that information. A neuropsychological evaluation can help parents, teachers, as well as the child, know more about how she learns and how she can improve learning.

Taking a closer look: what happens during a neuropsychological learning evaluation?

A battery of tests, which yields a profile of the child's strengths and weakness across several domains, or areas, of functioning is administered. Many of these tests are standardized, which means that the child will be compared to large groups of children in the United States of the same age. The battery may include measures of intellectual functioning, language abilities, memory functioning, and academic achievement. In addition, specific neuropsychological tests which examine attention/concentration, visual spatial/visual-motor/visual perceptual skills, sensorimotor functioning, and executive functioning may be included. These tests assess the child's competence in the basic cognitive abilities that lay the foundation for learning. Social/ emotional/behavioral issues are also taken into consideration.

To provide information on a child's learning profile, two models of analyzing test results are often used: l) a discrepancy model which looks at uneven performance among and between tests and subtests, and 2) a deficit domain model which looks at specific deficits in the domains described above. A general knowledge of the functions of the cerebral cortex of the brain can be helpful in analyzing a child's learning strengths and weaknesses. Some basics to keep in mind:

The brain is made up of two hemispheres, the left and the right hemisphere. Both hemispheres process information from all sensory modalities. Each hemisphere regulates the motor skills on opposite sides of the body.

Damage or altered development in one hemisphere may cause either diminished functioning or augmented functioning in other hemisphere.

Left hemisphere

• is dominant for speech in most people
• is associated with formal logic, science-mindedness, attention to details, the words of emotion
• controls reading, writing, understanding and speaking, verbal thinking and verbal memory
• processes information in a linear, sequential, serial, time-oriented fashion damage can cause aphasias (trouble with understanding or using language), verbal memory loss, concrete thinking, learning disorders, poor complex motor movement

Right hemisphere

• mediates complex non-verbal material associated with intuition, nonverbal perceptiveness, inspirational hunches, uncritical imagination, nonverbal emotional processing
• processing and storage of visual, tactile, spatial, music information
• Gestalt thinking, holistic, simultaneous processing, synthesis
• damage can cause verbosity, poor judgment, organization, processing of complex information, inferential thinking, spatial organization, math, construction, insight

Although there is not a one-to-one connection, each area, or domain, of functioning is assigned to an area of the brain, so that if we know that a certain domain is disrupted, it means that an area of the brain is not working well or is not wired as expected. For example, memory is controlled by several areas; language is most often on the left side of the brain (temporal lobe on the figure); executive functions are in the front as are motor skills (frontal lobe and primary motor cortex on the figure), and visual skills are located in the back of the brain (occipital lobe and portions of the parietal lobe on the figure).

The following principal domains of functioning may be assessed and a profile of strengths and weaknesses can be developed. The evaluation procedure may include measures of the different skills that represent the brain's functioning. These include:

Intellectual Functioning

A measure of intelligence is administered to serve as a basis for determining a child's potential and to provide a context for evaluating a child's competence. The measures that are typically used try to find out how a child approaches many different types of challenges. Measures of intelligence, what we have come to call "IQ," do not simply measure a child's ability to answer many different factual questions, but they also assess the child's ability to solve a wide variety of problems, including problems involving verbal information, visual-spatial skills, and making sense of novel material.

The most commonly used instruments are the l) Wechsler Scales, which include the Wechsler Preschool and Primary Scale of Intelligence (WPSSI- III), Wechsler Intelligence Scale for Children (WISC-IV), Wechsler Adult Intelligence Scale (WAIS-III), and 2) The Stanford Binet V. Although an overall "IQ score" is calculated from the child's performance on these tests, this overall score represents an average of many different, smaller subtests and thus may be less meaningful for understanding the child than a closer evaluation of the child's performance across the different, smaller measures.

Language Domain

An evaluation looks at language from its smallest unit (the sound) to its most complex units (sentences, paragraphs) and examines how a child takes in or understands language and how the child expresses herself.

Given the importance of understanding the components of language, the following areas, which are building blocks of language, should be assessed:

Phonology How does the child hear, sequence and process sounds? Can he blend sounds into words and understand parts of words?' (For example, if we change the /p/ in pan to /f/ it makes the word fan.)

Morphology Can the child make a connection about the general use of the ending of the word? (For example: If we say 'build' and then put 'er' on it, we have 'builder.' adding er as in teacher, painter means the word refers to a person who does that particular job.) In addition, the following aspects of language should be assessed:

Receptive language refers to the way a child listens to, takes in and understands language and is assessed by giving the child increasingly lengthy and complicated oral directions and requiring a non-verbal, pointing response. The following should be noted:

Does the child understand temporal, directional and quantitative words? (For example, in a younger child, words such as below, next to, above, half, etc.)

Is the child able to follow directions? (For example, if the teacher says take out your book, open it up to page 32, and look at the diagrams on the right side of the page).

Expressive language refers to the way a child uses language to tell what she knows.

Does the child use a wide range of vocabulary?

Does the child respond quickly or talk around the topic? A child who has trouble finding words may have concomitant problems with reading, reading comprehension, or writing.

Is the child fluent in producing language? Does she speak clearly, using full sentences, or hesitantly? Does she formulate a variety of sentence types or rely on simple sentences? Are the ideas in sequence? Is the flow of ideas logical or random?

The pragmatic aspects of language are also important.

How are the child's social skills during conversation? Does she make eye contact, wait for the other person to finish speaking before she speaks, ask a question and wait for the response? Does the child understand rules of politeness and social norms?

Metalinguistic awareness refers to the ability to take someone else's perspective. For example, when a person unfamiliar with the child's school asks him about his class routines and class requirements, can he take into account that the questioner doesn't know the teacher or the school and explain details about class procedures and rules? The ability to take the point of view of another person is important because children are constantly required to make inferences, draw conclusions and understand how someone else might think about a situation. If they're unable to do that in conversation, it is unlikely that they can do it in a more formal academic setting.

Memory Domain

This area of functioning, which is an important component of learnng, relates to how well a child learns new information and retains it over time. The questions that will be answered by an evaluation of these skills include:

Can the child

• learn and then recall both verbal and visual information?
• remember information that is presented only one time versus information that has repeated presentations?
• recall information that is well- organized versus material that is less-structured?

An evaluation tries to approximate some of the many different ways that new information is presented to children in the real world. Although there are many different aspects to memory, five important facets of learning and remembering need to be examined in a neuropsychological assessment.

Registration and short-term storage is a very short process in which a child is alert to information and keeps it in mind for a very short time. This process is related to attention and lasts about 30 seconds; after that point the information can be lost. Thus, if the child becomes distracted or is not paying attention to what she wants to remember, the new information cannot be recalled.

Working memory is a process in which a child may hold on to information for a longer period of time and has that information available to use. This process can last anywhere from 30 seconds to one hour. For example: When someone tells you their name or telephone number, that new information can be available to you for a short while after you have heard it, and it may be available to you for a longer time if it is particularly meaningful. In a classroom, working memory is important because sometimes a child must hold in mind some new information even when other things are happening. For example, a child may need to write down the homework while everyone else is packing up their bags. This child will need to recall what the teacher said so that she can write it down accurately. (Working memory, both verbal and non- verbal, plays a crucial role in executive functioning, discussed in the next section)

Consolidation is the process through which information is taken from working memory and is processed in order to form a more lasting memory. Consolidation can last from the point at which that information is registered and can go on for years. A person may take in information in the form of a picture or in the form of words; consolidation, or integration, means that the mind does something with the information, works on it and puts all the pieces of information together. Consolidation may take longer for some children than for others. For example, a child who sees a picture during the day and goes to sleep, may wake up later and remember more details about the picture than she could the day before. Her mind has been integrating and digesting the information and thinking about it even though she's not consciously aware that this is happening.

Long-term storage is the process that we typically think of when we talk about memory. Long term storage refers to how a child takes in information and stores it away in the file cabinet of his mind so that he can have access to it later. He can retrieve the information and use it in the service of new learning, he can attach new meaning to old information, or he can use that old information in a new way.

Retrieval and recognition is the process involved in getting the information out of the file drawer. It refers to information filed away (vocabulary words, stories, etc.) and to how a child gets that information out and then demonstrates knowledge of the information through drawing or speaking or writing. Retrieval and recognition are different processes: retrieval means that the child accesses learned material on her own and recognition means that an external prompt, like a verbal reminder or an image, jogs the child's memory and facilitates recollection. Typically, if a child does not easily retrieve the information well, she is likely to recognize it if given a clue.

Other Cognitive Functions

Attention

While attention is an important precursor to remembering information, and a process that helps people guide their behavior (a set of skills described below that are called executive functions), it is also a skill worth examining on its own because it is critical to learning and to success at meeting the demands of a child's environment. Attention has the following components:

Attention span is the amount of information a child can hold in mind at any given moment. (it is commonly thought that 7 things or 7 digits, as in a phone number, is the amount of information that can be held in mind)

Selective attention refers to the decision to choose to focus attention on one specific thing rather than another. When children are described as distracted, they often have difficulties in this area. Selective attention can be examined by asking children to perform simple tasks that require minimal focus such as repeating or recalling numbers, letters or sentences, or searching for visual images from an array of many pictures.

Concentration is the ability to maintain attention and work with material on which the child has focused. Concentration may require a child to hold onto information presented to her for a short time while she solves a problem using that material. This ability can be examined by asking the child to do things like mental arithmetic.

Sustained attention is the process of maintaining focused attention on one task for a longer period of time. Sometimes, one must stay focused on a task for longer than one or two minutes, and it is important to know if a child can do this, particularly when things are not stimulating. Sustained attention can be examined when children are asked to focus on a task for a long period of time, typically between 4 to 15 minutes.

The observations of the examiner and the reports of parents and teachers also help to determine if there are difficulties with attention. Since teachers and parents see the child throughout the day and for longer periods of time, they can notice instances when attention fades that may not be observed by an examiner.

Executive functioning

Executive functions are best thought of as those aspects of cognition that relate to an internal supervisor who directs a child's thinking and guides her behavior. These skills directly help a child make goals for herself and come up with the ideas that will help her meet those goals efficiently. These skills develop in young children and continue to evolve well into the teen years and young adulthood. Specific aspects of these broad skills include:

Verbal working memory refers to the efforts a child makes in order to guide behavior and stay on task. Often children exhibit this when they use internal "self- talk" to remind themselves of how to act in a special situation and may also be seen when they internally generate rules about the way they should behave.

Nonverbal working memory also allows the child to guide behavior, but it is more focused on the ways to do this that are not verbal in nature. In this way, a child often holds events in mind, sequences these events and uses a sense of time to help manage behavior in a coordinated way.

Inhibition reflects the ability to stop oneself from doing something that is automatically done in favor of acting in a more goal directed manner and using feedback to coordinate responses in a more specific manner.

Fluency and flexibility are skills related to being able to quickly generate strategies for problem solving and to being able to use forethought and planning to make solutions happen quickly and easily. These skills also refer to how easily a child can adapt her behavior to fit the demands of a particular situation and to shift between different scenarios smoothly.

Self-regulation/motivation/arousal are a set of processes that encompass a child's awareness of himself and help him to maintain appropriate behaviors, control interest and enthusiasm for activities (even if he is not thrilled to be engaged in these activities), and to be consistently alert to the events and stimuli around him.

Visual Skills and the Sensorimotor Domains

These areas refer to visual and tactile ways of taking in information as well as motor planning, motor speed and coordination, and the precision of motor skills to accomplish a set goal. The child has to recognize and discriminate what information to look at, touch and feel. The child then has to decide which modality to use for providing an answer - a verbal response, a constructional response, or a graphomotor response through writing.

Difficulties in any of the areas described above may lead to problems in academics. Children with compromised intellectual functioning will not be expected to perform as well as their peers in academic areas. Similarly, problems with language, reduced skills for remembering new information, and weaknesses in attention, executive functioning, visual-spatial skills, or sensorimotor functioning may contribute to or cause problems with learning in general. These cognitive weaknesses may also be related to difficulties learning specific subjects or may lead a child to be less invested in learning because it is difficult for him to perform some of the basic skills required for solid academic performance. It is important to note that some children may show some problems in the areas described above which do not appear to lead to any academic delays.

Putting it All Together - Academic Functioning

Demands change

All academic areas of functioning have two features; a mechanical aspect and a higher level, or language-based, aspect. In reading, a child learns the mechanics of decoding words and also reads for meaning. In mathematics, a child computes written problems and also solves functional word problems. In writing, a child learns handwriting skills and also organizes and expresses her ideas in paragraphs. By third grade a child is no longer learning to read. It's assumed that he's mastered mechanical decoding skills and is reading for meaning: making inferences, drawing conclusions, processing ambiguities and comprehending figurative expressions; in other words, he is reading in order to learn. The emphasis changes in middle school, where a child is learning how to learn. She needs to adjust her reading to the demands of the text and has to express her thinking in writing. There are increasing demands for metacognition, which is concerned with developing strategies and understanding the purpose of their work. In middle school, a child is required to become more independent, and, in high school, it's assumed that he's independent, that he has developed strategies and knows when to use them. For example, in middle school a teacher might say "this is how you should study; now go home and do it." In high school he has to figure out which strategy to apply in order to be successful.

In all academic areas, some children have good basic skills development, but have difficulty with study skills, such as monitoring and checking work familiarizing themselves with school requirements studying by reorganizing the material rather than merely reading and re-reading it acquiring strategies for retaining information, moving information to long term storage knowing how to consolidate or integrate what they've learning prioritizing and keeping track of long and short term assignments

Reading

The mechanical aspect of reading is decoding; the higher level, language-based aspect is comprehension. Assessment of reading includes

1. decoding (sight words, phonemic awareness, reading rate and accuracy)
2. comprehension, literal and inferential
3. fluency and automaticity

Some characteristics in a child with a reading problem are: lack of automaticity in learning letters, associating letters with sounds, rhyming and playing sound games, hesitant and dysfluent reading, difficulty retaining facts or a story line, understanding character, plot, setting or theme.

Math

The mechanical aspect of math is computation; the higher level aspect is understanding and solving word problems.

Assessment of math includes

1. calculations (automaticity and computational processes)
2. word problems
3. fluency of math fact recall and steps involved in problem solving

Some characteristics of a child with a math problem are: using fingers for computation, poor ability to complete simple math computation in addition, subtraction, multiplication and division with whole numbers, then fractions and decimals, lack of automaticity of math fact recall, confusing columns, poor spacing when writing out math problems, not understanding the mathematical implications of words such as half, second, etc., inability to identify the key word in a problem or what operation the problem calls for.

Writing

The mechanical aspect of writing is spelling and handwriting; the higher level aspect is the ability to sequence events, write an outline and write a paragraph or story. Assessment of writing includes

1. handwriting (grip, posture, motor planning and production)
2. spelling (rules and conventions, spelling of words with predictable vs. irregular patterns)
3. writing process (planning, revising, formulation, fluency, structure, mechanics)

Some characteristics of a child with a writing problem are: motor problems, lack of automaticity in letter formation, copying from the board, organizing and sequencing of ideas.

How the Child Thinks and Feels

Some children with learning difficulties may feel demoralized or guilty or worried or sad or angry. Questionnaires completed by the child, parent and teacher can be helpful, and for some children projective measures will contribute to understanding the child's psychological functioning.

Next Steps

Formulation of diagnosis

Good evaluations offer a comprehensive approach and tailor the assessment to the needs of the child. The evaluation appointments provide a time for structured tests as well as a setting to try specific interventions that may then be used at home or at school. Recommendations to the school and family should be useful, specific and practical so that the appropriate resources are brought to bear in a child's behalf. A good evaluation should help the parents, teachers, and the child know what things can be done so that the child can do better in school and learn skills necessary for life after school. They can also help all people involved know how to have reasonable expectations about the child's abilities and to know when, where, and under what conditions she may have more difficulty with learning.

Collaboration between home and school in reviewing findings in the context of the child's history, including medical, familial and social factors, is critical. Depending on the child's age, the child should be included as a partner in order to help him understand himself, to be able to advocate for himself, and to cooperate with a remediation plan, when appropriate. The family should be informed of their legal rights.

Possible diagnoses, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), that might result from a neuropsychological evaluation include Reading Disorder, Mathematics Disorder, Disorder of Written Expression, Learning Disorder Not Otherwise Specified, Developmental Coordination Disorder, Expressive Language Disorder, Mixed Receptive-Expressive Language Disorder, Attention-Deficit/Hyperactivity Disorder.

Educational options

After the evaluation has been completed and the parents and professionals have met, the next step is a meeting with school personnel to make decisions about what class placement would be appropriate and what special services the child requires to be successful in class.

Class placement options

The child may remain in the mainstream in a regular class or in what might be called a "collaborative" or "inclusion" class. When a child remains in the mainstream, in a regular education class, daily instruction is provided by the classroom teacher, sometimes in consultation with any specialists with whom the child works. In an inclusion class, which consists of a selected number of students with special needs, there is a team of teachers -- one regular education classroom teacher and one special education classroom teacher. Often in an inclusion class the class size is somewhat smaller.

A self-contained special education class is another placement option. Usually this classroom is in a child's home school, but sometimes the class can be anywhere within the school district. Special education classes can have 8 to 12 children, one special education teacher and one paraprofessional. The size of a special education class depends on the classification of the students and the severity of their special needs.

Special or related services required by the child during the school day.

These services can be included or "pushed in" to the classroom, or they may be provided in another room so that the child is "pulled out' of the classroom for the services. Sometimes push-in and pull- out services are combined. Services may consist of the following:

A child in the mainstream may receive one hour daily of resource room services with a special education teacher who is often a learning specialist by training. This service can be in a small group of 5 or as many as 8 children. The focus of resource room services can be development of an academic skill area as well as specific strategy development in one domain. In addition, resource room teachers work on organizational skills and time management.

A child with specific needs related to speech and language development requires special services provided by a speech /language pathologist. These services can target articulation (the clarity and mechanics of speech), or language development, and can be provided individually or in a small group from one hour weekly to five hours weekly.

A child who struggles with motor coordination may meet with either an occupational therapist or a physical therapist who targets fine motor precision, motor planning, or other motor coordination issues, including adaptive needs such as use of a laptop or other aids. These services can be one hour per week or more, individually or in a small group. Some children who struggle with motor coordination might be in an adaptive physical education class.

The last related service that might be appropriate would be related to a hearing impairment, visual impairment or auditory processing issue. In some cases, a consultant works with the child and classroom teacher regarding hearing or visual aids, or auditory training equipment.

About the Authors

Susan Schwartz, MA.Ed., Clinical Instructor of Psychiatry, is the Clinical Coordinator of the Institute for Learning and Academic Achievement at the NYU Child Study Center Ms. Schwartz has expertise in the assessment and treatment of children with language, reading, writing, math and study/organizational difficulties. She has worked extensively with children and adolescents and has lectured to professionals and parents at numerous conferences and seminars.

Matthew Cruger, Ph. D., is an Assistant Research Scientist with the Institute of Learning and Academic Achievement at the NYU Child Study Center. Dr. Cruger has a strong interest in neuropsychological and psychological assessment and has worked with children, adolescents, and adults with a variety of problems including learning difficulties, mental health problems, traumatic and acquired brain injuries, and medical illnesses. He is also the Director of the Prevention and Relationship Enhancement Program (PREP ®), a research-based program designed to help couples improve their communication and satisfaction, through the Family Studies Program.

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About the NYU Child Study Center

The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at http://www.aboutourkids.org/.