Associated concerns

There is a strong relation between language and learning. Some children with language difficulties experience academic difficulties when they enter schools. Language difficulties in children can hinder their ability to properly develop literacy skills, math concepts and writing skills. Phonological difficulties can also affect their spelling. Moreover, children who have a history of delay in their first language development often experience difficulties with acquiring a second language.

• Learning Disability is a generic term that refers to a group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical problems.
• These disorders are intrinsic to the individual and presumed to be due to central nervous system dysfunction that occurs despite of normal auditory-visual-cognitive abilities & given opportunities.
• Even though a learning disability may occur concomitantly with other handicapping conditions (e.g. sensory impairment, mental retardation, social and emotional disturbance) or environmental influences (e.g. cultural differences, insufficient/inappropriate instruction, psychogenic factors), it is not the direct result of those conditions or influences.
• Learning disabilities impair the child’s ability to achieve an age appropriate achievement level.
• The child’s actual level of academic functioning is the first step in diagnosis. Thus, if the child is not functioning below the expected level for age or grade, he is not considered LD even if his intelligent quotient and ability score are discrepant. The most common type of LD is disability in reading (dyslexia)

• Etiology
  • The causes for learning disabilities are not well understood, and sometimes there is no apparent cause for a learning disability. However, in some cases learning disabilities might be related to:
    • Neurological causes:
      • Structural brain damage
      • Neurological activation abnormality
    • Maturational delay:
      • Delay in skills maturation e.g. slow acquisition of language skills
      • Perceptual abnormalities
    • Heredity / Genetic causes:
      • Learning disabilities often run in the family. Children with learning disabilities are likely to have parents or other relatives with similar difficulties
      • It can be attributed to multi-factorial inheritance / complex interaction between genetic predisposition & environmental factors.
    • Perinatal causes:
    • Problems during pregnancy and birth – Learning disabilities can result from:
      • Anomalies in the developing brain
      • Maternal illness or injury
      • Fetal exposure to alcohol or drugs
      • Low birth weight
      • Oxygen deprivation
      • Premature labor
      • Prolonged labor
    • Environmental causation:
      • Head injuries / accidents after birth
      • Malnutrition
      • toxic exposure (such as heavy metals or pesticides)
      • Drug consumption
      • Inappropriate school placement

     

    CENTRAL AUDITORY DYSFUNCTION AS A CAUSE OF LEARNING DISABILITY:

    Auditory discrimination, localization, attention, figure-ground, discrimination, closure, blending, association, memory & sequential memory)
    • Classification
      • Clinical classification
      • Classification according to the stage of information processing
      • Academic classification
      • Verbal & non-verbal classification
    • I-Clinical classification
    • Learning disabilities characterized primarily by disorders of linguistic functioning:
    • • Basic phonological processing disorder
      • Phoneme grapheme matching disorder
      • Word finding difficulties
      • Learning disabilities characterized primarily by disorders of non-verbal functioning
      • Learning disabilities characterized primarily by output disorders in all modalities
    • II- Classification according to the stage of information processing
    • Learning disabilities fall into broad categories based on the four stages of information processing used in learning: input, integration, storage, and output.
    • Input:
    • This is the information perceived through the senses, such as visual and auditory perception.
    • • Difficulties with visual perception can cause problems with recognizing the shape, position and size of items seen. There can be problems with sequencing which can relate to deficits with processing time intervals or temporal perception.
      • Difficulties with auditory perception can make it difficult to screen out competing sounds in order to focus on one of them, such as the sound of the teacher's voice, confusion between words & phrases that sound like, seem not listening or paying attention
      • Some children appear to be unable to process tactile input, For example, they may seem insensitive to pain or dislike being touched.
    • Integration (interpretation – association - sequencing – abstraction –organization)
      • Visual sequential memory
      • Auditory sequential memory
      • Auditory reception
      • Auditory association
      • Visual association
    • Storage / Memory
    • Most memory difficulties occur in the area of short-term memory, which can make it difficult to learn new material without many more repetitions than is usual. Difficulties with visual memory can impede learning to spell. Difficulties can also be related to deficits in long term memory.
    • Output (expression):
    • Language
    • • Word finding difficulty
      • Semantics deficiency (affecting both receptive as well as expressive aspects)
      • Syntactic deficiency
    • Motor:
      • Goss motor disability
      • Fine motor disability
      • Difficulties with motor abilities can cause problems with gross and fine motor skills.
    • People with gross motor difficulties may be clumsy, that is, they may be prone to stumbling, falling, or bumping into things. They may also have trouble running, climbing, or learning to ride a bicycle. People with fine motor difficulties may have trouble buttoning shirts, tying shoelaces, or with handwriting.
    • III- Classification according to the function impaired
    • It is possible for an individual to have more than one of these difficulties. This is referred to as co-morbidity or co-occurrence of learning disabilities.
    • Reading disorder
      • This is the most common learning disability. Of all students with specific learning disabilities, 70%-80% have deficits in reading. The term "⦁ Developmental Dyslexia" is often used as a synonym for reading disability; however, many researchers assert that there are different types of reading disabilities, of which dyslexia is one.
      • A reading disability can affect any part of the reading process, including difficulty with accurate or fluent word recognition, or both, word decoding, reading rate, prosody (oral reading with expression), and reading comprehension. Before the term "dyslexia" came to prominence, this learning disability used to be known as "word blindness. “
      • Common indicators of reading disability include difficulty with phonemic awareness—the ability to break up words into their component sounds, and difficulty with matching letter combinations to specific sounds (sound-symbol correspondence).
    • Disorder of Written Expression
      • The DSM-IV-TR criteria for a Disorder of Written Expression is writing skills (as measured by standardized test or functional assessment) that fall substantially below those expected based on the individual's chronological age, measured intelligence, and age appropriate education.
      • This difficulty must also cause significant impairment to academic achievement and tasks that require composition of written text and if a sensory deficit is present, the difficulties with writing skills must exceed those typically associated with the sensory deficit.
      • Individuals with a diagnosis of a Disorder of Written Expression typically have a combination of difficulties in their abilities with written expression as evidenced by grammatical and punctuation errors within sentences, poor paragraph organization, multiple spelling errors, and excessively poor handwriting.
      • A disorder in spelling or handwriting without other difficulties of written expression does not generally qualify for this diagnosis. If poor handwriting is due to impairment in motor coordination, a diagnosis of  Developmental coordination disorder should be considered.
      • The term "dysgraphia" has been used as an overarching term for all disorders of written expression. Others, such as the International Dyslexia Association, use the term "dysgraphia" to refer to difficulties with handwriting.
    • Math disability (dyscalculia):
      • A math disability involves such difficulties as learning math concepts (such as quantity, place value, and time), difficulty memorizing math facts, difficulty organizing numbers, and understanding how problems are organized on the page.
      • Students having dyscalculia are often referred to as having poor "number sense".
    • Nonverbal learning disability
      • Nonverbal learning disabilities often manifest in motor clumsiness, poor visual-spatial skills, problematic social relationships, difficulty with math, and poor organizational skills.
      • These individuals often have specific strengths in the verbal domains, including early speech, large vocabulary, early reading and spelling skills, excellent rote-memory and auditory retention, and eloquent self-expression.
    • Disorders of speaking and listening:
      • Difficulties that often co-occur with learning disabilities include difficulty with memory, social skills and executive functions (such as organizational skills and time management).
    • IV-Language-based vs. non-verbal
      • Language-based disabilities (LLD) 90%
      • This group affects reading, spelling, writing and mathematics (in conjunction with reading as in story problems).
      • Non-verbal type (10%):
      • Mathematic problems along with neuro-cognitive & adaptive functions attributed to right hemisphere concerned with spatial cognitive functions.
    • Clinical Picture
      • Perceptual deficits:
      • Visual perception difficulty: the child sees the visual stimulus as unrelated parts and the letter as unrelated lines
      • Discrimination deficits:
        • Visual (letter discrimination-spacing-staying on line) Auditory (sounds-syllables- environmental sounds)
        • Auditory (sounds-syllables- environmental sounds)
      • Auditory memory & association
      • Auditory processing deficits
      • Cognition information processing deficits
      • Attention problems
      • Academic  problems:
        • Reading:
        • Writing
        • Spelling
        • Mathematics
    • Assessment steps
      • Elementary Diagnostic Procedures:
        • History (teachers, convulsions, hearing, impaired recognition of letters, delayed language development)
        • Examination: General, vocal tract, and neurological
      • Clinical Diagnostic Aids:
        • Cognitive test
        • Language test
        • Illinois test of psycholinguistic abilities
        • Reading test (Neal analysis of reading abilities)
        • Spelling test (Midlnd spelling test)
        • Sequencing tests (words forwards & backwards + shapes)
      • Tests for central auditory functions:
        • Auditory attention
        • Auditory figure ground
        • Auditory discrimination
        • Auditory closure
        • Auditory blending
        • Auditory analysis
        • Auditory memory
        • Auditory sequential memory
      • Additional Instrumental Measures:
        • Electroencephalography (EEG) (EEG may reveal dysrhythmia, epileptic focus / EEG abnormalities)
        • Computerized Tomography (CT scan)
        • Magnetic Resonance Imaging
        • Genetic
    • Diagnosis
      • IQ (intelligent quotient)-Achievement Discrepancy
      • Academic achievement testing
      • Low classroom performance
      • Limited social interactions
      • Other areas of assessment may include perception, cognition, memory, attention, and language abilities
      • The resulting information is used to determine whether a child's academic performance is commensurate with his or her cognitive ability. If a child's cognitive ability is much higher than his or her academic performance, the student is often diagnosed with a learning disability

     

    EXAMPLES OF THE TESTS THAT CAN BE USED

    • Many norm assessments can be used in evaluating skills in the primary academic domains: reading, including word recognition, fluency, and comprehension; mathematics, including computation and problem solving; and written expression, including handwriting, spelling and composition.
    • The most commonly used comprehensive achievement tests include the Woodcock-Johnson III (WJ III), Wechsler Individual Achievement Test II (WIAT II), the Wide Range Achievement Test III (WRAT III), and the Stanford Achievement Test–10th edition. These tests include measures of many academic domains that are reliable in identifying areas of difficulty.
    • In the reading domain, there are also specialized tests that can be used to obtain details about specific reading deficits.
    • Assessments that measure multiple domains of reading include Gray's Diagnostic Reading Tests–2nd edition (GDRT II) and the Stanford Diagnostic Reading Assessment. Assessments that measure reading sub-skills include the Gray Oral Reading Test IV – Fourth Edition (GORT IV), Gray Silent Reading Test, Comprehensive Test of Phonological Processing (CTOPP)
    • Tests of Oral Reading and Comprehension Skills (TORCS)
    • Test of Reading Comprehension 3 (TORC-3)
    • Test of Word Reading Efficiency (TOWRE)
    • Test of Reading Fluency

     

    INTERVENTION

    The purpose of assessment is to determine what is needed for intervention, which also requires consideration of contextual variables and whether there are co-morbid disorders that must also be identified and treated, such as behavioral issues or language delays.

     

    MASTERY MODEL:

    This approach is most likely to be used with adult learners or outside the mainstream school system. It is base d on the following facts:
    • Learners work at their own level of mastery
    • Practice is very important
    • It is essential that the student gains fundamental skills before moving onto the next level

     

    DIRECT INSTRUCTION:

    • Highly structured, intensive instruction
    • Emphasizes carefully planned lessons for small learning increments
    • Scripted lesson plans
    • Rapid-paced interaction between teacher and students
    • Correcting mistakes immediately
    • Achievement-based grouping
    • Frequent progress assessments

     

    CLASSROOM ADJUSTMENTS:

    • Special seating assignments
    • Alternative or modified assignments
    • Modified testing procedures
    • Quiet environment

     

    SPECIAL EQUIPMENTS:

    • Word processors with  spell checkers and dictionaries
    • Text-to-speech and speech-to-text programs
    • Talking calculators
    • Books on tape
    • Computer-based activities

     

    CLASSROOM ASSISTANTS:

    • Note-takers
    • Readers
    • Proofreaders
    • Scribes

     

    SPECIAL EDUCATION:

    • Prescribed hours in a resource room
    • Placement in a resource room
    • Enrollment in a special school for learning disabled students
    • Individual Education Plan (IEP)
    • Educational therapy

     

    TREATMENT OF CO-MORBID CONDITIONS:

    • Cognitive behavioral & language therapy
    • Educational approaches used for ADHD---assist the child in developing positive attitude
    • Teaching interpersonal cognitive problem solving skills
    • Pharmacotherapy

     

    PHONOLOGICAL AWARENESS TRAINING

    • A-Phonological awareness
      • Segmenting
      • Rhyming
      • Blending
      • Phoneme/grapheme matching
    • B-Sound production
      • To facilitate cognitive reorganization of the child’s phonological system:
      • Minimal contrast therapy
      • Auditory bombardment
      • Auditory input therapy

     

    TREATMENT OF HIGHER ORDER PROCESSING DEFICITS, HERE THE FOCUS WILL BE ON THE FOLLOWING AREAS:

    • Vocabulary deficit – increase the size of vocabulary in each category – word finding difficulties– repetitive semantic training
    • Semantics: antonyms, synonyms, hyponyms, semantic category
    • Syntax
    • Attention
    • Memory

     

    Orton Gillingham Remediation Technique
    • This is an alphabetic approach for dyslexic children
    • Principle: multi-sensory, simple to complex
    • Materials: Drill cards – word cards
    • Goal: word attack habits (reading + writing + spelling)
    • Procedures: Teaching the letters
    • Simultaneous oral spelling
    • Small words– sentences-reading
    • Syllable & word attack skills

     

    ANALYTIC PHONICS INSTRUCTION

    • Analytic phonics instruction (whole word approach)
    • Learning words then isolating letters & sounds

     

    MATCHING APPROACH

    • Goal: recognize words in isolation + in context
    • Picture-word association
    • Paired and multiple picture-word discrimination

     

    WHOLE MULTISENSORY APPROACH (FERNALD APPROACH)

    • Tracing words (trace, say, repeat, write, look)
    • Printed words
    • Recognize new words

     

    COMPUTER ASSISTED INSTRUCTION:

    • Writing-to read approach (spell words phonemically)
    • Attention
    • See on the monitor then repeat along with the computer voice
    • Auditory comprehension
    • Yes/ No questions
    • Following commands
    • Auditory sequencing
    • Auditory discrimination
    • Auditory reasoning for words, statements & paragraphs

     

    RELATED TOPICS

    • Response to Intervention
    • Contrast with other conditions
    • MRI spectroscopy (MRIS) & Functional MRI
    • Reading & dyslexia + children at risk for reading disability

     

    RESPONSE TO INTERVENTION (RTI)

    Much current research has focused on a treatment-oriented diagnostic process known as response to intervention (RTI). Researcher recommendations for implementing such a model include early screening for all students, placing those students who are having difficulty into research-based early intervention programs, rather than waiting until they meet diagnostic criteria. Their performance can be closely monitored to determine whether increasingly intense intervention results in adequate progress.  Those who respond will not require further intervention. Those who do not respond adequately to regular classroom instruction (often called "Tier 1 instruction") and a more intensive intervention (often called "Tier 2" intervention) are considered "no responders." These students can then be referred for further assistance through special education, in which case they are often identified with a learning disability. Some models of RTI include a third tier of intervention before a child is identified as having a learning disability.

     

    BENEFITS OF RTI

    • A primary benefit of such a model is that it would not be necessary to wait for a child to be sufficiently far behind to qualify for assistance
    • This may enable more children to receive assistance before experiencing significant failure, which may in turn result in fewer children who need intensive and expensive special education services.

    LIMITATIONS OF RTI

    • The process does not take into account children's individual neuropsychological factors such as phonological awareness and memory that can help design instruction.
    • RTI can take considerably longer than established techniques, often many months to find an appropriate tier of intervention.
    • Third, it requires a strong intervention program before students can be identified with a learning disability.
    • Lastly, RTI is considered a regular education initiative and is not driven by psychologists, reading specialists, or special educators.