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Overview of Learning Disabilities

by Stephen Brian Sulkes, MD

Learning disabilities are conditions that cause a discrepancy between potential and actual levels of academic performance as predicted by the person’s intellectual abilities. Learning disabilities involve impairments or difficulties in concentration or attention, language development, or visual and aural information processing. Diagnosis includes cognitive, educational, speech and language, medical, and psychologic evaluations. Treatment consists primarily of educational management and sometimes medical, behavioral, and psychologic therapy.

Specific learning disabilities affect the ability to understand or use spoken or written language, do mathematical calculations, coordinate movements, or focus attention on a task. These disabilities include problems in reading, mathematics, spelling, written expression or handwriting, and understanding or using verbal and nonverbal language (see Common Learning Disabilities). Most learning disabilities are complex or mixed, with deficits in more than one system.

Although the number of children with learning disabilities is unknown, about 5% of the school-age population in the US receives special educational services for learning disabilities. Among affected children, boys outnumber girls 5:1.

Learning disabilities may be congenital or acquired. No single cause has been defined, but neurologic deficits are evident or presumed. Genetic influences are often implicated. Other possible causes include

  • Maternal illness or use of toxic drugs during pregnancy

  • Complications during pregnancy or delivery (eg, spotting, toxemia, prolonged labor, precipitous delivery)

  • Neonatal problems (eg, prematurity, low birth weight, severe jaundice, perinatal asphyxia, postmaturity, respiratory distress)

Potential postnatal factors include exposure to environmental toxins (eg, lead), CNS infections, cancers and their treatments, trauma, undernutrition, and severe social isolation or deprivation.

Common Learning Disabilities

Disability

Manifestation

Dyslexia

Problems with reading

Phonologic dyslexia

Problems with sound analysis and memory

Surface dyslexia

Problems with visual recognition of forms and structures of words

Dysgraphia

Problems with spelling, written expression, or handwriting

Dyscalculia

Problems with mathematics and difficulties with problem-solving

Ageometria

Problems due to disturbances in mathematical reasoning

Anarithmia

Disturbances in basic concept formation and inability to acquire computational skills

Dysnomia

Difficulty recalling words and information from memory on demand

Symptoms and Signs

Children with learning disabilities typically have at least average intelligence, although such disabilities can occur in children with lower cognitive function as well. Symptoms and signs of severe disabilities may manifest at an early age, but most mild to moderate learning disabilities are usually not recognized until school age, when the rigors of academic learning are encountered. Affected children may have trouble learning the alphabet and may be delayed in paired associative learning (eg, color naming, labeling, counting, letter naming). Speech perception may be limited, language may be learned at a slower rate, and vocabulary may be decreased. Affected children may not understand what is read, have very messy handwriting or hold a pencil awkwardly, have trouble organizing or beginning tasks or retelling a story in sequential order, or confuse math symbols and misread numbers.

Disturbances or delays in expressive language or listening comprehension are predictors of academic problems beyond the preschool years. Memory may be defective, including short-term and long-term memory, memory use (eg, rehearsal), and verbal recall or retrieval. Problems may occur in conceptualizing, abstracting, generalizing, reasoning, and organizing and planning information for problem solving. Visual perception and auditory processing problems may occur; they include difficulties in spatial cognition and orientation (eg, object localization, spatial memory, awareness of position and place), visual attention and memory, and sound discrimination and analysis.

Some children with learning disabilities have difficulty following social conventions (eg, taking turns, standing too close to the listener, not understanding jokes); these difficulties are often components of mild autism spectrum disorders as well (see Autism Spectrum Disorders (ASD)). Short attention span, motor restlessness, fine motor problems (eg, poor printing and copying), and variability in performance and behavior over time are other early signs. Difficulties with impulse control, non–goal-directed behavior and overactivity, discipline problems, aggressiveness, withdrawal and avoidance behavior, excessive shyness, and excessive fear may occur. Learning disabilities and attention-deficit/hyperactivity disorder (ADHD—see Attention-Deficit/Hyperactivity Disorder (ADHD, ADD)) often occur together.

Diagnosis

  • Cognitive, behavioral, medical, and psychologic evaluations

Children with learning disabilities are typically identified when a discrepancy is recognized between academic potential and academic performance. Speech and language, intellectual, educational, medical, and psychologic evaluations are necessary for determining deficiencies in skills and cognitive processes. Social and emotional-behavioral evaluations are also necessary for planning treatment and monitoring progress.

Cognitive evaluation typically includes verbal and nonverbal intelligence testing and is usually done by school personnel. Psychoeducational testing may be helpful in describing the child’s preferred manner of processing information (eg, holistically or analytically, visually or aurally). Neuropsychologic assessment is particularly useful in children with known CNS injury or illness to map the areas of the brain that correspond to specific functional strengths and weaknesses. Speech and language evaluations establish integrity of comprehension and language use, phonologic processing, and verbal memory.

Behavioral assessment and performance evaluation by teachers’ observations of classroom behavior and determination of academic performance are essential. Reading evaluations measure abilities in word decoding and recognition, comprehension, and fluency. Writing samples should be obtained to evaluate spelling, syntax, and fluency of ideas. Mathematical ability should be assessed in terms of computation skills, knowledge of operations, and understanding of concepts.

Medical evaluation includes a detailed family history, the child’s medical history, a physical examination, and a neurologic or neurodevelopmental examination to look for underlying disorders. Although infrequent, physical abnormalities and neurologic signs may indicate medically treatable causes of learning disabilities. Gross motor coordination problems may indicate neurologic deficits or neurodevelopmental delays. Developmental level is evaluated according to standardized criteria.

Psychologic evaluation helps identify ADHD, conduct disorder, anxiety disorders, depression, and poor self-esteem, which frequently accompany and must be differentiated from learning disabilities. Attitude toward school, motivation, peer relationships, and self-confidence are assessed.

Treatment

  • Educational management

  • Medical, behavioral, and psychologic therapy

  • Occasionally drug therapy

Treatment centers on educational management but may also involve medical, behavioral, and psychologic therapy. Effective teaching programs may take a remedial, compensatory, or strategic (ie, teaching the child how to learn) approach. A mismatch of instructional method and a child’s learning disability and learning preference aggravates the disability.

Some children require specialized instruction in only one area while they continue to attend regular classes. Other children need separate and intense educational programs. Optimally and as required by US law, affected children should participate as much as possible in inclusive classes with peers who do not have learning disabilities.

Drugs minimally affect academic achievement, intelligence, and general learning ability, although certain drugs (eg, stimulants, such as methylphenidate and several amphetamine preparations—see Drugs) may enhance attention and concentration, allowing children to respond more efficiently to instruction. Many popular remedies and therapies (eg, eliminating food additives, using antioxidants or megadoses of vitamins, patterning by sensory stimulation and passive movement, sensory integrative therapy through postural exercises, auditory nerve training, optometric training to remedy visual-perceptual and sensorimotor coordination processes) are unproved.

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  • CONCERTA, RITALIN

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