LEARNING DISORDERS: Reading (Dyslexia), Math & Writing
Academic problems are some of the most frequent reasons for obtaining a neuropsychological evaluation. Problems in school are due to a variety of factors including poor attention, behavior problems, medical or neurological illness or disorder, and bona fide Learning Disorders. The purpose of the neuropsychological evaluation is to determine the cause of the academic problems so that proper services and treatment can be put in place.
Learning Disorders, which are estimated to impact approximately 7% of school-age children, are diagnosed when an individual's ability in reading, writing or math skills is below what would be expected based on age and/or grade level and interfere significantly with the individual’s functioning in school or in activities of daily living where reading, writing or math may be necessary. Learning disorders are typically divided into three subtypes, according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). These are: 1) Reading Disorder: 2) Mathematics Disorder; & 3) Disorder of Written Expression.
Reading Disorder (RD) / Dyslexia
It is estimated that approximately 5% of school children have a Reading Disorder or dyslexia and these children account for approximately half of the special education population. Genes are presumed to underlie at least some aspects of reading disorders. For instance, many children who struggle with reading have parents or siblings who also struggle. However, it is likely that multiple chromosomes are involved. Other causes of reading problems include poor educational opportunities and traumatic brain injuries. When a reading disorder is caused by trauma to the brain, the disorder is referred to as alexia.
When an individual presents with reading difficulties, problems are usually reported with decoding and/or comprehension. Frequent complaints include having to read and re-read text multiple times, forgetting what one has read, reading very slowly or substituting/guessing words based on context. For an individual to develop into an effective reader, three components are essential: phonological processes, orthographic processes and phonological fluency.
Children who have difficulty with phonological processing are often have auditory processing deficits that result in poor phonological awareness. These children (and adults) have normal hearing, based on audiological examination, but may have been prone to ear infections and required myringotomy tubes. In addition, language issues may also be prominent. For example, as infants, the children may have experienced delays in language development. Articulation issues may have been noted (e.g., pronouncing the l sound as w) or the child may present with problems in receptive language (i.e., language comprehension) and expressive language (i.e., the ability to express oneself using language).
Children with the phonological subtype of reading disorder have a poor understanding of the sound-symbol relationship, which refers to the their understanding of the sounds of which a particular language is comprised and the letters used to represent the sounds (It is interesting note that children who struggle in their mother tongue, also struggle when attempting to learn a foreign language). As a consequence, their phonological awareness (i.e., the understanding of the sounds and ability to manipulate them) is impaired. Intact phonological awareness is essential for the decoding process – sounding out the words. When phonological awareness is impaired, children often rely on compensatory strategies, such as sight words and guessing at words based on their configuration or the context in which they are located. This results in poor comprehension of written material, particularly in higher grades.
Children with deficits in orthographic processes experience problems with graphemes & morphemes. Morphemes are the smallest units of sound in a language that convey meaning. For example, the ending ed is most frequently used to denote the past tense of a word (e.g., climbed is the past tense of climb). Graphemes are the written versions of morphemes. In this type of RD, children have little difficulty with words that make phonemic sense (e.g., words such as to that sound like they are spelled), but have trouble with words that are irregular in some way (e.g., two may be read as t-w-ah). Their reading tends to be slow and laborious. This is the type of RD where words and letter appear to move, letters are misidentified (e.g., confusion of b,d, p, q, s, & z) or transposed (i.e., letters within a word are switched), or letters in the middle of words are missed during reading.
Fluent reading refers to reading that is smooth, rapid, and automatic. Children who struggle with this component of reading tend to have adequate decoding skills (i.e., both the phonological and orthographic processes may be age-appropriate). In contrast, these children read slowly and make many spelling errors. In addition, the children report forgetting what they have read. Forgetting is due to the fact that working memory only has a short amount of time to process information. When processing speed is poor, at least a portion of the information obtained from reading text is likely to be lost. This type of RD is more likely to be associated with deficits in executive functions and is commonly found in children with the inattentive type of ADHD.
Children with RD grow up to become adults with RD. Adults typically experience difficulties with fluency but tend to read most words accurately. This means that they are accurate but slow readers, requiring more time to get through text than is typical. This can impact performance in college and at work and can lead a fairly capable person to perform well below his or her capacity.
The role of the neuropsychological evaluation is to determine why the child or adult is struggling with reading, specifically, looking to determine which of the aspect or aspects of reading process (e.g., phonological processes, orthographic processes, or fluency) is/are not operating properly. By providing a detailed assessment, this enables an individualized program to be developed based on the child's individual needs.
Disorder of Written Expression (DWE)
Writing-based learning disorders, or dysgraphia, more often than not occur within the context of other learning or language disorders. To be an effective writer the person has to develop adequate spelling skills, knowledge of grammar and handwriting. For proper spelling skills to develop, the individual has to have adequate phonological awareness. It is not surprising therefore, that individuals with inadequate phonological awareness have poor reading and spelling abilities. Grammar refers to the rules by which we organize the components of the language. Handwriting refers to how well the actual symbols and symbol combinations are produced.
The neuropsychological evaluation focuses on each of the components that are necessary for adequate writing skills to develop: spelling, grammar and handwriting, looking at phonological awareness, ability to translate thoughts into written form and the fine motor skills necessary to accurately produce the symbols and space words.
Mathematics Disorder (MD)
Learning disorders in the area of math are found in approximately 6% of the population. Although the research is not conclusive, there is a growing consensus that three types of Mathematics Disorder exist: semantic-memory subtype, procedural, and visual-spatial subtypes. The semantic-memory subtype commonly co-occurs with Reading Disorder and is characterized by deficits in the ability to recognize the symbolic nature between the Arabic numbers and the quantities they represent. In addition, individuals with this subtype of MD have poor automaticity that is associated with inadequate learning of math facts. Individuals demonstrating the procedural subtype are characterized by adequate quantitative knowledge and symbol-quantity relationships, but demonstrate inadequate strategy use and reliance on more immature strategies. They tend to work slowly and are prone to calculation errors. This subtype is often associated with the inattentive subtype of ADHD. Finally, the visual-spatial subtype is characterized by problems with alignment of numbers in columns and of place values due to poor visuospatial organization associated with right hemisphere dysfunction (children with Aspergers Disorder are more likely to have this subtype of math issue).
The neuropsychological evaluation assesses arithmetic abilities in various ways including number problems, word problems, practical applications and fluency/automaticity. Visuospatial skills are also examined to see if they are involved in the arithmetic problems that the individual is experiencing.
While many children may have undergone a school-based psychological or educational evaluation, this type of assessment is often not sufficient to identify learning disorders in reading, writing or math. Typical school-based evaluations use a discrepancy model to determine the presence of learning disorders, which means that they look for a large difference between the child’s level of intelligence (as determined by an IQ test) in comparison to performance on a measure of academic achievement. This method fails to correctly identify approximately 50% of individuals with learning disorders. The neuropsychological evaluation includes both measures of intellectual and academic functioning, but also employs methods that evaluate those brain functions involved in reading, math and writing as well as the more subtle components involved in each of those academic domains. The neuropsychological evaluation not only allows for more accurate diagnosis of the problem, but can also uncover the aspects that are causing the problem, leading to the development and implementation of more effective treatment and services.
For more information, contact Dr. Rozenblatt at (866) 840-9790 or firstname.lastname@example.org.
For a more thorough discussion of the neuropsychology of learning disabilities the reader is directed to the book:
School Neuropsychology: A Practitioner's Handbook, by James B. Hale & Catherine A. Fiorello, published by Guilford Press.