Abnormal Child Psychology - 6th

7
Communication and Learning

Disorders
If you can read this, thank a teacher.

—Anonymous
CHAPTER PREVIEW
Definitions and History Childhood-Onset Fluency SLD with Impairment in Written

Disorder (Stuttering) Expression
Language Development
Phonological Awareness Social (Pragmatic) SLD with Impairment in
Communication Disorder Mathematics
Communication
Disorders Specific Learning Disorder
Language Disorder SLD with Impairment in
Reading
195
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E VERYONE HAS IMPORTANT NEEDS and ideas.
Imagine not being able to get them across. Sights
and sounds surround you, but you cannot focus your
was also quite worried about Francine’s lack of friends
and the way other children treated her.
attention long enough to make sense of them. When you Her mother and father proudly shared their daugh-
ter’s early childhood history and developmental mile-
are shown how to read or add, you find that the letters
stones with me during our first interview. “Francine
and numbers look and sound too much alike. Children
walked before she was a year old, and was a very talk-
and adolescents with communication and learning dis- ative baby and toddler, who picked up new words quite
orders experience these difficulties daily. Everyday tasks quickly. She was a healthy and normal baby—we can’t
can be confusing and frustrating, and sometimes result figure out why she seems so uninterested in school and
in a cycle of academic failure and lowered self-esteem. other kids.” They went on to explain: “When she entered
preschool and kindergarten, she seemed uninterested
in making friends. The other kids basically ignored her,
even though she didn’t do anything to bother them. My
JAMES husband and I didn’t think much of it at first. In fact, we
bragged about how she took an early interest in read-
Smart but Can’t Read ing and would spend a lot of her time alone with a book
or magazine, even when she was 4 or 5, although she
James, age 9, was a growing concern for his teacher: didn’t usually understand what she read. But we grew
“James is obviously a very bright boy, and he wants more concerned around age 5 because she paid little at-
to do well. I’ve noticed that he likes art, and is always tention to popular movies, toys, and things other kids
wanting to draw. But he gets really upset when I ask him her age played with. When she was a preschooler, we
to do some work in class. also noticed that she had trouble with numbers and un-
He looks like he dreads coming to school. And he derstanding concepts like “more,” “less,” or “bigger.” She
complains that some words he tries to read don’t make knows what these words mean now, but she is still con-
sense to him. I’m worried that his increasing frustra- fused when we ask her to count something.
tion is going to cause other problems in school or with Yesterday I gave her her allowance and just for the
friends. Sometimes he gets mad at something and he has heck of it, I used pennies, nickels, and dimes to see if she
trouble calming down. If he is trying to create something could add them up. No matter how hard we tried, she
that doesn’t turn out the way he envisioned it, he ex- became confused, switching from one coin to the other,
plodes and slams his fist against the wall.” and she thought she had a bigger allowance if I stacked
What James’s mother heard was all too familiar. She the pennies up! And if you ask her to arrange something,
knew that her son would get involved in something only like setting the table for dinner, you never know what
if he could do it his own way. Her mind wandered briefly you’ll end up with!” (Based on authors’ case material.)
to when he was a toddler and sometimes got so anxious
and worried about something that he had trouble sleep-
ing or felt sick. She shared with his teacher her frustra-
tion at trying to find out what the problem was: “Getting Children with communication or learning disorders
him to read at home is like pulling teeth. He won’t read can learn, and they are as intelligent as anyone else.
at all on his own because he knows he can’t read many Their disorders usually affect only certain limited as-
of the words.” (Based on authors’ case material.) pects of learning, and rarely are they severe enough to
impair the pursuit of a normal life—but they can be
very stressful. Consider the experiences of James and
Francine: James and Francine have different learn-
FRANCINE ing problems. James’s are with language and reading.
His ability to distinguish between different language
Shunned and Falling Behind sounds (phonemes) is underdeveloped, which is the pri-
mary reason for his poor word recognition and writing
Francine, age 7, was entering a new school for the sec- ability. Francine’s problems are mostly with nonverbal
ond time in 2 years. The first school was too challenging, learning, such as math. She can read quite well, but she
and the other kids teased her because she “doesn’t know has difficulty understanding some of the subtleties of
what 2 plus 2 is.” She is content to play for hours by her- others’ facial expressions and gestures. She also con-
self and is not interested in the things that other kids her fuses terms and instructions that describe numerical
age are doing. “Most of the time,” her mother explained,
or spatial relationships, such as “larger than” or “sit
“Francine seems sad and in a bit of a fog.” Although
beside the couch.”
school performance was a major concern, her mother
The field of learning and communication disor-
ders, broadly referred to as “learning disabilities,”
196 P a r t 2 Neurodevelopmental Disorders
has changed dramatically during the past 50 years.
For many years, learning problems were attributed
to poor motivation or poor instruction. Fortunately,
breakthroughs in neuroimaging techniques has led to
increased recognition of the differences in the neu-
rological makeup and development of children with
problems in language and related cognitive tasks. With
Opus/amanaimages/Jupiter Images
recent advances in detection and intervention aimed at
early language development, signs of communication
problems are detected at an early age and children are
taught using alternative methods that build on their
developmental strengths.
In this chapter, we emphasize the relationship
between language development and the subsequent ap-
pearance of a learning problem once the child enters Slowly but surely, most children learn the letters of the
alphabet and how to use them to read and write words.
school. We put these problems in a developmental
For children with certain learning disabilities, however,
context by showing how communication disorders
the shapes and sounds of different letters continue to be
(diagnosed primarily in early childhood) and learning
confusing.
disorders (identified most often during early school
years) have interconnected features and underlying
causes. As a case in point, preschoolers with commu-
nication disorders are more likely to develop a learn-
ing disability by middle childhood or early adolescence affect a narrow range of ability, whereas others may
(Beitchman & Brownlie, 2014). affect many different tasks and social situations. Each
type of learning disability, whether it is related to
reading, writing, math, or language, is characterized
DEFINITIONS AND HISTORY by distinct definitions and diagnoses. Knowledge of
communication and learning disorders is growing
Learning disability (LD) is still commonly used as a rapidly as a result of increased scientific interest and
general term for learning problems that occur in the research support. We now recognize that a learning
absence of other obvious conditions, such as intel- disability, though challenging, does not have to be a
lectual disability or brain damage. In the Diagnostic handicap. Many well-known people with learning dif-
and Statistical Manual of Mental Disorder, 5th edition ficulties used their talents in exceptional ways, includ-
(DSM-5) two more specific terms are used, communi- ing Albert Einstein, Winston Churchill, and Thomas
cation disorders and learning disorders, but the com- Edison.
mon use of the term learning disability requires that it The main characteristic all children with learning
be clarified and defined. difficulties share is failing to perform at their expected
A learning disability affects how individuals with level in school. Otherwise, symptoms vary tremen-
normal or above-average intelligence take in, retain, dously (Beitchman & Brownlie, 2014). Many children
or express information. Incoming or outgoing infor- and adults who are unable to acquire academic skills
mation can be scrambled as it passes between the at a normal rate have been helped by recognizing and
senses and the brain. Unlike most physical disabili- attending to specific learning problems.
ties, a learning disability is hidden and is often unde- Children with learning disabilities constitute a third
tected in young children (Lovett & Lewandowski, in of all children in the United States and Canada who
2014). Thus, children with learning disabilities often receive special education services (National Center for
must cope not only with their limitations in reading, Educational Statistics, 2012). Yet, experts still struggle
writing, or math but also with the frustration of con- to adequately define learning disabilities because of
vincing others that their problems are as legitimate as their many forms and overlapping symptoms, which
visible disabilities. you will note in the following lengthy definition:
Learning difficulties often show up in schoolwork Learning disability is a lay term (not a diagnostic
and can impede a child’s ability to learn to read, write, term) that refers to significant problems in mastering
or do math, but they also can affect many other parts one or more of the following skills: listening, speaking,
of life, including work, daily routines, family life, and reading, writing, reasoning, and mathematics. Learning
friendships. Some learning problems are specific and disabilities do not include visual, hearing, or physical
C h a p t e r 7 Communication and Learning Disorders 197
impairments; intellectual disability; emotional distur- language disorder (problems using language to
▲
bance; or environmental disadvantage. Emotional and communicate, such as spoken words or sign lan-
social disturbances and other adaptive deficiencies may guage, or understanding what other people say)
occur with learning problems, but they do not by them- speech sound disorder (deficits in productive speech
▲
selves constitute a learning disability (Individuals with sounds)
Disabilities Education Improvement Act [IDEA], 2004). childhood-onset fluency disorder (problems in
▲
In Chapter 5 we described intellectual disability as speech fluency, such as stuttering)
involving deficits in basic cognitive abilities that include
social (pragmatic) communication disorder
▲
problem solving, verbal skills, and mental reasoning. But
the broader concept of intelligence also includes logical, These communication disorders are developmen-
mathematical, and language abilities that reflect a pattern tally connected to the later onset of learning disorders.
of relative strengths and weaknesses possessed by every- Specific learning disorder is a diagnostic term that
one. For example, we are all stronger in some areas of refers to specific problems in learning and using aca-
learning and performance than in others (e.g., we enjoy demic skills. The DSM-5 integrates the frequently
writing and reading, but don’t ask us to fix your car). Sim- co-occurring problems in reading, mathematics, and
ilarly, children with specific learning disorders who have written expression into this one category, and uses
normal intelligence show a pattern of relative strengths specifiers to designate impairments in one or more of
and weaknesses that can make some learning tasks much these areas. Specific learning disorder is determined
more difficult. This pattern is noteworthy mostly because by achievement test results that are substantially be-
it is so extreme and unexpected for a child who otherwise low what is expected for the child’s age, schooling,
shows normal cognitive and physical development. and intellectual ability.
Communication disorder is a diagnostic term that An unexpected pattern of strengths and weaknesses
refers to deficits in language, speech, and communication in learning was first noted and studied during the late
(APA, 2013). Communication disorders include the fol- nineteenth century by physicians who were treating
lowing diagnostic categories: patients with medical injuries (Hammill, 1993).
Franz Joseph Gall, a pioneer of language disorders,
was struck by what he observed among some of his
brain-injured patients: They had lost the capacity
to express their feelings and ideas clearly through
speech, yet they did not seem to suffer any intellec-
tual impairment. One of his patients could not speak,
but had no problem writing his thoughts on paper.
Because he knew that this patient had normal speech
before the head injury, Gall reasoned that the prob-
lem must have resulted from brain damage that had
disrupted the neurological processes related to speech.
For the first time, scientists began to pinpoint areas in
the brain that control the ability to express and
receive language processes.
These early observations, based on known medical
injuries, raised the possibility that people with learning
disabilities differ from people with intellectual disability
in terms of relative strengths and deficits. People with
learning disabilities have normal intellectual processes
in most areas but are relatively weaker in others, which
is known as having an unexpected discrepancy between
measured ability and actual performance. This premise
remained the foundation of most definitions of learn-
Bettmann/Corbis
ing disability for many years. However, researchers and

practitioners eventually agreed that subaverage perfor-
mance on achievement tests, rather than a discrepancy
Few realize that Albert Einstein had early speech and between potential and actual performance, was a bet-
language difficulties, given his monumental contributions ter way to capture these learning difficulties (Maehler
to society. & Schuchardt, 2011).
The links between intellectual disability, organic The fact that these children had normal intelligence
brain damage, and learning problems fascinated gave parents and teachers hope that difficulties in
scientists, who had a firmer understanding of brain– reading, writing, and math could be overcome if only
behavior relationships by the 1940s. During that time, the right set of instructional conditions and settings
the question still remained as to why some children could be identified (Lyon et al., 2003). These devel-
who did not fit the definition of intellectual disability opments led to the recent Response-to-Intervention
based on IQ had significant problems in learning. Could (RTI) movement, which views LD in terms of what
intellectual disability be restricted to only certain intel- academic help children need rather than what disabil-
lectual abilities? Were academic problems the same as ity they might have (Lovett & Lewandowski, in press).
those assessed by measures of general intelligence? Thus, with the collaborative leadership of parents, ed-
Strauss and Werner (1943) shed light on this is- ucators, and specially trained professionals, the field
sue by pointing out that children learn in individual of learning disabilities grew from its beginning in the
ways, challenging the concept that learning is a rela- 1960s to the major component of educational services
tively uniform, predictable process in children without it is today.
intellectual disabilities. Three important concepts from
this period continue to influence the field to this day
(Hallahan, Pullen, & Ward, 2013): Section Summary
1. Children approach learning in different ways, so Definitions and History
each child’s individual learning style and uniqueness ●● Learning disability is a general lay term for communication
should be recognized and used to full advantage. and learning problems that occur in the absence of other
2. Educational methods should be tailored to an indi- obvious conditions such as intellectual disability or brain
vidual child’s pattern of strengths and weaknesses; damage.
one method should not be imposed on everyone. ●● Children and adults with learning disabilities show specific
3. Children with learning problems might be helped deficits in using spoken or written language, often referred
by teaching methods that strengthen existing abili- to as relative strengths and weaknesses.
ties rather than emphasize weak areas. ●● Parents and educators assumed a major role in bring-
By the early 1960s, the modern learning disabilities ing recognition and services to children with learning
disabilities.
movement had begun. Parents and educators were dis-
satisfied that children often had to be diagnosed with
an intellectual disability in order to receive special
education services. A category was needed to describe Language Development
learning problems that could not be explained on the
basis of intellectual disability, lack of learning oppor- From birth, infants selectively attend to parental
tunities, psychopathology, or sensory deficits (Lyon, speech sounds and soon learn to communicate with
Fletcher, & Barnes, 2003). basic gestures and sounds of their own. Usually, by
Thus, the emerging concept of learning disabilities their first birthday they can recognize several words
made intuitive sense to many who were familiar with and use a few of their own to express their needs
the varied needs of children, and it was welcomed as and emotions. Over the next 2 years, their language
states and provinces began to support special educa- development proceeds at an exponential pace, and
tion programs and services. The domination of phy- their ability to formulate complex ideas and express
sicians and psychologists in the field gave way to new concepts is a constant source of amazement and
greater input from educators, parents, and clinicians. amusement for parents. Adults play an important role
Teacher training expanded to include new ways to in encouraging language development by providing
teach youngsters who could not respond to typical clear examples of language and enjoying the child’s
classroom methods. Professionals trained in speech expressions.
and language pathology became an important part of Language consists of phonemes, which are the basic
school-based services. sounds (such as sharp ba’s and da’s and drawn-out ee’s
As the focus of the learning disabilities movement and ss’s) that make up language. When a child hears a
shifted from the clinic to the classroom, parents and phoneme over and over, receptors in the ear stimulate
educators assumed a major role in programming and the formation of dedicated connections to the brain’s
placement. They were encouraged by the fact that the auditory cortex. A perceptual map forms that repre-
term learning disabled did not stigmatize children, but sents similarities among sounds and helps the infant
rather brought them needed services (Hammill, 1993). learn to discriminate among different phonemes. These
or cognitive disorder. Rather, such deviations from nor-
mal may be just that—deviations—and may be accom-
panied by superior abilities in other areas of cognitive
functioning. Albert Einstein, who is considered an in-
tellectual genius, began speaking late and infrequently,
causing his parents to worry that he was “subnormal.”
© Monkey Business Images/Shutterstock.com

According to family members, when his father asked
his son’s headmaster what profession his son should
adopt, the answer was simply, “It doesn’t matter,
he’ll never make a success of anything” (R. W. Clark,
1971, p. 10).
Since language development is an indicator of gen-
eral mental development, children in whom language
fails to develop or who show severe delays in acquiring
From an early age, children love to express language are considered at risk of having a language-
themselves.
based learning disability. Albert Einstein notwithstand-
ing, early language problems are considered highly
predictive of subsequent communication and learning
maps form quickly; 6-month-old children of English-
disorders (Heim & Benasich, 2006; Williams, 2010).
speaking parents already have auditory maps different
Phonology is the ability to learn and store pho-
from infants in non-English-speaking homes, as mea-
nemes as well as the rules for combining the sounds
sured by neuron activity in response to different sounds
into meaningful units or words. Deficits in phonology
(Kuhl et al., 2006). By their first birthday, the maps
are a chief reason that most children and adults with
are complete, and infants are less able to discriminate
communication and learning disorders have problems
sounds that are not important in their own language.
in language-based activities such as learning to read
Rapid development of a perceptual map is why
and spell (Larkin & Snowling, 2008; Nation, Snowling,
learning a second language after—rather than with—
& Clarke, 2007).
the first language is difficult; brain connections are
A young child is required to recognize that speech
already wired for English, and the remaining neurons
is segmented into phonemes (the English language
are less able to form basic new connections for, say,
contains about 42, such as ba, ga, at, and tr). This task
Swedish. Once the basic circuitry is established, infants
is difficult for many children because speech does not
can turn sounds into words, and the more words they
consist of separate phonemes produced one after an-
hear, the faster they learn language. The sounds of
other. Instead, sounds are co-articulated (overlapped
words serve to strengthen and expand neural connec-
with one another) to permit rapid communication,
tions that can then process more words. Similar cortical
rather than pronounced sound-by-sound (Liberman
maps are formed for other highly refined skills, such as
& Shankweiler, 1991). About 80% of children can
musical ability (Huss et al., 2011). A young child who
segment words and syllables into their proper pho-
learns to play a musical instrument may strengthen the
nemes by the time they are 7 years old. The other 20%
neural circuits that underlie not only music, but verbal
cannot, and it is these children who struggle hardest
memory as well (Ho, Cheung, & Chan, 2003).
to read (S. E. Shaywitz & Shaywitz, 2013; Vellutino
et al., 2004).
Generally, early language problems surface as
Phonological Awareness learning problems when children enter school,
Not all children progress normally through the mile- because in school children are taught to connect spo-
stones of language development. Some are noticeably ken and written language. Those who do not easily
delayed, continuing to use gestures or sounds rather learn to read and write often have difficulty learning
than speech. Others progress normally in some areas, the alphabetic system—the relationship of sounds to
such as following spoken directions and attending letters. They also cannot manipulate sounds within
to commands, but have trouble finding the words to syllables in words, which is called a lack of phonolog-
express themselves clearly. ical awareness and is a precursor to reading problems
Although the development of language is one of the (Rvachew, 2007).
best predictors of school performance and overall intel- Phonological awareness is a broad construct that
ligence (Sattler, 2008), delays or differences in develop- includes recognizing the relationship between sounds
ment are not a definitive sign of intellectual disability and letters, detecting rhyme and alliteration, and being
aware that sounds can be manipulated within syllables disorders. (Stuttering has a unique clinical feature and
in words. Primary-grade teachers detect phonological developmental course, so it is discussed separately.)
awareness as they ask children to rhyme words and Consider Jackie’s communication problems at age
manipulate sounds. For example, the teacher can say 3 years:
“hat” and ask the child to say the word without the h
sound, or say “trip” and have the child say the word
without the p. To assess the child’s ability to blend J AC K I E
sounds, teachers can say the three sounds t, i, and n, for
example, and see whether the child can pull the sounds Screaming, Not Talking
together to say “tin.”
In addition to serving as a prerequisite for basic Jackie’s mother explained with no hesitation why she
reading skills, phonological awareness and process- asked for help: “My 3-year-old daughter is a growing
ing also appear highly related to expressive language concern. Since she was a baby, she has been plagued
development (Boada & Pennington, 2006). Read- by ear infections and sleep problems. Some nights she
ers with core deficits in phonological processing have screams for hours on end, usually because of the ear in-
difficulty segmenting and categorizing phonemes, re- fections. She has violent temper outbursts and refuses to
trieving the names of common objects and letters, storing do simple things that I ask her to do, like get dressed or
phonological codes in short-term memory, and produc- put on her coat.”
ing some speech sounds. Reading and comprehension The child, waiting in the playroom, could be heard
screaming over her mother’s voice. Jackie was asking my
depend on the rapid and automatic ability to decode
assistant for something, but she could not make out what
single words. Children who are slow and inaccurate at
Jackie was saying. It was pretty obvious how frustrated
decoding have the most difficulties in reading compre- both the child and her mother must feel on occasion.
hension (Melby-Lervåg, Lyster, & Hulme, 2012). Her mother explained how she and Jackie’s father had
divorced when Jackie was less than 2 years old, and that
after weekend exchanges it sometimes took a few days
Section Summary for Jackie’s routine to return to some degree of normalcy.
I opened the letter she had brought from Jackie’s
Language Development preschool teacher, someone who I knew had a great
●● Language development is based on innate ability and deal of experience with children of this age. “Jackie is a
environmental opportunities to learn, store, and express bright and energetic child,” the letter began, “but she is
having a great deal of difficulty expressing herself with
important sounds in the language. It proceeds very rapidly
words. When she gets frustrated, she starts to give up or
during infancy.
becomes angry—she won’t eat her meals or she fights
●● Deficits in phonological awareness—the ability to distin- with staff at nap time, even if she is hungry or tired. If a
guish the sounds of language—have been identified as a new teacher at day care is introduced, it takes Jackie a
major cause of communication and learning disorders. long time to get used to the new person. Jackie seems to
understand what she is being asked, but can’t find the
words to express herself, which understandably leads to
Communication Disorders an emotional reaction on her part.” (Based on authors’
case material.)
Children with communication disorders have difficulty
producing speech sounds, using spoken language to
communicate, or understanding what other people say.
In DSM-5, communication disorders include the diag-
nostic subcategories of language disorder, speech sound
Language Disorder
disorder, childhood-onset fluency disorder (stuttering), Jackie’s problems met the criteria for a language
and social (pragmatic) communication disorder. These disorder, which is a communication disorder charac-
subcategories are distinguished by the exact nature of terized by difficulties in the comprehension or pro-
the child’s impairment. duction of spoken or written language. As a result of
Recall that during development phonological prob- these deficits, Jackie showed her frustration loudly
lems appear before problems in language reception and inappropriately.
or expression, yet they have strong similarities. The Children’s language development follows spe-
following discussion focuses on language disorder in cific steps, although each child may proceed through
an effort to highlight early childhood problems that the steps at a different pace. Normal variations can
represent the fundamental features of communication make it difficult to predict that a given child’s early
communication problems will later become major vocabulary, limited sentence structure, or impairments
problems in learning. A common example is the child in their ability to carry on a conversation. A child’s
who points to different objects and makes grunting or expressive and receptive abilities may differ such that
squealing noises that the parent quickly recognizes as his or her language comprehension, for example, is
“more milk” or “no peas.” Prior to age 3 or so, many stronger than his or her language expression. For ex-
children communicate this way unless parents actively ample, when asked by her parents to go upstairs, find
encourage using words and discourage nonverbal com- her socks, and put them on, Jackie was quite capable
munications. Nevertheless, despite plenty of verbal ex- of complying. When asked by her mother to describe
amples and proper language stimulation, some children what she has just done, however, she might respond
do not develop in some areas of speech and language, simply, “find socks.”
and they later have problems in school. This develop- The linguistic abilities of children with language
mental connection makes the study of communication disorders vary significantly, based on the severity of
disorders highly pertinent to understanding and treat- the disorder and the age of the child. Most often, these
ing subsequent learning problems. children begin speaking late and progress slowly in
Table 7.1 shows the major features of the DSM-5 their speech development. Their vocabulary often is
diagnostic criteria for language disorder. Children with limited and is marked by short sentences and simple
a language disorder, such as Jackie, do not suffer from grammatical structure, as in Jackie’s response. To fit
intellectual disability or from autism spectrum disorder, the diagnostic criteria, these problems must be sub-
which affect speech and language. Rather, they show stantially below the abilities of other children of the
persistent difficulties in acquiring and using language same age, resulting in functional limitations in com-
to communicate (Criterion A). A child’s ability to use munication, social participation, or academic achieve-
language depends on both receptive skills (i.e., receiv- ment (Criterion B). In addition, the symptoms must
ing and comprehending language) and expressive skills begin in the early developmental period (Criterion C)
(i.e., production of vocal, gestural, or verbal signals). and not be attributable to other sensory impairments
Thus, children with this disorder often show reduced or medical conditions (Criterion D).
Although their hearing is normal, children with lan-
guage disorder may have difficulty understanding par-
ticular types of words or statements, such as complex
TABLE 7.1
| iagnostic Criteria for Language
D
Disorder
if–then sentences. In severe cases, the child’s ability to
understand basic vocabulary or simple sentences may be
(A) Persistent difficulties in the acquisition DSM-5 impaired, and there may be deficits in auditory process-
and use of language across modalities ing of sounds and symbols and in their storage, recall,
(i.e., spoken, written, sign language, or other) due to and sequencing. Understandably, these problems make
deficits in comprehension or production that include the the child seem inattentive or noncompliant, and the dis-
following:
order can be easily misdiagnosed. Imagine how it would
(1) Reduced vocabulary (word knowledge and use). feel to be in Greece visiting an English-speaking host
(2) Limited sentence structure (ability to put words and and her Greek husband. Unless your host is present, try-
word endings together to form sentences based on
ing to engage in friendly conversation can be frustrating
the rules of grammar and morphology).
and uncomfortable. Even if both you and the husband
(3) Impairments in discourse (ability to use vocabulary
can each understand a few words the other is saying,
and connect sentences to explain or describe a topic
or series of events or have a conversation). you probably cannot actually converse. If you have ever
(B) Language abilities are substantially and quantifiably faced a similar communication barrier, you probably
below those expected for age, resulting in functional limi- have an appreciation of the frustration and discomfort
tations in effective communication, social participation, that accompany a language disorder.
academic achievement, or occupational performance, When the developmental language problem involves
individually or in any combination. articulation or sound production rather than word
(C) Onset of symptoms is in the early developmental period. knowledge, a speech sound disorder may be an appro-
(D) The difficulties are not attributable to hearing or other priate diagnosis. Children with this disorder have trouble
sensory impairment, motor dysfunction, or another medi- controlling their rate of speech, or lag behind playmates
cal or neurological condition and are not better explained in learning to articulate certain sounds. Typically, chil-
by intellectual disability (intellectual developmental dis- dren learn phonemes and use intelligible speech by the
order) or global developmental delay.
age of 3 years or so, with the exception of some of the
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. American
more difficult sounds such as l, r, s, z, th, and ch, which
Psychiatric Association. may take a few years longer to articulate (APA, 2013).
Depending on the severity of the disorder, the speech communication problems and further alter the course
quality of these children may be unusual, and even un- of development in terms of how these children re-
intelligible. For example, at age 6, James still said “wab- late to peers or keep up with educational demands
bit” instead of “rabbit” and “we-wind” for “rewind.” (Durkin & Conti-Ramsden, 2010). To give children
Preschoolers, of course, often mispronounce words or with special needs the opportunity to interact with
confuse the sounds they hear, which is a normal part of typically developing children, school systems have be-
learning to speak. When these problems persist beyond gun to include these children in regular, rather than
the normal developmental range (age 4) or interfere with segregated, classrooms. Inclusion education strategies
academic and social activities by age 7, they deserve are based on the premise that the abilities of children
separate attention. with special needs will improve from associating with
normally developing peers and that by doing so these
children will be spared the effects of labeling and
Prevalence and Course special placements.
Children usually reveal problems in speech articu-
lation and expression as they attempt to tackle new Causes
sounds and express their own concepts. Even though Notable findings that support the role of genetics, brain
prevalence estimates account for normal variations function, and environmental risk factors associated
in language development and are based on individu- with a higher incidence of learning disorders are dis-
als who meet specific diagnostic criteria, the degree of cussed in the following sections.
severity can vary considerably. For example, in early
childhood, milder forms of speech sound disorder
Genetics
are relatively common, affecting close to 10% of pre-
schoolers. Many of these children outgrow their earlier Language processes appear to be heritable to a sig-
difficulties, so only 2% to 3% of preschoolers meet the nificant degree, although the specific genetic under-
criteria for speech sound disorder. However, language pinnings are difficult to pinpoint. About 50% to 75%
disorder is a bit more common, affecting about 7% of of all children with a language disorder show a posi-
younger school-age children across studies (Beitchman tive family history of some type of learning disabil-
& Brownlie, 2014; Heim & Benasich, 2006). ity (American Speech–Language–Hearing Association
Communication disorders are identified almost [ASHA], 2008; Heim & Benasich, 2006). Twin studies
twice as often in boys as in girls (Pinborough- and adoption studies also suggest a genetic connection
Zimmerman et al., 2007); boys’ language difficulties (McGrath et al., 2007; Plomin, Haworth, & Davis,
are more often accompanied by behavior problems, 2010; Whitehouse et al., 2011).
and consequently, they are referred and diagnosed Scientists are zeroing in on specific deficits in brain
with communication learning disorders more often functioning that lead to communication disorders
than girls (Vellutino et al., 2004). By 4 years of age and may be heritable. Studies comparing language-
a child’s individual differences in language stabilize, impaired children with and without an affected par-
so problems that remain past this age are highly pre- ent suggest that temporal processing deficits occur
dictive of later outcomes. About 50% fully outgrow significantly more often in children with a positive
their problems, whereas the other 50% may show im- family history for a language-based learning disabil-
provement but still have some degree of impairment ity (Caylak, 2011; Flax et al., 2003). That is, affected
into adulthood. Children with receptive language children have more difficulty deciphering certain
impairments, in particular, have a poor progno- speech sounds because of subtle but important differ-
sis as compared with those with primarily expres- ences in the way neurons fire in response to various
sive impairments. Receptive language problems are sounds. In a twin study, Bishop et al. (1999) found
more resistant to treatment and are often associated that the variation in temporal processing was due to
with reading difficulties throughout their education environmental factors and not to genetics because
(APA, 2013). twin–twin correlations were similar for monozygotic
Even though language problems usually diminish (MZ) and dizygotic (DZ) twins. However, what does
with time, children with communication disorders appear to be genetic is a deficit in phonological short-
often have higher-than-normal rates of negative behav- term memory.
iors that began at an early age (van Daal, Verhoeven,
& van Balkom, 2007). Associated behavior prob- The Brain
lems, such as attention-deficit/hyperactivity disor- Language functions develop rapidly and are housed
der (ADHD) and social skill limitations, can add to primarily in the left temporal lobe of the brain
Dendrites Axon terminal
Nucleus Signals travel away from
the cell body, down the axon. Synapse
Axon
Neurons form a vast, miniaturized informational network that transmits information

in the form of electrical signals. When electrical signals move through a neuron,
the cell ejects chemicals called neurotransmitters into the synapses (spaces
between neurons). The neurotransmitters then cross the synapses and act like
switches to turn adjacent cells on or off.
The cortex is a thin layer of cells that The parietal lobe is

essentially covers the entire surface of involved with perception
the forebrain. A well-developed cortex and sensory experiences.
allows a person to read, understand,
talk about, and remember the Parietal
concepts in this text. The vast
majority of our neurons are Frontal The occipital lobe is
located in the cortex. involved with processing
visual information.
Temporal
Occipital
The frontal lobe is involved The temporal lobe is

with personality, emotions, involved with hearing and
and motor behaviors. speaking.
● F I GU R E 7 . 1 | Areas of the brain involved in language functions.

From Plotnik/Kouyoumdjian. Introduction to Psychology, 9th ed. 2011 Wadsworth, a part of Cengage Learning, Inc
(see ● Figure 7.1). A circular feedback loop helps less brain activity in the left temporal region, suggesting
strengthen the developmental process of language re- that phonological problems may stem from neurologi-
ception and expression. The better children compre- cal deficits or deviations in posterior left-hemisphere
hend spoken language, the better they will be able to systems that control the ability to process phonemes
express themselves. Feedback from their own vocaliza- (Richlan et al., 2011; S. E. Shaywitz et al., 2009). We
tions, in turn, helps shape their subsequent expressions. return to these findings on brain function later, in our
Lack of comprehension and absence of feedback re- discussion of reading disorders.
duces verbal output, and thus interferes with the de- Recurrent otitis media (middle ear infection) in early
velopment of articulation skills (Vellutino et al., 2007). childhood was long thought to contribute to language
Anatomical and neuroimaging studies show that difficulties, because hearing loss accompanies frequent or
deficits in phonological awareness and segmentation long bouts of infections. Although otitis media that oc-
are related to problems in the functional connections curs often during early childhood may lead to speech and
between brain areas, not to a specific dysfunction of language delays, these delays improve relatively quickly
any single area of the brain (Lyon et al., 2006; Richlan, and largely disappear by age 7 (Zumach et al., 2010).
Kronbichler, & Wimmer, 2011). Some brain imaging In summary, although biological findings point to ab-
studies have indicated that poor performance on tasks normal brain functioning, how this abnormality originates
demanding phonological awareness is associated with is still unclear. The best guess is that communication
disorders result from an interaction of genetic influences, For Jackie, we designed ways that her parents and
slowness or abnormalities of brain maturation, and pos- day-care teachers could build on her existing strengths.
sibly, minor brain lesions that escape clinical detection Her day-care teacher had an excellent idea: Because
(S. E. Shaywitz, Morris, & Shaywitz, 2008). Jackie loved to draw and to talk about her artwork,
why not use her interest in drawing to increase her en-
Home Environment thusiasm for speaking? When I visited her class, Jackie
How much does the home environment contribute ran up to show me her drawing, exclaiming, “I draw
to communication disorders? Do some parents fail to picture of mom, dad, kitty, and lake.” We agreed that
provide adequate examples to stimulate their children’s her behavior problems could be managed by simple
language? Because of the important role parents play forms of ignoring and distracting and the occasional
in children’s development, psychologists have studied time-out. Jackie became attached to computer graph-
this issue carefully. ics and images, and she soon was able to identify let-
We noticed when we first visited Jackie at home that ters and small words and to move shapes around the
her stepfather was a very quiet man who often commu- screen. All the while, her expressive language improved,
nicated nonverbally—a gesture, a frown, a short phrase. and by age 5 she could pronounce all the letters of the
Her mother used very simple speech when talking to alphabet and was eager to start kindergarten.
Jackie but not when talking to Jackie’s 6-year-old sister.
These observations match those of researchers (St. James- Childhood-Onset Fluency Disorder
Roberts & Alston, 2006; Whitehurst & Lonigan, 1998)
who compared verbal interactions of families with and (Stuttering)
without a child who had a language disorder. They found Childhood-Onset Fluency Disorder (Stuttering) is the re-
that parents changed the way they spoke to their chil- peated and prolonged pronunciation of certain syllables
dren, depending on their children’s abilities. When the that interferes with communication. It is quite normal
child spoke in simple, two- or three-word sentences, the for children who are still learning to speak to go through
parents adjusted their speech accordingly. Note that, a period of nonfluency, or unclear speech, as part of their
except in extreme cases of child neglect or abuse, it is development. It takes practice and patience for a child to
unlikely that communication disorders are caused by develop the coordination for the tongue, lips, and brain
parents. Parental speech and language stimulation may to work in unison to produce unfamiliar or difficult com-
affect the pace and range of language development, but binations of sounds. For most children, this period of
not the specific impairments that characterize the disor- speech development passes without notice, and for most
ders (Glascoe & Leew, 2010; McGrath et al., 2007). parents it is full of wonder and amusement as their chil-
dren wrestle with new words. Some children, however,
Treatment progress slowly through this stage, repeating (wa-wa-
Although communication disorders in some children may wa) or prolonging (n-ah-ah-ah-o) sounds; they struggle
self-correct by age 6 or so, those with more severe com- to continue or develop ways to avoid or compensate for
munication and language difficulties will continue to lag certain sounds or words. Four-year-old Sayad has speech
behind their peers and are at risk of havingbehavioral or problems that typify the pattern of stuttering:
social problems if the difficulties are left untreated. Thus,
parents should seek help in understanding their child’s
speech delays and to ensure that they are doing everything
possible to stimulate language development. In general,
treatment for children with communication disorders is S AYA D
based on three principles (Beitchman & Brownlie, 2014):
(1) treatment to promote the child’s language competen- Family Legacy
cies; (2) treatment to adjust the environment in ways that
accommodate the child’s needs; and (3) therapy with the Sayad’s parents had received a lot of informal advice
child (or youth) to equip him or her with knowledge and from friends and relatives about their son’s speech prob-
skills to reduce behavioral and emotional symptoms. lems, but most of what they said was worrisome. “He’ll
Specialized preschools, for example, have had good struggle with this for most of his life,” his grandmother
had warned. “If something isn’t done right away, he’ll
results using a combination of computer- and teacher-
become a stutterer, and be so self-conscious that he won’t
assisted instruction to teach early language skills to
be able to keep up in school or with his friends.”
young children, which helps to pace the child’s practice
of new skills (Hatcher et al., 2006; Loo et al., 2010; (continues)
Smith-Lock et al., 2013).
(continued)
TABLE 7.2
| iagnostic Criteria for Childhood-
D
Onset Fluency Disorder (Stuttering)
Sayad started repeating and prolonging some of his
(A) Disturbances in the normal fluency and DSM-5
words when he was about 2, but now his problem had
time of patterning of speech that are
grown more noticeable. As he spoke, he pursed his lips, inappropriate for the individual’s age and
closed his eyes, and shortened his breathing, seeming language skills, persist over time, and are characterized
to tense up his face. Yet his interactions with me were by frequent and marked occurrences of one (or more) or
friendly and at ease. “M-m-m-m-y words get stuck in the following:
m-m-m-m-y m-m-mouth,” he explained, “and I-I-I-I talk
(1) Sound and syllable repetitions.
t-t-t-t-too fast. Wh-wh-wh-why can’t I talk right?” I soon
(2) Sound prolongations of consonants as well as words.
discovered why his grandmother was so concerned: The
child’s great-grandfather and great-uncle both stuttered, (3) Broken words (e.g., pauses within a word).
and Sayad’s father had been a stutterer until he was a (4) Audible or silent blocking (filled or unfilled pauses in
teenager. speech).
Sayad’s mother had been trying to ignore the problem (5) Circumlocutions (word substitutions to avoid prob-
and not draw attention to it, but she was growing more lematic words).
aware that Sayad’s peers teased and imitated him. She ex- (6) Words produced with an excess of physical tension.
plained why she came for an assessment: “We were on the (7) Monosyllabic whole-word repetitions (e.g., “I-I-I-I” see
way to the store when Sayad kept saying ‘where’ over and him).
over. After I stopped the car and unfastened his seatbelt, (B) The disturbance causes anxiety about speaking or limita-
he finished his question—‘is daddy?’ After that, I gave up tions in effective communication, social participation, or
on my ‘leave it alone’ notion and began trying ways to academic or occupational performance, individually or in
slow Sayad down a bit.” (Based on authors’ case material.) any combination.
(C) The onset of symptoms is in the early developmental
period (Note: Later-onset cases are diagnosed as adult-
onset fluency disorder).
(D) The disturbance is not attributable to a speech-motor or
DSM-5 diagnostic criteria for Childhood-Onset sensory deficit, dysfluency associated with neurological
insult (e.g., stroke, tumor, trauma), or another medical
Fluency Disorder (Stuttering) are shown in Table 7.2. concern and is not better explained by another mental
This disorder involves disturbance in the normal fluen- disorder.
cy and time patterning of speech that is atypical for the
child’s age and that occurs often and persists over time. Source: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American
Stuttering is characterized by sound and syllable rep- Psychiatric Association.
etitions, sound prolongations, pauses within a word,

word substitutions to avoid problematic words, and
similar pronunciation and speech difficulties. These the lifespan (i.e., the number of individuals of all ages
difficulties lead to anxiety about speaking or partici- who meet the diagnostic criteria at any point in time)
pating in activities that require effective communica- is below 1% (Yairi & Ambrose, 2013). Higher rates of
tion or social participation. Over time the child may parent-reported stuttering have been noted among
develop a fearful anticipation of speaking in front of African American and Hispanic children in the United
others and attempt to avoid speech situations such as States, although how racial and cultural factors may af-
talking by telephone or in class. The disorder may be fect stuttering remains unclear (Boyle et al., 2011).
accompanied by motor movements such as eye blinks,
tics, tremors of the lips or face, etc. (APA, 2013). Causes and Treatment
Many myths and falsehoods surround stuttering. The
Prevalence and Course widely held view that stuttering is caused by an unresolved
Stuttering is relatively common as young children emotional problem or by anxiety is not supported by any
learn to articulate sounds clearly and appropriately. evidence (Packman et al., 2007). Because the problem
Population-based surveys indicate that 11% of children runs in families, researchers have focused on family char-
stutter by age 4, with girls affected as much as boys (Reil- acteristics as the major causes. However, it is not likely
ly et al., 2013; Yairi & Ambrose, 2013). However, few this behavior is acquired primarily as a function of the
children receive a diagnosis of childhood-onset fluency child’s linguistic environment. Sayad’s grandmother and
disorder because about 80% recover from stuttering mother would be relieved to know that the communica-
as they attend school for a year or so (Packman, Code, tive behavior of mothers does not significantly contribute
& Onslow, 2007). The prevalence of stuttering across to the development of stuttering (Howell & Davis, 2011).
Genetic factors play a strong role in the etiology of
stuttering, accounting for approximately 70% of the
TABLE 7.3
| Diagnostic Criteria for Social (Pragmatic)
Communication Disorder
variance in the causes of stuttering (Dworzynski et al.,
(A) Persistent difficulties in the social use of DSM-5
2007). Environmental factors, such as premature birth
verbal and nonverbal communication as
or parental mental illness, account for the remaining manifested by all of the following:
causal influences (Ajdacic-Gross et al., 2010). Genetic
(1) Deficits in using communication for social purposes,
factors most likely influence speech by causing an ab- such as greeting and sharing information, in a manner
normal development in the location of the most promi- that is appropriate for the social context.
nent speech centers in the brain, which are usually in (2) Impairment of the ability to change communication
the left hemisphere. This biological source for stutter- to match context or the needs of the listener, such as
ing explains many of its clinical features, including the speaking differently in a classroom than on a play-
loss of spontaneity and occasional problems in self- ground, talking differently to a child than to an adult,
esteem (Howell, 2011; Kell et al., 2009). and avoiding use of overly formal language.
Since most children outgrow stuttering, one of the (3) Difficulties following rules for language and storytell-
most frustrating problems for parents and therapists ing, such as taking turns in conversation, rephrasing
when misunderstood, and knowing how to use verbal
is to decide whether therapy would be intervention or
and nonverbal signals to regulate interaction.
interference. Therapy is usually recommended if sound
(4) Difficulties understanding what is not explicitly stated
and syllable repetitions are frequent, if the parent or (e.g., making inferences) and nonliteral or ambiguous
child is concerned about the problem, or if the child meanings of language (e.g., idioms, humor, meta-
shows, like Sayad, facial or vocal tension. A common phors, multiple meanings that depend on the context
psychological treatment for children who stutter is to for interpretation).
teach parents how to speak to their children slowly and (B) The deficits result in functional limitations in effective
use short and simple sentences, consequently removing communication, social participation, social relationships,
the pressure the child may feel about speaking (Howell, academic achievement, or occupational performance,
2011; Rousseau, Packman, Onslow, Harrison, & individually or in combination.
Jones, 2007). Other beneficial treatments for stuttering (C) The onset of the symptoms is early in the developmental
include contingency management, which uses positive period (but deficits may not become fully manifest
until social communication demands exceed limited
consequences for fluency and negative consequences
capacities).
for stuttering (Bothe et al., 2006; Murphy, Yaruss, &
(D) The symptoms are not attributable to another medi-
Quesal, 2007), and habit reversal procedures, such as
cal or neurological condition or to low abilities in the
learning to regulate breathing (Bate et al., 2011). domains of word structure and grammar, and are not bet-
ter explained by autism spectrum disorder, intellectual
disability (intellectual developmental disorder), global
Social (Pragmatic) Communication developmental delay, or another mental disorder.
Disorder
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American
Social (Pragmatic) Communication Disorder (SCD) Psychiatric Association.
is a new disorder in DSM-5. It involves persistent dif-

ficulties with pragmatics—the social use of language
and communication (APA, 2013). Pragmatics are cul- Difficulties changing their communication to match
▲
turally specific practices and skills related to social the situation or the listener, such as the classroom
uses of language, conversational norms, and the use versus the playground.
of nonverbal communication, such as eye contact and Problems following the rules of language, such as
▲
gestures (Beitchman & Brownlie, 2014). Pragmatic dif- taking turns in a conversation,
ficulties involve both expressive and receptive skills— Difficulties understanding what someone is not ex-
▲
being able to adapt one’s communication to the social plicitly saying, such as being able to make inferences
context and being able to understand the nuances and based on the context of the situation.
social meanings expressed by others.
A diagnosis of SCD is not typically made until the
The first requirement for a diagnosis of social (prag-
child is 4 or 5 years old, to determine whether he or she
matic) communication disorder involves persistent dif-
has shown adequate developmental progress in speech
ficulties across four areas (Table 7.3):
and language. Signs of language impairment, such as
Deficits in using communication for social purposes. a history of delay in reaching language milestones, are
▲
A child may show difficulty greeting others or shar- common, but it is the specific deficits in social com-
ing information appropriately. munication that determine this disorder. As with other
communication disorders, onset must be early in de- Specific Learning Disorder
velopment and result in functional limitations in com-
munication, social participation, social relationships or People do not understand what it costs in time and suffer-
academic functioning. ing to learn how to read. I have been working at it for eighty
Social (pragmatic) communication disorder was
years, and I still can’t say that I’ve succeeded.
added to the DSM because of the number of children
who did not meet conventional criteria for an autism —Goethe (1749–1832)
spectrum disorder (ASD) yet who had persistent dif- Whether we are studying Roman history or calculus,
ficulties with social aspects of communication and peer applying ourselves to the task of learning requires ex-
relations. SCD is differentiated from ASD largely on ertion and concentration. Like physical activities, some
the basis of fewer restricted/repetitive patterns of be- learning activities are more difficult than others, espe-
haviors and interests (Gibson et al., 2013). The symp- cially for younger children who have not developed a
toms of SCD also overlap with ADHD, social anxiety foundation of good study habits and successful learn-
disorder, and intellectual disability in that they share ing experiences. Parents and teachers may notice that
problems in social, pragmatic communication. Al- a child is struggling unusually hard to master a par-
though this diagnostic category is new, studies based on ticular skill, such as reading, and wonder why. The
similar samples of children suggest that some children problem may be formally assessed by an IQ test and
show improvement over time while others continue to various standardized tests that assess abilities in spe-
show social communication deficits into adulthood. cific academic areas.
Regardless of improvements in social communication, When achievement in reading, math, or writing is
children with SCD may suffer lasting impairments in well below average for the child’s age and intellectual
peer relations due to their early difficulties. Thus, peer- ability, he or she may be diagnosed with a specific
assisted interventions are recognized as effective ways learning disorder (SLD). In other words, a child with
to build pragmatic communication and social skills for a specific learning disorder is intellectually capable of
these children (Murphy, Faulkner, & Farley, 2014). learning key academic concepts of reading, writing,
and math, but seems unable to do so. The phrase “un-
expected academic underachievement” captures this
Section Summary notion that the child’s learning problems are indeed
specific and not due to intellectual disability or global
Communication Disorders developmental delay (APA, 2013).
●● Speech and language problems that emerge during early
childhood include difficulty producing speech sounds,
demonstrating speech fluency, using spoken language to JAMES
communicate, or understanding what other people say.
●● Even though most children with communication disor- Strong Points Shine
ders acquire normal language by mid-to-late adolescence,
early communication disorders are developmentally con- The look on the 9-year-old’s face said it all—he did not
nected to the later onset of learning disorders. want to be here. “I’m tired of talking to people” was his
●● Language disorder is a communication disorder involving terse greeting. I wondered for a moment whether he would
difficulties in comprehension or production of spoken or talk to me at all, but as soon as he saw my computer,
written language. he brightened a bit. To allow time for him to feel more
●● Childhood-Onset Fluency Disorder (Stuttering) is relatively comfortable, I invited James to play a quick game or two.
common among younger children, and declines signifi- His skill at the action games told me a lot about his basic
cantly once the child enters school. energy and problem-solving ability—he was a whiz at fig-
uring out the rules of each game and getting a high score.
●● Social (Pragmatic) Communication Disorder is new to
We spoke casually during the warm-up, but it was clear to
DSM-5. Its primary characteristics involve difficulties in the
me that he preferred to concentrate on the game.
social use of verbal and nonverbal communication. A half hour passed, with little more than a few sen-
●● Causes of communication disorders include genetic influ- tences exchanged. A quick trip to the snack bar gave
ences and slow or abnormal brain maturation. us the common ground we needed to open up and talk
●● Many communication disorders resolve themselves after a bit. “Why does my teacher want me to come here?”
children begin attending school. Treatment is recom- he reasonably asked. As he listened and replied to my
mended for children who show significant language explanation, his language problems stood out. His sen-
delays or difficulties; it involves accommodating the child’s tences were short, simple, and rapid. Here is an example:
needs to strengthen speech and language skills.
“James, tell me something about your favorite story and let me outta here.” As I searched for something to
or a recent movie you’ve seen.” say, I asked Tim to tell me a little about his family: “Do
“I like the movie. Lots of dogs.” you have any brothers or sisters? Does your family like
“What movie is that, James?” to do anything special together?” His tired response, “I
“Dog movie.” have two brothers, my father works all day, mom plays
piano. We want a boat,” sent me a clear message as to
During testing, James often tried to start before I had
his mood and interest in this activity. My usual ploy of
finished telling him what to do. He was eager to do what
turning on the computer games fell flat—“I hate com-
I asked, but he stopped abruptly as soon as he had trou-
puters” was Tim’s preemptive response. I wondered, “Is
ble. James could focus on only one sound at a time, so if
he depressed, angry, hurt, frustrated? Just what is going
he missed early cues or initial instructions, he would be-
on here?”
come disoriented, frustrated, and uncooperative. James
Having looked at his school record, I knew he was
wanted to do well, but I could see he was struggling. He
struggling, especially in math and physical sciences,
completed the WISC-IV (Wechsler Intelligence Scale for
but his speech and affect expressed more than only
Children, 4th ed.) in less than an hour, hurrying almost
academic problems. His school records flashed the news
as if to escape his own mistakes. His measured general
that Tim had a specific learning disorder, as evidenced
intelligence was within the normal range, but his per-
by his WISC-IV performance score of 79 that fell in the
formance abilities (performance IQ, 109) were much
borderline-to-low-average range, and his verbal score of
stronger than his verbal abilities (verbal IQ, 78). It was
108 that fell in the average range. The test administrator
obvious as well that the test underestimated his true abil-
had politely described Tim’s test-taking approach as “re-
ity, as a result of his eagerness to finish and his difficulty
luctant.” Notes by teachers indicated that he commonly
with understanding some of the instructions.
had problems on tasks involving drawing, particularly
To my surprise, James was ready to continue on to
if they required memory, and his math and social skills
the next test after only a short computer game break. He
were far below those of others in his class.
explained why this was so: “I put things together, like
I pulled out my Where’s Waldo? book and we began
puzzles. I make cars and planes at my house.” As long as
looking at it together. In addition to being fun, looking
I gave him small breaks on the computer, he was willing
for Waldo and his friends (small figures amidst millions
to tackle the material on the tests. Some of his spelling er-
of figures and colors) required Tim to be patient. At first
rors stood out immediately, such as skr for square, and srke
he balked, but I noticed that he improved if he used his
for circle. When asked to write the sentence “he shouted
own verbally mediated strategy to solve the problem.
a warning,” he wrote “he shtd a woin.” He read “see the
Tim talked to himself as he thought aloud: “Look around
black dog” as “see the black pond,” and “she wants a ride
the edges first, then start to look closer and closer to
to the store” as “she was rid of the store.” He seemed to
the middle of the page. Look for Waldo’s red and white
use a “best guess” strategy in tackling reading, based on
shirt—look closely at each section!” The more interested
the sounds that he knew: When asked to write the word
he was, the more he would talk. Once he warmed up, his
bigger, he wrote just her. But I noticed that James’s enthu-
smile appeared, along with his admission that “this sure
siasm picked up a bit as he began telling stories from pic-
beats math lesson.” (Based on authors’ case material.)
tures he was shown, and he marveled at his own ability to
rotate shapes on the computer to complete a picture. He
left my office more animated and talkative than when he
arrived, which showed how nice it must have felt for him
to experience success. (Based on authors’ case material.) James’s pattern of strengths and weaknesses shows
that although he has reading problems, other strengths
compensate for this disability. He has strong talents for
James, at age 9, had problems primarily in read- figuring out how things work and for drawing ideas
ing and spelling. Contrast his reading difficulties with on paper. Tim has several strengths, too, especially
those of Tim, who struggles with spatial orientation in linguistic skills such as word recognition, sentence
and mathematical reasoning. structure, and reading. In contrast to James, Tim has
problems primarily in the visual, spatial, and organi-
TIM zational spheres, which show up as difficulties with
tactile (touch) perception, psychomotor activity (e.g.,
Warming with Interest throwing and catching), and nonverbal problem solv-
ing (e.g., figuring out math problems and assembling
When I first saw Tim, he seemed aloof and disinterested. things).
His eyes stayed focused on the floor, and his body re- Both boys fit the diagnostic criteria for SLD. Note
mained expressionless, as if to say, “Leave me alone, how Tim’s academic problems, in particular, were al-
most masked by his frustration and low self-esteem.
To understand the nature of specific learning disor-
ders, picture yourself asking for directions to a famous
monument at an information booth in an unfamiliar
town. The attendant hands you a map with written di-
rections: “Go out the driveway and turn right. Go till
you reach the second light, turn left, and look for the
Zigy Kaluzny/The Image Bank/Getty Images

sign to Amityville. It’s about 3 miles down the road.
You’ll pass a cemetery and a red schoolhouse, and go
under a railroad trestle before you get to Highway 18.
When you see the sign, turn right.” Most of us would
have trouble recalling these verbal directions, so having
them written in the map makes them easier to follow.
However, children or adults with an SLD in reading ex-
perience confusion in these common situations that in-
For children with specific learning disorders, following volve understanding the meaning of what is read. Specific
simple instructions can be confusing and frustrating.
learning problems can be difficult to recognize because,
for most of us, the material in question is straightfor-
Emotional problems are often seen in children who are ward and simple. The child may be blamed for not
bright enough to recognize that their performance is be- listening, not paying attention, or for being “slow,”
low that of others and are frustrated with their poor per- which further disguises the true nature of the learning
formance at school. The limitations of both James and problems.
Tim can affect every aspect of their formal education The main diagnostic feature of SLD is that the
as well as their interpersonal abilities; therefore, these child has difficulties learning keystone academic skills
disorders require comprehensive and ongoing treatment of reading, writing, spelling, or math (see Table 7.4).
plans. These difficulties may appear in one or more of these
T able 7 . 4 | Diagnostic Criteria for Specific Learning Disorder

(A) Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symp- DSM-5
toms that have persisted for at least six months, despite the provision of interventions that target those difficulties:
(1) Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently
guesses words, has difficulty sounding out words).
(2) Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand sequence, relation-
ships, inferences, or deeper meanings of what is read).
(3) Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
(4) Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences; employs poor
paragraph organization; written expression of ideas lacks clarity).
(5) Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of numbers, their magnitude,
and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do; gets lost in the
midst of arithmetic computation and may switch procedures).
(6) Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to
solve quantitative problems).
(B) The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age, and
cause significant interference with academic or occupational performance, or with activities of daily living, as confirmed by indi-
vidually administered standardized achievement measures and comprehensive clinical assessment. For individuals aged 17 years
and older, a documented history of impairing learning difficulties may be substituted for the standardized assessment.
(C) The learning difficulties begin during school-age years but may not become fully manifest until the demands of those affected
academic skills exceed the individuals limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a
tight deadline, excessively heavy academic loads).
(D) The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other men-
tal or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate
educational instruction.
Note: The four diagnostic criteria are to be met based on a clinical synthesis of the individual’s history (developmental, medical, family, educational), school reports, and
psychoeducational assessment.
(continues)
TABLE 7.4 | D
iagnostic Criteria for Specific Learning Disorder (continued)
Specify if:
With impairment in reading:

Word reading accuracy
Reading rate or fluency
Reading comprehension
With impairment in written expression:

Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression
With impairment in mathematics:

Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning
Specify current severity:
Mild: Some difficulties learning skills in one or two academic domains, but of mild enough severity that the individual may be
able to compensate or function well when provided with appropriate accommodations or support services, especially during
the school years.
Moderate: Marked difficulties learning skills in one or more academic domains, so that the individual is unlikely to become
proficient without some intervals of intensive and specialized teaching during the school years. Some accommodations or
supportive services at least part of the day at school, in the workplace, or at home may be needed to complete activities accu-
rately and efficiently.
Severe: Severe difficulties learning skills, affecting several academic domains, so that the individual is unlikely to learn these
skills without ongoing intensive individualized and specialized teaching for most of the school years. Even with an array of
appropriate accommodations or services at home, at school, or in the workplace, the individual may not be able to complete
all activities efficiently.
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Association.
skills, including inaccurate or slow reading, difficulty disability, despite their test findings or poor achieve-
understanding the meaning of what is read, difficulties ment.) Finally, the learning difficulties appear during
with spelling and/or written expression, or difficulties the school-age years, and cannot be better accounted
mastering number sense, calculation, or mathematical for by a sensory problem (such as impaired hearing or
reasoning. The affected academic skills would need sight), intellectual disability, psychosocial adversity, or
to be substantially below what it should be for the inadequate educational instruction.
child’s age and intellectual ability. In practice, this of- Because many aspects of speaking, listening, reading,
ten means that the child’s achievement test scores in writing, and arithmetic overlap and build on the same
academic subjects are at least 1.5 standard deviations functions of the brain, it is not surprising that a child
below average for their age and sex (which trans- or adult can have more than one form of SLD (Scanlon,
lates to a standard score of 78, or below the seventh 2013). Recall that phonological awareness facilitates
percentile). the ability to speak and, later on, to read and write. A
To be classified as a disorder, the performance single gap in the brain’s functioning can disrupt many
problems must significantly interfere with academic types of cognitive activity. These disruptions, in turn,
achievement or daily living, and to persist for more can interfere with the development of important fun-
than 6 months despite efforts to improve them. (Some damental skills and compound the learning difficulties
children and adults have found ways to compensate for in a short time. Moreover, as we saw with both James
their learning problems and therefore do not display a and Tim, numerous secondary problems can emerge,
such as temper outbursts and withdrawal from social Build ideas and images?
▲
situations, as a result of frustration and lack of success. Compare new ideas with what you already know?
▲
As noted earlier in this chapter, DSM-5 integrates Store ideas in memory?
▲
the frequently co-occurring problems in reading, math-
ematics, and written expression into one category, and Most of us have forgotten all the effort that goes into
uses specifiers to designate all academic domains and reading, especially in the beginning. Not surprisingly,
subskills that are impaired. Table 7.4 also describes the children’s initial attempts are laborious and monoto-
degrees of severity (mild, moderate, or severe) associ- nous as they wrestle with the sounds and complexities
ated with each impairment. Degrees of severity reflect of combined letters. Such mental processing requires
both the extent of the child or adolescent’s learning a complex intact network of nerve cells that connect
difficulties as well as the appropriate accommodations our vision, language, and memory centers (Grigorenko,
or supports he or she requires to learn the academic 2007). A small problem in any area can cause reading
skill(s) and complete activities at school, work or home difficulties. The most common underlying feature of a
as efficiently as possible. Below we take a closer look reading disorder, however, is an inability to distinguish
at the three core academic skill impairments specified or to separate the sounds in spoken words. Phono-
in SLD. logical skills are fundamental to learning to read, and
therefore this deficit is critical.
To assess a child’s need for additional practice in
SLD with Impairment in Reading mastering phonemes and words, it is important to
He has only half learned the art of reading who has not understand that there are two systems that operate
when one reads words, which are essential in the de-
added to it the more refined art of skipping and skimming.
velopment of reading. The first system operates on in-
—Arthur James Balfour dividual units (phonemes) and is relatively slow; the
Children are naturally attracted to reading, and its second system operates on whole words more quickly.
importance in our society is unequaled by any other In normal readers, whole words are learned through
academic accomplishment. We are surrounded by the development of phonologically based word analy-
written signs and messages and, by about age 5 or sis. However, persistently poor readers seem to rely on
so, most children want to know what they mean. rote memory for recognizing words (S. E. Shaywitz &
(Capitalizing on this natural curiosity, advertisers Shaywitz, 2013).
have become expert in pairing recognizable symbols Many clinical signs of reading disorders are first
with the names of their product or establishment so evident only to a trained eye. Some testing methods
that children can “read” more quickly.) By the first developed by teachers and school psychologists show
grade, natural interest and developmental readiness how children with reading disorders function in the
are channeled into formally learning how to read. For classroom. They often have trouble learning basic sight
many children, this process is difficult and tedious; for words, especially those that are phonetically irregu-
a sizable minority, however, it can be confusing and lar and must be memorized, such as the, who, what,
upsetting. The role of parents in this process is criti- where, was, laugh, said, and so forth. These children
cal, because children need positive feedback and need have developed their own unique and peculiar read-
to feel satisfied with their performance, regardless of ing patterns, which signal the need for different teach-
their speed and accuracy. ing methods. Typical errors include reversals (b/d;
When you consider everything involved in learn- p/q), transpositions (sequential errors such as was/
ing the basics of reading, such as associating shapes saw, scared/sacred), inversions (m/w; u/n), and omis-
of letters (graphemes) with sounds (phonemes), it is sions (reading place for palace or section for selection).
not surprising that some children have difficulty and However, these errors are common in many younger
can quickly fall behind. Read the following sentence: children who are just learning to read and write and do
“I believe that abnormal child psychology is one of the not necessarily imply a reading disorder.
most fascinating and valuable courses I have taken.” As To assess a child’s need for additional practice in
you read the sentence, did you notice that you had to certain areas, teachers may log the types of errors the
simultaneously: child makes while reading out loud. In addition to
decoding words, reading comprehension is assessed
Focus attention on the printed marks and control by having the student retell a story or suggest the next
▲
your eye movements across the page? episode. Average readers rely heavily on auditory and
Recognize the sounds associated with letters? visual modalities for gathering new information, but
▲
Understand words and grammar? children with reading disorders may prefer a mode
▲
of touch or manipulation to assist them in learning.
These various patterns of strengths and weaknesses, him to copy by hand some of the figures he drew on the
if adequately assessed, can then be used to the child’s computer, after first printing them for him on paper. In
advantage in planning additional teaching methods doing so, he switched to his preferred hand in the middle
of the task. He also showed several letter reversals (b/d;
such as computer-based learning (S. E. Shaywitz et al.,
p/q), and pushed down very hard on the pencil in an
2008).
attempt to trace or draw the figures. Throughout these
A child with a SLD with impairment in reading tasks he talked freely and asked a lot of questions, mak-
lacks the critical language skills required for basic ing me wonder at times who was assessing whom.
reading: word reading accuracy, reading comprehen- Carlos showed evidence on neuropsychological testing
sion, and reading rate or fluency. Dyslexia is an alter- of finger agnosia (he could not tell which finger I touched
native term sometimes used to describe this pattern when his hand was behind his back), especially with
of reading difficulties. These core deficits stem from his left hand. He also had considerable difficulty copy-
problems in decoding—breaking a word into parts ing a triangle, a circle, and a square based on examples
rapidly enough to read the whole word—coupled shown to him (see ● Figure 7.2). On the WISC-IV he
with difficulty reading single small words (Vellutino obtained a performance score of 91, in the low-average
et al., 2007). When a child cannot detect the phono- range, and a verbal IQ score of 117, in the high-average
range. On performance subtests he had particular prob-
logical structure of language and automatically rec-
lems with block design and puzzles, such as object as-
ognize simple words, reading development will very
sembly. He had more difficulty with verbal IQ subtests
likely be impaired (Peterson & Pennington, 2010). that involved concentration and attention, such as math
The slow and labored decoding of single words re- and digit-span tasks. Throughout the testing, I found
quires substantial effort and detracts from the child’s Carlos to be impulsive and sometimes quite defiant: If he
ability to retain the meaning of a sentence, much less didn’t want to do something, he simply would not do it.
a paragraph or page. These observations were consistent with his parents’ frus-
tration at his immature behavior and defiance at home.
SLD with Impairment in Written Expression
C A R LO S
Slowly Taking Shape
Carlos, age 7, was about to finish second grade when his

teacher and parents met to discuss his handwriting prob-
lems. The year had gone well in general, but his parents
were bracing for bad news. Smiling and pulling out some
workbooks, Carlos’s teacher lined up examples of how
he had gradually become able to print some letters over
the course of the year. But what his parents saw was self-
explanatory: His shapes were very poor and looked more
© Cengage Learning®
like those of his 3-year-old sister. Sensing both parents’
apprehension, his teacher clarified: “Carlos is having a
few problems in his fine motor coordination, in activities
such as artwork, putting puzzles together, and similar
tasks. He goes too fast when trying to do these tasks,
and he forgets to be careful or to follow the pattern. He ● F I GU R E 7 . 2 | Top: Drawings produced by Carlos
makes a half-hearted attempt on his writing assignments when asked to copy a triangle, a circle, and a square.
and then starts talking to his classmates. I’d like him to Bottom: Examples of a triangle, circle, and square from a
be seen by a psychologist for testing, and hopefully next typically developing 7-year-old boy.
fall his new teacher can strengthen his writing and fine (Based on authors’ case material.)
motor skills with some additional exercises.”
During the initial interview, Carlos took an immedi-
ate interest in my computer games, exclaiming how easy
it was to use the mouse to draw figures. When asked to
Carlos has a specific learning disorder related to writ-
use a pencil and paper, however, Carlos balked. I asked
ten expression. He has strong language and reasoning
abilities, as well as normal problem-solving skills for his
age, yet he is considerably weaker in his visual–motor
abilities, as shown by his writing, figure copying, and $ 62.04 75
figure rotation. Like reading and math, writing derives
5.30 8
from several interconnected brain areas that produce
vocabulary, grammar, hand movement, and memory.
SLD with impairment in written expression may
● F I GU R E 7 . 3 | Errors in math computation by a
manifest as problems in spelling accuracy, grammar
10-year-old girl with a mathematics disorder.
and punctuation accuracy, and/or clarity or organiza-
tion of written expression. This particular SLD is often From “Learning Disabilities” by H.G. Taylor, 1988, p. 422. In E.J. Mash and L.G. Terdal
(Eds.) “Behavioral Assessment of Childhood Disorders”, 2nd ed.
found in combination with SLD in reading or math-
ematics, which also have underlying core deficits in
language and neuropsychological development.
Children with impairment in written expression alternative term sometimes used to describe this pattern
often have problems with tasks that require eye– of math difficulties. Many skills are involved in arith-
hand coordination, despite their normal gross motor metic: recognizing numbers and symbols, memorizing
development. Teachers notice that, as compared with facts (the multiplication table), aligning numbers, and
children who have normal writing skills, children with understanding abstract concepts such as place value
impairments in writing produce shorter, less interest- and fractions. Any or all may be difficult for children
ing, and poorly organized essays and are less likely to with a mathematics disorder (Vukovic & Siegel, 2010).
review spelling, punctuation, and grammar to increase Children and adults with this disorder may have dif-
clarity (Hooper et al., 2011, 2013). However, spelling ficulty not only in math, but also in comprehending
errors or poor handwriting that do not significantly abstract concepts or in visual–spatial ability. Examples
interfere with daily activities or academic pursuits of calculation errors typical of children with a mathe-
do not qualify a child for this diagnosis. In addition, matics disorder are shown in ● Figure 7.3, an example
problems in written expression signal the possibil- that points out errors that suggest spatial difficulties
ity of other learning problems because of shared and directional confusion.
metacognitive processes: planning, self-monitoring, Children with an SLD with impairment in math-
self-evaluation, and self-modification (Heim & ematics typically have core deficits in arithmetic cal-
Benasich, 2006). culation and/or mathematics reasoning abilities, which
include naming amounts or numbers; enumerating,
comparing, and manipulating objects; reading and
SLD with Impairment in Mathematics writing mathematical symbols; understanding concepts
During their preschool years, children are not as and performing calculations mentally; and perform-
naturally drawn to mathematical concepts as they are ing computational operations (Andersson, 2010; Lyon
to reading. This changes rapidly as they discover that et al., 2006). These deficits imply that the neuropsy-
they need to count and add to know how much money chological processes underlying mathematical reason-
it takes to buy something or how many days remain ing and calculation are underdeveloped or impaired.
until vacation. As in reading, the need to know pro-
pels children to learn new and difficult concepts, and
little by little their new skills help them understand the Prevalence and Course
world better. Estimates of the prevalence of SLD across all three
For some children, like Francine and Tim, this curi- domains (reading, writing, and math) range from 5%
osity about numbers is compromised by their inability to 15% among school-aged children (APA, 2013).
to grasp the abstract concepts inherent in many forms Reasons for this large range focus on the notion that
of numerical and cognitive problem solving. Francine’s SLD in reading—the most common form—may be
difficulty with numbers and concepts began to show up part of a continuum of reading abilities rather than a
well before she attended school, which is typically the discrete, all-or-none phenomenon. Children with read-
case. When she encountered math concepts in second ing disorders are essentially those who fall at the lower
grade that required some abstract reasoning, she fell end of the reading continuum (Snowling, 2008). This
further and further behind. consideration of the range of ability is useful and im-
The DSM-5 criteria for SLD with impairment in portant because, clearly, there are strong readers and
mathematics include difficulties in number sense, mem- weak readers, and no definitive cutoff point easily dis-
orization of arithmetic facts, accurate or fluent calcula- tinguishes the two. Estimates of the prevalence of SLD
tion, and/or accurate math reasoning. Dyscalculia is an with impairment in mathematics or written expression
are unclear due to the overlap among all three subtypes, the point that deficits in phonological awareness oc-
although consensus is that they occur at a much lower cur more frequently among populations that use non-
rate than do reading difficulties (Landerl & Moll, 2010). standard English. They followed a random sample of
SLD impairments are considered lifelong, although 485 Caucasian (55%) and African American (45%)
the course varies based on severity and available supports. children from first grade through third grade, and they
Recognition of SLD typically emerges during elementary found that although African American youngsters read
school years, when a student falls significantly behind at the same grade level as Caucasian children at the
classmates in one or more of these subjects, though par- beginning of the first grade, they show marked declines
ents often note problems in language delays or counting in reading by the third grade and severe declines by the
in early childhood. Parents and teachers may notice spe- fifth grade. These findings suggest that greater atten-
cific delays in early skill development, or notice behavior- tion to differences in dialect can lead to better learning
al signs of the child’s struggles, such as his or her unwill- opportunities.
ingness to learn to read, write, or work with numbers. In Whereas attention to cultural and ethnic issues per-
elementary school, the child shows marked difficulty in taining to SLD is a recent addition to research, sex dif-
learning letter–sound correspondence and may commit ferences have a long and contentious history. Boys are
reading errors by connecting sounds and letters (e.g.,“big” more often referred for learning difficulties than girls,
for “got”) and have difficulty sequencing numbers and perhaps because boys are more likely to show associ-
letters (APA, 2013). ated behavior problems such as aggression or inatten-
By the middle grades children with SLD may show tion. Girls with learning problems often are quiet and
poor reading comprehension and poor spelling and withdrawn rather than loud and attention seeking, and
written work. They may be able to read and pronounce they may be overlooked unless educators and parents
the first part of a word correctly but then guess the are well informed. Nonetheless, when male–female ra-
rest of the word. As they struggle with these difficul- tios of SLD are derived from epidemiological estimates
ties throughout elementary school, being fearful of rather than from referrals, the ratio of boys to girls falls
or refusing to read aloud is common. By adolescence between 2:1 and 3:1 (APA, 2013).
through to adulthood, these patterns often shift from
basic coding difficulties to marked problems in read- Psychological and Social Adjustment
ing comprehension and written expression, including For many years, a diagnosis of learning disability or
poor spelling and poor mathematical problem solv- disorder required a discrepancy between IQ and per-
ing. Over time, teens and adults learn to manage these formance, which hampered early identification because
difficulties to the best of their ability, but may avoid the assessment often was not done until the child had
situations that require reading, writing, or numerical attempted and failed at reading, usually by the third
ability. Thus, over the life span SLD is associated with grade. By that time, the child’s achievement would be
many functional consequences, such as lower academic low enough to warrant a diagnosis, but the child had
achievement, higher school dropout rates, poor overall failed in reading for 2 to 3 years and may have de-
mental health and well-being, and lower employment veloped other behavioral and emotional problems as
and income (APA, 2013). a result.
Today’s recognition of SLD as an early neurodevel-
Cultural, Class, and Gender Variations opmental disorder is improving detection of children
Social and cultural factors are less relevant to SLD than with difficulties, but they still face significant obstacles
other types of cognitive and behavioral problems; in in their peer adjustment and academic progress. Chil-
fact, the diagnostic criteria state that they cannot be dren with SLD often do not know how or why they are
attributed to these factors. Nevertheless, some cultural different, but they do know how it feels to be unable
and ethnic factors may affect how children with SLD to keep up with others in the classroom. Hearing them-
are identified and treated (Johansson, 2006). selves described as “slow,” “different,” or “behind,”
Many childhood disorders reflect an interaction be- they may identify more with their disabilities rather
tween the child’s inherent abilities and resources and than with their strengths. These daily experiences may
the opportunities that exist in the child’s local envi- cause some children to act out by either withdrawing
ronment, as emphasized throughout this text. In the or becoming angry and noncompliant. Like James,
case of learning to read, some teaching approaches they may stop trying to learn. Like Francine, they may
do not explicitly emphasize specific sound–symbol become isolated and limit their participation in activi-
relationships that are inherent in the dialect of chil- ties that their peers enjoy.
dren from diverse ethnic backgrounds. For example, Students with SLD with reading impairment feel
an interesting study by Wood et al. (1991) illustrated less supported by their parents, teachers, and peers than
do normal readers, and they are more likely to express of problems that overlap with features of conduct dis-
poor academic or scholastic self-concepts (Heim & order (CD), oppositional defiant disorder (ODD), and
Benasich, 2006). Perhaps as a result of the interaction attention-deficit/hyperactivity disorder (ADHD) across
of their disorder and their environment, children and all ages (APA, 2013).
adolescents with SLD are more likely than their peers These co-occurring problems are often interpreted
to show internalizing problems such as anxiety (Nelson as individual reactions and coping styles in response
& Harwood, 2011) and mood disorders (Maughan to failure, frustration, and, in some instances, punish-
et al., 2003), as well as externalizing behaviors such as ment and negative attention. However, in terms of de-
ADHD (Goldston et al., 2007). The range and types velopment, it is hard to say which comes first: Behavior
of problems are generally similar for both younger problems may precede, follow, or co-occur with learn-
and older age groups. Accordingly, issues pertaining ing problems (Hinshaw, 1992). Whereas many of these
to both younger and older children and adolescents behavioral and emotional problems gradually decrease
with SLD are considered jointly unless particular de- from childhood to adolescence, adolescents with SLD
velopmental differences warrant attention. Many of continue to face challenges in their social relationships
these issues are common to all domains of SLD unless (St Clair et al., 2011).
otherwise noted. Based on a review of over 150 studies, Kavale and
The connection between SLD and behavioral or Forness (1996) found that about three of every four
emotional disorders has generated considerable inter- students with SLD have significant deficits in social
est but only cautious conclusions. Common sense sug- skills. As a group, they are more isolated and less pop-
gests that children with SLD encounter considerable ular among peers than other children, and they tend to
challenges that are likely to take a toll on self-esteem make negative impressions on others (Durkin & Con-
and, in time, their social relationships. However, chil- ti-Ramsden, 2010). Like Francine, who was described
dren’s self-concepts in sports and appearance are usu- by her mother as “humorless and in a bit of a fog,”
ally less affected (Lyon et al., 2006). most children with SLD have difficulty grasping the
Parents and teachers describe children with SLD as nuances of social interaction and may not know how
being more difficult to manage than typical children, to greet others, make friends, or join in playground
beginning at an early age. Although overall reports games. Subtle cues of social interaction may be missed
of behavior problems increase considerably for all chil- or ignored. These children may not always interpret
dren between early and middle childhood, behavior correctly or respond appropriately to the frequent
problems among children with SLD are about three nonverbal—but very expressive—communication of
times higher than typically developing children by other children, such as rolling the eyes to show dis-
8 years of age (i.e., 32% vs. 9%; Benasich, Curtiss, & like or disinterest. When children with SLD misun-
Tallal, 1993) (see ● Figure 7.4). Most of these prob- derstand the situation and act inappropriately, other
lems are not specific to SLD but cover a broad range children turn away.
A child with SLD also can be an emotional burden
for family members. Parents may experience a wide
35% range of emotions, including denial, guilt, blame, frus-
8-years
years old
tration, anger, and despair. Brothers and sisters often
30% feel annoyed, embarrassed, or jealous of the attention
25% their sibling receives. Because behavioral problems are
usually so disruptive, a child’s distress and emotional
8-years old
20% needs may easily be overlooked.

years old
4-years
15%
years old
8
10% Adult Outcomes

4
4-years
5% Unfortunately, the social and emotional difficulties

connected to communication and learning disorders
4
0%
may continue into adulthood, largely because of inad-
Behavioror problems
prroblem
ms a
among Behavior
or pr
problems
roblem
ms among
a
typically developing children children with LD equate recognition and services (Johnson et al., 2010).
Adults may find ways to disguise their problems, such
● F I GU R E 7 . 4 | Percentage of clinically significant as watching television news rather than reading news-
behavior problems among children with and without papers. On the other hand, many excel in nonacademic
learning disorders, at 4 years and 8 years of age. subjects such as art, music, dance, or athletics. Still oth-
Data from Benasich et al., 1993 ers may become outstanding architects and engineers,
or they may have extraordinary interpersonal skills
(Lyon et al., 2006). Each child and adolescent has
A Closer Look 7.1
many strengths that can be developed to compensate
Factors That Increase Resilience
for his or her known deficits. Thus, despite their earlier
risk for academic failure and psychosocial problems, and Adaptation
many adults with SLD lead successful and productive Several personal characteristics and circumstances aid those
lives (Lovett & Lewandowski, in press). with learning disorders in their successful adaptation from
Men with SLD with impairments in reading do childhood, through adolescence, to young adulthood. As
not differ from their peers regarding feelings of global part of a longitudinal study of all children born in 1955 on the
self-worth; symptoms of depression; feelings of com- island of Kauai, Hawaii, E. E. Werner (1993) followed 22 chil-
petency and satisfaction with jobs, marriages, and dren with learning disabilities and 22 matched controls. She
other relationships; or frequency of antisocial be- found that most children with learning disabilities adapted
havior (Boetsch, Green, & Pennington, 1996). How- successfully to adult life. Those who showed the greatest
ever, men still perceive lower levels of social support resilience and flexibility over time had: (1) a basic tempera-
from parents and relatives—the only people still in ment that elicited positive responses from others; (2) a well-
their lives who knew of their problems as children— developed sense of efficacy, preparedness, and self-esteem
which confirms the indelible impressions left by early that guided their lives; (3) competent caregivers and support-
experiences. ive adults; and (4) opportunities for a second chance if they
One adult describes his own way of compensating made mistakes or got into trouble with the law. Although
for learning problems: some of these characteristics are present from birth (e.g.,
temperament), many of the other supportive factors can be
I faked my way through school because I was very increased through the efforts of family members, schools,
bright. I resent most that no one picked up my weak- and communities. (Based on authors’ case material.)
nesses. Essentially I judge myself on my failures. . . . [I]
have always had low self-esteem. . . . A blow to my self-
esteem when I was in school was that I could not write
a poem or a story. . . . I could not write with a pen or
pencil. The computer has changed my life. I do every- (and women have more obstacles in this regard than
thing on my computer. It acts as my memory. I use it men), both men and women with SLD can build on
to structure my life and for all of my writing since my their existing strengths, skills, and talents (Hatch,
handwriting and written expression has always been so Harvey, & Maughan, 2010).
poor. (Polloway, Schewel, & Patton, 1992, p. 521) It is safe to say that even though aspects of SLD
may remain, people who are given proper educational
Whereas the long-term outlook for men with SLD
experiences have a remarkable ability to learn through-
is generally positive, the troublesome issue of sexism
out their life spans (Gregg, 2011). A Closer Look 7.1
arises when considering how adult women with SLD
describes some of these important opportunities that
fare over time. As a group, women with SLD have
increase resilience. Adults can learn to read, although
more adjustment problems than men as they leave
it is difficult because brain development slows down
school and face the demands of adult life. Similar to
after puberty. Current gains in knowledge of the causes
other adults with disabilities, they also face greater risk
and early signs of SLD are likely to have a positive im-
of sexual assault and related forms of abuse (Brownlie
pact on early recognition and proper instruction. Non-
et al., 2007). Problems and breakdowns in relation-
intrusive electrophysiological measurements of brain
ships are common, which may reflect the lack of oppor-
reactivity may permit an early diagnosis based on un-
tunity available to these women to achieve in areas that
derlying deficits in phonological processing rather than
capitalize on their strengths.
on performance alone. Thus, early identification and
Reading problems often cause poorly qualified
intervention may be the key to preventing the long-
graduates to take relatively undemanding and unre-
term consequences of these disorders (S. E. Shaywitz &
warding jobs. Women who lack competitive skills and
Shaywitz, 2013).
strong career options because of school failure tend
to get involved at an early age in intimate relation-
ships that are generally unsupportive (Fairchild, 2002). Causes
Young men, in contrast, have more wide-ranging op- Most learning disorders do not stem from problems in
tions once they leave school, which facilitates more a single area of the brain, but from difficulties in bring-
positive social functioning in adulthood. Thus, if they ing information from various brain regions together
are able to select their own environments in adulthood so that information can be integrated and understood
(Damasio et al., 2004; Meyer & Damasio, 2009). Min- transmission provides a plausible explanation for the
ute disturbances may underlie phonological process- relative risk of SLD in reading or mathematics being
ing deficits. Emerging evidence suggests that in many 4 to 8 times and 5 to 10 times higher, respectively, in
cases these subtle disturbances begin very early during first-degree relatives of persons with SLD as compared
development, perhaps prenatally (McGrath et al., 2007; to those without it (APA, 2013; Shalev, 2007). Keep
Raschle, Chang, & Gaab, 2011). in mind that environmental factors also play a role
Recent findings suggest two distinguishable types in moderating genetic influences on SLD outcomes
of children with reading disorders—children who are (i.e., gene–environment interaction; Petrill, 2013).
persistently poor readers and those who are accuracy-
improved (i.e., they learn ways to compensate for Neurobiological Factors
their reading difficulties and improve over time) Our understanding of learning disorders, particularly
(S. E. Shaywitz, Mody, & Shaywitz, 2006). Persistently reading-based and language-based problems, took an
poor readers and accuracy-improved readers have important new direction in the mid-1980s with the dis-
comparable reading skills and socioeconomic sta- covery that the brains of people with these problems
tus when they begin school, but by the time they are were characterized by cellular abnormalities in the left
young adults, the accuracy-improved readers show hemisphere, which contains important language cen-
better cognitive ability. The presence of compensatory ters (Galaburda et al., 1985). The fact that these cel-
factors, such as stronger cognitive ability, may allow lular abnormalities could occur only during the fifth to
the accuracy-improved individuals to minimize the seventh months of fetal development strengthened the
consequences of their phonological defect over time view that learning disorders evolve from subtle brain
(Ferrer et al., 2010). These compensatory factors may deficits present at birth (Lyon et al., 2003). Initial au-
be genetically based, and thus the child’s ability im- topsy findings were confirmed by sophisticated brain
proves with maturity, whereas the persistently poor imaging technology that reveals the brain directly at
readers may face greater environmental challenges, work and makes it possible to detect subtle malfunc-
often associated with poverty and inequality, that tions that never could be seen before.
reduce reading opportunities. The suspected deficits, which likely are genetically
based, involve specific discrimination tasks, such as
Genetic and Constitutional Factors detecting visual and auditory stimuli, as well as more
Children who lack some of the skills needed for read- pervasive visual–organizational deficits associated with
ing, such as hearing the separate sounds of words, are reasoning and mathematical ability (Benassi et al.,
more likely to have a parent with a related problem. 2010; Pennington, 2006). A probable location of these
Around the turn of the twentieth century this prob- deficits is a structure called the “planum temporale,” a
lem was studied largely by physicians, who considered language-related area in both sides of the brain. In a
reading disorders to be an inherited condition called normal brain, the left side of the planum temporale is
congenital word blindness (W. P. Morgan, 1896). To- usually larger than the right side; however, in the brain
day, estimates based on behavioral genetic studies in- of an individual with a reading disorder, the two sides
dicate that heritability accounts for over 60% of the are equal (Tallal, 2003).
variance in reading disorders (V. M. Bishop, 2006; Plo- B. A. Shaywitz et al. (2002) found lower activation
min et al., 2010), although the exact mode of transmis- in numerous sites—primarily the left hemisphere of
sion remains undetermined. the brains of dyslexic children as compared with non-
Most attention paid to heritability is aimed at ge- impaired children—including the inferior frontal, pa-
netic transmission of critical brain processes underly- rietotemporal, and occipitotemporal gyri. These three
ing phonetic processing (Scerri & Schulte-Körne, 2010; areas of the brain are responsible for understanding
Vellutino et al., 2004). Because a parent’s learning dis- phonemes, analyzing words, and automatically detect-
order may take a slightly different form in the child— ing words, respectively. Once a word is learned, this
the father may have a writing disorder and his child three-part center recognizes it automatically, without
an expressive language disorder—it seems unlikely that first having to decipher it phonetically (S. E. Shaywitz
subtypes of specific learning disorders are inherited di- & Shaywitz, 2013).
rectly. More likely, what is inherited is a subtle brain From a cognitive standpoint, these neurological
dysfunction that, in turn, can lead to a learning disorder findings suggest that children with learning disorders
(Newbury et al., 2011; Richlan et al., 2011; Scerri & are distinctively disadvantaged as compared with av-
Schulte-Körne, 2010). For example, on chromosome 6 erage readers in terms of the processing underlying
an area has been identified that predisposes children their short-term and working memory. Impairments
to reading disorders (Grigorenko, 2007). Genetic in short-term memory affect the recall of phonemes
Primary auditory cortex
Auditory association area
Temporal lobe
How the brain processes speech

1 The primary auditory cortex (shown in red), which is located on the top edge of each
temporal lobe, receives electrical signals from receptors in the ears and transforms these
signals into meaningless sound sensations, such as vowels and the consonants in ba and ga.
2 The meaningless sound sensations are sent from the primary auditory cortex to another area
in the temporal lobe, called the auditory association area.
3 The auditory association area (shown in blue), which is located directly below the primary
auditory cortex, transforms basic sensory information, such as noises or sounds, into
recognizable auditory information, such as words or music. Here, sounds are matched
with existing patterns that have been previously formed and stored.
● F I GU R E 7 . 5 | How the brain processes speech.

From Plotnik/Kouyoumdjian. Introduction to Psychology, 9E. © 2011 Wadsworth, a part of Cengage Learning, Inc. Reproduced by permission.
www.cengage.com/permissions.
and numbers; similarly, impairments in working another group? Can you distinguish the music of one
memory affect how such information is processed group from another? As we listen, we tend to cluster
and stored so that it can be rapidly accessed. Consid- sounds into various categories, acquiring our taste for
erable support now exists concerning how memory music as we store more collections and melodies into
deficits explain the performance difficulties of chil- memory. Each time we hear new music, we match it
dren with a learning disorder (Carretti et al., 2009; to what we already know and appreciate. Young peo-
Maehler & Schuchardt, 2011; Swanson, Zheng, & ple are particularly adept at assimilating new sounds,
Jerman, 2009). thereby broadening their tastes. In contrast, people
We have stressed that most children with reading who have already formed specific musical tastes tend
and writing disorders have difficulty distinguishing to stick to what they know, rejecting unrecognizable
phonemes that occur rapidly in speech. But why is this sounds. This gap in music appreciation is analogous
so? Consider what is involved, as shown in ● Figure 7.5. to the gap researchers describe in the phonic abili-
The sound must be processed by various brain areas ties of children with learning disorders—they lack
as it is carried by nerve impulses from the ear to the certain auditory sites that allow certain sounds to be
thalamus to the nerve cells within the auditory cortex, recognized, so their appreciation of certain words is
where it is matched to existing patterns, or phonic bins, compromised.
that have been previously formed and stored. Each neuron in the language-processing areas of
Compare this process to listening to music. When the brain has immense specificity. Some neurons fire
you first hear a new song, do you recognize aspects when you silently name an object but not when you
that resemble other recordings by that group or read the object’s name out loud, and vice versa. Certain
neurons are activated when bilingual people speak one quickly say which of two numbers is larger (e.g., “13”
language, but not when they speak the other (Ojemann, vs. “31”), but students with mathematics disorder are
1991). Someone can have an expressive language prob- slower and less accurate than their peers at doing so
lem despite full comprehension, because the same neu- (Rousselle & Noël, 2007).
rons that are active when a person hears a word are not Recall that Francine had well-developed word rec-
active when that person speaks it. ognition and spelling abilities, but significantly worse
In the visual system, different aspects of what you see, mechanical–arithmetic skills. SLD with impairment
such as form, color, and motion, are routed to different in mathematics, and perhaps SLD with impairment in
regions of the visual cortex. When something moves in written expression as well, are associated with brain
your visual field, the region of the cortex that responds deficits that differ from those described for language-
to visual motion is activated. Eden et al. (1996) first dis- based learning disorders. These deficits are largely
covered that adults with reading disorders show no ac- found in areas not related to verbal ability, which
tivation in visual motion when asked to view randomly has led to the term nonverbal learning disability.
moving dots. A specific defect in the perception of visual Nonverbal learning disability (NLD) is associated with
motion may interfere with many different brain func- deficits related to right-hemisphere brain function-
tions, and it has been noted among children with autism ing, which are characteristic of children who perform
as well as those with learning disorders (Benassi et al., considerably worse at math than reading. These defi-
2010; Skottun & Skoyles, 2008). To detect differences cits involve social/emotional skills, spatial orientation,
between consonant sounds—such as b and t—we must problem solving, and the recognition of nonverbal cues
be able to distinguish between very rapid changes in such as body language (Hulme & Snowling, 2009).
sound frequency. A subtle neurological deficit in sensi- In addition to math deficiencies, NLD may be accom-
tivity could prohibit this distinction, which would then panied by neuropsychological problems such as poor
show up clinically as problems in reading and phono- coordination, poor judgment, and difficulties adapt-
logical processing (Raschle et al., 2011). ing to novel and complex situations (Lyon et al., 2003;
Thus, two major findings implicate specific biologi- Semrud-Clikeman et al., 2010). To date, the unique as-
cal underpinnings of reading disorders: (1) language pects of NLD remain unconfirmed. Critics argue that
difficulties for people with reading disorders are spe- it may simply be a form of SLD with impairment in
cifically associated with the neurological processing of mathematics (Fine et al., 2013; Spreen, 2011).
phonology and storage of such information into mem-
ory; and (2) behavioral and physiological abnormali- Social and Psychological Factors
ties are found in the processing of visual information. Emotional and behavioral disturbances and other
It is not surprising, therefore, that phonological and signs of poor adaptive ability often accompany SLD.
visual processing problems often coexist among people This is no surprise, because children with one neuro-
with reading disorders (Skottun & Skoyles, 2008). developmental disorder (i.e., communication disorder,
Studies of the causes of SLD mostly involve chil- SLD, ADHD, or intellectual disability) are about 40%
dren with reading disorders, but the findings apply more likely to have another neurodevelopmental dis-
to disorders in written expression and mathematics order, most likely because of shared etiological factors
as well. Many—but not all—disabled writers show (Gooch et al., 2013). The overlap between SLD with
deficits in reading (Lyon et al., 2003), and some math- impairment in reading and ADHD, for example, ranges
ematical concepts require reading and writing as well from 30% to 70% depending on how ADHD is de-
as mathematics skills. Similar to how deficits in pho- fined (Del’Homme et al., 2007; Fletcher, Shaywitz, &
nological awareness underlie SLD with reading im- Shaywitz, 1999). Although this degree of overlap sug-
pairment, certain cognitive deficits involving concepts gests that behavioral and learning problems have cer-
of numbers appear to underlie SLD with impairment tain common aspects, they are still distinct and sepa-
in mathematics (Geary, 2013). For instance, if you rate disorders (Lyon et al., 2006). SLD is commonly
show small sets of dots, usually up to four dots per associated with deficits in phonological awareness,
set, to typically developing children they can tell you whereas ADHD has more variable effects on cognitive
instantly (i.e., without counting the items) how many functioning, especially in areas of rote verbal learning
items are in each set, a process known as subitizing. and memory (Jakobson & Kikas, 2007). ADHD, more-
But children with SLD with impairments in mathe- over, is relatively unrelated to phonological awareness
matics appear to have trouble subitizing even three tasks. However, some children with SLD show symp-
items, suggesting a deficit in their rapid visual pro- toms similar to those of ADHD, including inattention,
cessing of enumeration concepts (Ashkenazi, Mark- restlessness, and hyperactivity (Del’Homme et al.,
Zigdon, & Henik, 2013). Similarly, most children can 2007).
Prevention and Treatment
Francine’s problems in making friends were a major
What can be expected of Francine, James, Tim, and
concern to everyone, and we believed that they were
Carlos during their school years and beyond? Proper
directly linked to her learning disability. A cognitive–
planning and goal setting are the cornerstones of the behavioral intervention plan was developed in conjunc-
helping strategies for home and for school. Specific tion with her educational program. Because of Francine’s
learning disorders are not usually outgrown, but there strong verbal skills, we taught her to problem solve
is reason for optimism if educational planning and ac- through role playing, and encouraged her mother to
commodations are ongoing (Beitchman & Brownlie, invite one child at a time for her to play with so that she
2014). could practice her skills. Francine had drifted into being
Although SLD has strong biological underpinnings, a loner and seemed disinterested in looking after herself,
intervention methods rely primarily on educational so we also discussed ways to develop better self-care at
and psychosocial methods. Psychosocial treatments home by giving her an allowance for completing house-
hold chores. We spent considerable time explaining the
for James, Francine, Carlos, and Tim must be compre-
nature of her problems to her parents, and this guidance
hensive and ongoing, with each new task broken down
led to relief and understanding.
into manageable steps, including examples, practice, We saw the family once again one year later; al-
and ample feedback. Combined with proper teach- though some of Francine’s problems still existed, her
ing strategies, children and their families may benefit social abilities had improved. She still had difficulties in
from counseling aimed at helping the children develop developing friendships and tended to prefer being alone,
greater self-control and a more positive attitude to- but the problem had clearly lessened from the previous
ward their own abilities. Support groups for parents year. (Based on authors’ case material.)
also can fill an important gap between the school and
the home by providing information, practical sugges-
tions, and mutual understanding.
Someday, breakthroughs in brain research may lead Consider the coordinated planning and effort
to new medical interventions, but at present no biologi- that went into the treatment programs for Francine:
cal treatments exist for speech, language, and academ- Francine was able to get help because her problems
ic disabilities. In cases in which significant problems were detected; recall, however, that by the time she was
coexist in concentration and attention, some children referred, she had already begun to fail at formal school-
respond favorably to stimulant medications that may ing. The first step in solving any problem is to realize
temporarily improve attention, concentration, and the that it exists. The nature of learning disorders makes
ability to control their impulsivity, albeit with little or this difficult for many children and parents. Although
no improvement in learning. Typically, the medication numerous signs of language-based learning disorders
schedule ensures that the drug is active during peak are present from early childhood, sophisticated means
school hours, when reading and math are taught. of assessing problems are not yet available before chil-
dren are old enough to be formally tested.
FRANCINE
Slowly but Surely Improving
To reduce Francine’s difficulties with math and, espe-

cially, with peer relationships, we considered several fac-
tors. First, we decided that teaching should be primarily
verbal, with an understanding that she would have the
most difficulty in math and science. Her teachers favored
allowing Francine to use a calculator and a computer
to assist her in learning new concepts. An emphasis on
Phanie/Science Source
physical education was also planned, to help her with

her visual–motor coordination. Her math teacher agreed
that using graph paper might help her visualize numeri-
cal relationships, which led to noticeable improvements
in her schoolwork. Treatment of specific learning disabilities usually begins
with a careful assessment of a child’s abilities.
Issues of identification are important because a brief students (National Center for Educational Statistics
window of opportunity may exist for successful treat- (2012).
ment. If a problem is detected in early childhood—say,
by kindergarten—then language-based deficits can of- Response to Intervention Models
ten be remediated successfully. If the problem is not IDEA provides for the use of response to intervention
detected until age 8 or so, the rates of response to treat- (RTI) models to identify and assess children. RTI con-
ment are much lower (Hatcher et al., 2006). This is why sists of tiered instruction, in which children who have
prevention of reading difficulties is a hot topic: Train- difficulty learning to read using typical methods of in-
ing children in phonological awareness activities at an struction are provided with small-group, intensive in-
early age may prevent subsequent reading problems struction. Those who need additional intervention may
among children at risk (Duff & Clarke, 2011; Snowling receive one-on-one special education. This approach
& Hulme, 2012). These activities involve games of lis- seeks to provide each child with the appropriate level
tening, rhyming, identifying sentences and words, and of instruction required for his or her individual needs
analyzing syllables and phonemes. For example, the (National Institutes of Health, 2007).
child might analyze sand as s-and and then synthesize it Initiatives to allow children with special needs to re-
into sand, or colored alphabet blocks might be used to ceive services without being diagnosed or labeled as in-
break the word into separate phonetic sounds (s-a-n-d). tellectually disabled, learning disabled, and so forth have
Knowledge of communication and learning disor- become widely available and hold considerable prom-
ders has played leapfrog with the philosophy and prac- ise. However, implementation and teacher training, as
tice of classroom instruction during the past decade. well as the question of whether such initiatives succeed
Discoveries in neurosciences, as noted above, chal- in meeting the special needs of students, continue to be
lenged some prevailing educational practices, leading to unresolved (Lovett & Lewandowski, in 2014).
more systematic ways of assisting children with learn-
ing disorders, as explored in the following sections. Instructional Methods
Although controversy remains over the practical as-
pects of including all children in regular classrooms,
The Inclusion Movement most educators today favor direct instruction for
Integrating children with special needs into the regular children with learning disorders. Direct instruction
classroom began as the inclusion movement during the is a straightforward approach to teaching based on
1950s, based on studies showing that segregated classes the premise that to improve a skill, the instructional
for students with disabilities were ineffective and pos- activities must approximate those of the skill being
sibly harmful (Baldwin, 1958). Resource rooms and taught (see example in A Closer Look 7.2) (Hammill
specially trained teachers replaced the special classes et al., 2002). Direct instruction in word structure is
that had been in vogue, a change that had the further necessary because of the child’s phonological deficits.
advantage of removing the need to label and categorize Direct instruction in reading emphasizes the specific
children. The Education for All Handicapped Children learning of word structure and word reading until the
Act of 1975 in the United States (currently known as skill is learned, without concern for the full context
Individuals with Disabilities Education Improvement of the sentence or story. This method is based on the
Act [IDEA], 2004) and the provincial Education Acts in premise that a child’s ability to decode and recognize
Canada mandate that children with special needs must
be afforded access to all educational services, regard-
less of their handicaps. Today, children with special
educational needs in the United States, Canada, and A Closer Look 7.2
many other countries are placed in regular classrooms
whenever possible. Steps in Direct Behavioral Instruction
In 2002, the No Child Left Behind Act was signed 1. Review the child’s existing abilities.
into law in the United States. This act allowed for more 2. Develop a short statement of goals at the beginning of
intensified efforts by each state to improve the academic each lesson.
achievement of public school students considered
3. Present new concepts and material in small steps, each
at risk for school failure. Today, almost 14% (about
followed by student practice.
6.6 million) of school-age children in the United States
4. Provide clear and detailed instructions and explanations.
from all walks of life receive some level of support
through special education, and students with specific 5. Provide considerable practice for all students.
learning disabilities account for close to half of these
of meaning, vocabulary, spelling, and writing (Snowling
6. Check student understanding of concepts continually, in
& Hulme, 2012). Evidence-based evaluations show
response to teacher questions.
dramatic reductions in the incidence of reading fail-
7. Provide explicit guidance for each student during initial ure when direct and explicit instruction in these com-
practice. ponents is provided by the classroom teacher (Duff &
8. Provide systematic feedback and corrections. Clarke, 2011; Haager et al., 2007; Schuele & Boudreau,
9. Provide explicit instruction and practice for exercises com- 2008). Empirical support for teaching phonics from an
pleted by students at their desks. early age also is emerging from brain imaging studies.
Source: From Treatment of Learning Disabilities by G. R. Lyons and For example, instruction in phonemic awareness, pho-
L. Cutting, 1998. In E. J. Mash and L. C. Terdal (Eds.), Treatment of
Childhood Disorders. nics, and other reading skills produces more activation
The following example illustrates how the steps in direct
in the automatic recognition process, noted previously
behavioral instruction are applied. (see section on “Causes,” above). After undergoing
such training, brain scans of people who were once
Example: Direct Instruction Lesson poor readers begin to resemble those of good readers
A typical DI lesson includes explicit and carefully sequenced (National Institutes of Health, 2007).
instruction provided by the teacher (model) along with We now turn to some practical examples of how
frequent opportunities for students to practice their skills
(independent practice) over time (review). For example, if the
reading, writing, and math can be taught by apply-
sound /m/ appeared for the first time, the teacher might say, ing well-established principles of learning. Behavioral
“You’re going to learn a new sound. My turn to say it. When and cognitive–behavioral strategies have been highly
I move under the letter, I’ll say the sound. I’ll keep on saying beneficial in remediating the problems of children
it as long as I touch under it. Get ready. mmm” (model). “My
turn again. Get ready. mmm” (model). “Your turn. When I
and adolescents with communication and learning
move under the letter, you say the sound. Keep on saying it disorders (Lyon et al., 2006). In addition, new meth-
as long as I touch under it. Get ready.” (independent practice). ods based on the use of technology offer some chil-
“Again. Get ready.” (independent practice). If an error occurs dren additional ways to acquire basic and advanced
during instruction, the teacher would model the sound (“My
turn. mmm”), use guided practice (“Say it with me. Get ready.
academic skills.
mmm”), and have students practice independently (“Your
turn. Get ready”). A “starting over” would be conducted based
on this error; this might include starting over at the top of a Behavioral Strategies
column or row of sounds so that students get increased prac-
tice on the /m/ sound. The /m/ would appear throughout the Many problems that children with communication and
lesson and in subsequent lessons to ensure skill mastery (firm learning disorders have stem from the fact that the ma-
responding) over time. terial is simply presented too fast for them (Tallal &
Source: Marchand-Martella, Martella, & Ausdemore (2005). An Overview of Benasich, 2002). Thus, a strategy to provide children
Direct Instruction.
with a set of verbal rules that can be written out and re-
applied may be more beneficial than one that relies on
memory or on grasping the concept all at once. Tried-
and-true behavioral principles of learning are well suit-
words accurately and rapidly must be acquired before ed to this task of teaching systematically.
reading comprehension can occur (Hammill et al., In addition to academic concepts, some of the
2002; Haager, Klinger, & Vaughn, 2007). associated problems with peers can be addressed in
To prevent dyslexia, it is important to provide early the same fashion, as we saw with Francine. A simple,
interventions that teach both phonological and verbal gradual approach is more beneficial than an approach
abilities. Children must be able to learn the sounds of that tries to solve the problem all at once. Children
words to decode them, but they must also understand also need help learning to generalize new information
the meaning of a word to understand the message of to different situations. An individualized, skills-based
the text (S. E. Shaywitz & Shaywitz, 2013). The tech- approach does not have to be boring or routine; in fact,
niques that have been demonstrated to work are prac- speech and language therapists are skilled at providing
ticing manipulating phonemes, building vocabulary, a stimulating but structured environment for hearing
increasing comprehension, and improving fluency, and practicing language patterns. During an engaging
which helps strengthen the brain’s ability to link letters activity with a younger child, the therapist may talk
to sounds (Nation et al., 2007). about toys and then encourage the child to use the
In brief, the components of effective reading instruc- same sounds or words. The child may watch the thera-
tion are the same whether the focus is prevention or pist make the sound, feel the vibration in the therapist’s
intervention—phonemic awareness and phonemic de- throat, and then practice making the sounds himself or
coding skills, fluency in word recognition, construction herself in front of a mirror.
Behavioral methods often are used in conjunction
with a complete program of direct instruction, which methods, and they helped him bypass some aspects of
typically proceeds in a cumulative, highly structured his writing disability. I discussed practice strategies for
manner (Wright & Jacobs, 2003), as shown in A Closer visual–motor integration, such as drawing and tracing
and gradually made the task more complex. Because
Look 7.2. Because this method places a strong empha-
cursive writing is often easier for children than printing,
sis on the behavior of the teacher in terms of explicit
I suggested that Carlos bypass learning to print. A con-
correction, reinforcement, and practice opportunities, tinuous pattern of output is easier for Carlos to plan and
it is sometimes referred to as “faultless instruction”: produce than a discrete form of output, such as printing.
Each concept should be so clearly presented that only To help Carlos write a paper, I adopted a basic plan-
one interpretation is possible. Each lesson is structured ning strategy from Graham, MacArthur, Schwatz, and
according to field-tested scripts. Teachers work with Voth (1992), which helped him structure the tasks into
one small group of students at a time, and shoot ques- related subproblems. The acronym PLANS helps him to
tions at them at a rate as high as 10 to 12 per minute. remember to:
This highly structured, repetitive method is clearly Pick goals (related to length, structure, and purpose of
effective. Students who receive direct behavioral instruc- the paper)
tion typically outperform students who receive standard List ways to meet goals
classroom instruction by almost 1 standard deviation And
on various learning measures (Lyon et al., 2003). make Notes
Sequence notes
Cognitive–Behavioral Interventions This mnemonic was used in a three-step writing
Cognitive–behavioral interventions are also highly strategy to assist Carlos to: (1) do PLANS, (2) write and
suited for children with communication and learning say more, and (3) evaluate whether he is successful in
disorders. Like behavioral methods, these procedures achieving his goals. (Based on authors’ case material.)
actively involve students in learning, particularly in
monitoring their own thought processes. Considerable
emphasis is placed on self-control by using strate-
gies such as self-monitoring, self-assessment, self-
recording, self-management of reinforcement, and so Computer-Assisted Learning
on (Alwell & Cobb, 2009; Cobb et al., 2006). Essen- Studies have shown that a similar level of efficacy in
tially, children are taught to ask themselves several phonetic ability can be achieved by teachers as by
questions as they progress, to make themselves more clinicians (Duff & Clarke, 2011), which has led to
aware of the material. Try it yourself: “Why am I a growing number of computer and Internet train-
reading this? What’s the main idea the authors are trying programs. One problem in reading instruction
ing to get across? Where can I find the answer to this is maintaining a balance between the basic, but dull,
question? How does this follow from what I learned word decoding and the complex, but engaging, text
a minute ago?” comprehension. Not all the issues have been resolved,
Carlos’s treatment program shows how some of but computer-assisted methods for spelling, read-
these procedures were applied to his particular writing ing, and math provide more academic engagement
problems: and achievement than traditional pencil-and-paper
methods.
Computers have been used as simple instructional
C A R LO S tools to deliver questions and answers since the 1970s.
Since discovering phonological awareness and tim-
Plans ing problems in the brain, researchers are now testing
whether computers can remedy some basic auditory
In third grade, Carlos’s treatment plan was to integrate problems. Some children with communication and
a cognitive–behavioral approach into regular teaching learning disorders are unable to process information
methods. Rather than using one-to-one instruction, I that flashes by too quickly, such as the consonant
discussed with his teacher ways of blending some be- sounds ba and da, and this deficit interferes with vital
havioral methods into the classroom. For example, his
speech processes. Computer programs are able to slow
strengths are in the areas of thinking and speaking,
down these grammatical sounds, allowing young chil-
so I discussed using computers and tape recorders to
help him learn the materials. He seemed to like these
dren to process them more slowly and carefully (Loo
et al., 2010; Gaab et al., 2007; Palmer, Enderby, &
Hawley, 2007).
to ensure competency. As they progress, they should
practice more and more reading that is contextualized.
Reading materials should have controlled vocabularies
that contain mostly words the children can decode. As
children develop a core sight vocabulary, introduce only
those irregular words that can be read with high accuracy.
Guessing is counterproductive.
5. Teach for automaticity. Once basic decoding is mas-
BSIP/UIG via Getty Images

tered, children must be exposed to words often enough
that they become automatically accessible. This usually
requires a great deal of practice, which should be as pleas-
ant and rewarding as possible.
Source: From Rebecca H. Felton, Effects of Instruction on the Decoding Skills
of Children with Phonological-Processing Problems, Journal of Learning
New research raises cautious hope that computer games Disabilities, 26, 583–589
and exercises can help children with learning disabilities
develop key mental skills.
Whether taught by computers, teachers, or both, of a successful beginning reading program, elements
studies of interventions for learning disorders indicate that apply to other disabilities as well. For children
that successful approaches typically include explicit with reading disorders to learn how to read, they must
instruction in phonemic awareness and phonemic de- receive a balanced intervention program composed
coding. These interventions also provide students with of direct and explicit instruction in phonemic aware-
practice reading text and comprehending what they ness, a systematic way to generalize this learning to the
read, with ample assistance and almost daily sessions learning of sound–symbol relationships (phonics), and
(Torgesen et al., 2010). many opportunities to practice these coding skills by
In summary, treatment methods for communica- reading meaningful, interesting, and controlled texts.
tion and learning disorders are varied and beneficial. The sooner this intervention occurs in schools, the bet-
A Closer Look 7.3 reviews some of the basic elements ter (Haager et al., 2007).
Section Summary
A Closer Look 7.3 Specific Learning Disorder
Specific learning disorder (SLD) includes problems in read-
Critical Elements for a Successful
●●
ing, mathematics, or writing ability, with reading disorders

Beginning Reading Program being the most common. Mathematics and writing disor-
ders overlap considerably with reading disorders.
1. Provide direct instruction in language analysis. Identify at-
risk children early in their school careers—preferably in
●● Although SLD overlaps with behavioral disorders, they
kindergarten—and teach phonological awareness skills are distinct problems. Opportunities to develop and use
directly. particular strengths lead to more successful adult out-
comes.
2. Provide direct teaching of the alphabetic code. Code instruc-
tion should be structured and systematic, in a sequence
●● SLD in reading may be caused by phonological problems
that goes from simple to more complex. Teach the regu- that arise from physiological abnormalities in the process-
larities of the English language before introducing the ing of visual information in the brain. These deficits are be-
irregularities. Nothing should be left to guesswork—be lieved to be largely inherited.
as explicit as possible. Teach a child who is overly reliant ●● Treatments for children with communication and learning
on letter-by-letter decoding to process larger and larger disorders involve educational strategies that capitalize on
chunks of words. existing strengths, and behavioral strategies involving di-
3. Teach reading and spelling in coordination. Children should rect instruction.
learn to spell the words they are reading correctly. ●● Cognitive–behavioral techniques and computer-assisted
4. Provide intensive reading instruction. Children may need 3 instruction are also used successfully.
or more years of direct instruction in basic reading skills
Study Resources
SECTION SUMMARIES inclusion 203
language disorder 201
Definitions and History 197
learning disabilities 197
Language Development 199
nonverbal learning disabilities (NLD) 220
Communication Disorders 201
phonemes 199
Specific Learning Disorders 208
phonological awareness 200
phonology 200
KEY TERMS specific learning disorder 198
communication disorder 198 speech sound disorder 202
decoding 213 unexpected discrepancy 198
direct instruction 222
dyslexia 213
226 Part 2 Neurodevelopmental Disorders

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7

Communication and Learning

If you can read this, thank a teacher.

Definitions and History Childhood-Onset Fluency SLD with Impairment in Written

196 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 197

ing disability for many years. However, researchers and

198 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 199

© Monkey Business Images/Shutterstock.com

200 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 201

202 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 203

Neurons form a vast, miniaturized informational network that transmits information

The cortex is a thin layer of cells that The parietal lobe is

The frontal lobe is involved The temporal lobe is

● F I GU R E 7 . 1 | Areas of the brain involved in language functions.

204 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 205

etitions, sound prolongations, pauses within a word,

206 P a r t 2 Neurodevelopmental Disorders

is a new disorder in DSM-5. It involves persistent dif-

C h a p t e r 7 Communication and Learning Disorders 207

208 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 209

Zigy Kaluzny/The Image Bank/Getty Images

T able 7 . 4 | Diagnostic Criteria for Specific Learning Disorder

210 P a r t 2 Neurodevelopmental Disorders

With impairment in reading:

With impairment in written expression:

With impairment in mathematics:

C h a p t e r 7 Communication and Learning Disorders 211

212 P a r t 2 Neurodevelopmental Disorders

SLD with Impairment in Written Expression

Carlos, age 7, was about to finish second grade when his

C h a p t e r 7 Communication and Learning Disorders 213

214 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 215

20% needs may easily be overlooked.

10% Adult Outcomes

5% Unfortunately, the social and emotional difficulties

216 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 217

218 P a r t 2 Neurodevelopmental Disorders

Auditory association area

How the brain processes speech

● F I GU R E 7 . 5 | How the brain processes speech.

C h a p t e r 7 Communication and Learning Disorders 219

220 P a r t 2 Neurodevelopmental Disorders

To reduce Francine’s difficulties with math and, espe-

physical education was also planned, to help her with

C h a p t e r 7 Communication and Learning Disorders 221

222 P a r t 2 Neurodevelopmental Disorders

C h a p t e r 7 Communication and Learning Disorders 223

224 P a r t 2 Neurodevelopmental Disorders

BSIP/UIG via Getty Images

ing, mathematics, or writing ability, with reading disorders

C h a p t e r 7 Communication and Learning Disorders 225