Learning Disability

Learning Disabilities and Your Child

Learning disabilities are roughly divided along three lines; reading, writing, and arithmetic.  Each of these Learning Disorders, formerly “Academic Skills Disorders”, may be diagnosed in isolation or in combination with other learning problems.

It is important for the public to understand the process by how these disorders are diagnosed.  Initially the patient is given a test to determine their Full Scale intelligence quotient.  These tests typically require 1.5 to 3.0 hours to administer.  The patient is then administered tests of achievement.  These tests measure core academic skills in relation to others their own age.  Once the scores are tabulated and normalized, the psychologist compares the Full Scale IQ to each achievement subtest in reading, writing, and math.  If there is more than one standard deviation difference between their IQ and an achievement score, the psychologist may diagnose that patient with a specific learning disorder.

One standard deviation implies that the observed spread between the scores could not readily happen by chance alone, or at least less than a one-in-twenty chance of being purely random.  If the psychologist places their faith on 1.5 to 2.0 standard deviations, than there is an even smaller chance that the observed discrepancy between scores is chance alone.  The diagnostic manual for our field does not stipulate the exact statistical spread between scores, such that there is some room for interpretation-and error.

Most children and adults with learning disabilities cluster around math and reading/writing deficits.  It is rare that there is a significant difference between reading and writing scores, but it is common to have significant differences between language and math scores.  Reading and writing skills are neuropsychologically well correlated.

Most math deficits in children stem from visual-spatial difficulties, and most language errors from phonetic deficits.  Often children who can’t sound out a word are very slow to learn in the early grades, but rapidly attain normal reading when sight reading strategies emerge by the third grade.  Sight reading strategies depend heavily on visual-spatial skills, which circumvents the phonetic disability.  Children with good phonetics often progress rapidly in reading and writing in the early grades, but slow significantly at math and sight reading strategies by the third grade.  The emerging learning disability is typically visual-spatial in nature.  Native readers of Chinese pictographs become aware of visual-spatial deficits at the start of reading and writing instruction.  Unfortunately, some Learning Disorders are a mixed type, having both visual-spatial and phonetic deficits.

Treatment of Learning Disorders are generally accomplished with a plan that bridges the school into the home.  Neuropsychological remediation focuses more on the cognitive strengths than the rehabilitation of deficits.  After the age of 12, these Learning Disorder deficits tend to be lifelong.  Prior to age 12, IQ tends to be very unstable.  Many children who exhibit skill deficits at 8 years of age score as normal by 12 years of age.  This typically happens without any neuropsychological intervention.  If an adult or older child continues to experience problems with one or more academic areas, yet possess an Average IQ, then it is likely the deficit(s) will persist throughout their lifetime.  Targeted neuropsychological intervention can minimize the impact of the deficit(s), but be confidant that the remedial work is long and difficult.

Psychotherapy for Dummies

Learning Disabilities require a specific form of behavioral and neuropsychological therapy, which is not what people would typically think of as psychotherapy.  Many people ask, sheepishly, how psychotherapy really works.  The term “therapy” is mentioned constantly in the media as a short form of the word “psychotherapy.”  It’s natural that people are curious about something that is seemingly ubiquitous, yet apparently defies easy explanation.  There is nothing magical or new about psychotherapy.  Like most medications, however, there are aspects of its intrinsic functioning that remain a mystery.  The nebulous and fleeting words strewn about a psychotherapy session appear, mysteriously, to be less important than the conditions demanded by the therapeutic frame.  The “frame” of psychotherapy refers to all aspects of the session divorced from the actual words used within the session: for example, cost, time, place, office policies, etcetera.

Whatever the psycho-therapeutic school of thought, there are set features that are standard across most styles and techniques.  The most important element of effective psychotherapy is the promise of confidentiality.  Without a solid confidential therapeutic base, psychotherapy is nothing more than a Socratic conversation for hire.  One’s life may be blessed by many intimate trusted contacts, yet one cannot divulge literally everything to any one friend.  There are always social consequences, and consciously or unconsciously, all of us must monitor and filter the content of our conversations.  I do not believe that this encompassing social information management is strictly selfish.  As often as not, the filtering of information is used to protect the feelings of others.  Having intimate  friends is certainly important to one’s mental health, yet even the closest of relationships may be of little use when one’s situation is altered by psychological suffering.  For instance, most of my patients are very conscious of becoming a “burden” to others through ventilating their distress.  Unless the intimate attachment is based upon this sort of negative ventilation, the voicing of complaints may alter the basis of the friendship.  Existing social support may be lost.  For this reason alone, close friends are often of little help when psychological distress becomes significant.

Confidentiality is the boiler plate of psychotherapy.  Psychotherapy research of the last 50 years is convergent in revealing that the particular therapeutic technique employed is less important than confidentiality in achieving a favorable patient outcome.  Part of these findings may be explained by the decreased social risk obtained by ventilating to a professional.  Another aspect of these findings may be explained by the very nature of psychotherapy technique.  Each school of psychotherapy tends to focus on particular features of the human experience, yet similarities do exist.  Broadly, psychotherapy is dedicated to resolving problems that negatively affect one’s life.  The relative importance of thoughts versus behaviors differs, yet nearly all seek to identify “maladaptive” thoughts or behaviors that lower a person’s psychosocial functioning.  Many schools, such as Rogerian, eschew the whole notion of maladaptive, yet even the most positive and uplifting psychotherapy is seeking to alter one’s thoughts and/or behaviors.  It is unlikely that anyone would pursue psychotherapy as a treatment if they perceived their thoughts and behaviors to be wonderful.  Many schools of psychotherapy are better at appearing more positive and uplifting than others, but the mission is essentially the same.  For example, a new form of psychotherapy is termed “coaching.”  This form of psychotherapy/counseling even eschews the whole notion that it is a psychotherapy!  As in Rogerian therapy, there is a strong accent on the therapist being positive and proactive.  The word “coaching” is synonymous with “instructing.”  It appears that some people would forgo the benefits of an intimate attachment to a therapist, in order to avoid being perceived as a “psych case.”

Schools of psychotherapy are targeted towards individuals, couples or families.  While the number and relation of the individuals is different in various schools of thought, the mission to discover less than desirable thoughts and behaviors is the same.  Many therapists and schools of thought voice a focus on “communication.”  I am at a loss to know what else could be a focus of psychotherapy.  All psychotherapy assumes communication as essential to the experience, since no therapeutic school pretends to work with comatose or catatonic individuals.  Nonverbal behavior communicates a great deal to the therapist and others involved in the session.  Verbal and nonverbal communication is the very stuff with which we work, such that the notion of “communication” being a special focus is a bit absurd.  The greatest difference between psycho-therapeutic schools of thought are that each tend to emphasize particular features (subsets) of the therapeutic experience; thoughts versus behaviors and individuals versus groups.

If I may draw on the medication analogy again, the use of different forms of psychotherapy is similar to considering side effects in proscribing a particular medication.  If we know that two medications will work equally well to cure a condition, which should be employed?  The medication with side effects better tolerated by a particular individual would be the obvious choice.  For example, the new class of antidepressants called SSRI’s are very good, yet most cause serious reversible symptoms of sexual impairment.  If the patient is very sexually active, it might be better to use an older, though less effective, antidepressant without the unwanted sexual impairment.  Similarly, group psychotherapy is the most obvious choice to reduce social anxiety, yet initially it may be the worst form of treatment.  Exposed to the stimuli they fear the most, a group of people, the patient may experience recurrent trauma as a consequence of this treatment.  For this person, it is better to lessen the initial anxiety with individual psychotherapy, and then save the finishing touches for group psychotherapy.

The basics of psychotherapy are centered about confidentiality, a solid frame, and the identification of unwanted thoughts and/or behaviors.  The choice of which psychological technique to employ is similar to choosing amongst equally effective medications.  The choice of interventions should be based upon the comfort level of the particular patient, in light of their unique situation and lifestyle.

Psychotherapy Reconsidered

Perhaps you have read my last post “Psychotherapy 101” or “Psychotherapy for Dummies.”  The post “Psychotherapy 101″ is an introduction  into fundamental aspects of psychotherapy.  It also attempts to dispel common myths regarding psychotherapy.  I am satisfied with the post’s information, but a bit unhappy with its tone.  Perhaps in my rush to dispel the “fruit and nut” aspects of psychotherapy, I did not give an accurate description of its softer side.

Even though most people seek psychotherapy to solve particular problems, there are those whose mission is to grow as a person.  It is easy to categorize these people under the “problem” label, since a desire to grow as a person assumes a certain degree of dissatisfaction with one’s life.  Perceived in another way, one may regard these seekers of growth to be satisfied with their lives, yet eager to exceed the boundaries of their current existence.  It is less improving a bad thing than making a good thing even better.

Personal growth through psychotherapy is not problem oriented or solution focused.  There is no mountain of empirical literature to guide the psychologist’s movements.  It is a free style exploration of one’s existence.  Psychodynamic therapists have an interesting perspective on this form of exploration.  They maintain psychotherapy is the construction of a story that both the patient and therapist agree upon.  It is a simple sounding phrase, yet its meaning tends to enlarge as it is turned over in the mind.

The path of the growth oriented patient is less clear than the problem-oriented one.  The explicit goals and techniques of traditional psychotherapies render the measurement of progress and success rather easy.  The only goal of growth psychotherapy is to exceed one’s current psychological limitations.  Neither the psychologist or patient knows how or when the process will end.  The psychologist may perceive the patient as complete, but only the patient has the privilege of considering themselves complete.  In traditional psychotherapy, the psychologist is largely the owner of this privilege.  For example, once the patient stops smoking or their mood is brighter, the psychologist will pronounce success.  Psychotherapy is considered complete with the resolution of the problem-oriented goal.  In growth therapies, only the patient will truly know when they have reached their goal.

Many growth-oriented therapies eschew goals as an unnecessary stifling of personal exploration.  Perhaps this is based upon the assumption that the goals of an incomplete person will be incomplete as well.  It may be true that one has to reach a certain level of psychological sophistication to formulate reasonable goals.  While this concept rings true for many high functioning people, it is not very applicable to those with more fundamental problems.  Working with victims of head injury, the formulation of any goal may be a great victory for the patient.  Lacking awareness into their deficits, the psychologist must maintain the privilege of  controlling the nature and extent of the treatment.  Growth-oriented psychotherapy assumes good cognitive functioning.

Growth-oriented psychotherapy is likely most beneficial to those whose work and home-life are generally satisfactory.  Personal growth work is easily derailed by current emergencies and old traumas.  Personal growth as a goal is certainly noble and worthwhile.  The time and expense are considerable, and the commitment is extraordinary.  The shared experience of building an autobiography is very powerful.  One cannot help but be altered by the experience.  The person emerging from this process has yet to be revealed.  It is hoped that greater awareness will bring greater clarity, and the clarity will strength our purpose.

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