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 and Speech Sound
Disorders SLD with Impairment
in Reading

194

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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
fog.” Although school performance was a major concern,
her mother was also quite worried about Francine’s lack
attention long enough to make sense of them. When of friends and the way other children treated her.
Her mother and father proudly shared their
you are shown how to read or add, you find that the
daughter’s early childhood history and developmental
letters and numbers look and sound too much alike.
milestones with me during our first interview. “Francine
Children and adolescents with communication and walked before she was a year old, and was a very
learning disorders experience these difficulties daily. talkative baby and toddler, who picked up new words
Everyday tasks can be confusing and frustrating, and quite quickly. She was a healthy and normal baby—
sometimes result in a cycle of academic failure and we can’t figure out why she seems so uninterested in
lowered self-esteem. school and 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
JAMES bother them. My husband and I didn’t think much of it
at first. In fact, we bragged about how she took an early
Smart but Can’t Read
interest in reading and would spend a lot of her time
alone with a book or magazine, even when she was 4
James, age 9, was a growing concern for his teacher: or 5, although she didn’t usually understand what she
“James is obviously a very bright boy, and he wants read. But we grew more concerned around age 5 because
to do well. I’ve noticed that he likes art and is always she paid little attention to popular movies, toys, and
wanting to draw. But he gets really upset when I ask him things other kids her age played with. When she was a
to do some work in class. preschooler, we also noticed that she had trouble with
“He looks like he dreads coming to school. And he numbers and understanding concepts like ‘more,’ ‘less,’
complains that some words he tries to read don’t make or ‘bigger.’ She knows what these words mean now, but
sense to him. I’m worried that his increasing frustration she is still confused when we ask her to count something.
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 became confused, switching from one coin to the other,
explodes 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. the pennies up! And if you ask her to arrange something,
She knew that her son would get involved in something like setting the table for dinner, you never know what
only if he could do it his own way. Her mind wandered you’ll end up with!” (Based on authors’ case material.)
briefly to when he was a toddler and sometimes got
so anxious and worried about something that he had
trouble sleeping or felt sick. She shared with his teacher
her frustration at trying to find out what the problem Children with communication or learning disorders
was: “Getting him to read at home is like pulling teeth.
can learn, and they are as intelligent as anyone else. Their
He won’t read at all on his own because he knows he
disorders usually affect only certain limited aspects of
can’t read many of the words.” (Based on authors’ case
material.)
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 learning problems. James’s
are with language and reading. His ability to distin-
FRANCINE guish between different language sounds (phonemes)
Shunned and Falling Behind is underdeveloped, which is the primary reason for his
poor word recognition and writing ability. Francine’s
problems are mostly with nonverbal learning, such as
Francine, age 7, was entering a new school for the
math. She can read quite well, but she has difficulty
second time in 2 years. The first school was too
understanding some of the subtleties of others’ facial
challenging, and the other kids teased her because she
“doesn’t know what 2 plus 2 is.” She is content to play expressions and gestures. She also confuses terms and
for hours by herself and is not interested in the things instructions that describe numerical or spatial relation-
that other kids her age are doing. “Most of the time,” her ships, such as “larger than” or “sit beside the couch.”
mother explained, “Francine seems sad and in a bit of a The field of learning and communication disor-
ders, broadly referred to as “learning disabilities,”

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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
appearance 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 communi-
cation disorders are more likely to develop a learning affect many different tasks and social situations. Each
disability by middle childhood or early adolescence type of learning disability, whether it is related to
(Beitchman & Brownlie, 2014). reading, writing, math, or language, is characterized by
distinct definitions and diagnoses. Knowledge of com-
munication and learning disorders is growing rapidly
DEFINITIONS AND HISTORY as a result of increased scientific interest and research
support. We now recognize that a learning disability,
Learning disability (LD) is still commonly used as a though challenging, does not have to be a handicap.
general term for learning problems that occur in the Many well-known people with learning difficulties
absence of other obvious conditions, such as intellec- used their talents in exceptional ways, including Albert
tual disability or brain damage. In the Diagnostic and Einstein, Winston Churchill, and Thomas Edison.
Statistical Manual of Mental Disorder, 5th edition The main characteristic all children with learning
(DSM-5) two more specific terms are used, communica- difficulties share is failing to perform at their expected
tion disorders and learning disorders, but the common level in school. Otherwise, symptoms vary tremen-
use of the term learning disability requires that it be dously (Beitchman & Brownlie, 2014). Many children
clarified and defined. and adults who are unable to acquire academic skills
A learning disability affects how individuals with at a normal rate have been helped by recognizing and
normal or above-average intelligence take in, retain, or attending to specific learning problems.
express information. Incoming or outgoing informa- Children with learning disabilities constitute a third
tion can be scrambled as it passes between the senses of all children in the United States and Canada who
and the brain. Unlike most physical disabilities, a receive special education services (National Center for
learning disability is hidden and is often undetected in Educational Statistics, 2012). Yet, experts still struggle
young children (Lovett & Lewandowski, 2014). Thus, to adequately define learning disabilities because of
children with learning disabilities often must cope not their many forms and overlapping symptoms, which
only with their limitations in reading, writing, or math you will note in the following lengthy definition:
but also with the frustration of convincing others that Learning disability is a lay term (not a diagnostic
their problems are as legitimate as visible disabilities. term) that refers to significant problems in
Learning difficulties often show up in schoolwork mastering one or more of the following skills:
and can impede a child’s ability to learn to read, write, listening, speaking, reading, writing, reasoning, and
or do math, but they also can affect many other parts mathematics. Learning disabilities do not include
of life, including work, daily routines, family life, and visual, hearing, or physical impairments; intellectual
friendships. Some learning problems are specific and disability; emotional disturbance; or environmental
affect a narrow range of ability, whereas others may disadvantage. Emotional and social disturbances and

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 other adaptive deficiencies may occur with learning ▶▶ language disorder (problems using language to com-
problems, but they do not by themselves constitute municate, such as spoken words or sign language,
a learning disability. (Individuals with Disabilities or understanding what other people say)
Education Improvement Act [IDEA], 2004) ▶▶ speech sound disorder (deficits in productive speech
In Chapter 5, we described intellectual disability sounds)
as involving deficits in basic cognitive abilities that ▶▶ childhood-onset fluency disorder (problems in speech
include problem solving, verbal skills, and mental rea- fluency, such as stuttering)
soning. But the broader concept of intelligence also ▶▶ social (pragmatic) communication disorder
includes logical, mathematical, and language abilities
that reflect a pattern of relative strengths and weak- These communication disorders are developmen-
nesses possessed by everyone. For example, we are all tally connected to the later onset of learning disorders.
stronger in some areas of learning and performance Specific learning disorder is a diagnostic term that
than in others (e.g., we enjoy writing and reading, but refers to specific problems in learning and using aca-
don’t ask us to fix your car). Similarly, children with demic skills. The DSM-5 integrates the frequently co-
specific learning disorders who have normal intelli- occurring problems in reading, mathematics, and written
gence show a pattern of relative strengths and weak- expression into this one category, and uses specifiers to
nesses that can make some learning tasks much more designate impairments in one or more of these areas.
difficult. This pattern is noteworthy mostly because it Specific learning disorder is determined by achievement
is so extreme and unexpected for a child who otherwise test results that are substantially below what is expected
shows normal cognitive and physical development. for the child’s age, schooling, and intellectual ability.
Communication disorder is a diagnostic term that An unexpected pattern of strengths and weaknesses
refers to deficits in language, speech, and communica- in learning was first noted and studied during the late
tion (APA, 2013). Communication disorders include nineteenth century by physicians who were treating
the following 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 intellectual 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 problem 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 dis-
ability in terms of relative strengths and deficits. People
with learning disabilities have normal intellectual pro-
cesses 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 defini-
tions of learning disability for many years. However,
Bettmann/Getty Images

researchers and practitioners eventually agreed that

subaverage performance on achievement tests, rather
than a discrepancy between potential and actual per-
formance, was a better way to capture these learning
Few realize that Albert Einstein had early speech and difficulties (Maehler & Schuchardt, 2011).
language difficulties, given his monumental contributions The links between intellectual disability, organic
to society. brain damage, and learning problems fascinated

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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 remained as to why some children who did could be identified (Lyon et al., 2003). These develop-
not fit the definition of intellectual disability based on ments led to the recent Response to Intervention (RTI)
IQ had significant problems in learning. Could intellec- movement, which views LD in terms of what academic
tual disability be restricted to only certain intellectual help children need rather than what disability they
abilities? Were academic problems the same as those might have (Lewandowski & Lovett, 2014). Thus,
assessed by measures of general intelligence? with the collaborative leadership of parents, educa-
Strauss and Werner (1943) shed light on this issue tors, and specially trained professionals, the field of
by pointing out that children learn in individual ways, learning disabilities grew from its beginning in the
challenging the concept that learning is a relatively 1960s to the major component of educational services
uniform, predictable process in children without intel- it is today.
lectual 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 to receive special education
services. A category was needed to describe learning LANGUAGE DEVELOPMENT
problems that could not be explained based on intel-
lectual disability, lack of learning opportunities, psy- From birth, infants selectively attend to parental speech
chopathology, or sensory deficits (Lyon, Fletcher, & sounds and soon learn to communicate with basic ges-
Barnes, 2003). tures and sounds of their own. Usually, by their first
Thus, the emerging concept of learning disabilities birthday they can recognize several words and use a
made intuitive sense to many who were familiar with few of their own to express their needs and emotions.
the varied needs of children, and it was welcomed as Over the next 2 years, their language development
states and provinces began to support special educa- proceeds at an exponential pace, and their ability to
tion programs and services. The domination of physi- formulate complex ideas and express new concepts is
cians and psychologists in the field gave way to greater a constant source of amazement and amusement for
input from educators, parents, and clinicians. Teacher parents. Adults play an important role in encouraging
training expanded to include new ways to teach young- language development by providing clear examples of
sters who could not respond to typical classroom language and enjoying the child’s expressions.
methods. Professionals trained in speech and language Language consists of phonemes, which are the basic
pathology became an important part of school-based sounds (such as sharp ba’s and da’s and drawn-out ee’s
services. and ss’s) that make up language. When a child hears a
As the focus of the learning disabilities movement phoneme over and over, receptors in the ear stimulate
shifted from the clinic to the classroom, parents and the formation of dedicated connections to the brain’s
educators assumed a major role in programming and auditory cortex. A perceptual map forms that repre-
placement. They were encouraged by the fact that the sents similarities among sounds and helps the infant
term learning disabled did not stigmatize children, but learn to discriminate among different phonemes.
rather brought them needed services (Hammill, 1993). These maps form quickly; 6-month-old children of
The fact that these children had normal intelligence English-speaking parents already have auditory maps
gave parents and teachers hope that difficulties in different from infants in non-English-speaking homes,

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 cognitive functioning. Albert Einstein, who is consid-
ered an intellectual genius, began speaking late and
infrequently, causing his parents to worry that he was
“subnormal.” 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

Monkey Business Images/[Link]

matter, he’ll never make a success of anything” (R. W.
Clark, 1971, p. 10).
Since language development is an indicator of
general mental development, children in whom lan-
guage fails to develop or who show severe delays in
acquiring language are considered at risk of having a
language-based learning disability. Albert Einstein not-
withstanding, early language problems are considered
From an early age, children love to express themselves. highly predictive of subsequent communication and
learning disorders (H. L. Swanson, 2014).
Phonology is the ability to learn and store pho-
as measured by neuron activity in response to different nemes as well as the rules for combining the sounds
sounds (Kuhl et al., 2006). By their first birthday, the into meaningful units or words. Deficits in phonology
maps are complete, and infants are less able to dis- are a chief reason that most children and adults with
criminate sounds that are not important in their own communication and learning disorders have problems
language. in language-based activities such as learning to read
Rapid development of a perceptual map is why and spell (Hulme & Snowling, 2013).
learning a second language after—rather than with— A young child is required to recognize that speech
the first language is difficult; brain connections are is segmented into phonemes (the English language con-
already wired for English, and the remaining neurons tains about 42, such as ba, ga, at, and tr). This task
are less able to form basic new connections for, say, is difficult for many children because speech does
Swedish. Once the basic circuitry is established, infants not consist of separate phonemes produced one after
can turn sounds into words, and the more words they another. Instead, sounds are co-articulated (overlapped
hear, the faster they learn language. The sounds of with one another) to permit rapid communication,
words serve to strengthen and expand neural connec- rather than pronounced sound-by-sound (Liberman &
tions that can then process more words. Similar cortical Shankweiler, 1991). About 80% of children can seg-
maps are formed for other highly refined skills, such as ment words and syllables into their proper phonemes
musical ability (Huss et al., 2011). A young child who by the time they are 7 years old. The other 20% cannot,
learns to play a musical instrument strengthens the and it is these children who struggle hardest to read
neural circuits needed for the development of reading (S. E. Shaywitz & Shaywitz, 2013).
ability (Flaugnacco et al., 2015). Generally, early language problems surface as
learning problems when children enter school, because
in school children are taught to connect spoken and
Phonological Awareness written language. Those who do not easily learn to read
Not all children progress normally through the mile- and write often have difficulty learning the alphabetic
stones of language development. Some are noticeably system—the relationship of sounds to letters. They also
delayed, continuing to use gestures or sounds rather cannot manipulate sounds within syllables in words,
than speech. Others progress normally in some areas, which is called a lack of phonological awareness and is
such as following spoken directions and attending a precursor to reading problems (Hulme & Snowling,
to commands, but have trouble finding the words to 2016).
express themselves clearly. Phonological awareness is a broad construct that
Although the development of language is one of includes recognizing the relationship between sounds
the best predictors of school performance and overall and letters, detecting rhyme and alliteration, and being
intelligence (Sattler, 2014), delays or differences in aware that sounds can be manipulated within syllables
development are not a definitive sign of intellectual in words. Primary-grade teachers detect phonological
disability or cognitive disorder. Rather, such deviations awareness as they ask children to rhyme words and
from normal may be just that—deviations—and may manipulate sounds. For example, the teacher can say
be accompanied by superior abilities in other areas of “hat” and ask the child to say the word without the h

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sound, or say “trip” and have the child say the word
without the p. To assess the child’s ability to blend
JACKIE
sounds, teachers can say the three sounds t, i, and n, for Screaming, Not Talking
example, and see whether the child can pull the sounds
together to say “tin.”
Jackie’s mother explained with no hesitation why she
In addition to serving as a prerequisite for basic
asked for help: “My 3-year-old daughter is a growing
reading skills, phonological awareness and processing
concern. Since she was a baby, she has been plagued
also appear highly related to expressive language by ear infections and sleep problems. Some nights she
development (Boada & Pennington, 2006). Readers screams for hours on end, usually because of the ear
with core deficits in phonological processing have infections. She has violent temper outbursts and refuses
difficulty segmenting and categorizing phonemes, to do simple things that I ask her to do, like get dressed
retrieving the names of common objects and letters, or put on her coat.”
storing phonological codes in short-term memory, The child, waiting in the playroom, could be heard
and producing some speech sounds. Reading and screaming over her mother’s voice. Jackie was asking
comprehension depend on the rapid and automatic my assistant for something, but she could not make
ability to decode single words. Children who are slow out what Jackie was saying. It was pretty obvious how
frustrated both the child and her mother must feel on
and inaccurate at decoding have the most difficulties
occasion. Her mother explained how she and Jackie’s
in reading comprehension (Melby-Lervåg, Lyster, &
father had divorced when Jackie was less than 2 years
Hulme, 2012). old, and that after weekend exchanges it sometimes took
a few days for Jackie’s routine to return to some degree of
normalcy.
Section Summary I opened the letter she had brought from Jackie’s
preschool teacher, someone who I knew had a great
Language Development deal of experience with children of this age. “Jackie is a
●● Language development is based on innate ability and en- bright and energetic child,” the letter began, “but she is
vironmental opportunities to learn, store, and express im- having a great deal of difficulty expressing herself with
portant 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
new teacher at day care is introduced, it takes Jackie a
guish the sounds of language—have been identified as a
long time to get used to the new person. Jackie seems to
major cause of communication and learning disorders.
understand what she is being asked, but can’t find the
words to express herself, which understandably leads to
an emotional reaction on her part.” (Based on authors’
COMMUNICATION DISORDERS 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-
Language and Speech Sound Disorders
nostic subcategories of language disorder, speech sound Jackie’s problems met the criteria for a language dis-
disorder, childhood-onset fluency disorder (stuttering), order, which is a communication disorder character-
and social (pragmatic) communication disorder. These ized by difficulties in the comprehension or production
subcategories are distinguished by the exact nature of of spoken or written language. As a result of these
the child’s impairment. deficits, Jackie showed her frustration loudly and
Recall that during development, phonological prob- inappropriately.
lems appear before problems in language reception or Children’s language development follows specific
expression, yet they have strong similarities. The fol- steps, although each child may proceed through the
lowing discussion focuses on language disorder to steps at a different pace. Normal variations can make
highlight early childhood problems that represent the it difficult to predict that a given child’s early commu-
fundamental features of communication disorders. nication problems will later become major problems in
(Stuttering has a unique clinical feature and develop- learning. A common example is the child who points
mental course, so it is discussed separately.) to different objects and makes grunting or squealing
Consider Jackie’s communication problems at age noises that the parent quickly recognizes as “more
3 years. milk” or “no peas.” Prior to age 3 or so, many children

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communicate this way unless parents actively encourage example, is stronger than his or her language expres-
using words and discourage nonverbal communica- sion. For example, when asked by her parents to go
tions. Nevertheless, despite plenty of verbal examples upstairs, find her socks, and put them on, Jackie was
and proper language stimulation, some children do not quite capable of complying. When asked by her mother
develop in some areas of speech and language, and they to describe what she has just done, however, she might
later have problems in school. This developmental con- respond simply, “find socks.”
nection makes the study of communication disorders The linguistic abilities of children with language
highly pertinent to understanding and treating subse- disorders vary significantly based on the severity of the
quent learning problems. disorder and the age of the child. Most often, these chil-
Table 7.1 shows the major features of the DSM-5 dren begin speaking late and progress slowly in their
diagnostic criteria for language disorder. Children with speech development. Their vocabulary often is limited
a language disorder, such as Jackie, do not suffer from and is marked by short sentences and simple grammat-
intellectual disability or from autism spectrum dis- ical structure, as in Jackie’s response. To fit the diag-
order, which affect speech and language. Rather, they nostic criteria, these problems must be substantially
show persistent difficulties in acquiring and using lan- below the abilities of other children of the same age,
guage to communicate (Criterion A). A child’s ability resulting in functional limitations in communication,
to use language depends on both receptive skills (i.e., social participation, or academic achievement (Crite-
receiving and comprehending language) and expres- rion B). In addition, the symptoms must begin in the
sive skills (i.e., production of vocal, gestural, or verbal early developmental period (Criterion C) and not be
signals). Thus, children with this disorder often show attributable to other sensory impairments or medical
reduced vocabulary, limited sentence structure, or conditions (Criterion D).
impairments in their ability to carry on a conversa- Although their hearing is normal, children with lan-
tion. A child’s expressive and receptive abilities may guage disorder may have difficulty understanding par-
differ such that his or her language comprehension, for ticular types of words or statements, such as complex
if–then sentences. In severe cases, the child’s ability to
understand basic vocabulary or simple sentences may
TA B L E 7 . 1
| Disorder
Diagnostic Criteria for Language be impaired, and there may be deficits in auditory pro-
cessing of sounds and symbols and in their storage,
(A) Persistent difficulties in the acquisition recall, and sequencing. Understandably, these prob-
DSM-5 lems make the child seem inattentive or noncompliant,
and use of language across modalities
(i.e., spoken, written, sign language, or other) due to and the disorder can be easily misdiagnosed. Imagine
deficits in comprehension or production that include how it would feel to be in Greece visiting an English-
the following: speaking host and her Greek husband. Unless your host
(1) Reduced vocabulary (word knowledge and use). is present, trying to engage in friendly conversation can
(2) Limited sentence structure (ability to put words be frustrating and uncomfortable. Even if both you
and word endings together to form sentences and the husband can each understand a few words the
based on the rules of grammar and morphology). other is saying, you probably cannot actually converse.
(3) Impairments in discourse (ability to use vocabulary If you have ever faced a similar communication barrier,
and connect sentences to explain or describe a you probably have an appreciation of the frustration
topic or series of events or have a conversation).
and discomfort that accompany a language disorder.
(B) Language abilities are substantially and quantifiably
When the developmental language problem involves
below those expected for age, resulting in functional
limitations in effective communication, social
articulation or sound production rather than word
participation, academic achievement, or occupational knowledge, a speech sound disorder may be an appro-
performance, individually or in any combination. priate diagnosis. Children with this disorder have trouble
(C) Onset of symptoms is in the early developmental controlling their rate of speech, or lag behind playmates
period. in learning to articulate certain sounds. Typically, chil-
(D) The difficulties are not attributable to hearing or dren learn phonemes and use intelligible speech by the
other sensory impairment, motor dysfunction, or age of 3 years or so, except for some of the more difficult
another medical or neurological condition and are not sounds such as l, r, s, z, th, and ch, which may take a few
better explained by intellectual disability (intellectual years longer to articulate (APA, 2013). Depending on
developmental disorder) or global developmental the severity of the disorder, the speech quality of these
delay. children may be unusual, and even unintelligible. For
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. American
example, at age 6, James still said “wabbit” instead of
Psychiatric Association. “rabbit” and “we-wind” for “rewind.” Preschoolers, of

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course, often mispronounce words or confuse the sounds with special needs will improve from associating with
they hear, which is a normal part of learning to speak. normally developing peers and that by doing so these
When these problems persist beyond the normal devel- children will be spared the effects of labeling and spe-
opmental range (age 4) or interfere with academic and cial placements.
social activities by age 7, they deserve separate attention.
Causes
Prevalence and Course Notable findings that support the role of genetics, brain
Children usually reveal problems in speech articulation function, and environmental risk factors associated
and expression as they attempt to tackle new sounds with a higher incidence of language and speech sound
and express their own concepts. Even though prevalence disorders are discussed in the following sections.
estimates account for normal variations in language
development and are based on individuals who meet spe- Genetics
cific diagnostic criteria, the degree of severity can vary Language processes appear to be heritable to a signifi-
considerably. For example, in early childhood, milder cant degree, although the specific genetic underpinnings
forms of speech sound disorder are relatively common, are difficult to pinpoint. About 50% to 75% of all chil-
affecting close to 10% of preschoolers. Many of these dren with a language disorder show a positive family his-
children outgrow their earlier difficulties, so only 2% to tory of some type of learning disability (Hayiou-Thomas
3% of preschoolers meet the criteria for speech sound et al., 2016; Lewandowski & Lovett, 2014). Twin studies
disorder. However, language disorder is a bit more and adoption studies also suggest a genetic connection
common, affecting about 7% of younger school-age (Dale et al., 2015; McGrath et al., 2007; Whitehouse
children across studies (Beitchman & Brownlie, 2014). et al., 2011).
Communication disorders are identified almost twice Scientists are zeroing in on specific deficits in brain
as often in boys as in girls (Pinborough-Zimmerman functioning that lead to communication disorders and
et al., 2007); boys’ language difficulties are more often may be heritable. Studies comparing language-impaired
accompanied by behavior problems, and consequently, children with and without an affected parent suggest
they are referred and diagnosed with communication that temporal processing deficits occur significantly
learning disorders more often than girls (Vellutino more often in children with a positive family history for a
et al., 2004). By 4 years of age a child’s individual dif- language-based learning disability (Bellis & Bellis, 2015;
ferences in language stabilize, so problems that remain Caylak, 2011). That is, affected children have more dif-
past this age are highly predictive of later outcomes. ficulty deciphering certain speech sounds because of
About 50% fully outgrow their problems, whereas the subtle but important differences in the way neurons fire
other 50% may show improvement but still have some in response to various sounds. In a twin study, Bishop
degree of impairment into adulthood. Children with and colleagues (1999) found that the variation in tem-
receptive language impairments, in particular, have a poral processing was due to environmental factors and
poor prognosis as compared with those with primarily not to genetics because twin–twin correlations were sim-
expressive impairments. Receptive language problems ilar for monozygotic (MZ) and dizygotic (DZ) twins.
are more resistant to treatment and are often associ- However, what does appear to be genetic is a deficit in
ated with reading difficulties throughout their educa- phonological short-term memory (Bishop, 2015).
tion (APA, 2013).
Even though language problems usually diminish The Brain
with time, children with communication disorders Language functions develop rapidly and are housed
often have higher-than-normal rates of negative behav- primarily in the left temporal lobe of the brain (see
iors that began at an early age (Charman et al., 2015). ● Figure 7.1). A circular feedback loop helps strengthen
Associated behavior problems, such as attention-deficit/ the developmental process of language reception and
hyperactivity disorder (ADHD) and social skill limita- expression. The better children comprehend spoken
tions, can add to communication problems and further language, the better they will be able to express them-
alter the course of development in terms of how these selves. Feedback from their own vocalizations, in turn,
children relate to peers or keep up with educational helps shape their subsequent expressions. Lack of com-
demands (Durkin & Conti-Ramsden, 2010). To give prehension and absence of feedback reduces verbal
children with special needs the opportunity to interact output, and thus interferes with the development of
with typically developing children, school systems have articulation skills (Vellutino et al., 2007).
begun to include these children in regular, rather than Anatomical and neuroimaging studies show that
segregated, classrooms. Inclusion education strategies deficits in phonological awareness and segmentation
are based on the premise that the abilities of children are related to problems in the functional connections

202 P A R T 2 Neurodevelopmental Disorders

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 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 G U 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.

between brain areas, not to a specific dysfunction of any improve relatively quickly and largely disappear by
single area of the brain (Lyon et al., 2006; Schurz et al., age 7 (Zumach et al., 2010).
2015). Some brain imaging studies have indicated that In summary, although biological findings point to
poor performance on tasks demanding phonological abnormal brain functioning, how this abnormality
awareness is associated with less brain activity in the left originates is still unclear. The best guess is that language
temporal region, suggesting that phonological problems and speech sound disorders result from an interaction
may stem from neurological deficits or deviations in of genetic influences, slowness or abnormalities of brain
posterior left-hemisphere systems that control the ability maturation, and possibly, minor brain lesions that escape
to process phonemes (Schurz et al., 2015; S. E. Shaywitz clinical detection (Finn et al., 2014; Hulme et al., 2015).
et al., 2009). We return to these findings on brain func-
tion later, in our discussion of reading disorders. Home Environment
Recurrent otitis media (middle ear infection) in How much does the home environment contribute
early childhood was long thought to contribute to to communication disorders? Do some parents fail to
language difficulties, because hearing loss accompa- provide adequate examples to stimulate their children’s
nies frequent or long bouts of infections. Although language? Because of the important role parents play in
otitis media that occurs often during early childhood children’s development, psychologists have studied this
may lead to speech and language delays, these delays issue carefully.

C H A P T E R 7 Communication and Learning Disorders 203

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 We noticed when we first visited Jackie at home that time-out. Jackie became attached to computer graphics
her stepfather was a very quiet man who often commu- and images, and she soon was able to identify letters
nicated nonverbally—a gesture, a frown, a short phrase. and small words and to move shapes around the screen.
Her mother used very simple speech when talking All the while, her expressive language improved, and by
to Jackie but not when talking to Jackie’s 6-year-old age 5 she could pronounce all the letters of the alphabet
sister. These observations match those of researchers and was eager to start kindergarten.
(St. James-Roberts & Alston, 2006; Whitehurst &
Lonigan, 1998) who compared verbal interactions of
families with and without a child who had a language
Childhood-Onset Fluency Disorder
disorder. They found that parents changed the way (Stuttering)
they spoke to their children, depending on their chil- Childhood-Onset Fluency Disorder (Stuttering) is the
dren’s abilities. When the child spoke in simple, two- or repeated and prolonged pronunciation of certain syl-
three-word sentences, the parents adjusted their speech lables that interferes with communication. It is quite
accordingly. Note that, except in extreme cases of child normal for children who are still learning to speak to
neglect or abuse, it is unlikely that communication go through a period of nonfluency, or unclear speech, as
disorders are caused by parents. Parental speech and part of their development. It takes practice and patience
language stimulation may affect the pace and range for a child to develop the coordination for the tongue,
of language development, but not the specific impair- lips, and brain to work in unison to produce unfamiliar
ments that characterize the disorders (Dale et al., 2015; or difficult combinations of sounds. For most chil-
McGrath et al., 2007). dren, this period of speech development passes without
notice, and for most parents it is full of wonder and
Treatment amusement as their children wrestle with new words.
Although communication disorders in some children Some children, however, progress slowly through this
may self-correct by age 6 or so, those with more severe stage, repeating (wa-wa-wa) or prolonging (n-ah-ah-
communication and language difficulties will continue ah-o) sounds; they struggle to continue or develop
to lag behind their peers and are at risk of having ways to avoid or compensate for certain sounds or
behavioral or social problems if the difficulties are left words. Four-year-old Sayad has speech problems that
untreated. Thus, parents should seek help in under- typify the pattern of stuttering.
standing their child’s speech delays and to ensure that
they are doing everything possible to stimulate lan-
guage development. In general, treatment for children
SAYAD
with communication disorders is based on three prin-
ciples (Beitchman & Brownlie, 2014): (1) treatment to Family Legacy
promote the child’s language competencies; (2) treat-
ment to adjust the environment in ways that accom-
Sayad’s parents had received a lot of informal advice from
modate the child’s needs; and (3) therapy with the child
friends and relatives about their son’s speech problems,
(or youth) to equip him or her with knowledge and but most of what they said was worrisome. “He’ll struggle
skills to reduce behavioral and emotional symptoms. with this for most of his life,” his grandmother had
Specialized preschools, for example, have had good warned. “If something isn’t done right away, he’ll become
results using a combination of computer- and teacher- a stutterer, and be so self-conscious that he won’t be able
assisted instruction to teach early language skills to to keep up in school or with his friends.”
young children, which helps pace the child’s practice Sayad started repeating and prolonging some of his
of new skills (Berninger et al., 2015; Smith-Lock et al., words when he was about 2, but now his problem had
2013). grown more noticeable. As he spoke, he pursed his lips,
For Jackie, we designed ways that her parents closed his eyes, and shortened his breathing, seeming to
and preschool teachers could build on her existing tense up his face. Yet his interactions with me were friendly
and at ease. “M-m-m-m-y words get stuck in m-m-m-m-y
strengths. Her preschool teacher had an excellent idea:
m-m-mouth,” he explained, “and I-I-I-I talk t-t-t-t-too
Because Jackie loved to draw and to talk about her art-
fast. Wh-wh-wh-why can’t I talk right?” I soon discovered
work, why not use her interest in drawing to increase why his grandmother was so concerned: The child’s great-
her enthusiasm for speaking? When I visited her class, grandfather and great-uncle both stuttered, and Sayad’s
Jackie ran up to show me her drawing, exclaiming, “I father had been a stutterer until he was a teenager.
draw picture of mom, dad, kitty, and lake.” We agreed Sayad’s mother had been trying to ignore the problem
that her behavior problems could be managed by simple and not draw attention to it, but she was growing more
forms of ignoring and distracting and the occasional

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 or participating in activities that require effective com-
aware that Sayad’s peers teased and imitated him. She munication or social participation. Over time the child
explained why she came for an assessment: “We were may develop a fearful anticipation of speaking in front
on the way to the store when Sayad kept saying ‘where’ of others and attempt to avoid speech situations such
over and over. After I stopped the car and unfastened his
as talking by telephone or in class. The disorder may be
seatbelt, he finished his question—‘is daddy?’ After that,
accompanied by motor movements such as eye blinks,
I gave up on my ‘leave it alone’ notion and began trying
ways to slow Sayad down a bit.” (Based on authors’ case
tics, tremors of the lips or face, etc. (APA, 2013).
material.)
Prevalence and Course
Stuttering is relatively common as young children learn
to articulate sounds clearly and appropriately. Popula-
DSM-5 diagnostic criteria for Childhood-Onset
tion-based surveys indicate that 11% of children stutter
Fluency Disorder (Stuttering) are shown in Table 7.2.
by age 4, with girls affected as much as boys (Reilly
This disorder involves disturbance in the normal flu-
et al., 2013; Yairi & Ambrose, 2013). However, few
ency and time patterning of speech that is atypical
children receive a diagnosis of childhood-onset fluency
for the child’s age and that occurs often and persists
disorder because about 80% recover from stuttering as
over time. Stuttering is characterized by sound and syl-
lable repetitions, sound prolongations, pauses within they attend school for a year or so (Packman, Code, &
a word, word substitutions to avoid problematic Onslow, 2007). The prevalence of stuttering across the
words, and similar pronunciation and speech difficul- lifespan (i.e., the number of individuals of all ages who
ties. These difficulties lead to anxiety about speaking meet the diagnostic criteria at any point in time) is below
1% (Yairi & Ambrose, 2013). Higher rates of parent-
reported stuttering have been noted among African
American and Hispanic children in the United States,
TA B L E 7 . 2
| Onset
Diagnostic Criteria for Childhood-
Fluency Disorder (Stuttering) although how racial and cultural factors may affect stut-
tering remains unclear (Yari & Ambrose, 2013).
(A) Disturbances in the normal fluency and DSM-5
time of patterning of speech that are Causes and Treatment
inappropriate for the individual’s age and language Many myths and falsehoods surround stuttering. The
skills, persist over time, and are characterized by widely-held view that stuttering is caused by an unre-
frequent and marked occurrences of one (or more)
solved emotional problem or by anxiety is not sup-
or the following:
ported by any evidence (Packman et al., 2007; Smith &
(1) Sound and syllable repetitions.
Weber, 2016). Because the problem runs in families,
(2) Sound prolongations of consonants as well as words.
researchers have focused on family characteristics as the
(3) Broken words (e.g., pauses within a word). major causes. However, it is not likely this behavior is
(4) Audible or silent blocking (filled or unfilled pauses acquired primarily as a function of the child’s linguistic
in speech).
environment. Sayad’s grandmother and mother would
(5) Circumlocutions (word substitutions to avoid
be relieved to know that the communicative behavior of
problematic words).
mothers does not significantly contribute to the devel-
(6) Words produced with an excess of physical tension.
opment of stuttering (Howell & Davis, 2011).
(7) Monosyllabic whole-word repetitions (e.g., “I-I-I-I”
Genetic factors play a strong role in the etiology of
see him).
stuttering, accounting for approximately 70% of the
(B) The disturbance causes anxiety about speaking
or limitations in effective communication, social
variance in the causes of stuttering (Dworzynski et al.,
participation, or academic or occupational 2007). Environmental factors, such as premature birth
performance, individually or in any combination. or parental mental illness, account for the remaining
(C) The onset of symptoms is in the early developmental causal influences (Ajdacic-Gross et al., 2010). Genetic
period (Note: Later-onset cases are diagnosed as adult- factors most likely influence speech by causing an
onset fluency disorder). abnormal development in the location of the most
(D) The disturbance is not attributable to a speech- prominent speech centers in the brain, which are usually
motor or sensory deficit, dysfluency associated with in the left hemisphere. This biological source for stut-
neurological insult (e.g., stroke, tumor, trauma), or tering explains many of its clinical features, including
another medical concern and is not better explained the loss of spontaneity and occasional problems in self-
by another mental disorder. esteem (De Nil & Beal, 2015; Howell, 2011).
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American
Since most children outgrow stuttering, one of the
Psychiatric Association. most frustrating problems for parents and therapists

C H A P T E R 7 Communication and Learning Disorders 205

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is to decide whether therapy would be intervention or
interference. Therapy is usually recommended if sound
TA B L E 7 . 3
| (Pragmatic)
Diagnostic Criteria for Social
Communication Disorder
and syllable repetitions are frequent, if the parent or
child is concerned about the problem, or if the child (A) Persistent difficulties in the social use of DSM-5
shows, like Sayad, facial or vocal tension. A common verbal and nonverbal communication as
psychological treatment for children who stutter is to manifested by all of the following:
teach parents how to speak to their children slowly and (1) Deficits in using communication for social purposes,
use short and simple sentences, consequently removing such as greeting and sharing information, in a
manner that is appropriate for the social context.
the pressure the child may feel about speaking (Arnott
(2) Impairment of the ability to change
et al., 2014; Baxter et al., 2016). Other beneficial treat-
communication to match context or the needs
ments for stuttering include contingency management, of the listener, such as speaking differently in a
which uses positive consequences for fluency and nega- classroom than on a playground, talking differently
tive consequences for stuttering, and habit reversal pro- to a child than to an adult, and avoiding use of
cedures such as learning to regulate breathing (Bate overly formal language.
et al., 2011). (3) Difficulties following rules for language and
storytelling, such as taking turns in conversation,
rephrasing when misunderstood, and knowing
Social (Pragmatic) Communication how to use verbal and nonverbal signals to
regulate interaction.
Disorder (4) Difficulties understanding what is not explicitly
Social (Pragmatic) Communication Disorder (SCD) stated (e.g., making inferences) and nonliteral or
is a new disorder in DSM-5. It involves persistent dif- ambiguous meanings of language (e.g., idioms,
humor, metaphors, multiple meanings that depend
ficulties with pragmatics—the social use of language
on the context for interpretation).
and communication (APA, 2013). Pragmatics are cul-
(B) The deficits result in functional limitations in
turally specific practices and skills related to social effective communication, social participation, social
uses of language, conversational norms, and the use relationships, academic achievement, or occupational
of nonverbal communication, such as eye contact and performance, individually or in combination.
gestures (Beitchman & Brownlie, 2014). Pragmatic dif- (C) The onset of the symptoms is early in the
ficulties involve both expressive and receptive skills— developmental period (but deficits may not become
being able to adapt one’s communication to the social fully manifest until social communication demands
context and being able to understand the nuances and exceed limited capacities).
social meanings expressed by others. (D) The symptoms are not attributable to another medical
The first requirement for a diagnosis of social (prag- or neurological condition or to low abilities in the
matic) communication disorder involves persistent dif- domains of word structure and grammar, and are
ficulties across four areas (Table 7.3): not better explained by autism spectrum disorder,
intellectual disability (intellectual developmental
1. Deficits in using communication for social pur- disorder), global developmental delay, or another
poses. A child may show difficulty greeting others mental disorder.
or sharing information appropriately.
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American
2. Difficulties changing their communication to match Psychiatric Association.
the situation or the listener, such as the classroom
versus the playground.
3. Problems following the rules of language, such as
taking turns in a conversation. disorders, onset must be early in development and result
in functional limitations in communication, social par-
4. Difficulties understanding what someone is not
ticipation, social relationships, or academic functioning.
explicitly saying, such as being able to make infer-
Social (pragmatic) communication disorder was
ences based on the context of the situation.
added to the DSM because of the number of children
A diagnosis of SCD is not typically made until the child who did not meet conventional criteria for an autism
is 4 or 5 years old, to determine whether he or she has spectrum disorder (ASD) yet who had persistent dif-
shown adequate developmental progress in speech and ficulties with social aspects of communication and peer
language. Signs of language impairment, such as a history relations. SCD is differentiated from ASD largely on the
of delay in reaching language milestones, are common, basis of fewer restricted/repetitive patterns of behaviors
but it is the specific deficits in social communication that and interests (Gibson et al., 2013). The symptoms of
determine this disorder. As with other communication SCD also overlap with ADHD, social anxiety disorder,

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and intellectual disability in that they share problems exertion and concentration. Like physical activities,
in social, pragmatic communication. Although this some learning activities are more difficult than others,
diagnostic category is new, studies based on similar especially for younger children who have not devel-
samples of children suggest that some children show oped a foundation of good study habits and successful
improvement over time while others continue to show learning experiences. Parents and teachers may notice
social communication deficits into adulthood. Regard- that a child is struggling unusually hard to master a
less of improvements in social communication, children particular skill, such as reading, and wonder why. The
with SCD may suffer lasting impairments in peer rela- problem may be formally assessed by an IQ test and
tions due to their early difficulties. Thus, peer-assisted various standardized tests that assess abilities in specific
interventions are recognized as effective ways to build academic areas.
pragmatic communication and social skills for these When achievement in reading, math, or writing
children (Murphy, Faulkner, & Farley, 2014). is well below average for the child’s age and intellec-
tual ability, he or she may be diagnosed with a specific
learning disorder (SLD). In other words, a child with
Section Summary a specific learning disorder is intellectually capable of
learning key academic concepts of reading, writing, and
Communication Disorders math, but seems unable to do so. The phrase “unex-
●● Speech and language problems that emerge during early pected academic underachievement” captures this
childhood include difficulty producing speech sounds, notion that the child’s learning problems are indeed
demonstrating speech fluency, using spoken language to specific and not due to intellectual disability or global
communicate, or understanding what other people say. developmental delay (APA, 2013).
●● Even though most children with communication disorders
acquire normal language by mid-to-late adolescence, early
communication disorders are developmentally connected
to the later onset of learning disorders.
JAMES
●● Language disorder is a communication disorder involving Strong Points Shine
difficulties in comprehension or production of spoken or
written language; in contrast, a speech sound disorder in-
The look on the 9-year-old’s face said it all—he did not
volves problems articulating or producing speech.
want to be here. “I’m tired of talking to people” was his
●● Childhood-Onset Fluency Disorder (Stuttering) is relatively terse greeting. I wondered for a moment whether he would
common among younger children, and declines signifi- talk to me at all, but as soon as he saw my computer,
cantly once the child enters school. he brightened a bit. To allow time for him to feel more
●● Social (Pragmatic) Communication Disorder is new to DSM-5. comfortable, I invited James to play a quick game or two.
Its primary characteristics involve difficulties in the social His skill at the action games told me a lot about his basic
use of verbal and nonverbal communication. energy and problem-solving ability—he was a whiz at
●● Causes of communication disorders include genetic influ- figuring out the rules of each game and getting a high
ences and slow or abnormal brain maturation. score. We spoke casually during the warm-up, but it was
clear to me that he preferred to concentrate on the game.
●● Many communication disorders resolve themselves after
A half hour passed, with little more than a few
children begin attending school. However, early interven- sentences exchanged. A quick trip to the snack bar
tion is recommended for children who show significant gave us the common ground we needed to open up
language/speech delays or difficulties; intervention in- and talk a bit. “Why does my teacher want me to come
volves accommodating the child’s needs to strengthen here?” he reasonably asked. As he listened and replied
speech and language skills. to my explanation, his language problems stood out.
His sentences were short, simple, and rapid. Here is an
example:
SPECIFIC LEARNING DISORDER “James, tell me something about your favorite story
or a recent movie you’ve seen.”
People do not understand what it costs in time and suffering “I like the movie. Lots of dogs.”
to learn how to read. I have been working at it for eighty “What movie is that, James?”
“Dog movie.”
years, and I still can’t say that I’ve succeeded.
—Goethe (1749–1832) During testing, James often tried to start before I
had finished telling him what to do. He was eager
Whether we are studying Roman history or calculus,
applying ourselves to the task of learning requires (continues)

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 (continued) you have any brothers or sisters? Does your family like
to do what I asked, but he stopped abruptly as soon to do anything special together?” His tired response, “I
as he had trouble. James could focus on only one have two brothers, my father works all day, mom plays
sound at a time, so if he missed early cues or initial piano. We want a boat,” sent me a clear message as
instructions, he would become disoriented, frustrated, to his mood and interest in this activity. My usual ploy
and uncooperative. James wanted to do well, but I of turning on the computer games fell flat—“I hate
could see he was struggling. He completed the WISC-IV computers” was Tim’s preemptive response. I wondered,
(Wechsler Intelligence Scale for Children, 4th ed.) in “Is he depressed, angry, hurt, frustrated? Just what is
less than an hour, hurrying almost as if to escape his going on here?”
own mistakes. His measured general intelligence was Having looked at his school record, I knew he was
within the normal range, but his performance abilities struggling, especially in math and physical sciences,
(performance IQ, 109) were much stronger than his but his speech and affect expressed more than only
verbal abilities (verbal IQ, 78). It was obvious as well academic problems. His school records flashed the news
that the test underestimated his true ability, as a that Tim had a specific learning disorder, as evidenced
result of his eagerness to finish and his difficulty with by his WISC-IV performance score of 79 that fell in
understanding some of the instructions. the borderline-to-low-average range, and his verbal
To my surprise, James was ready to continue on to score of 108 that fell in the average range. The test
the next test after only a short computer game break. He administrator had politely described Tim’s test-taking
explained why this was so: “I put things together, like approach as “reluctant.” Notes by teachers indicated
puzzles. I make cars and planes at my house.” As long as that he commonly had problems on tasks involving
I gave him small breaks on the computer, he was willing drawing, particularly if they required memory, and his
to tackle the material on the tests. Some of his spelling math and social skills were far below those of others in
errors stood out immediately, such as skr for square, and his class.
srke for circle. When asked to write the sentence “he I pulled out my Where’s Waldo? book and we began
shouted a warning,” he wrote “he shtd a woin.” He read looking at it together. In addition to being fun, looking
“see the black dog” as “see the black pond,” and “she for Waldo and his friends (small figures amidst millions
wants a ride to the store” as “she was rid of the store.” He of figures and colors) required Tim to be patient. At
seemed to use a “best guess” strategy in tackling reading, first he balked, but I noticed that he improved if he
based on the sounds that he knew: When asked to write used his own verbally mediated strategy to solve the
the word bigger, he wrote just her. But I noticed that problem. Tim talked to himself as he thought aloud:
James’s enthusiasm picked up a bit as he began telling “Look around the edges first, then start to look closer
stories from pictures he was shown, and he marveled and closer to the middle of the page. Look for Waldo’s
at his own ability to rotate shapes on the computer to red and white shirt—look closely at each section!” The
complete a picture. He left my office more animated and more interested he was, the more he would talk. Once
talkative than when he arrived, which showed how nice he warmed up, his smile appeared, along with his
it must have felt for him to experience success. (Based on admission that “this sure beats math lesson.” (Based on
authors’ case material.) authors’ case material.)

James, at age 9, had problems primarily in reading James’s pattern of strengths and weaknesses shows
and spelling. Contrast his reading difficulties with those that although he has reading problems, other strengths
of Tim, who struggles with spatial orientation and compensate for this disability. He has strong talents for
mathematical reasoning. figuring out how things work and for drawing ideas
on paper. Tim has several strengths, too, especially
in linguistic skills such as word recognition, sentence
TIM structure, and reading. In contrast to James, Tim has
problems primarily in the visual, spatial, and organiza-
Warming with Interest tional spheres, which show up as difficulties with tactile
(touch) perception, psychomotor activity (e.g., throwing
When I first saw Tim, he seemed aloof and disinterested. and catching), and nonverbal problem solving (e.g., fig-
His eyes stayed focused on the floor, and his body uring out math problems and assembling things).
remained expressionless, as if to say, “Leave me alone, Both boys fit the diagnostic criteria for SLD. Note
and let me outta here.” As I searched for something to how Tim’s academic problems, in particular, were
say, I asked Tim to tell me a little about his family: “Do almost masked by his frustration and low self-esteem.
Emotional problems are often seen in children who are

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 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 direc-
tions: “Go out the driveway and turn right. Go till you
reach the second light, turn left, and look for the sign to

Zigy Kaluzny/The Image Bank/Getty Images

Amityville. It’s about three 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 experience confusion
in these common situations that involve understanding
For children with specific learning disorders, following the meaning of what is read. Specific learning problems
simple instructions can be confusing and frustrating.
can be difficult to recognize because, for most of us, the
material in question is straightforward and simple. The
bright enough to recognize that their performance is child may be blamed for not listening, not paying atten-
below that of others and are frustrated with their poor tion, or for being “slow,” which further disguises the true
performance at school. The limitations of both James nature of the learning problems.
and Tim can affect every aspect of their formal educa- The main diagnostic feature of SLD is that the
tion as well as their interpersonal abilities; therefore, child has difficulties learning keystone academic skills
these disorders require comprehensive and ongoing of reading, writing, spelling, or math (see Table 7.4).
treatment plans. These difficulties may appear in one or more of these

T A B L E 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 DSM-5
symptoms that have persisted for at least 6 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,
relationships, 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
individually 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 individual’s 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
mental 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)

C H A P T E R 7 Communication and Learning Disorders 209

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T A B L E 7 . 4 | Diagnostic 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
accurately 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 Finally, the learning difficulties appear during the
understanding the meaning of what is read, difficulties school-age years, and cannot be better accounted for by
with spelling and/or written expression, or difficulties a sensory problem (such as impaired hearing or sight),
mastering number sense, calculation, or mathematical intellectual disability, psychosocial adversity, or inad-
reasoning. The affected academic skills would need to equate educational instruction.
be substantially below what it should be for the child’s Because many aspects of speaking, listening,
age and intellectual ability. In practice, this often means reading, writing, and arithmetic overlap and build on
that the child’s achievement test scores in academic sub- the same functions of the brain, it is not surprising
jects are at least 1.5 standard deviations below average that a child or adult can have more than one form of
for their age and sex (which translates to a standard SLD (Scanlon, 2013). Recall that phonological aware-
score of 78, or below the seventh percentile). ness facilitates the ability to speak and, later on, to
To be classified as a disorder, the performance prob- read and write. A single gap in the brain’s functioning
lems must significantly interfere with academic achieve- can disrupt many types of cognitive activity. These dis-
ment or daily living, and to persist for more than ruptions, in turn, can interfere with the development
6 months despite efforts to improve them. (Some chil- of important fundamental skills and compound the
dren and adults have found ways to compensate for their learning difficulties in a short time. Moreover, as we
learning problems and therefore do not display a dis- saw with both James and Tim, numerous secondary
ability, despite their test findings or poor achievement.) problems can emerge, such as temper outbursts and

210 P A R T 2 Neurodevelopmental Disorders

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withdrawal from social situations, as a result of frus- ▶▶ Build ideas and images?
tration 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
as efficiently as possible. Below we take a closer look of a reading disorder, however, is an inability to dis-
at the three core academic skill impairments specified tinguish or to separate the sounds in spoken words.
in SLD. Phonological 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
added to it the more refined art of skipping and skimming. when one reads words, which are essential in the
development of reading. The first system operates on
—Arthur James Balfour individual 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 anal-
written signs and messages and, by about age 5 or so, ysis. However, persistently poor readers seem to rely on
most children want to know what they mean. (Capital- rote memory for recognizing words (S. E. Shaywitz &
izing on this natural curiosity, advertisers have become Shaywitz, 2013).
expert in pairing recognizable symbols with the names Many clinical signs of reading disorders are first
of their product or establishment so that children evident only to a trained eye. Some testing methods
can “read” more quickly.) By the first grade, natural developed by teachers and school psychologists show
interest and developmental readiness are channeled how children with reading disorders function in the
into formally learning how to read. For many chil- classroom. They often have trouble learning basic
dren, this process is difficult and tedious; for a sizable sight words, especially those that are phonetically
minority, however, it can be confusing and upsetting. irregular and must be memorized, such as the, who,
The role of parents in this process is critical, because what, where, was, laugh, said, and so forth. These chil-
children need positive feedback and need to feel satis- dren have developed their own unique and peculiar
fied with their performance, regardless of their speed reading patterns, which signal the need for different
and accuracy. teaching methods. Typical errors include reversals (b/d;
When you consider everything involved in learning p/q), transpositions (sequential errors such as was/
the basics of reading, such as associating shapes of saw, scared/sacred), inversions (m/w; u/n), and omis-
letters (graphemes) with sounds (phonemes), it is not sions (reading place for palace or section for selection).
surprising that some children have difficulty and can However, these errors are common in many younger
quickly fall behind. Read the following sentence: “I children who are just learning to read and write and do
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

C H A P T E R 7 Communication and Learning Disorders 211

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touch or manipulation to assist them in learning. These
various patterns of strengths and weaknesses, if ade- him on paper. In doing so, he switched to his preferred
quately assessed, can then be used to the child’s advan- hand in the middle of the task. He also showed several
tage in planning additional teaching methods such as letter reversals (b/d; p/q), and pushed down very hard
on the pencil in an attempt to trace or draw the figures.
computer-based learning (S. E. Shaywitz et al., 2008).
Throughout these tasks, he talked freely and asked a
A child with an SLD with impairment in reading
lot of questions, making me wonder at times who was
lacks the critical language skills required for basic assessing whom.
reading: word reading accuracy, reading comprehen- Carlos showed evidence on neuropsychological
sion, and reading rate or fluency. Dyslexia is an alter- testing of finger agnosia (he could not tell which finger I
native term sometimes used to describe this pattern of touched when his hand was behind his back), especially
reading difficulties. These core deficits stem from prob- with his left hand. He also had considerable difficulty
lems in decoding—breaking a word into parts rapidly copying a triangle, a circle, and a square based on
enough to read the whole word—coupled with dif- examples shown to him (see ● Figure 7.2). On the
ficulty reading single small words (Cho et al., 2017). WISC-IV he obtained a performance score of 91, in the
When a child cannot detect the phonological structure low-average range, and a verbal IQ score of 117, in the
high-average range. On performance subtests he had
of language and automatically recognize simple words,
particular problems with block design and puzzles, such
reading development will very likely be impaired
as object assembly. He had more difficulty with verbal IQ
(Peterson & Pennington, 2010). The slow and labored subtests that involved concentration and attention, such
decoding of single words requires substantial effort and as math and digit-span tasks. Throughout the testing,
detracts from the child’s ability to retain the meaning of I found Carlos to be impulsive and sometimes quite
a sentence, much less a paragraph or page. defiant: If he didn’t want to do something, he simply
would not do it. These observations were consistent with
his parents’ frustration at his immature behavior and
SLD with Impairment in Written Expression defiance at home.

CARLOS
Slowly Taking Shape

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

his teacher and parents met to discuss his handwriting
problems. 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 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 makes a half-hearted attempt on his writing
assignments and then starts talking to his classmates. ●● F I G U R E 7 . 2 | Top: Drawings produced by Carlos
I’d like him to be seen by a psychologist for testing, when asked to copy a triangle, a circle, and a square.
and hopefully next fall his new teacher can strengthen Bottom: Examples of a triangle, circle, and square from a
his writing and fine motor skills with some additional typically developing 7-year-old boy.
exercises.” (Based on authors’ case material.)
During the initial interview, Carlos took an
immediate interest in my computer games, exclaiming
how easy it was to use the mouse to draw figures.
When asked to use a pencil and paper, however, Carlos Carlos has a specific learning disorder related to
balked. I asked him to copy by hand some of the figures written expression. He has strong language and rea-
he drew on the computer, after first printing them for soning abilities, as well as normal problem-solving
skills for his age, yet he is considerably weaker in his

212 P A R T 2 Neurodevelopmental Disorders

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visual–motor abilities, as shown by his writing, figure
copying, and figure rotation. Like reading and math, $ 62.04 75
writing derives from several interconnected brain
5.30 8
areas that produce vocabulary, grammar, hand move-
ment, and memory.
SLD with impairment in written expression may
●● F I G U 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-
From “Learning Disabilities” by H.G. Taylor, 1988, p. 422. In E.J. Mash and L.G. Terdal
tion of written expression. This particular SLD is often (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 lan-
guage 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–hand of math difficulties. Many skills are involved in arith-
coordination, despite their normal gross motor devel- metic: recognizing numbers and symbols, memorizing
opment. Teachers notice that, as compared with chil- facts (the multiplication table), aligning numbers, and
dren who have normal writing skills, children with understanding abstract concepts such as place value
impairments in writing produce shorter, less inter- and fractions. Any or all may be difficult for children
esting, and poorly organized essays and are less likely to with a mathematics disorder (Andersson, 2010). Chil-
review spelling, punctuation, and grammar to increase dren and adults with this disorder may have difficulty
clarity (Hooper et al., 2011, 2013). However, spelling not only in math, but also in comprehending abstract
errors or poor handwriting that do not significantly concepts or in visual–spatial ability. Examples of cal-
interfere with daily activities or academic pursuits culation errors typical of children with a mathematics
do not qualify a child for this diagnosis. In addition, disorder are shown in ● Figure 7.3, an example that
problems in written expression signal the possibility points out errors that suggest spatial difficulties and
of other learning problems because of shared meta- directional confusion.
cognitive processes: planning, self-monitoring, self- Children with an SLD with impairment in math-
evaluation, and self-modification (Lewandowski & ematics typically have core deficits in arithmetic cal-
Lovett, 2014). 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 natu- and performing calculations mentally; and performing
rally drawn to mathematical concepts as they are to computational operations (Tolar et al., 2016). These
reading. This changes rapidly as they discover that they deficits imply that the neuropsychological processes
need to count and add to know how much money it underlying mathematical reasoning and calculation are
takes to buy something or how many days remain until underdeveloped or impaired.
vacation. As in reading, the need to know propels chil-
dren to learn new and difficult concepts, and little by Prevalence and Course
little their new skills help them understand the world Estimates of the prevalence of SLD across all three
better. domains (reading, writing, and math) range from 5%
For some children, like Francine and Tim, this curi- to 15% among school-aged children (APA, 2013). Rea-
osity about numbers is compromised by their inability sons for this large range focus on the notion that SLD
to grasp the abstract concepts inherent in many forms in reading—the most common form—may be part of
of numerical and cognitive problem solving. Francine’s a continuum of reading abilities rather than a discrete,
difficulty with numbers and concepts began to show up all-or-none phenomenon. Children with reading dis-
well before she attended school, which is typically the orders are essentially those who fall at the lower end
case. When she encountered math concepts in second of the reading continuum (Snowling, 2008). This con-
grade that required some abstract reasoning, she fell sideration of the range of ability is useful and impor-
further and further behind. tant because, clearly, there are strong readers and weak
The DSM-5 criteria for SLD with impairment in readers, and no definitive cutoff point easily distin-
mathematics include difficulties in number sense, mem- guishes the two. Estimates of the prevalence of SLD
orization of arithmetic facts, accurate or fluent calcula- with impairment in mathematics or written expres-
tion, and/or accurate math reasoning. Dyscalculia is an sion are unclear due to the overlap among all three

C H A P T E R 7 Communication and Learning Disorders 213

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subtypes, although consensus is that they occur at a the point that deficits in phonological awareness occur
much lower rate than do reading difficulties (Landerl & more frequently among populations that use nonstan-
Moll, 2010). dard English. They followed a random sample of 485
SLD impairments are considered lifelong, although Caucasian (55%) and African American (45%) chil-
the course varies based on severity and available sup- dren from first grade through third grade, and they
ports. Recognition of SLD typically emerges during ele- found that although African American youngsters read
mentary school years, when a student falls significantly at the same grade level as Caucasian children at the
behind classmates in one or more of these subjects, beginning of the first grade, they show marked declines
though parents often note problems in language delays in reading by the third grade and severe declines by the
or counting in early childhood. Parents and teachers fifth grade. These findings suggest that greater atten-
may notice specific delays in early skill development, or tion to differences in dialect can lead to better learning
notice behavioral signs of the child’s struggles, such as opportunities.
his or her unwillingness to learn to read, write, or work Although attention to cultural and ethnic issues per-
with numbers. In elementary school, the child shows taining to SLD is a recent addition to research, sex dif-
marked difficulty in learning letter–sound correspon- ferences have a long and contentious history. Boys are
dence and may commit reading errors by connecting more often referred for learning difficulties than girls,
sounds and letters (e.g., “big” for “got”) and have dif- perhaps because boys are more likely to show associ-
ficulty sequencing numbers and 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
rest of the word. As they struggle with these difficul- ratios of SLD are derived from epidemiological esti-
ties throughout elementary school, being fearful of mates rather than from referrals, the ratio of boys to
or refusing to read aloud is common. By adolescence girls falls between 2:1 and 3:1 (APA, 2013).
through to adulthood, these patterns often shift from
basic coding difficulties to marked problems in reading Psychological and Social Adjustment
comprehension and written expression, including poor For many years, a diagnosis of learning disability or
spelling and poor mathematical problem solving. Over disorder required a discrepancy between IQ and per-
time, teens and adults learn to manage these difficul- formance, which hampered early identification because
ties to the best of their ability, but may avoid situa- the assessment often was not done until the child had
tions that require reading, writing, or numerical ability. attempted and failed at reading, usually by the third
Thus, over the life span SLD is associated with many grade. By that time, the child’s achievement would
functional consequences, such as lower academic be low enough to warrant a diagnosis, but the child
achievement, higher school dropout rates, poor overall had failed in reading for 2 to 3 years and may have
mental health and well-being, and lower employment developed other behavioral and emotional problems as
and income (APA, 2013; Pierce, 2016). 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 (Ortiz, 2011). selves described as “slow,” “different,” or “behind,”
Many childhood disorders reflect an interaction they may identify more with their disabilities rather
between 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

214 P A R T 2 Neurodevelopmental Disorders

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do normal readers, and they are more likely to express disorder (CD), oppositional defiant disorder (ODD),
poor academic or scholastic self-concepts (Heim & and attention-deficit/hyperactivity disorder (ADHD)
Benasich, 2006). Perhaps because of the interaction of across all ages (APA, 2013).
their disorder and their environment, children and ado- These co-occurring problems are often interpreted
lescents with SLD are more likely than their peers to as individual reactions and coping styles in response to
show internalizing problems such as anxiety and mood failure, frustration, and, in some instances, punishment
disorders (Mammarella et al., 2016; Maughan et al., and negative attention. However, in terms of develop-
2003; Nelson & Harwood, 2011), as well as external- ment, it is hard to say which comes first: Behavior prob-
izing behaviors such as ADHD (Gray & Climie, 2016). lems may precede, follow, or co-occur with learning
The range and types of problems are generally similar problems (Hinshaw, 1992). However, many of these
for both younger and older age groups. Accordingly, behavioral and emotional problems gradually decrease
issues pertaining to both younger and older children from childhood to adolescence, adolescents with SLD
and adolescents with SLD are considered jointly unless continue to face challenges in their social relationships
particular developmental differences warrant attention. (St Clair et al., 2011).
Many of these issues are common to all domains of Based on a review of over 150 studies, Kavale and
SLD unless otherwise noted. Forness (1996) found that about three of every four stu-
The connection between SLD and behavioral or dents with SLD have significant deficits in social skills.
emotional disorders has generated considerable interest As a group, they are more isolated and less popular
but only cautious conclusions. Common sense suggests among peers than other children, and they tend to make
that children with SLD encounter considerable chal- negative impressions on others (Mok et al., 2014). Like
lenges that are likely to take a toll on self-esteem and, Francine, who was described by her mother as “humor-
in time, their social relationships. However, children’s less and in a bit of a fog,” most children with SLD have
self-concepts in sports and appearance are usually less difficulty grasping the nuances of social interaction and
affected (Lyon et al., 2006). may not know how to greet others, make friends, or
Parents and teachers describe children with SLD as join in playground games. Subtle cues of social inter-
being more difficult to manage than typical children, action may be missed or ignored. These children may
beginning at an early age. Although overall reports of not always interpret correctly or respond appropri-
behavior problems increase considerably for all chil- ately to the frequent nonverbal—but very expressive—
dren between early and middle childhood, behavior communication of other children, such as rolling the
problems among children with SLD are about three eyes to show dislike or disinterest. When children with
times higher than typically developing children by SLD misunderstand the situation and act inappropri-
8 years of age (i.e., 32% vs. 9%; Benasich, Curtiss, & ately, other children turn away.
Tallal, 1993) (see ● Figure 7.4). Most of these prob- A child with SLD also can be an emotional burden
lems are not specific to SLD but cover a broad range for family members. Parents may experience a wide
of problems that overlap with features of conduct range of emotions, including denial, guilt, blame, frus-
tration, anger, and despair. Brothers and sisters often
feel annoyed, embarrassed, or jealous of the attention
35%
8 years old their sibling receives. Because behavioral problems are
30% usually so disruptive, a child’s distress and emotional
needs may easily be overlooked.
25%

Adult Outcomes
8 years old

20%
4 years old

15%
Unfortunately, the social and emotional difficulties con-
nected to communication and learning disorders may
4 years old

10% continue into adulthood, largely because of inadequate

5%
recognition and services (Botting et al., 2016; Johnson,
Beitchman, & Brownlie, 2010). Adults may find ways
0% to disguise their problems, such as watching television
Behavioror problems
prroblem
ms among
a Behavior
or problems
prroblem
ms among
a
news rather than reading newspapers. On the other
typically developing children children with LD
hand, many excel in nonacademic subjects such as art,
●● F I G U R E 7 . 4 | Percentage of clinically significant music, dance, or athletics. Still others may become out-
behavior problems among children with and without standing architects and engineers, or they may have
learning disorders, at 4 years and 8 years of age. extraordinary interpersonal skills (Lyon et al., 2006).
Data from Benasich et al., 1993 Each child and adolescent has many strengths that can

C H A P T E R 7 Communication and Learning Disorders 215

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be developed to compensate for his or her known defi-
cits. Thus, despite their earlier risk for academic failure A CLOSER Factors That Increase
and psychosocial problems, many adults with SLD
lead successful and productive lives (Lewandowski &
LOOK Resilience and Adaptation
Lovett, 2014).
7.1
Several personal characteristics and cir-
Men with SLD with impairments in reading do not
cumstances aid those with learning disorders in their suc-
differ from their peers regarding feelings of global self-
cessful adaptation from childhood, through adolescence, to
worth; symptoms of depression; feelings of competency young adulthood. As part of a longitudinal study of all chil-
and satisfaction with jobs, marriages, and other rela- dren born in 1955 on the island of Kauai, Hawaii, E. E. Werner
tionships; or frequency of antisocial behavior (Boetsch, (1993) followed 22 children with learning disabilities and 22
Green, & Pennington, 1996). However, men still per- matched controls. She found that most children with learn-
ceive lower levels of social support from parents and ing disabilities adapted successfully to adult life. Those who
relatives—the only people still in their lives who knew showed the greatest resilience and flexibility over time had
of their problems as children—which confirms the (1) a basic temperament that elicited positive responses
indelible impressions left by early experiences. from others; (2) a well-developed sense of efficacy, prepared-
One adult describes his own way of compensating ness, and self-esteem that guided their lives; (3) competent
for learning problems: caregivers and supportive adults; and (4) opportunities for
a second chance if they made mistakes or got into trouble
I faked my way through school because I was very
with the law. Although some of these characteristics are
bright. I resent most that no one picked up my
present from birth (e.g., temperament), many of the other
weaknesses. Essentially I judge myself on my
supportive factors can be increased through the efforts of
failures. . . . [I] have always had low self-esteem. . . .
family members, schools, and communities. (Based on au-
A blow to my self-esteem when I was in school was
thors’ case material.)
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 everything on my computer. It
acts as my memory. I use it to structure my life and for
all of my writing since my handwriting and written It is safe to say that even though aspects of SLD
expression has always been so poor. (Polloway, may remain, people who are given proper educa-
Schewel, & Patton, 1992, p. 521) tional experiences have a remarkable ability to learn
Although the long-term outlook for men with SLD is throughout their life spans (Gregg, 2014). A Closer
generally positive, the troublesome issue of sexism arises Look 7.1 describes some of these important opportuni-
when considering how adult women with SLD fare over ties that increase resilience. Adults can learn to read,
time. As a group, women with SLD have more adjust- although it is difficult because brain development slows
ment problems than men as they leave school and face the down after puberty. Current gains in knowledge of the
demands of adult life. Like other adults with disabilities, causes and early signs of SLD are likely to have a posi-
they also face greater risk of sexual assault and related tive impact on early recognition and proper instruction.
forms of abuse (Brownlie et al., 2007). Problems and Nonintrusive electrophysiological measurements of
breakdowns in relationships are common, which may brain reactivity may permit an early diagnosis based on
reflect the lack of opportunity available to these women underlying deficits in phonological processing rather
to achieve in areas that capitalize on their strengths. than on performance alone. Thus, early identification
Reading problems often cause poorly qualified and 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- Causes
ships that are generally unsupportive (Fairchild, 2002). Most learning disorders do not stem from problems in a
Young men, in contrast, have more wide-ranging single area of the brain, but from difficulties in bringing
options once they leave school, which facilitates more information from various brain regions together so
positive social functioning in adulthood. Thus, if they that information can be integrated and understood
are able to select their own environments in adult- (Damasio et al., 2004; Man et al., 2015). Minute dis-
hood (and women have more obstacles in this regard turbances may underlie phonological processing defi-
than men), both men and women with SLD can build cits. In many cases these subtle disturbances begin very
on their existing strengths, skills, and talents (Hatch, early during development, perhaps prenatally (Mayes,
Harvey, & Maughan, 2010). Reilly, & Morgan, 2015; McGrath et al., 2007).

216 P A R T 2 Neurodevelopmental Disorders

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 Recent findings suggest two distinguishable types Neurobiological Factors
of children with reading disorders—children who are Our understanding of learning disorders, particularly
persistently poor readers and those who are accuracy- reading-based and language-based problems, took an
improved (i.e., they learn ways to compensate for important new direction in the mid-1980s with the dis-
their reading difficulties and improve over time) (S. E. covery that the brains of people with these problems
Shaywitz, Mody, & Shaywitz, 2006). Persistently poor were characterized by cellular abnormalities in the left
readers and accuracy-improved readers have compa- hemisphere, which contains important language cen-
rable reading skills and socioeconomic status when they ters (Galaburda et al., 1985). The fact that these cel-
begin school, but by the time they are young adults, lular abnormalities could occur only during the fifth
the accuracy-improved readers show better cognitive to seventh months of fetal development strengthened
ability. The presence of compensatory factors, such the view that learning disorders evolve from subtle
as stronger cognitive ability, may allow the accuracy- brain deficits present at birth (Lyon et al., 2003). Initial
improved individuals to minimize the consequences of autopsy findings were confirmed by sophisticated brain
their phonological defect over time (Ferrer et al., 2010). imaging technology that reveals the brain directly at
These compensatory factors may be genetically based, work and makes it possible to detect subtle malfunc-
and thus the child’s ability improves with maturity, tions that never could be seen before.
whereas the persistently poor readers may face greater The suspected deficits, which likely are genetically
environmental challenges, often associated with pov- based, involve specific discrimination tasks, such as
erty and inequality, that reduce reading opportunities. detecting visual and auditory stimuli, as well as more
pervasive visual–organizational deficits associated with
Genetic and Constitutional Factors reasoning and mathematical ability (Benassi et al.,
Children who lack some of the skills needed for 2010; Pennington & Peterson, 2015). A probable loca-
reading, such as hearing the separate sounds of tion of these deficits is a structure called the “planum
words, are more likely to have a parent with a related temporale,” a language-related area in both sides of the
problem. Around the turn of the twentieth century brain. In a normal brain, the left side of the planum
this problem was studied largely by physicians, who temporale is usually larger than the right side; however,
considered reading disorders to be an inherited condi- in the brain of an individual with a reading disorder,
tion called congenital word blindness (W. P. Morgan, the two sides are equal (Tallal, 2003).
1896). Today, estimates based on behavioral genetic B. A. Shaywitz et al. (2002) found lower activation
studies indicate that heritability accounts for over in numerous sites—primarily the left hemisphere of the
60% of the variance in reading disorders (Bishop, brains of dyslexic children as compared with nonim-
2015; Plomin et al., 2010), although the exact mode paired children—including the inferior frontal, parieto-
of transmission remains undetermined. temporal, and occipitotemporal gyri. These three areas
Most attention paid to heritability is aimed at of the brain are responsible for understanding pho-
genetic transmission of critical brain processes under- nemes, analyzing words, and automatically detecting
lying phonetic processing (Finn et al., 2014). Because a words, respectively. Once a word is learned, this three-
parent’s learning disorder may take a slightly different part center recognizes it automatically, without first
form in the child—the father may have a writing dis- having to decipher it phonetically (S. E. Shaywitz &
order and his child an expressive language disorder— Shaywitz, 2013).
it seems unlikely that subtypes of specific learning From a cognitive standpoint, these neurological
disorders are inherited directly. More likely, what is findings suggest that children with learning disorders
inherited is a subtle brain dysfunction that, in turn, can are distinctively disadvantaged as compared with
lead to a learning disorder (Mayes et al., 2015; New- average readers in terms of the processing underlying
bury et al., 2011). For example, on chromosome 6 an their short-term and working memory. Impairments in
area has been identified that predisposes children to short-term memory affect the recall of phonemes and
reading disorders (Grigorenko, 2007). Genetic trans- numbers; similarly, impairments in working memory
mission provides a plausible explanation for the rela- affect how such information is processed and stored so
tive risk of SLD in reading or mathematics being 4 that it can be rapidly accessed. Considerable support
to 8 times and 5 to 10 times higher, respectively, in now exists concerning how memory deficits explain
first-degree relatives of persons with SLD as compared the performance difficulties of children with a learning
to those without it (APA, 2013; Shalev, 2007). Keep disorder (Carretti et al., 2009; Maehler & Schuchardt,
in mind that environmental factors also play a role in 2016; Swanson, Zheng, & Jerman, 2009).
moderating genetic influences on SLD outcomes (i.e., We have stressed that most children with reading
gene–environment interaction; Petrill, 2013). and writing disorders have difficulty distinguishing

C H A P T E R 7 Communication and Learning Disorders 217

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 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 G U 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. [Link]

phonemes that occur rapidly in speech. But why is this with learning disorders—they lack certain auditory
so? Consider what is involved, as shown in ● Figure 7.5. sites that allow certain sounds to be recognized, so their
The sound must be processed by various brain areas appreciation of certain words is compromised.
as it is carried by nerve impulses from the ear to the Each neuron in the language-processing areas of
thalamus to the nerve cells within the auditory cortex, the brain has immense specificity. Some neurons fire
where it is matched to existing patterns, or phonic bins, when you silently name an object but not when you
that have been previously formed and stored. read the object’s name out loud, and vice versa. Certain
Compare this process to listening to music. When neurons are activated when bilingual people speak one
you first hear a new song, do you recognize aspects that language, but not when they speak the other (Ojemann,
resemble other recordings by that group or another 1991). Someone can have an expressive language
group? Can you distinguish the music of one group problem despite full comprehension, because the same
from another? As we listen, we tend to cluster sounds neurons that are active when a person hears a word are
into various categories, acquiring our taste for music as not active when that person speaks it.
we store more collections and melodies into memory. In the visual system, different aspects of what you
Each time we hear new music, we match it to what see, such as form, color, and motion, are routed to dif-
we already know and appreciate. Young people are ferent regions of the visual cortex. When something
particularly adept at assimilating new sounds, thereby moves in your visual field, the region of the cortex that
broadening their tastes. In contrast, people who have responds to visual motion is activated. Eden et al. (1996)
already formed specific musical tastes tend to stick first discovered that adults with reading disorders show
to what they know, rejecting unrecognizable sounds. no activation in visual motion when asked to view ran-
This gap in music appreciation is analogous to the gap domly moving dots. A specific defect in the perception
researchers describe in the phonic abilities of children of visual motion may interfere with many different

218 P A R T 2 Neurodevelopmental Disorders

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brain functions, and it has been noted among children reading. These deficits involve social/emotional skills,
with autism as well as those with learning disorders spatial orientation, problem solving, and the recognition
(Benassi et al., 2010; Skottun, 2015). To detect differ- of nonverbal cues such as body language (Mammarella &
ences between consonant sounds—such as b and t—we Cornoldi, 2014; Mammarella et al., 2015). In addition to
must be able to distinguish between very rapid changes math deficiencies, NLD may be accompanied by neuro-
in sound frequency. A subtle neurological deficit in sen- psychological problems such as poor coordination, poor
sitivity could prohibit this distinction, which would then judgment, and difficulties adapting to novel and complex
show up clinically as problems in reading and phono- situations (Lyon et al., 2003; Semrud-Clikeman, Fine,
logical processing (Raschle, Chang, & Gaab, 2011). & Bledsoe, 2016). To date, the unique aspects of NLD
Thus, two major findings implicate specific biolog- remain unconfirmed. Critics argue that it may simply be
ical underpinnings of reading disorders: (1) language a form of SLD with impairment in mathematics (Fine
difficulties for people with reading disorders are spe- et al., 2013; Spreen, 2011).
cifically associated with the neurological processing
of phonology and storage of such information into Social and Psychological Factors
memory; and (2) behavioral and physiological abnor- Emotional and behavioral disturbances and other
malities are found in the processing of visual informa- signs of poor adaptive ability often accompany SLD.
tion. It is not surprising, therefore, that phonological This is no surprise, because children with one neuro-
and visual processing problems often coexist among developmental disorder (i.e., communication disorder,
people with reading disorders (Skottun, 2015). SLD, ADHD, or intellectual disability) are about 40%
Studies of the causes of SLD mostly involve chil- more likely to have another neurodevelopmental dis-
dren with reading disorders, but the findings apply to order, most likely because of shared etiological fac-
disorders in written expression and mathematics as tors (Gooch et al., 2013). The overlap between SLD
well. Many—but not all—disabled writers show defi- with impairment in reading and ADHD, for example,
cits in reading (Lyon et al., 2003), and some mathe- ranges from 30% to 70% depending on how ADHD
matical concepts require reading and writing as well is defined (Gray & Climie, 2016; Fletcher, Shaywitz,
as mathematics skills. Similar to how deficits in pho- & Shaywitz, 1999). Although this degree of overlap
nological awareness underlie SLD with reading impair- suggests that behavioral and learning problems have
ment, certain cognitive deficits involving concepts of certain common aspects, they are still distinct and sep-
numbers appear to underlie SLD with impairment in arate disorders (Lyon et al., 2006). SLD is commonly
mathematics (Geary, 2013). For instance, if you show associated with deficits in phonological awareness,
small sets of dots, usually up to four dots per set, to whereas ADHD has more variable effects on cognitive
typically developing children they can tell you instantly functioning, especially in areas of rote verbal learning
(i.e., without counting the items) how many items are and memory (Hahn & Morgan, 2015). ADHD, more-
in each set, a process known as subitizing. But children over, is relatively unrelated to phonological awareness
with SLD with impairments in mathematics appear to tasks. However, some children with SLD show symp-
have trouble subitizing even three items, suggesting a toms similar to those of ADHD, including inattention,
deficit in their rapid visual processing of enumeration restlessness, and hyperactivity.
concepts (Ashkenazi, Mark-Zigdon, & Henik, 2013).
Similarly, most children can quickly say which of two Prevention and Treatment
numbers is larger (e.g., “13” vs. “31”), but students What can be expected of Francine, James, Tim, and
with mathematics disorder are slower and less accurate Carlos during their school years and beyond? Proper
than their peers at doing so (Mejias et al., 2012). planning and goal setting are the cornerstones of the
Recall that Francine had well-developed word rec- helping strategies for home and for school. Specific
ognition and spelling abilities, but significantly worse learning disorders are not usually outgrown, but there is
mechanical–arithmetic skills. SLD with impairment reason for optimism if educational planning and accom-
in mathematics, and perhaps SLD with impairment in modations are ongoing (Beitchman & Brownlie, 2014).
written expression as well, are associated with brain defi- Although SLD has strong biological underpinnings,
cits that differ from those described for language-based intervention methods rely primarily on educational
learning disorders. These deficits are largely found in and psychosocial methods. Psychosocial treatments
areas not related to verbal ability, which has led to the for James, Francine, Carlos, and Tim must be compre-
term nonverbal learning disability. Nonverbal learning hensive and ongoing, with each new task broken down
disability (NLD) is associated with deficits related to right- into manageable steps, including examples, practice,
hemisphere brain functioning, which are characteristic of and ample feedback. Combined with proper teaching
children who perform considerably worse at math than strategies, children and their families may benefit

C H A P T E R 7 Communication and Learning Disorders 219

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from counseling aimed at helping the children develop
greater self-control and a more positive attitude toward
their own abilities. Support groups for parents also can
fill an important gap between the school and the home
by providing information, practical suggestions, and
mutual understanding.
Someday, breakthroughs in brain research may lead
to new medical interventions, but at present no bio-

Sergey Novikov/[Link]
logical treatments exist for speech, language, and aca-
demic disabilities. In cases in which significant problems
coexist in concentration and attention, some children
respond favorably to stimulant medications that may
temporarily improve attention, concentration, and the
ability to control their impulsivity, albeit with little or
no improvement in learning. Typically, the medication Treatment of specific learning disabilities usually begins
with a careful assessment of a child’s abilities.
schedule ensures that the drug is active during peak
school hours, when reading and math are taught.
Consider the coordinated planning and effort that
went into the treatment programs for Francine: Francine
FRANCINE could get help because her problems were detected;
Slowly but Surely Improving recall, however, that by the time she was referred, she
had already begun to fail at formal schooling. The first
step in solving any problem is to realize that it exists.
To reduce Francine’s difficulties with math and,
The nature of learning disorders makes this difficult
especially, with peer relationships, we considered
for many children and parents. Although numerous
several factors. First, we decided that teaching should
be primarily verbal, with an understanding that she
signs of language-based learning disorders are present
would have the most difficulty in math and science. Her from early childhood, sophisticated means of assessing
teachers favored allowing Francine to use a calculator problems are not yet available before children are old
and a computer to assist her in learning new concepts. enough to be formally tested.
An emphasis on physical education was also planned, Issues of identification are important because a brief
to help her with her visual–motor coordination. Her window of opportunity may exist for successful treat-
math teacher agreed that using graph paper might ment. If a problem is detected in early childhood—say,
help her visualize numerical relationships, which led to by kindergarten—then language-based deficits can
noticeable improvements in her schoolwork. often be remediated successfully. If the problem is not
Francine’s problems in making friends were a major detected until age 8 or so, the rates of response to treat-
concern to everyone, and we believed that they were
ment are much lower (Snowling et al., 2016). This is
directly linked to her learning disability. A cognitive–
why prevention of reading difficulties is a hot topic:
behavioral intervention plan was developed in
conjunction with her educational program. Because of
Training children in phonological awareness activities
Francine’s strong verbal skills, we taught her to problem at an early age may prevent subsequent reading prob-
solve through role playing, and encouraged her mother lems among children at risk (Duff & Clarke, 2011;
to invite one child at a time for her to play with so that Snowling & Hulme, 2012). These activities involve
she could practice her skills. Francine had drifted into games of listening, rhyming, identifying sentences and
being a loner and seemed disinterested in looking after words, and analyzing syllables and phonemes. For
herself, so we also discussed ways to develop better self- example, the child might analyze sand as s-and and
care at home by giving her an allowance for completing then synthesize it into sand, or colored alphabet blocks
household chores. We spent considerable time might be used to break the word into separate phonetic
explaining the nature of her problems to her parents,
sounds (s-a-n-d).
and this guidance led to relief and understanding.
Knowledge of communication and learning disor-
We saw the family once again one year later;
although some of Francine’s problems still existed, her
ders has played leapfrog with the philosophy and prac-
social abilities had improved. She still had difficulties in tice of classroom instruction during the past decade.
developing friendships and tended to prefer being alone, Discoveries in neurosciences, as noted above, challenged
but the problem had clearly lessened from the previous some prevailing educational practices, leading to more
year. (Based on authors’ case material.) systematic ways of assisting children with learning dis-
orders, as explored in the following sections.

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The Inclusion Movement with learning disorders (Scammacca et al., 2015). Direct
Integrating children with special needs into the regular instruction is a straightforward approach to teaching
classroom began as the inclusion movement during the based on the premise that to improve a skill, the
1950s, based on studies showing that segregated classes instructional activities must approximate those of the
for students with disabilities were ineffective and possibly skill being taught (see example in A Closer Look 7.2)
harmful (Baldwin, 1958). Resource rooms and specially (Hammill et al., 2002). Direct instruction in word struc-
trained teachers replaced the special classes that had been ture is necessary because of the child’s phonological
in vogue, a change that had the further advantage of deficits. Direct instruction in reading emphasizes the
removing the need to label and categorize children. The specific learning of word structure and word reading
Education for All Handicapped Children Act of 1975 in
the United States (currently known as Individuals with
Disabilities Education Improvement Act [IDEA], 2004)
A CLOSER Steps in Direct Behavioral
and the provincial Education Acts in Canada mandate
that children with special needs must be afforded access LOOK Instruction
to all educational services, regardless of their handicaps. 7.2
Today, children with special educational needs in the
1. Review the child’s existing abilities.
United States, Canada, and many other countries are
2. Develop a short statement of goals at the beginning of
placed in regular classrooms whenever possible. each lesson.
Federal, state, and provincial legislation (e.g., the 3. Present new concepts and material in small steps, each
U.S. Every Student Succeeds Act [ESSA]) allows for followed by student practice.
intensified efforts by each state and province to improve 4. Provide clear and detailed instructions and explanations.
the academic achievement of public school students 5. Provide considerable practice for all students.
considered at risk for school failure. Today, almost 14% 6. Check student understanding of concepts continually, in
(about 6.6 million) of school-age children in the United response to teacher questions.
States from all walks of life receive some level of support 7. Provide explicit guidance for each student during initial
through special education, and students with specific practice.
learning disabilities account for close to half of these stu- 8. Provide systematic feedback and corrections.
dents (National Center for Educational Statistics, 2012). 9. Provide explicit instruction and practice for exercises com-
pleted by students at their desks.
Response to Intervention Models Source: From Treatment of Learning Disabilities by G. R. Lyons and L. Cutting,
1998. In E. J. Mash and L. C. Terdal (Eds.), Treatment of Childhood Disorders.
IDEA provides for the use of Response to Intervention
The following example illustrates how the steps in direct
(RTI) models to identify and assess children. RTI consists
behavioral instruction are applied.
of tiered instruction, in which children who have diffi-
culty learning to read using typical methods of instruc- Example: Direct Instruction Lesson
tion are provided with small-group, intensive instruction. A typical DI lesson includes explicit and carefully sequenced
Those who need additional intervention may receive instruction provided by the teacher (model) along with frequent
one-on-one special education. This approach seeks to opportunities for students to practice their skills (independent
practice) over time (review). For example, if the sound /m/
provide each child with the appropriate level of instruc- appeared for the first time, the teacher might say, “You’re
tion required for his or her individual needs (“NIH Fact going to learn a new sound. My turn to say it. When I move
Sheets: Reading Difficulty and Disability,” 2010). under the letter, I’ll say the sound. I’ll keep on saying it as long
Initiatives to allow children with special needs to as I touch under it. Get ready. mmm” (model). “My turn again.
Get ready. mmm” (model). “Your turn. When I move under the
receive services without being diagnosed or labeled as letter, you say the sound. Keep on saying it as long as I touch
intellectually disabled, learning disabled, and so forth under it. Get ready.” (independent practice). “Again. Get ready.”
have become widely available and hold considerable (independent practice). If an error occurs during instruction, the
promise. However, implementation and teacher training, teacher would model the sound (“My turn. mmm”), use guided
practice (“Say it with me. Get ready. mmm”), and have students
as well as the question of whether such initiatives suc- practice independently (“Your turn. Get ready”). A “starting
ceed in meeting the special needs of students, continue over” would be conducted based on this error; this might
to be unresolved (Lewandowski & Lovett, 2014). include starting over at the top of a column or row of sounds so
that students get increased practice on the /m/ sound. The /m/
would appear throughout the lesson and in subsequent lessons
Instructional Methods to ensure skill mastery (firm responding) over time.
Although controversy remains over the practical aspects
Source: Marchand-Martella, Martella, & Ausdemore (2005). An Overview of
of including all children in regular classrooms, most Direct Instruction.
educators today favor direct instruction for children

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until the skill is learned, without concern for the full on memory or on grasping the concept all at once.
context of the sentence or story. This method is based Tried-and-true behavioral principles of learning are
on the premise that a child’s ability to decode and rec- well suited to this task of teaching systematically.
ognize words accurately and rapidly must be acquired In addition to academic concepts, some of the associ-
before reading comprehension can occur (Haager & ated problems with peers can be addressed in the same
Vaughn, 2013; Roberts et al., 2015). fashion, as we saw with Francine. A simple, gradual
To prevent dyslexia, it is important to provide early approach is more beneficial than an approach that tries
interventions that teach both phonological and verbal to solve the problem all at once. Children also need help
abilities. Children must be able to learn the sounds learning to generalize new information to different situ-
of words to decode them, but they must also under- ations. An individualized, skills-based approach does
stand the meaning of a word to understand the mes- not have to be boring or routine; in fact, speech and lan-
sage of the text (S. E. Shaywitz & Shaywitz, 2013). The guage therapists are skilled at providing a stimulating
techniques that have been demonstrated to work are but structured environment for hearing and practicing
practicing manipulating phonemes, building vocabu- language patterns. During an engaging activity with a
lary, increasing comprehension, and improving fluency, younger child, the therapist may talk about toys and then
which helps strengthen the brain’s ability to link let- encourage the child to use the same sounds or words.
ters to sounds (Heim, Choudhury, & Benasich, 2016; The child may watch the therapist make the sound, feel
Roberts et al., 2015). the vibration in the therapist’s throat, and then practice
In brief, the components of effective reading instruc- making the sounds himself or herself in front of a mirror.
tion are the same whether the focus is prevention or Behavioral methods often are used in conjunction
intervention—phonemic awareness and phonemic with a complete program of direct instruction, which
decoding skills, fluency in word recognition, construc- typically proceeds in a cumulative, highly structured
tion of meaning, vocabulary, spelling, and writing manner (Wright & Jacobs, 2003), as shown in A Closer
(Snowling & Hulme, 2012). Evidence-based evalua- Look 7.2. Because this method places a strong emphasis
tions show significant reductions in the incidence of on the behavior of the teacher in terms of explicit cor-
reading failure when direct and explicit instruction in rection, reinforcement, and practice opportunities, it is
these components is provided by the classroom teacher sometimes referred to as “faultless instruction”: Each
(Scammacca et al., 2015; E. Swanson et al., 2014). concept should be so clearly presented that only one
Empirical support for teaching phonics from an early interpretation is possible. Each lesson is structured
age also is emerging from brain imaging studies. For according to field-tested scripts. Teachers work with
example, instruction in phonemic awareness, phonics, one small group of students at a time, and shoot ques-
and other reading skills produces more activation in tions at them at a rate as high as 10 to 12 per minute.
the automatic recognition process, noted previously This highly structured, repetitive method is clearly
(see section on “Causes,” above). After undergoing such effective. Students who receive direct behavioral instruc-
training, brain scans of people who were once poor tion typically outperform students who receive standard
readers begin to resemble those of good readers (“NIH classroom instruction by almost 1 standard deviation
Fact Sheets: Reading Difficulty and Disability,” 2010). on various learning measures (Lyon et al., 2003).
We now turn to some practical examples of how
reading, writing, and math can be taught by applying Cognitive–Behavioral Interventions
well-established principles of learning. Behavioral and Cognitive–behavioral interventions are also highly
cognitive–behavioral strategies have been highly bene- suited for children with communication and learning
ficial in remediating the problems of children and ado- disorders. Like behavioral methods, these procedures
lescents with communication and learning disorders actively involve students in learning, particularly in
(Lyon et al., 2006). In addition, new methods based on monitoring their own thought processes. Considerable
the use of technology offer some children additional emphasis is placed on self-control by using strategies
ways to acquire basic and advanced academic skills. such as self-monitoring, self-assessment, self-recording,
self-management of reinforcement, and so on (Ciullo
Behavioral Strategies et al., 2016; Cobb et al., 2009). Essentially, children
Many problems that children with communication are taught to ask themselves several questions as they
and learning disorders have stem from the fact that the progress, to make themselves more aware of the mate-
material is simply presented too fast for them (Tallal & rial. Try it yourself: “Why am I reading this? What’s the
Benasich, 2002). Thus, a strategy to provide children main idea the authors are trying to get across? Where
with a set of verbal rules that can be written out and can I find the answer to this question? How does this
reapplied may be more beneficial than one that relies follow from what I learned a minute ago?”

222 P A R T 2 Neurodevelopmental Disorders

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 Carlos’s treatment program shows how some of
these procedures were applied to his particular writing
problems.

CARLOS

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Plans

In third grade, Carlos’s treatment plan was to integrate

a cognitive–behavioral approach into regular teaching
methods. Rather than using one-to-one instruction,
I discussed with his teacher ways of blending some
behavioral methods into the classroom. For example,
his strengths are in the areas of thinking and speaking, New research raises cautious hope that computer games
so I discussed using computers and tape recorders to and exercises can help children with learning disabilities
help him learn the materials. He seemed to like these develop key mental skills.
methods, and they helped him bypass some aspects of
his writing disability. I discussed practice strategies for
visual–motor integration, such as drawing and tracing
and gradually made the task more complex. Because Computers have been used as simple instruc-
cursive writing is often easier for children than printing, tional tools to deliver questions and answers since
I suggested that Carlos bypass learning to print. A the 1970s. Since discovering phonological aware-
continuous pattern of output is easier for Carlos to plan
ness and timing problems in the brain, researchers
and produce than a discrete form of output, such as
are now testing whether computers can remedy some
printing.
To help Carlos write a paper, I adopted a basic
basic auditory problems. Some children with commu-
planning strategy from Graham, MacArthur, Schwatz, nication and learning disorders are unable to process
and Voth (1992), which helped him structure the tasks information that flashes by too quickly, such as the
into related subproblems. The acronym PLANS helps him consonant sounds ba and da, and this deficit inter-
remember to: feres with vital speech processes. Computer programs
Pick goals (related to length, structure, and purpose of
are able to slow down these grammatical sounds,
the paper) allowing young children to process them more slowly
List ways to meet goals and carefully (Bonacina et al., 2015; Horowitz-Kraus
And et al., 2014).
make Notes Whether taught by computers, teachers, or both,
Sequence notes studies of interventions for learning disorders indicate
This mnemonic was used in a three-step writing
that successful approaches typically include explicit
strategy to assist Carlos to (1) do PLANS, (2) write and instruction in phonemic awareness and phonemic
say more, and (3) evaluate whether he is successful in decoding. These interventions also provide students
achieving his goals. (Based on authors’ case material.) with practice reading text and comprehending what
they read, with ample assistance and almost daily ses-
sions (Kunkel, 2016; Torgesen et al., 2010).
In summary, treatment methods for communication
Computer-Assisted Learning and learning disorders are varied and beneficial. A Closer
Studies have shown that a similar level of efficacy in Look 7.3 reviews some of the basic elements of a suc-
phonetic ability can be achieved by teachers as by cli- cessful beginning reading program, elements that apply
nicians (Haager & Vaughn, 2013), which has led to to other disabilities as well. For children with reading
a growing number of computer and Internet training disorders to learn how to read, they must receive a bal-
programs. One problem in reading instruction is main- anced intervention program composed of direct and
taining a balance between the basic, but dull, word explicit instruction in phonemic awareness, a systematic
decoding and the complex, but engaging, text com- way to generalize this learning to the learning of sound–
prehension. Not all the issues have been resolved, but symbol relationships (phonics), and many opportunities
computer-assisted methods for spelling, reading, and to practice these coding skills by reading meaningful,
math provide more academic engagement and achieve- interesting, and controlled texts. The sooner this inter-
ment than traditional pencil-and-paper methods. vention occurs in schools, the better.

C H A P T E R 7 Communication and Learning Disorders 223

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 A CLOSER Critical Elements for a become automatically accessible. This usually requires
a great deal of practice, which should be as pleasant and
LOOK Successful Beginning rewarding as possible.
7.3 Reading Program Source: From Rebecca H. Felton (1993), Effects of Instruction on the Decoding
Skills of Children with Phonological-Processing Problems, Journal of Learning
Disabilities, 26, 583–589.
1. Provide direct instruction in language analysis. Identify
at-risk children early in their school careers—preferably in
kindergarten—and teach phonological awareness skills
directly.
2. Provide direct teaching of the alphabetic code. Code instruc- Section Summary
tion should be structured and systematic, in a sequence that
goes from simple to more complex. Teach the regularities of Specific Learning Disorder
the English language before introducing the irregularities. ●● Specific learning disorder (SLD) includes problems in read-
Nothing should be left to guesswork—be as explicit as pos- ing, mathematics, or writing ability, with reading disorders
sible. Teach a child who is overly reliant on letter-by-letter being the most common. Mathematics and writing disor-
decoding to process larger and larger chunks of words. ders overlap considerably with reading disorders.
3. Teach reading and spelling in coordination. Children should ●● Although SLD overlaps with behavioral disorders, they are
learn to spell the words they are reading correctly. distinct problems. Opportunities to develop and use par-
4. Provide intensive reading instruction. Children may need ticular strengths lead to more successful adult outcomes.
three or more years of direct instruction in basic reading ●● SLD in reading may be caused by phonological problems
skills to ensure competency. As they progress, they should
that arise from physiological abnormalities in the process-
practice more and more reading that is contextualized.
ing of visual information in the brain. These deficits are
Reading materials should have controlled vocabularies
believed to be largely inherited.
that contain mostly words the children can decode. As
●● Treatments for children with communication and learn-
children develop a core sight vocabulary, introduce only
ing disorders involve educational strategies that capitalize
those irregular words that can be read with high accuracy.
on existing strengths, and behavioral strategies involving
Guessing is counterproductive.
direct instruction.
5. Teach for automaticity. Once basic decoding is mastered,
children must be exposed to words often enough that they ●● Cognitive–behavioral techniques and computer-assisted
instruction are also used successfully.

Study Resources
SECTION SUMMARIES dyslexia 212
inclusion 202
Definitions and History 196
language disorder 200
Language Development 198
learning disability 196
Communication Disorders 200
nonverbal learning disabilities (NLD) 219
Specific Learning Disorder 207
phonemes 198
phonological awareness 199
KEY TERMS phonology 199
communication disorder 197 specific learning disorder 197
decoding 212 speech sound disorder 201
direct instruction 221 unexpected discrepancy 197

224 P A R T 2 Neurodevelopmental Disorders

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203